The role of the health system in basic occupationalhealth service provision for underserved groups –experiences and challengesDraft22 May 2011
Table of Contents1. Introduction ........................................................................................................................... 3 1.1. Purpose of this paper & target audience ...................................................................... 5 1.2. Scope and limitations of this paper .............................................................................. 5 1.3. Why do these target groups deserve special attention? .............................................. 5 1.4. Challenges of meeting the target groups ..................................................................... 72. The potential role of the health system in providing BOSH ................................................. 8 2.1. Essential components of BOSH ................................................................................... 8 2.2. Delivering BOSH services to informal and vulnerable Workers ................................ 10 2.3. Advantages of integrating BOSH into PHC ................................................................ 13 2.4. Development and delivery of OSH within PHC .......................................................... 15 2.5. Extending Healthcare Funding Mechanisms to include BOSH ................................. 173. Delivery of BOSH in practice - country experience ........................................................... 21 3.1. Thailand – an integrated PHC approach .................................................................... 21 3.2. Indonesia – a PHC Approach to BOSH ..................................................................... 22 3.3. China - piloting an integrated PHC/BOSH approach ................................................ 23 3.4. Brazil – an integrated PHC approach ......................................................................... 26 3.5. Indonesia – a PHC Approach to OSH ........................................................................ 26 3.6. Tanzania - UMASIDA Health Insurance Scheme, a community based insurance approach.................................................................................................................................. 27 3.7. India – SEWA, a community based insurance approach.......................................... 28 3.8. Chile – a dual social & private health insurance approach ........................................ 294. Conclusions and challenges ............................................................................................... 30
1. IntroductionBasic occupational safety and health (BOSH) practice is firmly rooted in the principles ofprimary health care. Prevention is the primary focus of occupational health interventions.Rantanen1 argues that the “theoretical basis for BOSH lies in the general theory of publichealth…..The main focus is on the elimination, prevention and control of factors that arehazardous to health in the work environment”.The Alma Ata Declaration recognised that governments “have a responsibility for the health oftheir people which can only be fulfilled by the provision of adequate health and socialmeasures”. The Declaration went on to emphasise that PHC should be based on practical,scientifically sound and socially acceptable methods that should be available to all. Theimportance of providing healthcare both where people live and where they work wasrecognised: “PHC involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors…”In practice however, the focus over the last 30 or so years of PHC implementation has beenon providing health services where people live rather than where they work.Traditional single cause – single effect public health approaches are still valid in certaincircumstances such as when dealing with illness caused by bacterial infections or thoughchemical exposure. There is an acknowledgment that many of the challenges of occupationalhealth are more complex and may involve complex interactions between a range of causalfactors or determinants. There is also recognition that the occupational health approach mustmove beyond the large industrial or commercial environment and into a much broader rangeof settings if is to be effective in the modern world.Prevention should be at the centre of efforts to integrate BOSH and PHC – the greatestchallenge for occupational health in developing countries is to eliminate hazards in the workenvironment.ILO Convention No. 187 (Promotional Framework for Occupational Safety and Health) agreedin 2006, sets out the essential elements of a national OSH system (see Table 1). Included isthe requirement to “develop support mechanisms for a progressive improvement of OSHconditions in micro, small and medium-sized enterprises, and in the informal economy”.Table 1: Essential Elements of a National Occupational Safety and Health System● Legislation and any other relevant OSH ● Occupational health servicesinstruments ● Research on OSH● One or more authorities or bodies responsible for ● A mechanism for the collection and analysis ofOSH data on occupational injuries and diseases● Regulatory compliance mechanisms, including ● Provisions for collaboration with relevantsystems of inspection insurance or social security schemes covering● A national tripartite advisory mechanism occupational injuries and diseasesaddressing OSH issues ● Support mechanisms for a progressive● Arrangements to promote at the enterprise improvement of OSH conditions in micro, small andlevel, cooperation between employers and medium-sized enterprises, and in the informalworkers economy● OSH information and advisory services● Systems for the provision of OSH trainingILO Convention No. 1871 Basic occupational health services—their structure, content and objectives, Jorma Rantanen, SJWEHSuppl 2005: no 1:5-15
OSH has traditionally had a ‘workplace’ orientation which has looked at workers in the contextof the formal business, factory or office setting in which they are employed. However, theworkplace has changed radically in the past few decades as home working, growing numbersof SMEs, sub-contracting & self-employment and work in informal or precarious settings(street vendors etc.) become increasingly common for hundred of millions of workers. All ofthese work settings fall outside the scope of most existing employment or labour legislation.In 2007, the 60th World Health Assembly, concerned at the lack of workers’ access to OSHhealth services called for the 193 WHO Member States “to work towards full coverage of allworkers including those in the informal economy, small- and medium-sized enterprises,agriculture, and migrant and contractual workers, with essential interventions and basicoccupational health services for primary prevention of occupational and work-related diseasesand injuries”2.Attention was primarily focused on workers in agriculture, small and medium sized enterprises(SME), the informal economy and migrant workers. WHO was requested to develop guidanceto countries on basic packages, tools, working methods and models of good practices foroccupational health services and also to stimulate international efforts for capacity building aspart of the Global Plan of Action on Workers’ Health 2008 – 2017 (GPAWH).A broad range of interventions to improve standards and access to OHS were outlined in theGPAWH. These included: the development of improved policies on workers health; improvedassessment and management of workplace health risks; improving access and quality ofoccupational health services; developing and disseminating evidence for action and practice;and strengthened cross sectoral cooperation to promote the inclusion of workers’ health inother sectors policies3.The WHO Global Occupational Health Programme (GOHP) based in Geneva hasresponsibility for coordinating and overseeing the OSH agenda defined in the 2008 – 2017Global Plan of Action on Workers’ Health (GPAWH). The GPAWH identified a number of keystrategies including: 1) Establishing national policies for occupational health; and 2) Covering all workers with essential interventions and basic occupational safety and health services (BOSH) for the primary prevention of work-related diseases and injuries.The following principles were applied to the GPAWH BOSH service development: Available to all working people Address local needs Adapted to local conditions Affordable to providers and clients Organized by the employer for employees Provided by the public sector for the self-employed and the informal sector Supported by intermediate level services.The GOHP is in the process of developing global guidance, policy options andrecommendations for financing and delivering essential OHS interventions and basicoccupational health services to underserved working populations and work settings in thecontext of integrated primary health care.2 WHA Resolution 60.26, “Workers’ Health: Global Plan of Action”3 Sixtieth World Health Assembly, Agenda item 12.13, May 2007
1.1. Purpose of this paper & target audienceThe purpose of this paper is to look at some of the health systems implication of integratingbasic occupational health services into PHC for poor and vulnerable groups and to contributeto the development of a WHO White Paper on occupational health.The principal target audiences for this paper are primarily health planners and policy makers,health economists and those officials with a responsibility for allocating and managing humanand financial resources within ministries of health and ministries of finance. 1.2. Scope and limitations of this paperThis paper will draw upon recent published articles in English relating to approaches toorganising and financing OHS programmes and interventions in a number of different countrycontexts from around the world. The focus of this paper is on looking at OHS interventions andservices intended to serve workers in vulnerable employments, the unemployed, migrants,those employed in the informal economy and agriculture.There is very limited published literature on this topic and much of what is available is mainlydescriptive. So the information base from which evidence has been extracted and conclusionsdrawn is relatively modest. Unpublished, grey literature has been used where this has beenfelt to be useful, available and appropriate. 1.3. Why do these target groups deserve special attention?In 2009 it was estimated that worldwide there were 1.5 billion or 50 percent of all workers ininformal or vulnerable employment out of a total of 3 billion people globally who wereeconomically active. Of those, 1 billion worked in agriculture, 666 million in industry and theremaining 1.3 billion in the service sector4. Vulnerable employment has been defined by theILO as a measure of individuals engaged under relatively precarious employmentcircumstances including the self-employed and their family members. As these workers areless likely to have formal work arrangements, access to benefits or social protection, theiremployment status is categorised as “vulnerable”5. Their access to occupational health andsafety services will also be greatly reduced.Many workers in informal or vulnerable employments are engaged in hazardous activities suchas mining, fishing or agriculture where workers are routinely exposed to dangerous chemicals.In total, it is estimated that there are 337 million work related accidents and up to 2.3 millionwork related deaths each year with 650,000 of those being due to exposure to hazardoussubstances – this figure has doubled in recent years. The economic cost of poor occupationalsafety and health (OSH) practices is substantial. It is calculated that $US1.25 trillion,representing 3 - 4% of global GDP, are lost every year due to costs such as lost working time,workers’ compensation, loss of production and medical expenses6.The 2002 World Health Report identified the following occupational health factors: workrelated risk factors for injuries, exposure to carcinogens and particulates, ergonomic stressorsand noise as making the following contribution to global morbidity: 37 percent of back pain, 16percent of hearing loss, 13 percent of chronic obstructive lung disease, 11 percent of asthmacases, 10 percent of injuries and 9 percent of cancers.Whilst industrialised countries have seen a steady reduction in the numbers of occupationalaccidents and diseases, the opposite trend is being seen in countries under-going rapidindustrialisation or those too poor to maintain effective, national OSH systems. Developingcountries have seen an increase in the numbers of work related accidents as OSH practicesfall far below acceptable practices7.4 Global Employment Trends 2011, ILO5 Guide to the new Millennium Development Goals, Employment Indicators, ILO, 20096 World of Work, Number 63, August 2008, ILO7 Ibid
Informal sector workers frequently live and work in difficult and dangerous conditions thatrender them more vulnerable to events such as illness, loss of assets and loss of income.Hazards that people may face at work are almost as varied as the different types of work thatthey may do, but will include: exposure to chemicals and biological agents, physical factors,adverse ergonomic conditions, and allergens. The consequences may result in a wide rangeof poor health outcomes, including injuries, cancer, hearing loss and respiratory,musculoskeletal, cardiovascular, reproductive, neurotoxic, skin and psychological disorders8.In addition, workers have little access to social safety nets such as insurance, pensions andsocial assistance. Basic services such as education, health care and adequate housing arefrequently beyond the means of these workers as many of them cannot afford to join formalsector social insurance schemes whose benefits may not meet their principal needs9.Workers in vulnerable employment, the unemployed, migrants and those employed in theinformal economy and agriculture frequently have little or no access to preventive or curativehealth services in their workplace10. This can have a dramatic impact on their income andfuture earning potential with potentially severe consequences for the worker and his/her familyor dependents.There are a number of highly effective interventions for the prevention of occupationaldiseases and injuries. Whilst, some countries already provide at least basic OSH services andinterventions, very few have managed to achieve universal coverage or the sustainableprovision of such services. Many countries do not have health systems able to deliver theseinterventions to those workers in greatest need. It is estimated that less than 15% of the globalworkforce has some coverage of occupational health services.In Africa, the informal economy is extremely important and most people are employed within it.In those countries where employment statistics are collected, it is estimated that the formaleconomy can only provide jobs for 5-10 per cent of new entrants to the labour market – mostnew jobs are being generated by the informal economy. The key issues for workers in theinformal economy relate to low productivity, low earning and high poverty levels.In China, rapid economic development has been accompanied by high rates of rural – urbanmigration as people seek to move out of agriculture to find more rewarding work in the rapidlygrowing towns and cities. Migrants have faced particular problems in accessing OSH servicesin China. The low skill level of migrants compared to urban workers and the barriers they facein accessing formal employment has led to migrants being concentrated in jobs with a highrisk of occupational illness and disease, often in SMEs which are not adequately regulatedand have poor access to basic OSH services. Migrants also tend to work longer hours, andhave poorer living conditions than other workers in China11.Whilst data on OSH are sparse and unreliable in India, it is believed that unsafe workingconditions are one of the leading causes of death and disability among India’s workingpopulation. ILO data, which are incomplete and very probably underestimate the scale of theproblem, suggest that as many as 400,000 people die each year as a result of work-relatedaccidents12. As in many countries, there is very little reliable data available on occupationaldiseases8 World Health Report 20029 Social Policy Framework for Africa, African Union, October 200810 Integration of workers’ health in strategies for primary health care, WHO/Government of Chile, May200911 Holdaway, J; Krafft, T and Wuyi, W (2011) Migration and health in China: challenges and responses,International Human Dimensions of Programme on Global Environmental Change, Issue 112 Beyond deaths and injuries: The ILO’s role in promoting safe and healthy jobs’, the InternationalLabour Organisation, 2008
1.4. Challenges of meeting the target groupsThose countries which have the greatest need for basic occupational health services, such asChina, India and most of sub-Saharan Africa generally have very limited or no occupationalhealth services. Sectors where workers are at particularly high risk such as construction,forestry, mining and agriculture often have very poor or no provision of services13.The nature of the informal sector – employment in small, medium sized and micro-enterprises,self employment, agricultural work in remote rural settings, a lack of worker organisation andthe often poor education and income levels of informal workers has led to four principal areasof exclusion14. These include: Exclusion from the inspection and safety regimes imposed on large, formal workplaces Exclusion from social protection programmes including health services Exclusion from labour legislation – laws on health and safety standards and workers’ rights are limited to those with an employer-employee relationship Lack of access to resources and servicesHistorically, there has been focus in OSH on gathering data in order to report headlinenumbers of occupation related injuries or illnesses. Efforts have also focused on identifying thelinks or relationships between workers’ health and working conditions. There has been verylittle research done in developing countries on measuring the impact of occupational illness orinjury on the incomes and living standards of workers and their families or dependents.As importantly, a traditional OHS focus (medical check-ups, registration, treatment andcompensation for occupational diseases and injuries) in large, formal enterprises means thatinformation and data on those workers who are unable to work due to poor OHS practicesoutside of those settings are very frequently not collected. The workers on whom poor healthand safety practices have had the greatest impact are therefore often not included in thestatistics.The exclusion of informal workers from the basic OSH protections and services, preventativeand curative, provided to workers in larger scale enterprises in the formal employment sectorhas played a significant role in increasing their exposure and vulnerability to workplaceaccidents and illnesses15.Mainstream health services are often not resourced or organised to identify and treatoccupational health related sickness resulting from employment and working conditions. Thisis particularly relevant for those workers operating in the informal sector. Frequently,occupational health services and general health services operate as parallel systems with veryfew or no links and almost no communication. The consequences are a lack of effectiveprevention of workplace related health problems, untreated disease, absenteeism, anincreasing lack of productivity and significant difficulties in re-integrating sick or injuredworkers back into the workplace. Losses in human, financial and economic terms aresubstantial16.13 Basic occupational health services—their structure, content and objectives, Jorma Rantanen, SJWEHSuppl 2005: no 1:5-1514 As cited in G. Litong, R. Lao, and J. Apolonio. An Assessment of the Situation of the Informal Sectorin the Philippines: A Human Rights Perspective15 Insecurities of Informal Workers in Gujarat, India, Unni J., U. Rani, ILO 200216 Integration of workers’ health in strategies for primary health care, WHO/Government of Chile, May2009
2. The potential role of the health system in providing BOSH 2.1. Essential components of BOSHThe next section of this paper outlines some of the key factors that need to be consideredwhen designing a package of BOSH services to fit within primary care provision in poor andmiddle income countries. Key components of Basic Occupational Safety and Health areadapted from a Finnish paper on the structure and content of basic occupational healthservices17. The Finnish paper develops the idea of BOSH in an essentially developed worldcontext.Universal coverage of OHS services is a useful goal, but it may be too ambitious to befeasible. However, given the financial and human resource constraints found in almost everydeveloping country, it is important to be realistic about what services can realistically beoffered and delivered to informal and vulnerable workers in those very different contexts.Whilst there has been a significant amount of research done in the developed world to assessthe costs, efficiency and effectiveness of OSH interventions, very little work has been done onthese issues in the developing world. Many health systems in poor countries are heavily aiddependent. If OSH interventions are going to be included as part of a basic package ofprimary health care, it will be necessary to be able to demonstrate that they are effective indelivering health gain and can be delivered at a reasonable cost.The individual elements of BOSH to be included in a package of primary health care anddelivered through local health providers will need to be developed to meet the specific needsof the local context in which the OSH services are being delivered. The needs of self-employed agricultural workers in remote locations are going to be very different from streetvendors in an urban context. There is no “one size fits all” approach that will be successful.Given the very significant resource constraints, it will be extremely important to adopt apractical and realistic and localised approach, when developing a limited and effectivepackage of OSH interventions to be delivered.The package of OSH interventions should be based on an evaluation of the burden of diseaseexperienced by specific groups of informal and vulnerable workers in specific country contexts.Interventions of proven efficacy and cost effectiveness that can be delivered by health staffand community volunteers with minimal amounts of training and supervision and with theresources available should be identified in the first instance. As the capacity of the healthsystem increases, health staff become more proficient and experienced in delivering OSHinterventions, and finance becomes available, the package of care on offer could be graduallyexpanded to include additional interventions.17 Basic occupational health services—their structure, content and objectives, Jorma Rantanen, SJWEHSuppl 2005: no 1:5-15
Figure 1: Key Components of Basic Occupational Safety and Health Risk assessment and Health education and Provision of basic monitoring of the work health promotion curative services environment including first aid Identification of workers Workers provided with Provision of first aid as or groups of workers appropriate information required exposed to specific on workplace risks and Identification of hazards hazards exposure(s) which may Control of causal agents Workers understand the cause occupational such as dust, harmful nature and severity of disease chemicals or heat. the risks to which they Diagnosis of occupation Suggestions for the are exposed related disease control of occupational Workers given Provision of basic health related risks information to manage, curative health services Identification and control mitigate and avoid those to treat occupation of occupational health risks by making their related diseases hazards through the use working practices safer Reporting of of personal protective occupational disease equipment etc. and injuries Adapted from a paper on Basic Occupational Health Services developed by Professor Jorma Rantanen of the Finnish Institute of Occupational Health.
Formatted: Bullets and Numbering 2.2.Delivering BOSH services to informal and vulnerable Workers 220.127.116.11.Experience from a number of countries around the world in delivering integrated PHC andBOSH suggests that there are three main models for delivering health services to poor andvulnerable populations:Model 1: Financing and delivering BOSH interventions through standalone community based insurance schemes Community based Contribution from Contributions from insurance Social Fund? workers Organisation (e.g. SEWA India) Defined package of OSH care and prevention offered through network of own providers SEWA Care SEWA Care SEWA Care provider provider providerIn India, SEWA is a trade union for workers, mainly women, in the informal sector. It hasintroduced a number of community based insurance (CBI) schemes including one for healthcover. Through its health scheme, it has addressed a number of important OSH issues by thetraining and development of a cadre of its own, local health workers. The coverage andoperation of the SEWA community based insurance scheme is discussed in more detail in thecountry case studies later in the report.A recent discussion paper by the World Bank’s Social Protection and Labour Division oncommunity based risk management arrangements noted a number of potential weaknesses18.These included: Exclusion of the most vulnerable groups leading to gaps in coverage and service provision particularly to the poorest May require the support of donor or government financed Social Funds to be fully effective CBI arrangements vulnerable to manipulation by local leaders especially in poor and isolated rural communities18 Community-based Risk Management Arrangements: An Overview and Implications for Social FundPrograms, Bhattamishra R., Barrett C, World Bank Division of Social Protection and Labor, Oct 2008
Model 2: Publicly funded BOSH interventions delivered by NGOs and private providers MoH and/or MoL Tax revenues & Sets norms and standards for BOSH user fees Provides funding and capacity building Donor funds Manages/regulates provision of services by third party providers BOSH funding, capacity building Information and oversight Intermediate level in the health system (e.g. district) Contract management Information and funding CSOs or private providers BOSH services Informal & Informal & vulnerable workers vulnerable workersThis approach to delivering care involves contracting NGOs or private providers alreadydelivering PHC to extend their reach to include the delivery of BOSH services to the targetgroups. The reach of government services/funding can be effectively extended through theappropriate use of non state actors. Experience in Cambodia and in other countries such asBangladesh has highlighted the effectiveness of using NGOs to deliver PHC to reachunderserved groups or geographically hard to reach areas19.However, there are certain pre-requisites if this approach is to be successful. These include:government capacity and commitment to the contracting out of services; capacity at thenational and intermediate levels to manage contracts and monitor compliance with servicelevel agreements etc; and the availability of NGOs or private sector providers with thecapability to deliver contractually agreed services.19 Cambodia: Using Contracting to Reduce Inequity in Primary Health Care Delivery, Schwartz B.,Bhushan I., World Bank 2004
A 2005 review of the impact of contracting out health service provision in a range of countriesconcluded that contracting out for the delivery of primary care “can be very effective, thatimprovements can be rapid and that contracting for health service delivery should beexpanded and evaluated rigorously”20. However, it was also noted that many countries whichlack the capacity to organise and deliver basic health services themselves may not have themeans with which to manage contracts with NGO or private suppliers effectively either.Model 3: Integrating BOSH into state delivered primary health care MoH Tax revenues & Sets norms and standards for BOSH in user fees partnership with Min of Labour? Donor funds Provides funding and capacity building Manages provision of services through own network of facilities and CHWs BOSH funding, capacity building Information and oversight Intermediate level in the health system (e.g. district) Training, capacity building & supervision Information Primary Health Care Facility BOSH integrated with PHC BOSH services – preventive & curative Community health workers Preventive interventions Informal & Informal & vulnerable workers vulnerable workersModel 3 illustrates how BOSH services might be both funded and integrated into a PHCapproach. MoH staff are responsible for developing a package of BOSH services in20 Buying Results? Contracting for health service delivery in developing countries, Loevinsohn B,Harding A., The Lancet 2005
partnership with the Ministry of Labour where appropriate and, providing adequate training,supervision and funding, managing its integration with other elements of PHC and thendelivering services through a network of primary care facilities and community health workers.Conventional public health interventions such as immunisation or DOTS treatment for TBfollow a fairly standard format and design that can be relatively easily replicated and adaptedfor different country contexts. Whilst, the mode of delivery may need to change according tothe setting in which the intervention is being applied, the essential nature of the treatment tobe applied (i.e. vaccine delivery or the provision of TB drugs) remains largely the same.However, the OSH needs of agricultural workers in Africa are going to be very different fromthose of street vendors or rubbish collectors in India or artesanal fishermen in the Philippines.This implies that a creative and flexible approach to OSH design needs to be taken that takesinto account the OSH needs of particular groups of workers and which tailors the interventionsto their requirements. There is therefore no “one size fits all” or standard approach todesigning and developing BOSH interventions. This will offer a particular challenge to thehealth sector. Moreover High level knowledge and skills will be needed to accomplish thiseffectively.It is therefore not possible to be prescriptive about how BOSH can be integrated into PHC ashealth systems vary so widely from country to country. Model 3 attempts to provide ageneralised outline of how integration could be organised. However, the existing structure ofthe health system in individual countries and the method of funding health services will in largepart determine how BOSH services can be effectively integrated into PHC. BOSH should beintegrated as seamlessly as possible into PHC delivery and funding mechanisms, whilstensuring that funding mechanisms do not throw up specific barriers to BOSH access.One size will not fit all and it will be important to adapt BOSH organisation and services to thelocal context. 18.104.22.168. Advantages of integrating BOSH into PHCInternational evidence indicates that a well organised and managed PHC approach will deliverbetter health outcomes in the most efficient and equitable way, at a lower cost and with higherlevels of user satisfaction than other approaches to providing healthcare21. The effective PHCsystem should aim to provide universal coverage of services that deliver comprehensive,integrated and appropriate care over time and that emphasises disease and accidentprevention and health promotion.In this context integration is defined as: “The organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money22”There are strong arguments for integrating BOSH services into existing arrangements forproviding primary healthcare within the health sector. One of the principal advantages of anintegrated PHC approach is that this will enable BOSH services to be provided closer to thelocations where people live and work. A number of countries are testing models to integratePHC and BOSH. Their experience is discussed in more detail later in this paper. However,experience gained to-date in a number of different countries indicates that it is possible tobegin to combine PHC and BOHS in order to provide essential OHS services to poor,previously underserved informal sector workers. An integrated approach should not try tofocus of all aspects of OSH – it is important to concentrate on those areas of OSH that willdeliver the greatest return.21 Is primary care essential? Starfield B., Lancet. 199422 Integrated Health Services – what and why, Technical Brief No.1, WHO, May 2008
A key advantage of integrating PHC and BOSH would be to bring BOSH services closer to theplaces where workers in the informal sector live and work. This potentially will make integratedservices easier to access and should help to increase utilisation rates. PHC is offered at thecommunity level through a combination of fixed facilities (health centres & health posts) andthrough outreach services offered by health workers and community health volunteers.Integrating BOSH into PHC will provide access to an already established network of healthprovision and could enable BOSH services to generate reach and impact reasonably quickly.Existing public health programmes, such as HIV/Aids, Malaria, MNCH etc. have beendemonstrated to be able to quickly reach at risk populations and to provide them with healthinformation and care. Some of the most successful among these have largely been verticallyfunded and managed but integrated with other PHC activities at the point of delivery.Similarly, BOSH effectively integrated into existing primary health care structures and systemscould enable similar opportunities for providing target worker populations with a range ofappropriate OSH services. Appropriate integrated BOSH/PHC models that identify systems,structures and health worker capacities need to be developedAn integrated BOSH/PHC approach should have a specific focus on providing services toworkers in SMEs, workers who are self-employed and those in the informal sector in order tobe able to provide these important groups with effective services. The design of BOSHservices should take careful account of what is really needed by informal workersIntegrating BOSH into PHC could lead to more efficient service delivery and less costlyutilisation by recipients than providing a standalone OSH system. There are a number ofpotential benefits from integration. These include:Improved access Integration would also assist with the reduction of OSH related illness through improved prevention practices and better access to education for workers through their local PHC system Clients could make one visit to one practitioner or group of practitioners rather than having to travel between different teams of providers in various locations thus improving continuity of service provision and reducing the likelihood of dropout. Informal sector workers would be more likely access BOSH services provided through their local health facility and may feel more comfortable in getting treatment in their normal healthcare setting rather than having to incur significant travel costs to be treated at a specialist facility in an urban centreGreater health system efficiency Specialist OSH workers are in very short supply in many countries; providing supplementary training in BOSH to existing health workers could be an effective strategy for rolling out these services into the community and providing prevention and treatment services for uncomplicated cases Using existing but up-skilled networks of health volunteers or auxiliary health workers to provide BOSH services may prove to be an effective strategy for delivering these services right to the community level. Integration of BOSH into PHC can avoid duplication in management and support costs. Separate programmes need separate staffing and infrastructure; and sometimes run separate supporting systems e.g. logistical and procurement systems. There is some evidence from studies of other programmes that have been integrated into PHC have demonstrated reduced overall costs and improved treatment practices2323 Jenkins R, Strathdee G: The Integration of Mental Health Care withPrimary Care. International Journal of Law and Psychiatry 2000, 23:277-291.
Integrating BOSH into PHC may be more cost effective. Duplicate implementation and management arrangements potentially increase the cost of programme delivery – however there is very little data on costs in the OSH studies that have been undertaken to date. Better prevention of illness Many of the disabling and costly OSH health conditions that health systems have to deal with are preventable. With appropriate support, additional complications can be avoided or their onset delayed and health outcomes for clients improved Health systems can optimise the returns from scarce human and financial resources through offering new services in innovative ways and by emphasising those activities that help to prevent accidents and illness and which delay the onset of complications.The existing evidence base describing the benefits of integrating PHC is limited. Reproductivehealth has been the focus of most of the work that has been done to date. The research thereis available suggests that the “move from disease specific programmes to integrated serviceshas risks as well as benefits and needs to be managed carefully”24. A 2006 CochraneCollaboration review of “Strategies for integrating primary health services in middle- and low-income countries at the point of delivery” concluded: Few studies of good quality, large and with rigorous study design have been carried out to investigate strategies to promote service integration in low and middle income countries. All describe the service supply side, and none examine or measure aspects of the demand side. Future studies must also assess the clients view, as this will influence uptake of integration strategies and their effectiveness on community health.”There have been few high quality studies of integrating health programmes into PHC. Morehigh quality research is needed to be able to draw satisfactory conclusions regarding theimpact of integration on cost, access, service quality and health outcomes 22.214.171.124. Development and delivery of OSH within PHCOSH has to compete with many other spending priorities in the resource poor countries wherethe majority of the world’s vulnerable and informal workers are located. For that reason, inmany areas of the world there has been insufficient investment in the development of effectivesystems of OSH. Rantonen argues that the returns from investment in OSH in countrieswhich have developed good systems of OSH (mainly in the developed world) have beensubstantial, not only in terms of improved health for workers but also by increasing workereffectiveness and productivity25. He proposes a four tier system for delivering increasinglymore complex OSH services. However, the last two stages are really only relevant in adeveloped country context and have been omitted from Figure 1 below. This represents onemethod for developing an integrated OSH / PHC delivery system approach – there will beothers24 Integrated Health Services – what and why, Technical Brief No.1, WHO, May 200825 Basic Occupational Health Services, Professor Jorma Rantanen, President of the InternationalCommission on Occupational Health, Sep 2007
Figure 1: Integrating Basic Occupational Safety and Health Service Delivery with PHC Basic OSH services Entry level services PHC Infrastructure Basic OSH services Practical Guides Advice on OH Training for community Accidents and health workers and Occupational volunteers diseases PHC Doctor or nurse with Community Health special training based workers / volunteers at health centre Services Services provided to provided to workers in workers in SMEs, & SMEs, & informal sector informal sector Adapted from a paper on Basic Occupational Health Services, by Professor Jorma RantanenIntegrated OSH services to be provided would include:Entry level OSH services - the starting point intended for those workers and workplaces thathave no access to OHS. Simple OHS services are offered through community based healthworkers with limited training operating out of community based PHC facilities Activities wouldbe focused on: Reducing the risk of accidents Basic training for heavy physical work (lifting etc) Training on chemical hazards (pesticides etc.) ReferralBasic Occupational Safety and Health Services (BOSH). Delivered by trained PHC healthworkers (doctors and nurses) located as close to workplaces and communities as possible.Activities would include: Surveillance of workers health and assessment of health risks Provision of health education and information Prevention of occupational health hazards Training and provision of personal protective equipment Diagnosis of occupational and work related disease Accident prevention & emergency preparedness First aid Record keeping and reporting
It is important to ensure the effective integration of BOSH services with existing PHCarrangements so that quality services are easily accessible and that they meet the OSH needsof working people, and particularly those in the informal sector. They also need to bedelivered with sufficient levels of quality to be able to provide effective solutions to the OSHproblems facing their recipients. Research looking at primary health care in developingcountries has shown that frequently services are of poor quality and that access and coverageare still far from universal.Where OSH services are being delivered in a primary care setting, the doctor or the nurseresponsible will need to have some specialist knowledge in order to be able to diagnose anOSH related condition and to prescribe effective treatment. Equally, the effective prevention ofOSH related accidents and illness also requires specialist knowledge and training. To do thiseffectively will require health workers to receive a minimum amount of knowledge, training andsupervision in OHS methods and approaches.The medicalisation of BOSH should be avoided in order that it can be successfully deliveredby a range of health workers in the primary health care setting. Putting the systems andinfrastructure in place to enable effective staff training and supervision at appropriate levels ofthe health system requires careful planning and will need to be tailored to the particularrequirements of countries’ health systems. Additional resources will be required for trainingsufficient numbers of health workers, to enable them to provide BOSH services and to coverthe costs of integrating a BOSH component into PHCBecause of problems with quality and access to public health services people often use bothqualified and unqualified private providers26 to meet their healthcare needs. This clearly hasimplications for the delivery of BOSH in so far as private providers of healthcare will beinvolved in delivering care but will not have received appropriate information and training to doso. The challenge for the public health system is to identify ways in which the capacity of theprivate sector can be increased and the quality of its services monitored and regulated. This ispotentially a very large and complex task. The focus of initial efforts to integrate BOSH intoPHC should be on developing the capacity of the public health system to deliver services. Formatted: Bullets and Numbering 2.5.Extending Healthcare Funding Mechanisms to include BOSH 126.96.36.199.The integration of primary health care services is taking place in many developing countriesaround the world. Many of the existing PHC programmes (Malaria, reproductive health,HIV/Aids, TB etc.) are vertically funded and managed interventions which are integrated at thepoint of delivery in health facilities or communities. Experience in many countries hasdemonstrated that whilst this approach can be very effective it can also lead to a number ofimportant problems such as poor allocation of funding across programmes (some can begreatly overfunded and vice-versa), inefficiency and duplication in the use of resources andreal difficulties in getting funding for training and operational costs down to the service deliverylevel. These are all challenges that will need to be tackled when integrating OSH with PHC.There are five main health financing approaches which are used to fund healthcare27 (thisanalysis does not include financial transfers from donors) and which could potentially serve asfunding mechanisms for OHS as it integrates with PHC. These are: Taxation – public funding of healthcare is provided through the collection of a range of taxes including income tax, corporation tax, customs duties and licence fees etc. Advantages – taxation is generally an inexpensive way of raising funds - most countries already have an existing revenue collection system which can be adapted or26 The performance of different models of primary care provision in Southern Africa’, Mills A., Palmer N. SocialScience and Medicine 59, 200427 Understanding Health Economics for Development, HLSP CD Rom, 2010
expanded. Taxation can be progressive meaning those who have the most pay the most (e.g. income tax) Disadvantages – tax revenues may be unpredictable due to fluctuations in the business cycles. The recent global financial crisis has had a significant impact on tax revenue collection in most countries around the world which has led to a reduction in the amount of funding available for public health systems and primary care. Taxes may be regressive - sales taxes and VAT have a disproportionate impact on the poor.This is potentially a mechanism for funding BOSH although any new package of interventionswould have to compete with existing PHC interventions and services for resources. Publicfunding of services frequently provides few incentives to improve staff performance and underperforming staff may be difficult to replace. Important issues such as the quality of care arealso difficult to address in a system that does not provide incentives (or disincentives) fordoing so. Social Insurance – a form of service funding where people contribute a fixed proportion of their income in return for a defined package of healthcare or other benefits. Advantages - By reinforcing the principle of risk pooling it can be a means to promote greater social solidarity in a health system, and can ultimately be used as a means of achieving universal coverage. It can be seen as a more transparent and more legitimate than tax-based funding as there is a clearer link between payments and benefits. Beneficiaries are seen as “members”. As such this approach may be more acceptable to the public and, as a result, also have the potential to raise more funds. Social insurance may be more responsive than tax funded systems as “everyone is a private patient not a nuisance”. It can also challenge the status quo as funding is tied to patients, not facilities, which is often not the case under a tax based system Disadvantages - Rarely self-sustaining (especially when coverage increases), requiring subsidies for the poor. Coverage of social health insurance is generally limited to curative and medical interventions (not public health). It does not always provide for expensive, catastrophic care – which insurance is best designed for. There is risk pooling although only between members and, as a result, the pool may not be that big if coverage is low. Social insurance must be financed from employment income - a narrower base than for general taxation (business taxes, import duties etc. Social insurance tends to be restricted (largely) to the formal sector given problems in collecting funds from the informal sector. Vulnerable groups of people are therefore likely to be excluded.China is piloting the use of social insurance to fund BOSH interventions for informal andmigrant workers delivered through a PHC network. Experience there, where the cost ofproviding BOSH is shared between the government and employers has demonstrated that thiscan be a reasonably effective system for providing services to the majority of workers. Anevaluation of the BOSH scheme in 2008 found that employers had spent 200 RMB for eachworker per year on OH per year (compared with 3000 RMB lost per worker per year due tooccupational disease). However, there were administrative problems in keeping migrantworkers enrolled in the system particularly when they moved jobs frequently28. Community based health insurance - is an emerging approach, whichaddresses the health care challenges faced in particular by the rural poor and which helps toaddress both health financing and service provision simultaneously (many of the CBI schemesare organised by local providers of health care). It has grown rapidly in recent years,particularly in West Africa.28 Basic Occupational Health Services in Ba’oan, China, Chen Y., Chen J, Journal of OccupationalHealth, 2010
Advantages - the success of community health insurance depends upon a number of factors, including: trust and solidarity, typically requiring significant community participation; a willingness to pay which depends on economic and social factors; subsidies - otherwise the approach will only meet some needs of the rural sector; good design (to counter adverse selection, moral hazard); and a strong marketing/business culture. Disadvantages - Although sometimes successful on a smaller scale, these approaches have rarely been taken to scale. Establishing schemes creates a dilemma. Initial subsidisation can be helpful in introducing the concept of insurance and reducing risks to those implementing any scheme, but this can be counterproductive and subsidies become difficult to remove. Sustainability is a key concern - access by the poor and vulnerable populations will invariably require subsides. The problem is that poor countries which have the greatest need to subsidise the poor are the very countries least able to provide such subsidies.There is some evidence from the SEWA scheme in India of the successful application of theCBI approach to providing a limited range of OSH services. However, coverage of the schemeis limited and there are challenges in taking this kind of approach to scale.Tanzania has developed a social health insurance organization (UMASIDA) targeted atthe informal sector in Dar es Salaam. The scheme provides both health and occupationalsafety and health services to its members. It was recognized that access to social serviceshas a large impact on productivity and organizations of informal workers would be anappropriate mechanism for providing such services. PHC services are provided through itsown network of dispensaries and by private providers. Secondary level care is provide throughgovernment funded hospitals29The main advantage of social or community health insurance schemes for informal workers isthat they improve health expenditure efficiency (the relationship between quality and cost ofhealth services. There are three main reasons why informal workers would prefer groupschemes to individual spending and financing on healthcare30: by making regular contributions, the problem of indebtedness brought about by high medical bills can be overcome the financial power of the group may enable its administrators to negotiate services of better quality or which represent better value for money from private health care providers; and the group may be willing to spend on preventive and health promotion activities so as to keep down the cost of curative services. Private health insurance - In low income countries, private insurance typically serves the rich, though it may enjoy both direct (tax relief) or indirect subsidies (e.g. through tax funding of the regulatory system). Disadvantages – whilst private insurance provides choice and is responsive to patient needs it introduces serious problems of adverse selection, moral hazard, supports little risk pooling and has the potential to absorb resources from elsewhere in the system (either directly or indirectly. It has high administration costs and also provides an escape route for the middle classes who might otherwise press for better services for29 The UMASIDA Mutual Health Care Scheme, A case study of an Urban based Community HealthFund, Kiwara A, Institute of Develoment Studies, May 200530 Working Paper on the Informal Economy The Informal Sector in Sub-Saharan Africa, ILO, 2002
the population at large. There is no evidence that subsidising private insurance reduces the burden on the public sector as is often claimed.This is not likely to be an effective approach for extending basic services to poor anddisadvantaged groups of workers given the scale of the costs involved and the disposableincomes of the workers concerned.User Fees - In the past user fees were seen as a way of raising revenue and deterringfrivolous use of health services. They were also seen as a way of formalising informal fees (orunder the table payments). Well meaning efforts to protect the poor through waivers orexemptions are almost always ineffective, although experience in Cambodia suggests thatexemptions may be possible. Recently there has been a strong political shift in favour of theabolition of fees based, in part, on positive experiences in Uganda. In some countries – mostnotably Uganda - the abolition of user fees has been associated with a large increase inutilisation, especially by the poor, although accompanying measures to improve the drugsupply and strengthen financial management also played key roles.This is not likely to be an effective approach for extending basic OH services to poor anddisadvantaged groups of workers.
3. Delivery of BOSH in practice - country experienceThis section of the paper aims to look at the different approaches taken to delivering BOSHand integrating it with PHC in a number of countries looking at the challenges, problems andsuccesses experienced. The literature on the implementation of BOSH is largely descriptiveand there is little hard data or information available on key issues such as costs and healthimpact and outcomes. 3.1. Thailand – an integrated PHC approachIn 2003, the total Thai workforce was estimated at 33.8 million people. Of these, at least 51per cent worked in the informal sector with approximately 40 per cent of the populationworking in agriculture, 16 per cent in manufacturing and 6 per cent in construction. There werealso an estimated two million migrant workers, mainly from Myanmar31.In Thailand, the Ministry of Public Health is responsible for the provision of the majority ofhealth services. The public health system has a four level structure: Health volunteers who have been trained in primary health care and provide services to 5-10 families in the local area. Primary Care Units (PCUs) of which there are approximately 7700 in Thailand, are normally staffed with eight trained health care workers who can provide more specialised services than health volunteers and who provide health care to the community. A PCU will service 10,000 people on average and its responsibilities will include disease prevention, health promotion, and treatment of illness. Secondary level services provided by medical and health personnel based in community hospitals. Tertiary level services which cover more specific and complicated cases provided by specialist medical and health care staff. These services are based in Regional, General, Specialised and University Hospitals.Health system financingFollowing the launch of universal health care coverage in 2002, general health services areavailable to all Thai citizens, funded through health insurance. More than 25 million Thaishowever do not hold public health insurance (Siriruttanapruk et al, 2006). Migrants who areregistered are able to access general health services through the Compulsory Migrant HealthInsurance (CMHI) scheme but this is not available to migrants who are not registered.Unregistered migrants pay for services out of pocket although hospital exemptions areavailable and international donors provide health services in many areas where migrants areconcentrated in addition to some provinces providing voluntary health insurance schemes tothe unregistered (IOM/WHO, 2009).Health services are also provided by private providers under the supervision of the MOPH andother public agencies such as the Ministry of Defence who provide services to officials andtheir families and the public32.Occupational Safety and Health in ThailandResponsibility for OSH in Thailand is divided between three government ministries. TheMinistry of Labour enforces OSH regulations and undertakes workplace safety inspections.The Ministry of Industry is responsible for enforcing the Factories Act which covers workplaceswith large machines and/or more than seven workers. The Ministry of Public Health providestechnical support for occupational health services in five main areas: occupational disease31 Labour Force Survey. National Statistics Office, Ministry of Information and CommunicationTechnology, Thailand. http://web.nso.go.th/eng/en/stat/lfs_e/lfse.htm (accessed 29 August, 2007).32 Integrating Occupational Health Services into Public Health Systems: A Model Developed withThailand’s Primary Care Units, Dr. Somkiat Siriruttanapruk and team Ministry of Public Health, Thailand,ILO (2006)
surveillance; technical support; development of OSH guidelines; training of health careworkers; and research and development.Traditionally, OSH services in Thailand have been provided through provincial and regionalpublic hospitals and also through some community hospitals in industrial areas. Typically, thestaff in these hospitals would have received some training in OSH and would have the meansavailable to monitor occupational safety risks in the workplace.The public health office in each province has a specialist in occupational and environmentalhealth that is responsible for developing OSH strategies for each province.Role of Primary Care Units (PCU) in providing BOSHIn order to improve the coverage and availability of OSH services an initial, strategy of usingPCUs to deliver both PHC and basic OSH services was developed. A pilot project wasestablished by the MOPH in 2004 to test a model which integrated occupational healthservices into the existing public health system and which assessed the capacity of PCU staffto deliver OSH services. The model was found to be reasonably effective and it wasdemonstrated that staff in PCUs were able to effectively deliver both PHC and basic OSHservices.PCU staff undertake OSH outreach visits to workplaces - these tend to be mainly factories orother formal work settings. However, workers in the informal sector would often still finddifficulty in accessing OSH services due to their dispersed, sometimes difficult to reach worklocations and a general lack of knowledge on their part of OSH issues.In 2007 the MOPH decided to extend the model in order to identify improved ways ofdelivering BOSH services to workers in the informal sector (Agriculture, SMEs, Fisheries,Migrant workers and Home workers). BOSH services to be provided included: Risk assessment and workplace improvement Surveillance of work-related diseases and chronic diseases Health promotion Provision of safety equipmentHealth volunteers were used to deliver both PHC and basic OSH services in the community(Siriruttanapruk et al, 2009). The health volunteers (who receive a small stipend from thegovernment) were trained to work with occupational health teams to provide basic OSHservices in addition to PHC. The rationale behind the strategy is that by up-skilling the largenetwork of health volunteers to provide PHC and OSH services, local needs can be met moreeffectively and services provided more efficiently to workers in the informal economy. In someof the test locations, health volunteers have been involved in providing workplace safetyimprovements and in reducing the use of dangerous chemicals and pesticides. 3.2. Indonesia – a PHC Approach to BOSHIndonesia is the fourth largest country in population terms after China, India and the USA. In2008, its total population was 228 million33. The total labour force (15 years and above) wasapproximately 108 million in 2007. In 2006 it was estimated that about 63 percent ofIndonesia’s workers were employed in the informal sector, mostly in agriculture, home-industries and fisheries etc. . Small enterprises contribute about 38 per cent of GDP34.PHC in Indonesia is largely provided through a large network of facilities that includes: healthcentres (PUSKESMAS), sub-health centres, mobile units and community based activities atthe village level. PHC and OSH services are co-funded by central and local governments. A33 Indonesian Country Paper on the Informal Sector and its Measurement, BPS-Statistics Indonesia,May 200834 The Informal Sector and Informal Employment in Indonesia, ADB Country Report, 2010
typical health centre is led by a medical doctor supported by a range of health and otherprofessionals. It is responsible for providing preventative and curative services to thecommunity including OH together with activities aimed at health promotion, education andempowerment35.In 1980 Indonesia introduced Occupational Health Posts (OHP) at the community level. It is aself-care model run by workers who are trained by health staff from a local health centre.Services provided by OHPs include: basic first aid delivery for accidents and OH relateddisease together with preventive and educative interventions intended to encourage workersto use appropriate safety equipment. Service provision is intended to be integrated within thePHC approach. Significant progress has been reported to-date in rolling-out the basic OSHtraining required by staff at all levels of the health system in order to implement the OHPapproach36.By 2008 it was reported that over 8,000 OHPs had been established although problems withfunding had been experienced. The provision of occupational health has not yet been includedin the basic PHC package of care in Indonesia and the support and financing of basic OSHhas been rather patchy both from the central level and through local administrations37. It isimportant to integrate OSH into the basic PHC package of care in oder to ensure thatappropriate structures are in place to provide training and supervision and also that funding forOSH is included in overall PHC allocations. 3.3. China - piloting an integrated PHC/BOSH approachThe economic reforms and industrialization over the last 25 years in China have resulted in asubstantial increase in the numbers of migrants moving from rural to urban areas of thecountry38. A rigid system of household registration (Hukou) that only allowed people to accesssocial services in the areas where they are registered has been applied. Whilst this has begunto be relaxed in a number of cities, it has still been identified as an area of concern. Asmigrants generally retain their rural registration, they are often excluded from accessingservices in the areas to which they migrate, including health care and occupational healthservices. In 2008 health insurance coverage was only 19% among rural migrants compared to58% of urban residents whose cover was generally linked to the place of work39.China lacks good quality, accessible primary care system. Traditionally, in urban areas,hospitals have provided PHC - there has been a widespread belief among the urban Chinesethat hospital is best and that the quality of care provided by hospital specialist is superior tothat of general practitioners. The creation of a comprehensive primary health care system isthe centre piece of China’s health care reform announced in 200940.The State Administration of Work Safety, a ministerial level national authority directly underthe State Council, is responsible for workplace safety and health inspection, and for ensuringcompliance with OSH provisions at provincial, city and country levels. The labourinspectorates enforce the implementation of various laws and regulations through supervisingemployers in order to establish and standardise labour contracts and collective contracts41.35 Revitalising Primary Health Care, Indonesia Country Experience, WHO Regional Conference, Aug200836 Ibid37 Impact and Effectiveness of Occupational Health Interventions: a qualitative study on multiplestakeholders in occupational health for informal sectors in Indonesia, Hanifa M. Denny, College ofPublic Health, University of Florida (on-going research project)38 Hesketh, T; Jun, Y. X; Mei, L. H.(2008) Health Status and Access to Health Care of Migrant Workersin China, Public Health Reports 2008 Mar–Apr; 123(2): 189–19739 Ibid40 China’s primary health-care reform, Liu Q., Wang B., The Lancet, March 201141 Zhu, C (2008) Labour protection for women workers in China, Asian-Pacific Newsletter onOccupational Health and Safety;15:47
Workers in SMEs, including migrants however have limited coverage of OSH which isattributed to a number of factors including: Factory managers and workers having little understanding of OHS. The small scale of SMEs making it difficult to provide in house services like larger companies. Human and financial resources constrain the government’s ability to provide OSH services through the health system.A gradual shift has been identified since 2000 where migrants are being increasingly seen asa vulnerable group with growing support for improving their access to public services,including OSH from the general public. Data on occupational health and injury rates in generalin China is unreliable as the information is collected by a number of agencies with incompletereporting. This is exacerbated among migrants who do not necessarily seek care fromhospitals (ibid). Clearly a major challenge in the Chinese context is in being able to collect andutilise accurate data on OSH. This will require better integrated and more robust datacollection systems. These should enable improved identification of need and better planning ofservices.In China, migrant workers are not eligible for Government Employee Insurance which coverspublic servants working in state institutions or Labour Insurance which is a work unit basedself-insurance system that covers medical costs for the workers and often their dependents aswell. (These are the main types of insurance available for employees with Hukou). Migrantworkers are also not eligible for the New Rural Cooperative Medical Insurance as they liveand work in the city42 (Mou et al, 2009).In 2006, the Ministry of Labour and Social Security developed plans to expand healthinsurance to include migrant workers with the aim of having 20 million migrant workersenrolled by the end of 2006 and almost all by the end of 2008. Urban governments haveemployed a variety of methods to greatly increase access of migrants to insurance althoughthis varies between cities. Monitoring and prevention of occupational health risks is includedas a goal of health system reform. China has piloted several schemes to extend the provisionof basic OSH to its large migrant population. In 2006, the MOH launched a Basic OccupationalHealth Services programme in 19 pilot counties in 10 provinces. This was then expanded to46 counties in 19 provinces in 201043.Bao’an county has a large migrant population who mainly work in SMEs (considered in Chinato be enterprises with less than 2000 employees and an annual revenue of less than 400million RMB)44 . A pilot scheme to test various models for providing OHS and primary careservices to groups including migrants at different levels was begun in 2008. The objectives ofthe pilot were: to develop working mechanisms for resource allocation; improve multi-sectoralcooperation and participation of workers; expand coverage of compulsory work-related injuryinsurance; expand OSH service delivery; integrate occupational health service into primaryhealth care at county and community level and to provide OSH training45.Ba’oan is divided in to towns and communities with a Centre for Disease Control andPrevention (CDC) at the district level, an institute of health care and prevention at the townlevel and at least one health service centre at the community level42. This structure allowsBOSH to be integrated with the primary health care system which follows the same structure.Three levels of service are provided:42 Health care utilisation amongst Shenzhen migrant workers: does being insured make a difference?,Mou J et al, BMC Health Services Research 2009, 9:21443 Migration and health in China: challenges and responses, Holdaway J, & Krafft T, InternationalHuman Dimensions of the Programme on Global Environmental Change, Issue 1, 201144 Basic Occupational Health Services in Ba’oan, China, Chen, Y; Chen, J, Journal of OccupationalHealth; 52: 82-8845 Dr Jian, F (undated) Basic occupational health services in China, Reports from the WHO regions andfrom ILO, WHO WPRO
Tier 1 – (Lowest level) are the community health service centres which provide services to all workers. Services include: o general health examination o first aid services o health promotion o OH education. Tier 2 (Intermediate level) comprises the institutes of healthcare and prevention in the towns of Ba’oan which provides services to workers not exposed to serious occupational hazards. Services include: o OH and general health examinations o surveillance of working environments o proposing prevention and control actions to eliminate health hazards o record keeping o health training for workers and education. Tier 3 – (Upper level) - the Centre for Disease Control and Prevention (CDC). Its main role is to provide services for workers in workplaces with serious potential risks and those exposed to serious hazards o OH examination and potential referral to specialist occupational medical clinics for treatment. o surveillance of the working environment o dealing with major OH accidents o risk control and assessment o providing information and training for basic OHS personnel.How is the pilot scheme funded?Under the BOSH scheme in Ba’oan, the cost is shared by the employer and the governmentwith employers being responsible for the surveillance of workers health and the workingenvironment. BOHS training, education and relevant tools were provided by the governmentwhich also offered BOHS to those who were self-employed or working in informal factories.An evaluation of the BOHS scheme in 2008 found that employers had spent 200 RMB foreach worker per year on OH per year compared with an estimated 3000 RMB lost per workerper year due to occupational disease46.Level of integration with other parts of the health systemUnder the Ba’oan scheme, OSH services were provided through a “primary health careapproach”. Specific OSH staff were appointed as occupational health personnel at all threelevels of the scheme although it is not clear if those staff had a wider health role. Agovernment steering group including the district governor, Bureau of Health leaders and othergovernment offices such as the bureaus of finance and industry was established. The groupwas responsible for organising OHS and ensuring financial and human resources to supportthe basic OSH system.Information and reportingWhere community health service centre physicians and nurses decide that an illness might beassociated with work, it is reported to the Institutes of Health Care and Prevention toinvestigate and make a definitive diagnosis. Where surveillance of workplaces has resulted inthe identification of serious hazards, they are reported and improvements required.An evaluation of BOSH in Ba’oan found that knowledge and recognition of occupationaldiseases had increased significantly in 2008 compared with 2006. Coverage rates of factorieswith OHS increase from 35% in 2006 to 82% in 2008 while the coverage rate of workers withhealth surveillance increased from 29% to 81%. However it was found to be difficult to providecover for all workers including those who changed their jobs and workplaces often sometimes46 Basic Occupational Health Services in Ba’oan, China, Chen Y., Chen J, Journal of OccupationalHealth, 2010
as much as three or more times a year47. The reasons for this were not explained but it seemslikely that the administrative complexities of transferring workers from one workplace toanother and possibly from one insurance scheme to another proved overwhelming. 3.4. Brazil – an integrated PHC approachPHC is at the centre of the Brazilian health system and it is delivered by a government fundedFamily Health Team (FHT) comprising a General Practitioner (GP), public health nurse,dentist, community health agent and a nursing assistant. The FHT is responsible for deliveringPHC and OSH services to 800-1000 families48. All members of the FHT receive training inOSH from OH trained physicians. The target groups for BOSH are mainly the self-employedand the informal sector. Large enterprises in Brazil are responsible for organising the deliveryof OSH services to their employees.The activities of FHTs however vary according to the local conditions and population. Healthpromotion and prevention are the responsibility of the FHT health agent.? By 2011, the aim isto provide OSH services through 70% of the FHTs. Key OSH services provided by the FHTsinclude: registering occupational accidents and diseases; following up on the health ofworkers; visiting workplaces and implementing prevention measures49. 3.5. Indonesia – a PHC Approach to OSHIndonesia is the fourth largest country in population terms after China, India and the USA. In2008, its total population was 228 million50. The total labour force (15 years and above) wasapproximately 108 million in 2007. In 2006 it was estimated that about 63 percent ofIndonesia’s workers were employed in the informal sector, mostly in agriculture, home-industries and fisheries etc. . Small enterprises contribute about 38 per cent of GDP51.PHC in Indonesia is largely provided through a large network of facilities that includes: healthcentres (PUSKESMAS), sub-health centres, mobile units and community based activities atthe village level. PHC and OSH services are co-funded by central and local governments. Atypical health centre is led by a medical doctor supported by a range of health and otherprofessionals. It is responsible for providing preventative and curative services to thecommunity including OH together with activities aimed at health promotion, education andempowerment52.In 1980 Indonesia introduced Occupational Health Posts (OHP) at the community level. It is aself-care model run by workers who are trained by health staff from a local health centre.Services provided by OHPs include: basic first aid delivery for accidents and OH relateddisease together with preventive and educative interventions intended to encourage workersto use appropriate safety equipment. Service provision is intended to be integrated within thePHC approach. Significant progress has been reported to-date in rolling-out the basic OSHtraining required by staff at all levels of the health system in order to implement the OHPapproach53.By 2008 it was reported that over 8,000 OHPs had been established although problems withfunding had been experienced. The provision of occupational health has not yet been includedin the basic PHC package of care in Indonesia and the support and financing of basic OSH47 Ibid48 The Primary Health Care Strategy in Brazil, Dr Luis Rolim Sampaio, National Director of PrimaryCare, Nov 200649 WHO/ Government of Chile (2009) Integration of workers health in strategies for primary health care,global inter-country consultation, 4-7 May, Santiago de Chile50 Indonesian Country Paper on the Informal Sector and its Measurement, BPS-Statistics Indonesia,May 200851 The Informal Sector and Informal Employment in Indonesia, ADB Country Report, 201052 Revitalising Primary Health Care, Indonesia Country Experience, WHO Regional Conference, Aug200853 Ibid
has been rather patchy both from the central level and through local administrations54. It isimportant to integrate OSH into the basic PHC package of care in oder to ensure thatappropriate structures are in place to provide training and supervision and also that funding forOSH is included in overall PHC allocations. 3.6. Tanzania - UMASIDA Health Insurance Scheme, a community based insurance approach “UMASIDA is an umbrella health insurance organization for the informal economy in Dar esSalaam, Tanzania. UMASIDA is an abbreviation in ki-Swahili (Umoja wa Matibabu katikaSekta Isiyo Ra smi Dar es Salaam), which means in English: health care community fund forthe informal sector in Dar es Salaam. It grew out of an ILO/UNDP project that, in 1994-96,experimented with the provision of integrated services for the urban informal sector in Bogota,Dar es Salaam and Manila.The main objective of the scheme is to provide health care to all its members and their familieson an insurance basis. One of the innovations of the project was that it not only concentratedon economic services, such as the provision of credit and training in finance, production,management and marketing, but also on social services, such as access to health care as wellas occupational safety and health measures. The idea behind this concept is that access tosocial services has a strong impact on productivity, and that organizations of informal sectorworkers would be an appropriate vehicle for organizing such services.Initially the scheme relied solely on private providers for care to its members. Contracts whichguided care contents were signed between UMASIDA and the providers. Now UMASIDA hasits own dispensaries in Dar es Salaam, Arusha and Moshi. Its members receive care from thiscombined system. Secondary level care is provided through government hospitalsBefore the scheme could become operational it was necessary to train both the beneficiariesand providers on the dos and don’ts of mutual health schemes55. The main messages were:-For the beneficiaries: Resist overuse of service. Consult provider only when necessary Overuse means higher premiums on your part Don’t facilitate provision of care to unentitled people Pay your premiums on time Always present your identity at the point of services for you and your families if you observe the above factors. For the providers Always ask for identity before providing services It is necessary to fill all the forms presented to you by those seeking care. Restrict prescriptions to the WHO approved essential drugs list. A functioning Health Insurance System is an assurance that you will continue to get patients whose services are prepaid.54 Impact and Effectiveness of Occupational Health Interventions: a qualitative study on multiplestakeholders in occupational health for informal sectors in Indonesia, Hanifa M. Denny, College ofPublic Health, University of Florida (on-going research project)55 The UMASIDA Mutual Health Care Scheme, A case study of an Urban based Community HealthFund, Kiwara A, Institute of Development Studies, May 2005
3.7. India – SEWA, a community based insurance approachThe informal sector in India employs an estimated 260 million workers out of a total workingpopulation estimated to be 500 million56. The majority of them are poor and have little or noaccess to social security or to healthcare. Provision of OSH services by the government isnegligible although the Government of India’s Eleventh Five Year Plan 2007-12 does includesome ambitious objectives for improving OSH including the introduction of no-fault insuranceschemes for workers in the formal and informal sectors. Is SEWA related to this?The main causes of occupational disease related morbidity and mortality in India are silicosis,musculoskeletal injuries, coal workers’ pneumoconiosis, obstructive lung diseases, asbestosis,byssinosis, pesticide poisoning and noise induced hearing loss57.Only workers in four sectors: mining, factories, ports and construction are currently covered byexisting OSH legislation and regulations in India. Factories and mines are the focus of themajor OSH legal provisions for workers’ health. However, the majority of workers in India donot work in either of these work settings and so have little legal protection. There is clearly aneed to extend legal protection to include these unprotected workers. Government spendingon occupational health in India is negligible. The provision of OSH services is not integratedwith PHC and the responsibility for it lies with the Ministry of Labour not the Ministry of Health.SEWA, established in 1972 is a trade union for workers, mainly women, in the informal sector.In 1992, SEWA Insurance, a community based insurance scheme was launched for itsmembers and provides; life, hospitalisation and asset cover. The health insurance componentis the most popular service offered, although members find it more difficult to access thiscomponent compared with life and asset protection58. However, as with many health insuranceschemes only hospital care is provided under the health insurance plan as this tends to havethe highest cost and potential to have a catastrophic impact on a poor family’s finances.As it is impossible to prevent all occupational injury and sickness, SEWA has providedinsurance against occupational injury and illness since 1994 as part of its integrated insurancescheme. The cost of seeking any medical treatment is met through the SEWA healthinsurance package. The combined cover helps an injured person to avoid further loss ofincome in addition to that already caused by the illness or injury.Lowering the cost of medical treatment through the provision of a community based insuranceapproach also provides a significant incentive for workers to seek medical attention whenrequired rather than continuing to work and potentially suffering additional health problems59.Workers are more likely to access PHC/OSH services and seek appropriate preventive andcurative services. Well integrated PHC/OSH services that are easy to use and which provideeffective treatment and advice are much more likely to be used and to deliver better healthoutcomes.SEWA has also addressed a number of important OSH issues through the training anddevelopment of a cadre of its own, local health workers. These provide SEWA members withOSH related health education and preventative health care and are also promoting the use ofpersonal protective work equipment . The SEWA health workers also provide curative carefrom their homes or from a health centre run by them where low-cost generic drugs aredispensed at cost to members (Raval 2000).56 CIA World Factbook, 200757 Do occupational health services really exisit in India?, Pingle S, Reliance Industries Ltd58 Tara Sinha, M Kent Ranson, Mirai Chatterjee, Akash Acharya And Anne J Mills (2006) Barriers toaccessing benefits in a community-based insurance scheme: lessons learnt from SEWA Insurance,Gujarat, Health Policy Plan. (March 2006) 21 (2): 132-142.59 Francie Lund and Anna Marriott (2005) Occupational Health and Safety and the Poorest: Final reportof a consultancy for the Department for International Development
OSH related activities include: tuberculosis screening for workers at risk from occupationalcauses, eye check-ups and a monthly mobile van out-reach service to remotely located salt-workers. Other activities such as improving access to water and the promotion of stress reliefactivities are undertaken. These also indirectly reduce the risk of injury and illness associatedwith fatigue and stress caused by paid and unpaid work activities which may have an impacton occupational health.Recognising that the national compensation system fails to cover informal workers and thatSEWA in conjunction with KKPKP (an association of informal scrap collectors and wastepickers) has collaborated with design institutes in India to produce equipment for informalworkers that better meets their needs. For example, gloves which do not get too hot havebeen designed for waste pickers, together with handcarts suitable for use by women. Howrelevant?SEWA’s integrated insurance packages, together with its provision of low cost, high quality,health care at the community level have helped to ensure that poor, working women are ableto afford and access PHC and basic OSH services where they live and work. “The healthinsurance has helped to address members’ concerns that the majority of what they earnedwas spent on health care and by reducing the personal income costs associated withoccupational injury and illness”60. Some of SEWA’s poorest members may find even the lowinsurance premiums charged by the organisation beyond their means and are excluded fromcover61.However, there have been some concerns expressed regarding the extent to whichinformation collected on OSH injuries and diseases amongst SEWA members is used toeffectively design preventive interventions. This is essential if an effective package of OSHinterventions and care is to be delivered and integrated into SEWA’s community healthprogrammes.. 3.8. Chile – a dual social & private health insurance approachPHC coverage in Chile is high. There is a dual healthcare system which allows Chileans to optto be covered by the government run National Health Insurance Fund (NHIF) or by a privateinsurance provider. An estimated 68 percent of the population is covered by the NHIFgovernment, 18 percent by private insurance companies and the remaining 14 percent isprovided by not-for-profit agencies or is uncovered62. Due to the multiple providerarrangements, the public and private health systems in Chile operate almost independentlyfrom one another – there is little coordination to achieve common health objectives. In contrastto the public sector, the private health care system has largely neglected the development ofPHC and instead has concentrated its resources in the hospital sector.PHC services are provided by a network of health centres and health posts located in ruraland urban areas. Health posts are the first point of contact and refer patients to health centres.OSH services in the formal sector are covered by mutual insurances (covering 40% ofworkers), the rest are covered by PHC centres funded by the NHIF. Eighty eight percent ofenterprises in Chile employ less than 10 workers. There are a number of programmes beingdeveloped by the public health sector which focus on integrating OSH and PHC services;recognising and diagnosing OH diseases; developing health education programmes; healthsurveys and providing services to vulnerable groups. .The health sector is undergoing reformand OSH services are being increasingly integrated into PHC. These reforms aim to improveequity, increase coverage to underserved groups, prevent occupational disease and promoteOSH35 .60 Ibid61 Livelihood security through community based health insurance in India, Chatterjee, M and M.K.Ranson, Global Health Challenges to Human Security, Harvard, 200362 Health care reform in Chile, Gabriel Bastias & Tomas Pantoja, Canadian Medical Association Journal,Dec 2008
4. Conclusions and challengesOver the last twenty years or so, a large variety of environmental, social, organisational andother determinants of workers’ health have been identified. Workplace settings have becomemore varied and complex and the determinants of occupational health have become multi-factorial. A number of models have been developed that explore the inter-dependentrelationship between ill-health or disability and poverty. A number of these acknowledge theimportant role of workplace health and safety63.It is argued that there is an interdependent or cyclical relationship between workplace relatedill health or disability and poverty. It is believed that chronic poverty reduces a worker’s optionsto refuse exposure to hazardous working conditions which then (together with other factors)increases the risk of illness, accident and disability. This may then further undermine theworker’s already precarious situation leading to an even weaker position and will contribute toreducing future earning potential64.Information and data on OSH in the developing world is sparse and unreliable. Patterns ofemployment, work contexts and conditions for informal and vulnerable workers varyenormously between countries and continents. The OSH challenges faced in sub-SaharanAfrica are quite different to those found in China and India for example. It is evident fromreviewing the studies that are available, that the nature of the OSH challenges for poor peoplevaries enormously both between countries and across different work settings within thosecountries.However, given the limited financial and human resources available to provide occupationalhealth and safety programmes particularly in developing countries, there is a real imperative tofocus on the most important determinants of health and safety in the workplace65 and todeliver a limited range of proven and effective preventive and curative interventions to thoseworkers most at risk of OSH related injury and disease.Conventional public health interventions such as immunisation or DOTS treatment for TBfollow a fairly standard format and design that can be relatively easily replicated and adaptedfor different country contexts. Whilst, the mode of delivery may need to change according tothe setting in which the intervention is being applied, the essential nature of the treatment tobe applied (i.e. vaccine delivery or the provision of TB drugs) remains largely the same.However, the OSH needs of agricultural workers in Africa are going to be very different fromthose of street vendors or rubbish collectors in India or artesanal fishermen in the Philippines.This implies that a creative and flexible OSH design approach needs to be taken that takesinto account the OSH needs of particular groups of workers and which tailors the interventionsto their requirements. There is therefore no “one size fits all” or standard approach todesigning and developing BOSH interventions. This will offer a particular challenge to thehealth sector. Moreover high level knowledge and skills will be needed to accomplish this taskeffectively.A review of the available OSH literature reveals that many countries are adopting an approachwhich integrates BOSH with PHC. The vast majority of the studies available are descriptiveand describe the approach taken and some of the implementation challenges encounteredwhen developing an integrated system. It was not possible to assess key issues such ascosts, outcomes or impact of BOSH interventions from any of the studies reviewed. Howeverthis data will be a key determinant of the preparedness of health systems to extend their range63 Occupational Health and Safety and the Poorest, Prof. Francie Lund & Anna Marriot, School ofDevelopment Studies, University of KwaZulu-Natal, March 200564 Chronic Poverty and Disability, Background Paper Number 4, Yeo R., Chronic Poverty ResearchCentre, UK, 200165 nd Basic occupational health services: a WHO/ILO/COH/FIOH guideline. 2 ed.
to include OHS, suggesting a research agenda which focuses on examining in greater detailthe lessons learned from these examples.There is little reliable, empirical evidence on the impact of occupational injury or illness oninformal or vulnerable workers. The information which is available suggests that OSH relatedmorbidity and mortality has a significant impact on these groups and is a major cause ofeconomic loss and poverty amongst these workers.There is a substantial literature on the design, content, costs, benefits and impact of OSHinterventions in the developed world. However, there are very few high quality studiesavailable relating to OSH interventions targeted at informal and vulnerable workers in thedeveloping world.BOSH will need to compete for funding with other, far better researched and evidence basedPHC interventions such as DOTS treatment for TB, HIV/Aids and malaria prevention andtreatment. High quality research to demonstrate the benefits and cost effectiveness of BOSHinterventions for informal and vulnerable workers in developing country contexts will need tobe undertaken.Where efforts are being made to integrate BOSH with PHC (e.g. China and Thailand) theseapproaches need to be thoroughly evaluated and documented. Much more and betterresearch is needed on the effectiveness of integrating BOSH into PHC.More information is required on the effectiveness of different approaches to funding BOSHthat are being employed. It would be useful to compare the effectiveness of tax based, versussocial insurance and community based insurance approaches in extending BOSH services toworkers in the target groups.A great deal of thinking will be required on how to develop the capacities of health systemsand health workers to develop effective packages of BOSH interventions tailored to the needsof specific groups of workers. Closely related is the requirement to be able to train and providehealth workers at all levels of the health system with the appropriate knowledge and skills todeliver BOSH.Given the lack of knowledge about the causes and impact of occupational disease andaccidents in the developing world, there is an urgent need to undertake high quality research nthis area. The research agenda should include but not be limited to: Developing a greater understanding of the disease burden of occupational related illness and accidents among informal and vulnerable workers Prioritising OSH related risks and exposures in order to be able to identify the determinants of occupational disease and injury that are most prevalent and amenable to prevention and/or treatment Identifying simple, low cost and effective interventions both preventive and curative that will have an impact on reducing the burden of disease Developing greater understanding of the financing and organisational approaches required to implement effective BOSH programmes for the target groups of workers More rigorous evaluation of existing BOSH programmes looking at key issues such as intervention design, delivery costs and impact in reducing the burden of disease.