Post on 22-Feb-2016
description
Diagnostic Challenges – a perspective from South Africa
Overview• Context• Policy, legislation & services• A systems approach• Prevention to compensation• Some lessons• Conclusion
The World…Village (n=100)
• 57 Asians• 21 Europeans• 14 Americans• 8 Africans
• 52 women & 48 men• 80 persons living in poverty• 70 illiterate• 50 suffering from hunger &
malnutrition• 1 person with a university degree• 1 person with a computer
Lueddeke GR. 2012
Resized World Maps (Lancet. 2011)
More Illness and Fewer Health Workers in Africa
WHO: Human Resources for Health, 2006
Worker Health in South Africa / Sub-Saharan Africa
• 53m South Africans (STATSSA 2013)• 17m work (13m formal & 4m informal) • 3 workers die every day from accidents
• 875m in Sub-Saharan Africa • 258 000 die from work accidents• 98.9/100 000 (73.3 – world) – Fatal Injuries
STATSSA; ILO; WHO
Occupational Health in Africa
• fragmentation of policy and legislative framework (Health, Labour, Mining)• inadequate occupational health system • deficient occupational health services• lack of human resources for occupational health• little access, coverage & equity in compensation systems• vulnerable workers (migrant, mobile, youth, informal (60% – 78%) • no surveillance system for injuries and diseases
The Labour Market in Africa
• Dualistic– Formal / Informal– Urban / Rural– Modern / Traditional– Organised / Unorganised– Gender differentiation
ILO, 2011
A=Fuelling Africa’s Growth
The Mining Economy• 1.8 Trillion USD sector (net asset value)• 7.7% of annual GDP DMR 2010
The Informal Sector
Trade Community Manufacturing Financial Household Construction Agriculture Transport Mining Electricity0
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2000 2007
Labour Force Survey. Statistics South Africa, 2008
Workers per Employment Sector (‘000)
Labour Force Survey. Statistics South Africa, 2008
Gender Distribution of Workers (2007)
Trade Community Manufacturing Financial Household Construction Agriculture Transport Mining Electricity0
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Male Female
Migrant Mine Workers in South AfricaYear RSA Mozambique Lesotho Swaziland % Non-
RSA
1920 74 452 77 921 10 439 3 449 57
1940 178 708 74 883 52 044 7 152 49
1960 141 406 101 733 48 824 6 623 62
1980 233 055 39 636 96 308 5 050 44
1995 122 562 55 140 87 935 15 304 58
2000 99 575 57 034 58 224 9 360 57
2010* 152 486 35 782 35 179 5 009 34
* Data from TEBA
Surveillance• “data for action” (Giesecke, 1999)• “ongoing, systematic collection, analysis & interpretation of data for planning, implementation & evaluation” (CDC, 1988)
Occupational Ill-health
• hard to find data; if found, difficult to interpret
Occupational Injuries• Abrupt break in …AGENT – HOST – ENVIRONMENT
balance• Cause established
Occupational Diseases• Not diagnosed / mis-diagnosed• Lack of knowledge• Masked by other diseases• Long lag time• Need special investigations• Difficult to find cause
1975
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0
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Active pulmonary tuberculosis in African miners at au-topsy, all commodities, 1975 - 2009
Year
Rat
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NIOH: Pathaut, 2010
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Silicosis at autopsy in gold miners, 1975 - 2009
Year
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Nelson et al. Three decades of silicosis: disease trends at autopsy in South African gold miners. Environ Health Perspect. 2010
Gold Price (2000 – current)
Occupational Exposure Limits for Silica (2008)
Country / Province# OEL (mg / m3)
Argentina 0.05#British Columbia 0.025
Chile 0.04
Ireland 0.05Italy 0.05Japan 0.03Portugal 0.05
USA - ACGIH* 0.025
USA - NIOSH* 0.05
*Advisory organisationSource: Maciejeska A. 2008. Int J of Occ Med & Env Health 21 (1): 1-23
Wilson K. NIOH. 2011
Safe Work, Australia.
2010
– Policy deliberations• ILO Decent Work, Safe Work• Seoul Declaration• ILO Plan of Action (2010 – 2016)• WHO Global Plan of Action (2012 – 2017)• Occupational Exposure Levels• HIV / AIDS • Gender• Environment
ILO / WHO / UNEP
A seat at the table…
– Policy• Safety, Health & Environment /
Occupational Health• HIV/TB• MDGs, African Union
– Legislation• Conventions, codes, guidelines (ILO &
WHO)• Legislation – Departments of Labour,
Mineral Resources, Health, others
Policy & Legislation
– Governance• Government, Trade Unions,
Employers, NGOs, Professional bodies
– Management• Development & maintenance of the
system• Delivery of services
Governance & Management
Occupational Health Services: Core Functions
• Preventive– Risk identification, assessment &
management– Recognise high risk groups & priorities
• Health Promotion– Optimal physical & mental health– Healthy lifestyles
• Curative services– General practice level– Referral to specialists– First aid
• Rehabilitation & Compensation
Conceptual Model – Delivery of Services
PHC / District Health System
General Specialist hospitals
Central hospita
ls
Community / PHC
District Hospital
Gen Spec Hosp
Central
PHC Nurse / CHW
Family Medicine / OHN / Occ Hyg
Occ Med Spec +
Academic / Reference Units
OH Service Model
REFERRAL
SUPPORT
34
One – Stop Service Framework• Health Services
– Benefit medical examinations– Rehabilitation assessment & services
• Health Promotion– Primary Health Care support
• Social Services– Social Development– Counselling
• Financial Services– Compensation– UIF, pension & provident funds
35
Service Delivery Challenges• Human resources (occ. health
practitioners; nurses; occ hygiene, etc)• Curative focus (non-renewable human
capital)• Fragmented service delivery • Little or no quality assurance (radiology,
audiology, spirometry, occ hygiene, laboratory)
• Dumping syndrome / Referral system
Occupational Health Human Resources• 4.1 / 100 000 doctors (712) – 4300*• 0.77 / 100 000 hygienists (100 or 450) -
1340*• 15.4 / 100 000 nurses (2000) – 8670*• 0.6 / 100 000 ergonomists (80) • Safety practitioners, ventilation etc• ? Education and training inputs* need
(Rees, NIOH)
A Systems Approach
Provision of education
Health needs
Demand for education
Educational needs
Labor market for health
professionals
Worker Population
Demand for health care
Provision of health care
EducationSystem
HealthSystem
Supply of health
workforce
Demand for health
workforce
Occupational Health System
Epidemiological and demographic
transitions
Technological innovation
Worker / Community demands
Professionaldifferentiation
Emerging Challenges to the Occupational Health System
Systemic Failures• Mismatch of competencies to need• Weak teamwork• Gender stratification• Curative over prevention & primary
care• Labour market imbalances• Weak leadership
Promoting Occupational HealthPublic Health Approach
• Action beyond workplace
• All health determinants• All workers (contract)• All stakeholders
• Overall policy / legal framework
Traditional Occ Health• Only at workplace
• Only work-related• Permanent employees• Employer’s
responsibility• Workers & employers
Natural History of Disease
• Susceptibility phase - Risk factors
• Pre-clinical phase - Biological process has begun
• Clinical phase - Signs and symptoms
• Recovery - Chronic disease, disability, death
Weiner JP. 2003
Levels of Prevention• Primordial – building healthy environments
• Primary – preventing the emergence of risk factors
• Secondary – treating the risk factors• Tertiary – minimising risk in those with established disease
National Institute for Occupational Health
Services
Research
Education / Training Back
Office
Local & International Partnerships
Government & Public Entities
Universities and other Institutions
Trade Unions, NGOs &
Employers
Services (referred persons, workplace &
laboratory assessments)• Public & private sectors (incl NGO &
Trade Union sectors)• Pathology services (deceased ex-
miners)• Occupational Medicine
– Clinical specialist referral service– Surveillance– Ergonomic assessments– Immunology & microbiology
Services (referred persons, site & laboratory assessments)
• Occupational hygiene (risk assessments & hazard management)
• Analytic services & Toxicology• Information services
– Query handling– Resource centre– Electronic journals– eLearning platform (in development)
Research• Epidemiology• Special emphasis on mining sector,
construction, informal sector, health & public sector
• Nanotoxicology• Scientific (peer reviewed)• Translation of science for popular use• Scientific endeavour for policy change
& service improvement• Support for legal challenges
Health Technology Assessment• Lifecycle analysis of technology• Multidisciplinary team• Standard setting & guidelines
‘fitness testing’
‘gloves’
N95 masks
Revocation of licence
UVGI?GUIDELINES FOR THE UTILISATION OF
ULTRAVIOLET GERMICIDAL IRRADIATION (UVGI)
TECHNOLOGY IN CONTROLLING TRANSMISSION OF
TUBERCULOSIS IN HEALTH CARE FACILITIES IN
SOUTH AFRICA – MRC et.al• does it work?
• implementation• type• fixture• weight• warnings etc
• ventilation
Education & Training• Training in Occupational Medicine,
Occupational Hygiene & Pathology• Continuing educational development
– Short courses– Updates– Journal clubs– Support to universities
• Professional groups, Government, Private Sector & Trade Unions
• Support for training in SADC region
Capital Infrastructure
HPLCTB
Bio-aerosols Records
Implementation• Policy and regulatory change• Cutting across silos in
professional training• Networks / communities of
practice
Traditional modelEducationalobjectives
Competency-based education model
Curriculum
Assessment
Occupational Health needs /Occupational
Health systems
Competenciesoutcomes Curriculum
Assessment
Competency-based Education
Model Pre-secondary education
Post-secondary education Practice
MD
Nursing
Public health
Other
Teamwork
Inter-professional
Trans-professional
Common
Core + specific competencies
Systematic teamwork Teamwork
Core + specific competencies
Systematic teamwork Teamwork
Models of inter- and trans-professional Education
Workplace OHS
professionals
Common
Common
Dominant
Level Objectives Outcome
Informative • Information•Skills
Experts
Formative •Socialization•Values
Professionals
Transformative •Leadership attributes
Change agents
Levels of Learning
Integrative FrameworkProcessStructure
Text
Institutional Design• Systemic Level Governance Financing Development of the teaching
workforce Interface education-health systems• Organizational level Division of labor Incentives Capacity strengthening• Global level Stewardship Networks and partnerships
Instructional Design• Criteria for admission• Competencies (definition)• Curriculum Content Courses• Channels Didactic methods Teaching technologies
Text
Text
OutcomesInterdependence
• Health and education systems• Global and local spheres• Categories of the occupational health
workforce• Context and competencies• Teaching and learning
Transformative learning• Inter-professional and team-based• IT-empowered and pro-active• Life-long• Evidence-based• Locally responsive and globally connected• Adaptive to versatile career paths• Socially accountable for new professionalism
Context
Global-Local
Entry Point for Occupational
HealthTraining
+
AdvancedUniversityCertificate
Masters / PhD
Elective Clinical
Elective Public Health
Elective Occ Hygiene
Diploma
+
1-2 years
1 – 2 years 4 years
OccasionalLearners
Postgraduate Training Centres
Some thoughts on where to start
• Joint accreditation and assessment teams• Critical mass of trainers, materials &
infrastructure• Joint learning activities
– primary care settings– workplaces– clinical care settings– institutes
Networks & Partnerships• WHO Collaborating Centres• ILO – CIS Centres• ICOH• Government, employers, unions• Developmental partners• Special Funds – compensation,
pensions / provident funds65
Three Questions?• Has work caused ill-health?• Has work aggravated ill-
health?• Does the worker have a
health condition that can affect work?
barry.kistnasamy@nioh.nhls.ac.za