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  1. 1. Draft Released for use by conference participants only. Not to be referenced or quoted. Scaling Up Access to Essential Interventions and Basic Services for Occupational Health Through Integrated Primary Health Care Background Document for the WHO Global Conference "Connecting Health and Labour: What Role for Occupational Health in Primary Health Care?" 29 November - 1 December 2011, The Hague, The Netherlands Geneva, November 201147 i
  2. 2. AcknowledgmentsThis document was produced under the overall direction of Ivan D. Ivanov, Team Leader forOccupational Health at WHO Headquarters.Contributions in the form of analysis and case studies were provided by: Carol Black, Peter Buijs,Jorma Rantanen, Adrienne Chattoe-Brown, Jody Tate, Jos Verbeek, Chen Rui, SomkiatSiriruttanapruk, and Claunara Mendonça.Suggestions were received from Rania Kawar, Carlos Dora, Igor Fedotov, Bill Gunnyeon and Chris vanWeel.Financial support from the Unites States National Institute of Occupational Safety and Health and theMinistry of Health, Welfare and Sport of the Netherlands is gratefully acknowledged.47 ii
  3. 3. Table of ContentsExecutive summary ............................................................................................................... 1I. Introduction................................................................................................................... 4II. Health systems and primary health care ........................................................................ 6III. Occupational health................................................................................................... 9 Essential interventions......................................................................................................10 Occupational health services ............................................................................................11IV. Occupational health in the context of integrated primary health care ......................14 Integrated health services.................................................................................................14 Integrated delivery............................................................................................................17 Integrated financing..........................................................................................................20V. Examples from countries ..............................................................................................24 United Kingdom - working for a healthier tomorrow ........................................................24 Thailand – primary care units............................................................................................26 Finland - municipal health centres ....................................................................................28 Indonesia – occupational health posts in the informal sector............................................29 China - piloting basic occupational health services ...........................................................30 Brazil – family health teams ..............................................................................................33 Tanzania - essential health interventions and community based insurance......................33 India – SEWA, a community based insurance approach....................................................35 Chile – a dual social and private health insurance approach..............................................37 The Netherlands - treating the "blind spot" ......................................................................37VI. Conclusions and recommendations ..........................................................................4047 iii
  4. 4. 47 iv
  5. 5. Executive summaryApproximately half of the worlds population spends at least one third of its time in theworkplace. Fair employment and decent work are important social determinants of healthand a healthy workforce is an essential prerequisite for productivity and economicdevelopment. However, only a small proportion of the global workforce has access tooccupational health services for primary prevention and control of occupational- and work-related diseases and injuries. Furthermore, certain global health problems, such as non-communicable diseases, result in increasing rates of long-term sick leave and challenge theability of health systems to preserve and restore working capacity.The 62nd World Health Assembly in 2009 emphasized the need to strengthen health systemsbased on primary health care (PHC) in keeping with the values and principles enshrined inthe Alma-Ata Declaration. Action must be taken to provide universal access to PHC bydeveloping comprehensive health services, introducing national equitable and sustainablefinancing mechanisms and implementing vertical health programmes, e.g. occupationalhealth, in the context of integrated primary health care.Currently, a number of countries are reforming their health systems based on the values andprinciples of PHC1 to improve service delivery, cost-efficiency and to ensure equity. Nationaldebates on health reforms often touch upon insufficient collaboration between health andlabour sectors, the organization of preventive and curative health services for workingpopulations, and their relation to primary care2. Employers, businesses and the privatesector are engaging in providing health services to workers and communities.In 2007, the 60th World Health Assembly urged Member States to work towards covering allworkers with essential interventions and basic occupational health services for primaryprevention of occupational- and work-related diseases and injuries. This coverage should beparticularly provided to those in the informal economy, small- and medium-sizedenterprises, agriculture, and migrant and contractual workers. How can this goal beachieved, bearing in mind that most countries experience a shortage of human resources forhealth and most people lack access to the most basic elements of social protection in aworld of work that is ever more diverse, small scale, precarious and informal?Recent decades have seen significant progress in the development of occupational healthservices in a number of industrialized countries and economies in transition and rapideconomic growth. Compulsory provision of services along with national funds for theirfinancing has led to almost universal coverage in some countries and a significant increase ofcoverage and quality in others. However, there are some concerns. In many countriescoverage remains low and increasingly inequitable and workers with the biggest needs, suchas those in agriculture, small enterprises and informal economy, remain without access to1 Primary health care (PHC) is a way of organizing a health system so that everyone, both rich and poor, is ableto access the services and the conditions necessary for realizing the highest level of health. It includesorganizing health systems to provide quality and comprehensive health care to all while ensuring that poor andother disadvantaged people have fair access to essential health services.2 Primary care is a component of PHC and refers to the first level of contact people havewith health-care teams. In some countries this may be a community health worker ormidwife; in others, it refers to the family practitioner.47 1
  6. 6. the most basic occupational health services. Where occupational health services exist, theyoften focus on provider-driven menus of few interventions and may not be adequate tomeet the health needs and expectations of workers. In addition, there are language,employment status and structural barriers to accessing services which in themselves arebecoming more and more profit-oriented. In many countries occupational health is stilldetached from other parts of the health system, thus resulting in fragmentation of care,difficulties with referral and follow up, and, in general, an inability to handle work-relatedhealth problems.The 1978 International Conference on Primary Health Care in Alma Ata called for bringinghealth care to where people live and work. However, when PHC was put into practice, thefocus was mostly on health services where people live. With only a few exceptions, theprovision of health care where people work was absent from the debate on programmesand strategies for primary health care. Thirty years after Alma Ata there are even morecompelling arguments for using the workplace as a point of entry to the health system. Theworkplace can be a setting for delivery of essential health interventions and for reaching outto workers’ families and communities. In some cases, the workplace is the only way ofproviding health care, e.g. for mining communities and migrant workers. Furthermore,improving workers’ health can help to reduce poverty, and is an essential prerequisite forproductivity and economic development.There have been a number of innovative attempts to extend the coverage of basicoccupational health services through integration of occupational health with primary care atthe point of delivery. One example consists of training primary care providers, such asgeneral practitioners, nurses, technicians and community health workers to understandwork-related health problems and to provide some basic support for small workplacesettings to improve working conditions, to train workers on how to work in a healthy andsafe way and to provide first aid. This has been undertaken primarily in rural areas and theinformal sector. Another example is designating a member of the primary care team toprovide occupational health support to workers and workplaces in the catchment area of theprimary care centre. Yet, a third example is when occupational health experts periodicallyvisit the primary care centre to hold an occupational health clinic providing consultationsand advice as needed.Whatever the model, integrated PHC-based services for workers would provide the firstpoint of contact within the health system while emphasizing primary prevention ofoccupational and work-related diseases and injuries, promotion of health and restoringworking capacity. Such services require active mechanisms for workers’ participation inplanning, delivery and evaluation, an adequate skill mix of service providers, equitablefinancing and purchasing mechanisms as well as a sound policy, legal and institutionalframework.In 2008, WHO launched a set of reforms to provide PHC to all citizens focusing on universalcoverage, people-centred care, participatory health governance and including health in allpolicies.Working towards universal coverage with occupational health services entails certaincomplex measures, such as reducing the proportion of costs to the individual undertakingthe service and/or workers (insurance schemes), adding interventions to the existingpackage of service provision (primary prevention in addition to curative care), increasing the47 2
  7. 7. number of workers covered, and reducing barriers to undertaking services and to individualsaccessing health services.A new health leadership should include a solid regulatory framework to guarantee a basiclevel of health protection in all workplaces and for all workers, as well as careful planning forthe provision of different occupational and primary health care services to under-servedworking populations. Collaboration between health and labour sectors is essential to ensurecomprehensiveness and continuity of care. A new leadership also requires participation ofworkers, employers and other workplace actors in the debate about health-care reforms.The delivery of the essential occupational health interventions can be leveraged significantlythrough integrated primary health care by putting people in the center of care. Occupationalhealth institutes, laboratories, clinics and information centres should provide expertise,information and laboratory support to occupational health services and to primary carecentres. The collaboration between occupational health services and primary care centresshould be improved. The content of occupational health services needs to be reorientedtowards the health needs and expectations of the workers and not geared towards a supplyof providers. Particularly in need is provision of workplace initiatives, practical tools andworking methods that enable workers, employers and other work actors to undertake themost basic measures for protecting and promoting health at work without unnecessarilyrelying on health services.Finally, delivering occupational health to all workers requires public policies that stimulateinter-sectoral collaboration and coordination, not least involving health, labour,environment, agriculture, industry, energy, transport, construction, finance, trade andeducation. Social security institutions, employers, trade unions, the private sector and civilsociety organizations have a particular role to play in shaping public policies for workers’health.47 3
  8. 8. I. IntroductionApproximately half of the worlds population spends at least one third of its time in theworkplace. Fair employment and decent work are important social determinants of healthand a healthy workforce is an essential prerequisite for productivity and economicdevelopment. When carried out under favourable conditions, work provides income tosupport human needs and has a positive impact on the health and well-being of individualsand on social and economic development.However, most of the world’s workers still labour under unhealthy and unsafe workingconditions, resulting in about 2 million deaths annually from diseases and injuries.Occupational risks account for a substantial portion of the burden of chronic diseases.Between 3 and 4% of global GDP is being lost to costs associated with sickness absenteeism,diseases and injuries resulting from work.The current financial and economic crises caused world production to contract and raisedthe number of unemployed people. In 2010 there were 205 million unemployed people inthe world. This is, however, is only the tip of the iceberg of labour market distress. Differentforms of underemployment, vulnerable employment and working poverty also increase. ILOestimates that in 2009 around 1.5 billion workers, or half of the worlds workers, were invulnerable employment The share of workers living with their families below the US$ 2 a daypoverty line is estimated at around 39 per cent, or 1.2 billion workers worldwide. 3There are a number of highly effective interventions for prevention of occupational diseasesand injuries. However in many countries health systems are not able to deliver theseinterventions to those workers in greatest need. Less than 15% of the global workforce havesome coverage with occupational health services. Furthermore, certain global healthproblems, such as non-communicable diseases, result in increasing rates of long-term sickleave and challenge the ability of health systems to preserve and restore working capacity.The 62nd World Health Assembly in 2009 emphasized the need to strengthen health systemsbased on primary health care (PHC) in keeping with the values and principles enshrined inthe Alma-Ata Declaration. Action must be taken to provide universal access to PHC bydeveloping comprehensive health services, introducing national equitable and sustainablefinancing mechanisms and implementing vertical health programmes, e.g. occupationalhealth, in the context of integrated primary health care.4Currently, a number of countries are reforming their health systems based on the values andprinciples of PHC5 to improve service delivery, cost-efficiency and to ensure equity. Nationaldebates on health reforms often touch upon insufficient collaboration between health andlabour sectors, the organization of preventive and curative health services for working3 Global Employment Trends 2011. International Labour Office, Geneva, 2011.4 Resolution WHA62.12. Primary health care, including health system strengthening. In: Sixty-second WorldHealth Assembly, Geneva, 18–22 May 2009. Resolution and decisions, annexes. Geneva, World HealthOrganization, 2009, (WHA62/2009/REC/1), pp 16-18.5 Primary health care (PHC) is a way of organizing a health system so that everyone, both rich and poor, is ableto access the services and the conditions necessary for realizing the highest level of health. It includesorganizing health systems to provide quality and comprehensive health care to all while ensuring that poor andother disadvantaged people have fair access to essential health services.47 4
  9. 9. populations, and their relation to primary care6. Employers, businesses and the privatesector are engaging in providing health services to workers and communities.Many countries have already in place some form of essential interventions and services foroccupational health for occupational health. Few countries, though, have managed toachieve a more universal coverage of workers with such interventions and to establishsustainable mechanisms for the provision of basic services for occupational health. Othercountries are approaching WHO for access to these experiences and for technical assistancein setting up their own programmes for scaling up coverage of workers with occupationalhealth care.In 2007, the 60th World Health Assembly urged Member States to work towards fullcoverage for all workers with essential interventions and basic occupational health servicesfor primary prevention of occupational- and work-related diseases and injuries. Thiscoverage should be particularly provided to those in the informal economy, small- andmedium-sized enterprises, agriculture, and migrant and contractual workers.7How can this goal be achieved, bearing in mind that most countries experience a shortageof human resources for health and most people lack access to the most basic elements ofsocial protection in a world of work that is ever more diverse, small scale, precarious andinformal?6 Primary care is a component of PHC and refers to the first level of contact people have with health-careteams. In some countries this may be a community health worker or midwife; in others, it refers to the familypractitioner.7 Resolution WHA 60.26 "Workers health: Global plan of action", In: Sixtieth World Health Assembly, Geneva,14–23 May 2007, Resolution and decisions, annexes. Geneva, World Health Organization, 2007,(WHASS1/2006–WHA60/2007/REC/1), pp 94-99.47 5
  10. 10. II.II. Health systems and primary health careA health system consists of all organizations, people and actions whose primary intent is topromote, restore or maintain health. This includes efforts to influence determinants ofhealth as well as more direct health-improving activities. A health system is therefore morethan the pyramid of publicly owned facilities that deliver personal health services. It includese.g. a mother caring for a sick child at home; private providers; behaviour changeprogrammes; vector-control campaigns; health insurance organizations; and occupationalsafety and health. It includes intersectoral action by health staff e.g. by encouraging theministry of education to promote female education, a well-known determinant of betterhealth.To achieve their goals, all health systems must carry out some basic functions, regardless ofhow they are organized: they have to provide services; develop health workers and otherkey resources; mobilize and allocate finances, and ensure health system leadership andgovernance (also known as stewardship, which is about oversight and guidance of the wholesystem). For the purpose of clearly articulating what WHO will do to help strengthen healthsystems, the following six essential “building blocks” have been defined; all are needed toimprove outcomes:• Good health services are those which deliver effective, safe, quality personal and non- personal health interventions to those that need them, when and where needed, with a minimum waste of resources.• A well-performing health workforce is one that works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).• A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.• A well-functioning health system ensures equitable access to essential products, vaccines and technologies for protecting and restoring health that are of assured quality, safety, efficacy and cost-effectiveness, as e well as scientifically sound and cost-effective to use.• A good health-financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient.47 6
  11. 11. • Leadership and governance involves ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system design and accountability8.The best measure of a health system’s performance is its impact on health outcomes.International consensus is growing: without urgent improvements in the performance ofhealth systems, the world will fail to meet its health-related goals. As health systems arehighly context-specific, there is no single set of best practices that can be put forward as amodel for improved performance. But health systems that function well have certain sharedcharacteristics. They have procurement and distribution systems that actually deliverinterventions to those in need. They are staffed with sufficient health workers having theright skills and motivation. And they operate with financing systems that are sustainable,inclusive, and fair. The costs of health care should not force impoverished households evendeeper into poverty.Primary health care is “essential health care based on practical, scientifically sound andsocially acceptable methods and technology made universally accessible to individuals andfamilies in the community through their full participation and at a cost that the communityand country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s healthsystem, of which it is the central function and main focus, and of the overall social andeconomic development of the community. It is the first level of contact of individuals, thefamily and community with the national health system bringing health care as close aspossible to where people live and work, and constitutes the first element of a continuinghealth-care process.”9Put simply, it is aimed at ensuring that everyone, rich and poor, is able to enjoy the servicesand conditions necessary for realizing the highest level of health. It includes organizinghealth systems to provide quality and comprehensive health care to all, while ensuring thatthe poor and other disadvantaged people have fair access to essential health services. PHCmobilizes society and requires community participation in defining and implementing healthagendas, and underscores intersectoral approaches to health. Most important, PHC ensuresthat national health development is an integral part of the overall social and economicdevelopment of countries.10 PHC is not poor care for the poor.Primary care is a component of PHC and usually refers to the first level of contact peoplehave with health-care teams. In some countries this may be a community health worker ormidwife; in others, a family practitioner.The concepts of PHC as they were expressed 30 years ago are still valid today. The WorldHealth Report of 2008 "Primary Health Care: Now More Than Ever" identified major avenues8 Everybodys business. Strengthening health systems to improve health outcomes. WHOs framework foraction. World Health Organization, Geneva, 20079 Declaration of Alma-Ata. In: Primary Health Care. Report of the International Conference on Primary HealthCare, Alma-Ata, USSR, 6-12 September 1978, Geneva, World Health Organization, 1978, pp 2-6.10 Equity in health (health status) means the attainment by all citizens of the highest possible level of physical,psychological and social well-being. Equity in health care means that health-care resources are allocatedaccording to need; health care is provided in response to legitimate expectations of the people; health servicesare received according to need regardless of the prevailing social attributes; and payment for health services ismade according to the ability to pay.47 7
  12. 12. for health systems to narrow the intolerable gaps between aspiration and implementation.These avenues are as four sets of reforms that reflect a convergence between the values ofprimary health care, the expectations of citizens and the common health performancechallenges that cut across all contexts. They include: • universal coverage reforms that ensure that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection; • service delivery reforms that re-organize health services around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world, while producing better outcomes; • public policy reforms that secure healthier communities, by integrating public health actions with primary care, by pursuing healthy public policies across sectors and by strengthening national and transnational public health interventions; and • leadership reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership indicated by the complexity of contemporary health systems.While universally applicable, these reforms do not constitute a blueprint or a manifesto foraction. The details required to give them life in each country must be driven by specificconditions and contexts, drawing on the best available evidence.1111 Primary Health Care: Now More than Ever, The World Health Report 2008. Geneva, World HealthOrganization, 2008.47 8
  13. 13. III.III. Occupational healthOccupational risk factors account for substantial part of the global burden of diseases. TheWHO study from 2004 found that 37% of back pain, 16% of hearing loss, 13% of chronicobstructive pulmonary disease, 11% of asthma, 8% of injuries, 9% of lung cancer and 2% ofleukaemia can be prevented through improving the work environment12.The Joint ILO/WHO Committee on Occupational Health defined the following objectives ofoccupational health: • promoting and maintaining workers’ health and work ability; • improving work and the working environment and work so it is conducive to safety and health; • steering work organization and culture in a direction that supports health and safety and, in so doing, also promotes productivity of an enterprise. 13,1412 Concha-Barrientos M et al. Selected occupational risk factors. In: Ezzati M et al., eds. Comparativequantification of health risks: global and regional burden of diseases attributable to selected major risk factors.Geneva: World Health Organization, 2004:1651-801.13 Joint ILO/WHO Committee on Occupational health. 1950. Report of the First Meeting, 28 August - 2September 1950. Geneva: ILO14 Joint ILO/WHO Committee on Occupational health. 1995. Defining Occupational Health. Geneva: ILO47 9
  14. 14. interventionsEssential interventionsThe range of the interventions addressing occupational and work-related diseases andinjuries may include both clinical (e.g. health examinations) and non-clinical interventions(e.g. workplace risk assessment). The interventions can be categorized as preventive andtreatment interventions, where preventive interventions are usually offered to personsunsolicited and without symptoms urging to seek help.Preventive interventions can be divided into primary, secondary or tertiary prevention.Primary preventive interventions aim at preventing disease or injury outcomes before theonset of the pathological process whereas other preventive interventions address laterstages. In occupational health, primary preventive interventions aim at eliminating anddecreasing exposure known to be hazardous to health or to create a barrier to exposure. Figure 1. Occupational health interventions for primary prevention (J. Verbeek, 2011)In 2011 WHO commissioned an analysis of the available systematic reviews on theeffectiveness of the interventions for primary prevention of these occupational risks. Theanalysis found that regulation and incentives for employers were one of the main causes ofreducing inhalation exposure to occupational risks in the industrialized world.Even though personal protective equipment could reduce exposure in a technical sense,there were many practical barriers that impeded its effectiveness in practice. Hearing lossprevention programmes were not sufficiently protective but regulation and enforcementwere found useful to reduce noise levels in workplaces. There was no evidence in theavailable studies that back pain could be prevented neither by training and education nor byergonomic improvements nor by pre-employment examinations.For preventing injuries, technical hazard controls such as roll-over protection structures ontractors could reduce fatal injuries but for most technical controls there were no studies orno systematic reviews. Incentives such as feedback and rewards for workers improved safetybehaviour and probably reduced injuries but there were no systematic reviews of measuresto improve the safety climate in an enterprise. Education and training to prevent injuries47 10
  15. 15. produced mixed results with some reviews providing evidence of effectiveness but withother reviews not. 15 Occupational health servicesEmployers and enterprises have the primary responsibility to ensure that the workplace,work processes and work organization do not pose risks to the health and safety of workers.In fulfilling these responsibilities employers are supported by experts in the different areasof occupational safety and health. Occupational health services are those entrusted withessentially preventive functions and responsible for advising employers, workers and theirrepresentatives on the requirements for establishing and maintaining a safe and healthyworking environment which will facilitate optimal physical and mental health in relation towork. ILO Convention No. 16116 specifies that occupational health services should includethose of the following functions that are adequate and appropriate to the occupational risksat the worksite: • identifying and assessing the risks from health hazards in the workplace; • surveillance of the factors in the working environment and working practices which may affect workers’ health, including sanitary installations, canteens and housing where these facilities are provided by the employer; • advice on planning and organization of work, including the design of workplaces, on the choice, maintenance and condition of machinery and other equipment, and on substances used in work; • participating in the development of programmes for the improvement of working practices, as well as testing and evaluation of health aspects of new equipment; • advice on occupational health, safety and hygiene, and on ergonomics and individual and collective protective equipment; • surveillance of workers’ health in relation to work; • promoting the adaptation of work to the worker; • contributing to measures of vocational rehabilitation; • collaborating in providing information, training and education in the fields of occupational health and hygiene and ergonomics; • organizing first aid and emergency treatment; • participating in analysis of occupational accidents and occupational diseases.Occupational health services can be organized in different ways. In countries where theprovision of general health care is not sufficient, the provision of workplace specificpreventative interventions is combined with general curative and preventive care forworkers and their families. Large enterprises usually have comprehensive occupationalhealth service on their premises where multidisciplinary teams provide a full range ofpreventative occupational health interventions and may also provide general health servicesto workers and their families. Medium size enterprises may have an in-plant unit that isstaffed by one or more occupational health nurses and a part-time occupational physician or15 Verbeek, J. Essential occupational safety and health interventions for low and middle income countries, anoverview of the evidence. Report prepared at the request of WHO. Finnish Institute of Occupational Health,Cochrane Occupational Safety and Health Review Group. Kuopio, 201116 Occupational Health Services Convention, 1985, Seventy-first Session of the General Conference of TheInternational Labour Organization, 7 June 1985, Geneva47 11
  16. 16. share an occupational health services with other enterprises in the same location orindustry. Hospitals provide services to injured or sick workers who seek care in theiroutpatient clinics and emergency rooms but in some cases also operate specializedoccupational health clinics or services including both preventative and curative care. Privatecentres are organized by a group of occupational health experts or a private entrepreneurialorganization to provide clinical and non-clinical (occupational hygiene) services toenterprises. In some countries the primary care centres organized by municipal or otherlocal authorities or by the national health service provide some basic packages of essentialoccupational health interventions to workplaces and work communities.17The Thirteenth session of the Joint ILO/WHO Committee for Occupational Health in 2003reviewed a new approach to providing occupational health services proposed by theInternational Commission of Occupational health (ICOH). In order to move towards universalcoverage of all workers with occupational health services, ICOH developed the so called"basic occupational health services" approach. Rantanen defined this approach as a stepwisedevelopment of occupational health services, where the most basic (starting) level uses fieldoccupational health workers, such as a nurse or safety agent who have a short training inoccupational health and who work for a primary health care unit or a respective grassrootslevel facility. The content of such service includes prevention of risks for accidents, healthyphysical work, basic sanitation and hygiene, and dealing with the most hazardous chemical,physical and biological factors, including HIV/AIDS and referral to specialized services asnecessary.18The next level is called "Basic Occupational Health Services" (BOHS) as an infrastructure-based services working as close as possible to the workplaces and communities. Figure 2depicts the key components of BOHS. The ILO/WHO Joint Committee on Occupational healthspecified that the core content of basic occupational health services should includesurveillance and assessment of OSH risks, surveillance of individual worker health, informingworkers and managers on health hazards at work and providing preventative advice on safepractices.1917 Rantanen, J. and I. Fedotov, Standards, principles and approaches in occupational health services, In:Encyclopaedia of Occupational Health and Safety, Fourth Edition, edited by J.M. Stellman, volume I, pp. 16.2-16.8, ILO, Geneva, 199818 Rantanen, J. Basic Occupational Health Services, 3rd Edition, Finnish Institute of Occupational Health. Helsinki,2007.19 Joint ILO/WHO Committee on Occupational health. 2003. Report of the Thirteenth Session. 9-12 December2003. Geneva: ILO.47 12
  17. 17. Basic Occupational Health Services Risk assessment Health education Provision of basic and monitoring of and health curative services the work promotion: including first aid: environment: •Workers provided •Provision of first aid •Identification of with appropriate as required workers or groups of information on workplace risks and •Identification of workers exposed to hazards exposure(s) which specific hazards may cause •Control of causal •Workers understand occupational disease agents such as dust, the nature and severity of the risks to •Diagnosis of harmful chemicals or which they are occupation related heat. exposed disease •Suggestions for the •Workers given •Provision of basic control of occupational information to curative health health related risks manage, mitigate and services to treat •Identification and avoid those risks by occupation related control of occupational making their working diseases health hazards practices safer •Reporting of through the use of occupational disease personal protective and injuries equipment etc. Adapted from J. Rantanen, basic Occupational health services, 2007 Figure 2 Content of the basic occupational health servicesBOHS are supposed to be staffed with a physician and a nurse with short (ten weeks) trainingin occupational health as well as support from an expert with competence in basic safety andaccident prevention. The skill mix required for delivery of BOHS includes workplace andhealth surveillance, risk assessment, disease and accident prevention, basic occupationalhygiene, general health care (GP level) in occupational medicine and general medicine,communication, health promotion, self-auditing. Rantanen estimates that a minimum onephysician and two nurses are needed for every 5000 workers with great variation dependingon industrial activities and the size of workplaces and argues that BOHS should be providedby the public sector, because of the very limited ability of small enterprises, self employedand informal sector settings to purchase external services.1547 13
  18. 18. IV.IV. Occupational health in the context of integrated primary health care Integrated health servicesThere is some evidence suggesting that integrated approaches to delivering health services,compared with vertical approaches improves outcomes in selected areas including HIV,mental health and certain communicable diseases. Nevertheless, Atun et al argue thatvertical programmes may be desirable as a temporary measure in the following cases: weakprimary health care, need for a rapid response to a health problem; to address the healthneeds of specific difficult to reach target groups, or to deliver certain complex healthinterventions that require highly specialized health workforce. In fact, most health servicesusually combine vertical and integrated elements, with varying degrees of balance betweenthem.20International evidence indicates that a well organized and integrated PHC approach willdeliver better health outcomes in the most efficient and equitable way, at a lower cost andwith higher levels of user satisfaction than other approaches to providing healthcare21. Theeffective PHC system should aim to provide universal coverage of services that delivercomprehensive, integrated and appropriate care over time and that emphasize disease andaccident prevention and health promotion. In this context integration is defined by WHO as: “The organization 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”For the user, integration means health care that is seamless, smooth and easy to navigate.For providers, integration means that separate technical services (and their managementsupport systems) are provided, managed, financed and evaluated either together, or in aclosely coordinated way. At the macro level of senior managers and policy-makers,integration happens when decisions on policies, financing, regulation or delivery are notinappropriately compartmentalized. Organizational integration happens when there aremergers, contracts or strategic alliances between different institutions. Professionalintegration occurs when different health professions or specialties work together to providejoined-up services. 23There are strong arguments for integrating some basic services for occupational health intoexisting arrangements for providing primary health care. One of the principal advantages ofan integrated PHC approach is that this will enable basic services for occupational health to20 Atun, R., S. Bennet, A. Duran, When do vertical (stand-alone) programmes have a place in health systems?WHO Regional Office for Europe, Copenhagen, 200821 Is primary care essential? Starfield B., Lancet. 199422 Integrated Health Services – what and why, Technical Brief No.1, WHO, May 200823 Ibid47 14
  19. 19. be provided closer to the locations where people live and work and to a much larger numberof workers than currently covered with specialized occupational health services.A number of countries are testing models to integrate PHC and the basic services foroccupational health. Their experience is discussed in more detail later in this paper.However, experience gained to-date indicates that it is possible to begin to combine PHCand occupational health in order to provide essential occupational health interventionsservices to working populations and settings with constrained resources and lack of accessto mutidiciplinary comprehensive occupational health services. An integrated approachshould not try to focus of all aspects of occupational health, but should concentrate on ahighly selective package of essential interventions that would deliver the greatest return.Some existing public health programmes, such as HIV/AIDS, Malaria, Maternity and ChildHealth, have demonstrated ability to quickly reach populations at risk and to provide themwith health information and care. Some of the most successful among these have largelybeen vertically funded and managed but integrated with other PHC activities at the point ofdelivery. Similarly, essential interventions and some basic services for occupational healthcan be effectively integrated into existing primary health care structures and local healthsystems could enable similar opportunities for providing target worker populations with arange of appropriate OSH services. Appropriate integrated models that identify systems,structures and health worker capacities need to be developedAn integrated approach should have a specific focus on providing services to workers inSMEs, workers who are self-employed and those in the informal sector in order to be able toprovide these important groups with effective services. The design of such integratedservices should take careful account of what is really needed by workers. Integratingessential interventions and basic services for occupational health into PHC could lead tomore efficient service delivery and less costly utilization by recipients than providing astandalone system for occupational safety and health.There are a number of potential benefits from integration. These include:Improved access • Integration would also assist with the reduction of occupational and work-related diseases and injuries 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. • Small enterprises and informal sector workers would be more likely access 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 • Specialists in occupational health are in very short supply in many countries, and, therefore, providing supplementary training in basic occupational health to existing primary health care workers could be an effective strategy for rolling out these47 15
  20. 20. services into the community and providing prevention and treatment for uncomplicated cases. • Using existing but up-skilled networks of health volunteers, auxiliary health workers, workers activists and community health workers to provide support for the delivery of essential interventions for occupational health may prove to be an effective strategy for delivering services right to the community level. • Integration of the basic services for occupational health 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. The experience of other programmes that have been integrated into PHC has demonstrated reduced overall costs and improved treatment practices24 • Integrating into PHC may also 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 studies that have been undertaken to date.Better prevention of illness and injury • Many of the disabling and costly occupational and work-related 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 optimize the returns from scarce human and financial resources through offering new services in innovative ways and by emphasizing 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.Reproductive health has been the focus of most of the work that has been done to date. Theresearch there is available suggests that the “move from disease specific programmes tointegrated services has risks as well as benefits and needs to be managed carefully”25. A2006 Cochrane Collaboration review of “Strategies for integrating primary health services inmiddle- 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.24 Jenkins R, Strathdee G: The Integration of Mental Health Care with Primary Care. International Journal of Lawand Psychiatry 2000, 23:277-291.25 Integrated Health Services – what and why, Technical Brief No.1, WHO, May 200847 16
  21. 21. Integrated delivery ntegratedIn 2011, HLSP Institute at the request of WHO reviewed the different practices for delivery ofessential interventions and basic services for occupational health in settings with constrainedresources26. The experience from a number of countries around the world in delivering basicoccupational health through integrated PHC was summarized in three main models asdescribed below.Model 1: Financing and delivering essential occupational health care through standalone community based insurance schemes Community based insurance Contribution from Organisation (e.g. SEWA, India) Contributions from Social Fund? workers Defined package of OH 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 weaknessesof community based insurance schemes27. 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 • vulnerability to manipulation by local leaders especially in poor and isolated rural communities26 HLSP, The role of health system in basic occupational health service provision for underserved groups -experiences and challenges, Report prepared at the request of WHO. London, 201127 Community-based Risk Management Arrangements: An Overview and Implications for Social Fund Programs,Bhattamishra R., Barrett C, World Bank Division of Social Protection and Labour, Oct 200847 17
  22. 22. Model 2: Publicly funded essential occupational health care delivered by NGOs and private providers MoH and/or MoL Tax revenues & • Sets norms and standards for OH user fees • Provides funding and capacity building Donor funds • Manages/regulates provision of services by third party providers OH funding, capacity building Information and oversight Intermediate level in the health system (e.g. district) Contract management Information and funding CSOs or private providers Essential OH interventions Informal & vulnerable Informal & vulnerable workers 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 areas28.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 service28 Cambodia: Using Contracting to Reduce Inequity in Primary Health Care Delivery, Schwartz B., Bhushan I.,World Bank 200447 18
  23. 23. level agreements etc; and the availability of NGOs or private sector providers with thecapability to deliver contractually agreed services.A 2005 review of the impact of contracting out health service provision in a range ofcountries concluded that contracting out for the delivery of primary care “can be veryeffective, that improvements can be rapid and that contracting for health service deliveryshould be expanded and evaluated rigorously”29. However, it was also noted that manycountries which lack the capacity to organize and deliver basic health services themselvesmay not have the means with which to manage contracts with NGO or private supplierseffectively either. Model 3: Integrating basic occupational health into state delivered primary health care Ministry of Health Tax revenues & • Sets norms and standards forOH 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 OH funding, capacity building Information and oversight Intermediate level in the health system (e.g. district) Training, capacity building & supervision Information Primary Health Care Facility OH integrated with PHC OH interventions – preventive & curative Community health workers Preventive interventions Informal & Informal & vulnerable workers vulnerable workers29 Buying Results? Contracting for health service delivery in developing countries, Loevinsohn B, Harding A., TheLancet 200547 19
  24. 24. Model 3 illustrates how basic services for occupational health might be both funded andintegrated into a PHC approach. MoH staff are responsible for developing a package ofessential occupational health interventions in partnership with the Ministry of Labour whereappropriate and, providing adequate training, supervision and funding, managing itsintegration with other elements of PHC and then delivering services through a network ofprimary care facilities and community health workers.Conventional public health interventions such as immunization or DOTS treatment for TBfollow a fairly standard format and design that can be relatively easily replicated andadapted for different country contexts. Whilst, the mode of delivery may need to changeaccording to the setting in which the intervention is being applied, the essential nature ofthe treatment to be applied (i.e. vaccine delivery or the provision of TB drugs) remainslargely the same.However, the OH needs of agricultural workers in Africa are going to be very different fromthose of street vendors or rubbish collectors in India or artisanal fishermen in thePhilippines. This implies that a creative and flexible approach to OH design needs to be takenthat takes into account the OH needs of particular groups of workers and which tailors theinterventions to their requirements. There is therefore no “one size fits all” or standardapproach to designing and developing OH interventions. This will offer a particular challengeto the health sector. Moreover High level knowledge and skills will be needed to accomplishthis effectively.It is therefore not possible to be prescriptive about how OH interventions can be integratedinto PHC as health systems vary so widely from country to country. Model 3 attempts toprovide a generalized outline of how integration could be organized. However, the existingstructure of the health system in individual countries and the method of funding healthservices will in large part determine how OH services can be effectively integrated into PHC.The essential interventions and services for occupational health should be integrated asseamlessly as possible into PHC delivery and funding mechanisms, whilst ensuring thatfunding mechanisms do not throw up specific barriers to access. One size will not fit all andit will be important to adapt the organization and services to the local context. Integrated Integrated financingThe 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 atthe point 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 servicedelivery level. These are all important challenges that will need to be tackled whenintegrating OH with PHC.47 20
  25. 25. There are five main health financing approaches which are used to fund healthcare30 (thisanalysis does not include financial transfers from donors) and which could potentially serveas funding mechanisms for OH 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 or expanded. Taxation can be progressive meaning those who have the most pay the most (e.g. income tax). Some countries are taxing good and products that are hazardous to health, such as alcohol, tobacco (sin 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 OH 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 andunder performing staff may be difficult to replace. Important issues such as the quality ofcare are also difficult to address in a system that does not provide incentives (ordisincentives) for doing 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 in30 Understanding Health Economics for Development, HLSP CD Rom, 201047 21
  26. 26. collecting funds from the informal sector. Vulnerable groups of people are therefore likely to be excluded.For example, China is piloting the use of social insurance to fund BOSH interventions forinformal and migrant workers delivered through a PHC network. Experience there, wherethe cost of providing BOSH is shared between the government and employers hasdemonstrated that this can be a reasonably effective system for providing services to themajority of workers. An evaluation of the BOSH scheme in 2008 found that employers hadspent 200 RMB for each worker per year on OH per year (compared with 3000 RMB lost perworker per year due to occupational disease). However, there were administrative problemsin keeping migrant workers enrolled in the system particularly when they moved jobsfrequently31.Community based health insurance - is an emerging approach, which addresses the healthcare challenges faced in particular by the rural poor and which helps to address both healthfinancing and service provision simultaneously (many of the CBI schemes are organized bylocal providers of health care). It has grown rapidly in recent years, particularly in WestAfrica. 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 subsidization 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 at theinformal sector in Dar es Salaam. The scheme provides both health and occupational safetyand health services to its members. It was recognized that access to social services has alarge impact on productivity and organizations of informal workers would be an appropriatemechanism for providing such services. PHC services are provided through its own networkof dispensaries and by private providers. Secondary level care is provide throughgovernment funded hospitals3231 Basic Occupational Health Services in Ba’oan, China, Chen Y., Chen J, Journal of Occupational Health, 201032 The UMASIDA Mutual Health Care Scheme, A case study of an Urban based Community Health Fund, KiwaraA, Institute of Develoment Studies, May 200547 22
  27. 27. The main advantage of social or community health insurance schemes for informal workersis that they improve health expenditure efficiency (the relationship between quality and costof health services. There are three main reasons why informal workers would prefer groupschemes to individual spending and financing on healthcare33: • 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 therich, though it may enjoy both direct (tax relief) or indirect subsidies (e.g. through taxfunding 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 for the population at large. There is no evidence that subsidizing 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 formalizing informal fees(or under 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 inutilization, 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.33 Working Paper on the Informal Economy The Informal Sector in Sub-Saharan Africa, ILO, 200247 23
  28. 28. V. Examples from countries countriesThis section looks at the approaches taken by different countries to delivering essentialinterventions and basic services for occupational health in the context of integrated primaryhealth care. The case studies were developed by the HLSP Institute and by experts whoparticipated in the inter-country consultation "Integration of Workers’ Health in theStrategies for Primary Health Care" organized by WHO and the Government of Chile on 4–7May 2009 in Santiago, Chile. The available evidence in this area was primarily fromdescriptive publications and there was little quantitative data or information available onkey issues such as costs and health impact and outcomes. United Kingdom - working for a healthier tomorrow 34The UK health-care system is universal and funded from taxation, free at the point ofdelivery, and covers the entire population. The National Health Service (NHS) is divided intoprimary and secondary care. Primary care is controlled by regional health authoritiesthrough primary care trusts. Primary care is the first point of contact for the public andincludes GP practices, pharmacists, opticians and dentists. Secondary care is hospital care,both acute and planned.Currently GPs have no access to occupational health services. Sixty years ago, when the NHSwas founded, occupational health was not included, as it was seen to be of most value andconcern to industries and businesses, and so to be paid for by employers. The currentcoverage of occupational health is about 30% of workers. The trend since the 1990s hasbeen to outsource in-house occupational health services to external contracted serviceunits. There are no national standards for occupational health provision in the UK as yet.The major causes of people leaving the workplace (2006 figures) are mental health problems(40%), musculoskeletal (18%), cardiovascular and respiratory diseases (8%), nervous systemdiseases (6%), injury and poisoning (6%) and others (22%). The overall cost of working-ageill-health is 100 billion pounds per year, and the cost of sickness absenteeism is 13 billionpounds per year. In addition, there are social problems and consequences beyond theworkplace, e.g. for children in workless families.At a time when rising dependency ratios and the effects of ever-greater global competitionplace huge pressures on economic and welfare systems all around the world, acting toprevent people from becoming ill at work – and supporting and rehabilitating those who dobecome ill – is not only crucial to the physical and mental health of the nation’s workforce,but ultimately critical to the nation’s financial health, the success of British business, theeconomy and the very fabric of society.Current occupational health structures in the UK may have been right when they werecreated, but there is a need now to make sure that they are appropriate for the present andthe future. It is time to reposition and redefine the role of occupational health as an integralpart of the new public health policy for the 21st century, and to reconsider the relationship34 Contribution from Professor Dame Carl Black, 200947 24
  29. 29. between occupational health and the NHS, especially primary care, together with the widercontribution of occupational health to the national economy.GPs are critically important colleagues, and need to be supported to change and enlargetheir attitude to work as a desirable outcome of a clinical encounter. There is now clearevidence that work is generally good for health, and therefore the benefits of work mustfeature more prominently in the advice that GPs give to their patients. But generalpractitioners cannot be expected to change without being offered significantly moresupport. Occupational health has a role in providing such support.The challenge for a new paradigm of occupational Health is to examine the care pathwaysfor working people and find new ways to support them before, during and after illness atwork. This will require forging new partnerships and new ways of working across traditionalboundaries. There is a need to bring together at local level anyone with interest or expertisein occupational health, to find locally tailored and ever more innovative ways to allowoccupational health to make its crucial contribution to the health of the national economy.Carol Blacks report to Government, Working for a healthier tomorrow, published in March2008, had three key objectives: i) preventing illness and promoting health and well-being in the workplace; ii) early intervention for those who are employed but absent with a “sick note”; iii) improving the health and well-being of unemployed people within the UK benefit system.The report included the following recommendations: • Government should work with employers to develop a robust model for measuring and reporting on the benefits of investment in health and well-being. • Employers should report at board level on staff health and well-being. • A health and well-being consultancy service should be set up to provide employers with advice and support. • The role of safety and health practitioners, and where present trades union safety representatives, in promoting the benefits of investing in health and well-being should be expanded.Practical ways should be explored to make it easier for smaller employers to establish healthand well-being initiatives. An integrated approach to working-age health should be taken,underpinned by: • inclusion of occupational health and vocational rehabilitation within mainstream healthcare; • clear professional leadership from the occupational health and vocational rehabilitation communities to expand their remits and work with new partners in supporting the health of all working-age people; • clear standards of practice and formal accreditation for all providers of OH engaged in supporting working-age people;47 25
  30. 30. • a revitalized OH workforce with the development of a sound academic base to provide research and support in relation to the health of all working-age people; • systematic gathering and analysis of data at the national, regional and local level to inform the development of policy and the commissioning of services relating to the health of working-age people; and • awareness and understanding of the latest evidence on the most effective interventions developed by organizations such as the Occupational Health Clinical Effectiveness Unit.The UK Government’s response to Blacks report, entitled Improving health and work:changing lives, was published in November 2008. The government accepted the broad thrustand most of the detail of the recommendations in the report. The response sets out newperspectives on health and work, improvement of workplaces, supporting people to workand measuring outcomes of the process.The new approach includes a new electronic “Fit Note”; piloting of a new “Fit for Work”service; training and education for healthcare professionals especially GPs; nationalstandards for occupational health providers; a strategy for mental health and employment; anational centre for working-age health and well-being; and a council of occupational health.The response says: “By working together, our efforts will help us to combat social exclusion,eradicate child poverty, support our aging population and build a workforce for tomorrow. Byimproving health and work we will make a real difference to people’s lives.” Thailand – primary care units35In 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. Therewere also an estimated two million migrant workers, mainly from Myanmar36.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 specialized 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.35 Contribution from HLSP and S. Siriruttanapruk, 200936 Labour Force Survey. National Statistics Office, Ministry of Information and Communication Technology,Thailand. (accessed 29 August, 2007).47 26
  31. 31. • 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, Specialized 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 MOPHand other public agencies such as the Ministry of Defence who provide services to officialsand their families and the public37.Occupational Safety and Health in ThailandResponsibility for occupational health and safety in Thailand is divided between threegovernment ministries. The Ministry of Labour enforces OSH regulations and undertakesworkplace safety inspections. The Ministry of Industry is responsible for enforcing theFactories Act which covers workplaces with large machines and/or more than sevenworkers. The Ministry of Public Health provides technical support for occupational healthservices in five main areas: occupational disease surveillance; technical support;development of OSH guidelines; training of health care workers; and research anddevelopment.Traditionally, OH services in Thailand have been provided through provincial and regionalpublic hospitals and also through some community hospitals in industrial areas. Typically,the staff in these hospitals would have received some training in OSH and would have themeans available to monitor occupational safety risks in the workplace. The public healthoffice in each province has a specialist in occupational and environmental health that isresponsible for developing OSH strategies for each province.Role of Primary Care Units (PCU) in providing basic occupational healthIn order to improve the coverage and availability of OH services an initial, strategy of usingPCUs to deliver both PHC and basic OH 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 OH outreach visits to workplaces - these tend to be mainly factories orother formal work settings. However, workers in the informal sector would often still find37 Integrating Occupational Health Services into Public Health Systems: A Model Developed with Thailand’sPrimary Care Units, Somkiat Siriruttanapruk and team Ministry of Public Health, Thailand, ILO (2006)47 27
  32. 32. difficulty in accessing OH 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 basic occupational health services to workers in the informal sector (Agriculture,SMEs, Fisheries, Migrant workers and Home workers). The services 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 OH 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 OH services, local needs can be met moreeffectively and services provided more efficiently to workers in the informal economy. Insome of the test locations, health volunteers have been involved in providing workplacesafety improvements and in reducing the use of dangerous chemicals and pesticides. Finland - municipal health centres38According to the Primary Health Care Act the entire Finnish population is covered by primaryhealth care services provided by municipal health centres. Finland has had a speciallegislation on occupational health services since 1978 and it was revised in 2001. The lawobligates the employer to organize preventive OHS for his/her employees by usingcompetent occupational health personnel (OHP + OHN) and according to need otherexperts, such as hygienists, psychologists, physiotherapists/ergonomists etc.. The obligationis universal in all sectors, private and public, regardless of the size of company, geographicallocation or type of employment contract. Provided the requirements of legislation are met,the employer is entitled to reimbursement of 50 to 60% of the costs of the services he/shehas provided to employees.The law requires preventive content of services, including among others workplacesurveillance, risk assessment, accident prevention, ergonomics, surveillance of health,promotion of health and work ability of workers and advice, information and education ofoccupational health, and safe and healthy working practices to workers and employers. Theemployer is entitled to provide also GP level curative services for his/her employees inconnection with occupational health services and about 80% of them do so. The employer isentitled to buy services from any of the competent and registered occupational healthservice units, organize own in-company services, group services, or buy the services from aprivate occupational health centre or from a municipal health centre.The municipal health centres have a legal obligation to provide occupational health servicesto anybody who is interested in getting them. Virtually all farmers and self-employed whoare covered by OHS are served by municipal health centres and for farmers the preventiveOHS workplace visits by experts are provided free of charge.38 Contribution from Professor J. Rantanen, 200947 28
  33. 33. The coverage of Finnish OHS is one of the highest in the world, about 85% of all (includingself-employed) and about 90% of the workers employed by the employer. The coverage ofservices is 90 to 100% of companies with 10 workers and more, while the coverage ofcompanies decreases substantially among the SMEs and self-employed being on average atthe level of 60%.The municipal health centres (primary health care units) have occupational health physicianand nurse for provision of services and they can use services of other experts, e.g.occupational hygienists or psychologists e.g. from the multidisciplinary teams of the regionaloffices of occupational health (FIOH).The experiences from provision of services by PHC units are positive. The municipal healthcentres accommodate 29% of all occupational health service units in Finland and provideoccupational health services for 32% of all workers covered by OHS and for 61% of allenterprises.Obstacles are the thin resources and shortage of service time of OHS personnel andtendency to prioritize the worker-oriented health service provided from the centre at thecost of preventive interventions to the work environment, which would require more activevisiting at the workplaces. occupational Indonesia – occupational health posts in the informal sectorIndonesia is the fourth largest country in population terms after China, India and the USA. In2008, its total population was 228 million39. 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 GDP40.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 OH 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 andempowerment41.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 encourageworkers to use appropriate safety equipment. Service provision is intended to be integratedwithin the PHC approach. Significant progress has been reported to-date in rolling-out thebasic OSH training required by staff at all levels of the health system in order to implementthe OHP approach42.39 Indonesian Country Paper on the Informal Sector and its Measurement, BPS-Statistics Indonesia, May 200840 The Informal Sector and Informal Employment in Indonesia, ADB Country Report, 201041 Revitalizing Primary Health Care, Indonesia Country Experience, WHO Regional Conference, Aug 200842 Ibid47 29
  34. 34. 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 beenincluded in the basic PHC package of care in Indonesia and the support and financing of basicOSH has been rather patchy both from the central level and through local administrations43.It is important to integrate OSH into the basic PHC package of care in order to ensure thatappropriate structures are in place to provide training and supervision and also that fundingfor OSH is included in overall PHC allocations. China - piloting basic occupational health services44 pilotingThe 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 thecountry45. A rigid system of household registration (Hukou) that only allowed people toaccess social services in the areas where they are registered has been applied. Whilst thishas begun to be relaxed in a number of cities, it has still been identified as an area ofconcern. As migrants generally retain their rural registration, they are often excluded fromaccessing services in the areas to which they migrate, including health care and occupationalhealth services. In 2008 health insurance coverage was only 19% among rural migrantscompared to 58% of urban residents whose cover was generally linked to the place ofwork46.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 200947.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 throughsupervising employers in order to establish and standardize labour contracts and collectivecontracts48.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.43 Impact and Effectiveness of Occupational Health Interventions: a qualitative study on multiple stakeholders inoccupational health for informal sectors in Indonesia, Hanifa M. Denny, College of Public Health, University ofFlorida (on-going research project)44 HLSP analysis45 Hesketh, T; Jun, Y. X; Mei, L. H.(2008) Health Status and Access to Health Care of Migrant Workers in China,Public Health Reports 2008 Mar–Apr; 123(2): 189–19746 Ibid47 China’s primary health-care reform, Liu Q., Wang B., The Lancet, March 201148 Zhu, C (2008) Labour protection for women workers in China, Asian-Pacific Newsletter on OccupationalHealth and Safety;15:4747 30