Who Counts as a Health Care Worker?

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A new report commissioned by the National Coordinating Group on Health Care Reform and Women (NCGHCRW) and the National Network on Environments and Women’s Health (NNEWH) argues that quality of health care across Canada is being threatened by new labour practices which treat certain workers as unimportant to good care. National statistics reveal that jobs in hospitals and home care such as cleaning, food preparation, laundry, medical record keeping and others are increasingly being labeled as ‘ancillary’ or secondary and contracted out to service companies. The workers—many of them immigrants and/or people of colour—suffer too when the companies cut their wages, hours of work and benefits to increase profits.

Virtually everyone would agree that doctors and nurses are health care workers. But do we include among our doctors those who practice chiropractics and homeopathy? Do we include nursing aides and orderlies when we talk about nurses? What about hospital cleaners, laundry workers, cooks, file and appointment clerks, home care and personal support workers? Are they an essential part of the health care team?

Increasingly, many of these jobs are described as “ancillary”. The Romanow Report on the Future of Health Care in Canada, for example, distinguishes between those who provide direct care and those who are engaged in ancillary services. While the Report doesn’t offer a clear definition of ancillary services, it does describe them as services “such as food preparation, cleaning and maintenance”. Clerical workers and laundry workers would also seem to fit in with this understanding of ancillary, given that they don’t provide ‘direct’ care either.

But in practice, the lines between direct and non-direct care work are difficult to draw. Both are integral to care, and there is constant overlap between the two. For instance, some of those who provide homemaking services do food preparation and cleaning but may also provide some direct care. At the same time, personal care providers who work in homes and hospitals do cleaning and food preparation, fitting them into both categories as well. To complicate things further, many nurses with foreign credentials now work as personal support and home care workers, as cleaners, cooks and administrative staff, and many nurses registered in this country do the cleaning if the cleaners are absent.

The term “ancillary” also implies a separate or secondary status in health care provision, obscuring these workers’ roles in the success of interventions, in recovery, in sustaining health and in preventing illness or disability. But the environments for care are part of care, and can be as critical to health as clinical interventions. Cleaners, for example, would not typically be included in traditional models of primary health care work. But proper sanitation greatly improves the success of medical intervention and plays a critical role in prevention, especially for the sick. The role of cleaners in ensuring safe conditions is utterly essential.

The question of where we draw the line between health care workers and non-health care workers is a central issue for policy development in health care, as well as for the women who do most of this work. The definition we use reflects and reinforces practices that allow workers in health care to be divided into two camps, with each camp treated differently. One consequence is that services defined as ancillary are increasingly contracted out to firms that do similarly defined work in the for-profit non-health care sector, with disastrous results for wage equity and labour conditions. In British Columbia, the wages of ancillary workers who have been contracted out have been cut almost in half, leaving them without pension, long-term disability plans, parental leave, or guaranteed hours of work.

With the exceptions of management, maintenance and security work, women constitute the overwhelming majority of those who cook and clean, provide home support, serve food and keep records. Such work is traditionally regarded as women’s work and is increasingly done by racialized women, although it is sometimes also done by marginalized men. As a result, the skills, effort, responsibilities and working conditions involved remain invisible and undervalued. In British Columbia, wages for this mainly female labour force are now equivalent to those paid in 1968. Perhaps unsurprisingly, male dominated jobs have fared better, creating a larger wage gap among ancillary workers. BC unions have charged the government under the Charter of Rights and Freedoms, claiming the action discriminates against women. The claim failed at the lower court level.

Ancillary work was once part of nursing, and is still done by nurses when it is not done by others, precisely because it is so critical to care. It is central to the provision of safe and substantial health care, and to a broader social project of public health, wellbeing, and care. Those who do this work are health care workers, and should be recognized as such.

For the full report, Critical to Care: Women and Ancillary Work in Health Care, visit: