47 i

Scaling Up Access Scaling Up Access Scaling Up Access Scaling Up Access

totototo EEEEssential ssential ssential ssential IIIInterventions nterventions nterventions nterventions

and and and and BBBBasic asic asic asic SSSServices ervices ervices ervices

for for for for OOOOccupational ccupational ccupational ccupational HHHHealth ealth ealth ealth

Through Integrated Primary Health Through Integrated Primary Health Through Integrated Primary Health Through Integrated Primary Health

CareCareCareCare

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 2011

Draft

Released for use by conference participants only.

Not to be referenced or quoted.

47 ii

Acknowledgments

This document was produced under the overall direction of Ivan D. Ivanov, Team Leader for

Occupational 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, Somkiat

Siriruttanapruk, and Claunara Mendonça.

Suggestions were received from Rania Kawar, Carlos Dora, Igor Fedotov, Bill Gunnyeon and Chris van

Weel.

Financial support from the Unites States National Institute of Occupational Safety and Health and the

Ministry of Health, Welfare and Sport of the Netherlands is gratefully acknowledged.

47 iii

Table of ContentsTable of ContentsTable of ContentsTable of Contents

Executive summary ............................................................................................................... 1

I. Introduction................................................................................................................... 4

II. Health systems and primary health care ........................................................................ 6

III. Occupational health................................................................................................... 9

Essential interventions......................................................................................................10

Occupational health services ............................................................................................11

IV. Occupational health in the context of integrated primary health care ......................14

Integrated health services.................................................................................................14

Integrated delivery............................................................................................................17

Integrated financing..........................................................................................................20

V. 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" ......................................................................37

VI. Conclusions and recommendations ..........................................................................40

47 iv

47 1

Executive summaryExecutive summaryExecutive summaryExecutive summary

Approximately half of the world's population spends at least one third of its time in the

workplace. Fair employment and decent work are important social determinants of health

and a healthy workforce is an essential prerequisite for productivity and economic

development. However, only a small proportion of the global workforce has access to

occupational 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 the

ability of health systems to preserve and restore working capacity.

The 62nd World Health Assembly in 2009 emphasized the need to strengthen health systems

based on primary health care (PHC) in keeping with the values and principles enshrined in

the Alma-Ata Declaration. Action must be taken to provide universal access to PHC by

developing comprehensive health services, introducing national equitable and sustainable

financing mechanisms and implementing vertical health programmes, e.g. occupational

health, in the context of integrated primary health care.

Currently, a number of countries are reforming their health systems based on the values and

principles of PHC1 to improve service delivery, cost-efficiency and to ensure equity. National

debates on health reforms often touch upon insufficient collaboration between health and

labour sectors, the organization of preventive and curative health services for working

populations, and their relation to primary care2. Employers, businesses and the private

sector are engaging in providing health services to workers and communities.

In 2007, the 60th World Health Assembly urged Member States to work towards covering all

workers with essential interventions and basic occupational health services for primary

prevention of occupational- and work-related diseases and injuries. This coverage should be

particularly provided to those in the informal economy, small- and medium-sized

enterprises, agriculture, and migrant and contractual workers. How can this goal be

achieved, bearing in mind that most countries experience a shortage of human resources for

health and most people lack access to the most basic elements of social protection in a

world of work that is ever more diverse, small scale, precarious and informal?

Recent decades have seen significant progress in the development of occupational health

services in a number of industrialized countries and economies in transition and rapid

economic growth. Compulsory provision of services along with national funds for their

financing has led to almost universal coverage in some countries and a significant increase of

coverage and quality in others. However, there are some concerns. In many countries

coverage remains low and increasingly inequitable and workers with the biggest needs, such

as those in agriculture, small enterprises and informal economy, remain without access to

1 Primary health care (PHC) is a way of organizing a health system so that everyone, both rich and poor, is able

to access the services and the conditions necessary for realizing the highest level of health. It includes

organizing health systems to provide quality and comprehensive health care to all while ensuring that poor and

other 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 have

with health-care teams. In some countries this may be a community health worker or

midwife; in others, it refers to the family practitioner.

47 2

the most basic occupational health services. Where occupational health services exist, they

often focus on provider-driven menus of few interventions and may not be adequate to

meet the health needs and expectations of workers. In addition, there are language,

employment status and structural barriers to accessing services which in themselves are

becoming more and more profit-oriented. In many countries occupational health is still

detached 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-related

health problems.

The 1978 International Conference on Primary Health Care in Alma Ata called for bringing

health care to where people live and work. However, when PHC was put into practice, the

focus was mostly on health services where people live. With only a few exceptions, the

provision of health care where people work was absent from the debate on programmes

and strategies for primary health care. Thirty years after Alma Ata there are even more

compelling arguments for using the workplace as a point of entry to the health system. The

workplace can be a setting for delivery of essential health interventions and for reaching out

to workers’ families and communities. In some cases, the workplace is the only way of

providing health care, e.g. for mining communities and migrant workers. Furthermore,

improving workers’ health can help to reduce poverty, and is an essential prerequisite for

productivity and economic development.

There have been a number of innovative attempts to extend the coverage of basic

occupational health services through integration of occupational health with primary care at

the point of delivery. One example consists of training primary care providers, such as

general practitioners, nurses, technicians and community health workers to understand

work-related health problems and to provide some basic support for small workplace

settings to improve working conditions, to train workers on how to work in a healthy and

safe way and to provide first aid. This has been undertaken primarily in rural areas and the

informal sector. Another example is designating a member of the primary care team to

provide occupational health support to workers and workplaces in the catchment area of the

primary care centre. Yet, a third example is when occupational health experts periodically

visit the primary care centre to hold an occupational health clinic providing consultations

and advice as needed.

Whatever the model, integrated PHC-based services for workers would provide the first

point of contact within the health system while emphasizing primary prevention of

occupational and work-related diseases and injuries, promotion of health and restoring

working capacity. Such services require active mechanisms for workers’ participation in

planning, delivery and evaluation, an adequate skill mix of service providers, equitable

financing and purchasing mechanisms as well as a sound policy, legal and institutional

framework.

In 2008, WHO launched a set of reforms to provide PHC to all citizens focusing on universal

coverage, people-centred care, participatory health governance and including health in all

policies.

Working towards universal coverage with occupational health services entails certain

complex measures, such as reducing the proportion of costs to the individual undertaking

the service and/or workers (insurance schemes), adding interventions to the existing

package of service provision (primary prevention in addition to curative care), increasing the

47 3

number of workers covered, and reducing barriers to undertaking services and to individuals

accessing health services.

A new health leadership should include a solid regulatory framework to guarantee a basic

level of health protection in all workplaces and for all workers, as well as careful planning for

the provision of different occupational and primary health care services to under-served

working populations. Collaboration between health and labour sectors is essential to ensure

comprehensiveness and continuity of care. A new leadership also requires participation of

workers, employers and other workplace actors in the debate about health-care reforms.

The delivery of the essential occupational health interventions can be leveraged significantly

through integrated primary health care by putting people in the center of care. Occupational

health institutes, laboratories, clinics and information centres should provide expertise,

information and laboratory support to occupational health services and to primary care

centres. The collaboration between occupational health services and primary care centres

should be improved. The content of occupational health services needs to be reoriented

towards the health needs and expectations of the workers and not geared towards a supply

of providers. Particularly in need is provision of workplace initiatives, practical tools and

working methods that enable workers, employers and other work actors to undertake the

most basic measures for protecting and promoting health at work without unnecessarily

relying on health services.

Finally, delivering occupational health to all workers requires public policies that stimulate

inter-sectoral collaboration and coordination, not least involving health, labour,

environment, agriculture, industry, energy, transport, construction, finance, trade and

education. Social security institutions, employers, trade unions, the private sector and civil

society organizations have a particular role to play in shaping public policies for workers’

health.

47 4

IIII.... IIIIntroductionntroductionntroductionntroduction

Approximately half of the world's population spends at least one third of its time in the

workplace. Fair employment and decent work are important social determinants of health

and a healthy workforce is an essential prerequisite for productivity and economic

development. When carried out under favourable conditions, work provides income to

support human needs and has a positive impact on the health and well-being of individuals

and on social and economic development.

However, most of the world’s workers still labour under unhealthy and unsafe working

conditions, 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 raised

the number of unemployed people. In 2010 there were 205 million unemployed people in

the world. This is, however, is only the tip of the iceberg of labour market distress. Different

forms of underemployment, vulnerable employment and working poverty also increase. ILO

estimates that in 2009 around 1.5 billion workers, or half of the world's workers, were in

vulnerable employment The share of workers living with their families below the US$ 2 a day

poverty line is estimated at around 39 per cent, or 1.2 billion workers worldwide. 3

There are a number of highly effective interventions for prevention of occupational diseases

and injuries. However in many countries health systems are not able to deliver these

interventions to those workers in greatest need. Less than 15% of the global workforce have

some coverage with occupational health services. Furthermore, certain global health

problems, such as non-communicable diseases, result in increasing rates of long-term sick

leave 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 systems

based on primary health care (PHC) in keeping with the values and principles enshrined in

the Alma-Ata Declaration. Action must be taken to provide universal access to PHC by

developing comprehensive health services, introducing national equitable and sustainable

financing mechanisms and implementing vertical health programmes, e.g. occupational

health, in the context of integrated primary health care.4

Currently, a number of countries are reforming their health systems based on the values and

principles of PHC5 to improve service delivery, cost-efficiency and to ensure equity. National

debates on health reforms often touch upon insufficient collaboration between health and

labour sectors, the organization of preventive and curative health services for working

3 Global Employment Trends 2011. International Labour Office, Geneva, 2011.

4 Resolution WHA62.12. Primary health care, including health system strengthening. In: Sixty-second World

Health Assembly, Geneva, 18–22 May 2009. Resolution and decisions, annexes. Geneva, World Health

Organization, 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 able

to access the services and the conditions necessary for realizing the highest level of health. It includes

organizing health systems to provide quality and comprehensive health care to all while ensuring that poor and

other disadvantaged people have fair access to essential health services.

47 5

populations, and their relation to primary care6. Employers, businesses and the private

sector are engaging in providing health services to workers and communities.

Many countries have already in place some form of essential interventions and services for

occupational health for occupational health. Few countries, though, have managed to

achieve a more universal coverage of workers with such interventions and to establish

sustainable mechanisms for the provision of basic services for occupational health. Other

countries are approaching WHO for access to these experiences and for technical assistance

in setting up their own programmes for scaling up coverage of workers with occupational

health care.

In 2007, the 60th World Health Assembly urged Member States to work towards full

coverage for all workers with essential interventions and basic occupational health services

for primary prevention of occupational- and work-related diseases and injuries. This

coverage should be particularly provided to those in the informal economy, small- and

medium-sized enterprises, agriculture, and migrant and contractual workers.7

How can this goal be achieved, bearing in mind that most countries experience a shortage

of human resources for health and most people lack access to the most basic elements of

social protection in a world of work that is ever more diverse, small scale, precarious and

informal?

6 Primary care is a component of PHC and refers to the first level of contact people have with health-care

teams. In some countries this may be a community health worker or midwife; in others, it refers to the family

practitioner.

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 6

IIIIIIII.... HHHHealth systemsealth systemsealth systemsealth systems and primary health care and primary health care and primary health care and primary health care

A health system consists of all organizations, people and actions whose primary intent is to

promote, restore or maintain health. This includes efforts to influence determinants of

health as well as more direct health-improving activities. A health system is therefore more

than the pyramid of publicly owned facilities that deliver personal health services. It includes

e.g. a mother caring for a sick child at home; private providers; behaviour change

programmes; vector-control campaigns; health insurance organizations; and occupational

safety and health. It includes intersectoral action by health staff e.g. by encouraging the

ministry of education to promote female education, a well-known determinant of better

health.

To achieve their goals, all health systems must carry out some basic functions, regardless of

how they are organized: they have to provide services; develop health workers and other

key resources; mobilize and allocate finances, and ensure health system leadership and

governance (also known as stewardship, which is about oversight and guidance of the whole

system). For the purpose of clearly articulating what WHO will do to help strengthen health

systems, the following six essential “building blocks” have been defined; all are needed to

improve 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 7

• 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 of

health systems, the world will fail to meet its health-related goals. As health systems are

highly context-specific, there is no single set of best practices that can be put forward as a

model for improved performance. But health systems that function well have certain shared

characteristics. They have procurement and distribution systems that actually deliver

interventions to those in need. They are staffed with sufficient health workers having the

right 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 even

deeper into poverty.

Primary health care is “essential health care based on practical, scientifically sound and

socially acceptable methods and technology made universally accessible to individuals and

families in the community through their full participation and at a cost that the community

and 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 health

system, of which it is the central function and main focus, and of the overall social and

economic development of the community. It is the first level of contact of individuals, the

family and community with the national health system bringing health care as close as

possible to where people live and work, and constitutes the first element of a continuing

health-care process.”9

Put simply, it is aimed at ensuring that everyone, rich and poor, is able to enjoy the services

and conditions necessary for realizing the highest level of health. It includes organizing

health systems to provide quality and comprehensive health care to all, while ensuring that

the poor and other disadvantaged people have fair access to essential health services. PHC

mobilizes society and requires community participation in defining and implementing health

agendas, and underscores intersectoral approaches to health. Most important, PHC ensures

that national health development is an integral part of the overall social and economic

development 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 people

have with health-care teams. In some countries this may be a community health worker or

midwife; in others, a family practitioner.

The concepts of PHC as they were expressed 30 years ago are still valid today. The World

Health Report of 2008 "Primary Health Care: Now More Than Ever" identified major avenues

8Everybody's business. Strengthening health systems to improve health outcomes. WHO's framework for

action. World Health Organization, Geneva, 2007

9 Declaration of Alma-Ata. In: Primary Health Care. Report of the International Conference on Primary Health

Care, 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 allocated

according to need; health care is provided in response to legitimate expectations of the people; health services

are received according to need regardless of the prevailing social attributes; and payment for health services is

made according to the ability to pay.

47 8

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 of

primary health care, the expectations of citizens and the common health performance

challenges 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 for

action. The details required to give them life in each country must be driven by specific

conditions and contexts, drawing on the best available evidence.11

11

Primary Health Care: Now More than Ever, The World Health Report 2008. Geneva, World Health

Organization, 2008.

47 9

IIIIIIIIIIII.... Occupational Occupational Occupational Occupational hhhhealthealthealthealth

Occupational risk factors account for substantial part of the global burden of diseases. The

WHO study from 2004 found that 37% of back pain, 16% of hearing loss, 13% of chronic

obstructive pulmonary disease, 11% of asthma, 8% of injuries, 9% of lung cancer and 2% of

leukaemia can be prevented through improving the work environment12.

The Joint ILO/WHO Committee on Occupational Health defined the following objectives of

occupational 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. 13,14

12

Concha-Barrientos M et al. Selected occupational risk factors. In: Ezzati M et al., eds. Comparative

quantification 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 - 2

September 1950. Geneva: ILO

14 Joint ILO/WHO Committee on Occupational health. 1995. Defining Occupational Health. Geneva: ILO

47 10

Essential iEssential iEssential iEssential interventionsnterventionsnterventionsnterventions

The range of the interventions addressing occupational and work-related diseases and

injuries may include both clinical (e.g. health examinations) and non-clinical interventions

(e.g. workplace risk assessment). The interventions can be categorized as preventive and

treatment interventions, where preventive interventions are usually offered to persons

unsolicited 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 the

onset of the pathological process whereas other preventive interventions address later

stages. In occupational health, primary preventive interventions aim at eliminating and

decreasing 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 the

effectiveness of the interventions for primary prevention of these occupational risks. The

analysis found that regulation and incentives for employers were one of the main causes of

reducing 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 loss

prevention programmes were not sufficiently protective but regulation and enforcement

were found useful to reduce noise levels in workplaces. There was no evidence in the

available studies that back pain could be prevented neither by training and education nor by

ergonomic improvements nor by pre-employment examinations.

For preventing injuries, technical hazard controls such as roll-over protection structures on

tractors could reduce fatal injuries but for most technical controls there were no studies or

no systematic reviews. Incentives such as feedback and rewards for workers improved safety

behaviour and probably reduced injuries but there were no systematic reviews of measures

to improve the safety climate in an enterprise. Education and training to prevent injuries

47 11

produced mixed results with some reviews providing evidence of effectiveness but with

other reviews not. 15

Occupational health servicesOccupational health servicesOccupational health servicesOccupational health services

Employers 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 areas

of occupational safety and health. Occupational health services are those entrusted with

essentially preventive functions and responsible for advising employers, workers and their

representatives on the requirements for establishing and maintaining a safe and healthy

working environment which will facilitate optimal physical and mental health in relation to

work. ILO Convention No. 16116 specifies that occupational health services should include

those of the following functions that are adequate and appropriate to the occupational risks

at 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 the

provision of general health care is not sufficient, the provision of workplace specific

preventative interventions is combined with general curative and preventive care for

workers and their families. Large enterprises usually have comprehensive occupational

health service on their premises where multidisciplinary teams provide a full range of

preventative occupational health interventions and may also provide general health services

to workers and their families. Medium size enterprises may have an in-plant unit that is

staffed by one or more occupational health nurses and a part-time occupational physician or

15

Verbeek, J. Essential occupational safety and health interventions for low and middle income countries, an

overview of the evidence. Report prepared at the request of WHO. Finnish Institute of Occupational Health,

Cochrane Occupational Safety and Health Review Group. Kuopio, 2011

16 Occupational Health Services Convention, 1985, Seventy-first Session of the General Conference of The

International Labour Organization, 7 June 1985, Geneva

47 12

share an occupational health services with other enterprises in the same location or

industry. Hospitals provide services to injured or sick workers who seek care in their

outpatient clinics and emergency rooms but in some cases also operate specialized

occupational health clinics or services including both preventative and curative care. Private

centres are organized by a group of occupational health experts or a private entrepreneurial

organization to provide clinical and non-clinical (occupational hygiene) services to

enterprises. In some countries the primary care centres organized by municipal or other

local authorities or by the national health service provide some basic packages of essential

occupational health interventions to workplaces and work communities.17

The Thirteenth session of the Joint ILO/WHO Committee for Occupational Health in 2003

reviewed a new approach to providing occupational health services proposed by the

International Commission of Occupational health (ICOH). In order to move towards universal

coverage of all workers with occupational health services, ICOH developed the so called

"basic occupational health services" approach. Rantanen defined this approach as a stepwise

development of occupational health services, where the most basic (starting) level uses field

occupational health workers, such as a nurse or safety agent who have a short training in

occupational health and who work for a primary health care unit or a respective grassroots

level facility. The content of such service includes prevention of risks for accidents, healthy

physical work, basic sanitation and hygiene, and dealing with the most hazardous chemical,

physical and biological factors, including HIV/AIDS and referral to specialized services as

necessary.18

The 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 2

depicts the key components of BOHS. The ILO/WHO Joint Committee on Occupational health

specified that the core content of basic occupational health services should include

surveillance and assessment of OSH risks, surveillance of individual worker health, informing

workers and managers on health hazards at work and providing preventative advice on safe

practices.19

17

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, 1998

18 Rantanen, J. Basic Occupational Health Services, 3

rd Edition, Finnish Institute of Occupational Health. Helsinki,

2007.

19 Joint ILO/WHO Committee on Occupational health. 2003. Report of the Thirteenth Session. 9-12 December

2003. Geneva: ILO.

47 13

Basic Occupational Health Services

Risk assessment

and monitoring of the work environment:

•Identification of workers or groups of workers exposed to specific hazards

•Control of causal agents such as dust, harmful chemicals or heat.

•Suggestions for the control of occupational health related risks

•Identification and control of occupational health hazards through the use of personal protective equipment etc.

Health education

and health promotion:

•Workers provided with appropriate information on workplace risks and hazards

•Workers understand the nature and severity of the risks to which they are exposed

•Workers given information to manage, mitigate and avoid those risks by making their working practices safer

Provision of basic

curative services including first aid:

•Provision of first aid as required

•Identification of exposure(s) which may cause occupational disease

•Diagnosis of occupation related disease

•Provision of basic curative health services to treat occupation related diseases

•Reporting of occupational disease and injuries

Adapted from J. Rantanen, basic Occupational health services, 2007

Figure 2 Content of the basic occupational health services

BOHS are supposed to be staffed with a physician and a nurse with short (ten weeks) training

in occupational health as well as support from an expert with competence in basic safety and

accident prevention. The skill mix required for delivery of BOHS includes workplace and

health surveillance, risk assessment, disease and accident prevention, basic occupational

hygiene, general health care (GP level) in occupational medicine and general medicine,

communication, health promotion, self-auditing. Rantanen estimates that a minimum one

physician and two nurses are needed for every 5000 workers with great variation depending

on industrial activities and the size of workplaces and argues that BOHS should be provided

by the public sector, because of the very limited ability of small enterprises, self employed

and informal sector settings to purchase external services.15

47 14

IVIVIVIV.... OOOOccupational ccupational ccupational ccupational hhhhealth ealth ealth ealth in the context of in the context of in the context of in the context of

integrated integrated integrated integrated pppprimary health rimary health rimary health rimary health ccccareareareare

Integrated health servicesIntegrated health servicesIntegrated health servicesIntegrated health services

There 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 that

vertical programmes may be desirable as a temporary measure in the following cases: weak

primary health care, need for a rapid response to a health problem; to address the health

needs of specific difficult to reach target groups, or to deliver certain complex health

interventions that require highly specialized health workforce. In fact, most health services

usually combine vertical and integrated elements, with varying degrees of balance between

them.20

International evidence indicates that a well organized and integrated PHC approach will

deliver better health outcomes in the most efficient and equitable way, at a lower cost and

with higher levels of user satisfaction than other approaches to providing healthcare21. The

effective PHC system should aim to provide universal coverage of services that deliver

comprehensive, integrated and appropriate care over time and that emphasize disease and

accident 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 management

support systems) are provided, managed, financed and evaluated either together, or in a

closely coordinated way. At the macro level of senior managers and policy-makers,

integration happens when decisions on policies, financing, regulation or delivery are not

inappropriately compartmentalized. Organizational integration happens when there are

mergers, contracts or strategic alliances between different institutions. Professional

integration occurs when different health professions or specialties work together to provide

joined-up services. 23

There are strong arguments for integrating some basic services for occupational health into

existing arrangements for providing primary health care. One of the principal advantages of

an integrated PHC approach is that this will enable basic services for occupational health to

20

Atun, R., S. Bennet, A. Duran, When do vertical (stand-alone) programmes have a place in health systems?

WHO Regional Office for Europe, Copenhagen, 2008

21 Is primary care essential? Starfield B., Lancet. 1994

22 Integrated Health Services – what and why, Technical Brief No.1, WHO, May 2008

23 Ibid

47 15

be provided closer to the locations where people live and work and to a much larger number

of workers than currently covered with specialized occupational health services.

A number of countries are testing models to integrate PHC and the basic services for

occupational 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 PHC

and occupational health in order to provide essential occupational health interventions

services to working populations and settings with constrained resources and lack of access

to mutidiciplinary comprehensive occupational health services. An integrated approach

should not try to focus of all aspects of occupational health, but should concentrate on a

highly selective package of essential interventions that would deliver the greatest return.

Some existing public health programmes, such as HIV/AIDS, Malaria, Maternity and Child

Health, have demonstrated ability to quickly reach populations at risk and to provide them

with health information and care. Some of the most successful among these have largely

been vertically funded and managed but integrated with other PHC activities at the point of

delivery. Similarly, essential interventions and some basic services for occupational health

can be effectively integrated into existing primary health care structures and local health

systems could enable similar opportunities for providing target worker populations with a

range of appropriate OSH services. Appropriate integrated models that identify systems,

structures and health worker capacities need to be developed

An integrated approach should have a specific focus on providing services to workers in

SMEs, workers who are self-employed and those in the informal sector in order to be able to

provide these important groups with effective services. The design of such integrated

services should take careful account of what is really needed by workers. Integrating

essential interventions and basic services for occupational health into PHC could lead to

more efficient service delivery and less costly utilization by recipients than providing a

standalone 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 centre

Greater 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 these

47 16

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. The

research there is available suggests that the “move from disease specific programmes to

integrated services has risks as well as benefits and needs to be managed carefully”25

. A

2006 Cochrane Collaboration review of “Strategies for integrating primary health services in

middle- and low-income countries at the point of delivery” concluded:

Few studies of good quality, large and with rigorous study design have been carried

out to investigate strategies to promote service integration in low and middle income

countries. All describe the service supply side, and none examine or measure aspects

of the demand side. Future studies must also assess the client's 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. More

high quality research is needed to be able to draw satisfactory conclusions regarding the

impact 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 Law

and Psychiatry 2000, 23:277-291.

25 Integrated Health Services – what and why, Technical Brief No.1, WHO, May 2008

47 17

IIIIntegratntegratntegratntegrated deliveryed deliveryed deliveryed delivery

In 2011, HLSP Institute at the request of WHO reviewed the different practices for delivery of

essential interventions and basic services for occupational health in settings with constrained

resources26

. The experience from a number of countries around the world in delivering basic

occupational health through integrated PHC was summarized in three main models as

described below.

Model 1: Financing and delivering essential occupational health care through standalone

community based insurance schemes

In India, SEWA is a trade union for workers, mainly women, in the informal sector. It has

introduced a number of community based insurance (CBI) schemes including one for health

cover. Through its health scheme, it has addressed a number of important OSH issues by the

training and development of a cadre of its own, local health workers. The coverage and

operation of the SEWA community based insurance scheme is discussed in more detail in the

country case studies later in the report.

A recent discussion paper by the World Bank’s Social Protection and Labour Division on

community based risk management arrangements noted a number of potential weaknesses

of 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

communities

26

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, 2011

27 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 2008

Community based insurance

Organisation (e.g. SEWA, India) Contributions from

workers

Contribution from

Social Fund?

Defined package of OH care

and prevention offered

through network of own

providers

SEWA Care

provider

SEWA Care

provider

SEWA Care

provider

47 18

Model 2: Publicly funded essential occupational health care delivered by NGOs and private

providers

This approach to delivering care involves contracting NGOs or private providers already

delivering PHC to extend their reach to include the delivery of BOSH services to the target

groups. The reach of government services/funding can be effectively extended through the

appropriate use of non state actors. Experience in Cambodia and in other countries such as

Bangladesh has highlighted the effectiveness of using NGOs to deliver PHC to reach

underserved 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 the

national and intermediate levels to manage contracts and monitor compliance with service

28

Cambodia: Using Contracting to Reduce Inequity in Primary Health Care Delivery, Schwartz B., Bhushan I.,

World Bank 2004

Intermediate level in the health system (e.g. district)

OH funding,

capacity building

and oversight

CSOs or private

providers

Contract management

and funding

Information

Informal & vulnerable

workers

Informal & vulnerable

workers

Essential OH

interventions

Information

MoH and/or MoL

• Sets norms and standards for OH

• Provides funding and capacity building

• Manages/regulates provision of services

by third party providers

Donor funds

Tax revenues &

user fees

47 19

level agreements etc; and the availability of NGOs or private sector providers with the

capability to deliver contractually agreed services.

A 2005 review of the impact of contracting out health service provision in a range of

countries concluded that contracting out for the delivery of primary care “can be very

effective, that improvements can be rapid and that contracting for health service delivery

should be expanded and evaluated rigorously”29. However, it was also noted that many

countries which lack the capacity to organize and deliver basic health services themselves

may not have the means with which to manage contracts with NGO or private suppliers

effectively either.

Model 3: Integrating basic occupational health into state delivered primary health care

29

Buying Results? Contracting for health service delivery in developing countries, Loevinsohn B, Harding A., The

Lancet 2005

Intermediate level in the health system (e.g. district)

OH funding,

capacity building

and oversight

Primary Health Care Facility OH integrated with PHC

Training, capacity

building & supervision Information

Informal &

vulnerable workers

OH

interventions

– preventive

& curative

Information

Ministry of Health

• Sets norms and standards forOH in

partnership with Min of Labour?

• Provides funding and capacity building

• Manages provision of services through

own network of facilities and CHWs

Tax revenues &

user fees Donor funds

Community

health workers

Informal &

vulnerable workers

Preventive interventions

47 20

Model 3 illustrates how basic services for occupational health might be both funded and

integrated into a PHC approach. MoH staff are responsible for developing a package of

essential occupational health interventions in partnership with the Ministry of Labour where

appropriate and, providing adequate training, supervision and funding, managing its

integration with other elements of PHC and then delivering services through a network of

primary care facilities and community health workers.

Conventional public health interventions such as immunization or DOTS treatment for TB

follow a fairly standard format and design that can be relatively easily replicated and

adapted for different country contexts. Whilst, the mode of delivery may need to change

according to the setting in which the intervention is being applied, the essential nature of

the treatment to be applied (i.e. vaccine delivery or the provision of TB drugs) remains

largely the same.

However, the OH needs of agricultural workers in Africa are going to be very different from

those of street vendors or rubbish collectors in India or artisanal fishermen in the

Philippines. This implies that a creative and flexible approach to OH design needs to be taken

that takes into account the OH needs of particular groups of workers and which tailors the

interventions to their requirements. There is therefore no “one size fits all” or standard

approach to designing and developing OH interventions. This will offer a particular challenge

to the health sector. Moreover High level knowledge and skills will be needed to accomplish

this effectively.

It is therefore not possible to be prescriptive about how OH interventions can be integrated

into PHC as health systems vary so widely from country to country. Model 3 attempts to

provide a generalized outline of how integration could be organized. However, the existing

structure of the health system in individual countries and the method of funding health

services 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 as

seamlessly as possible into PHC delivery and funding mechanisms, whilst ensuring that

funding mechanisms do not throw up specific barriers to access. One size will not fit all and

it will be important to adapt the organization and services to the local context.

IntegraIntegraIntegraIntegrated ted ted ted financingfinancingfinancingfinancing

The integration of primary health care services is taking place in many developing countries

around the world. Many of the existing PHC programmes (malaria, reproductive health,

HIV/Aids, TB etc.) are vertically funded and managed interventions which are integrated at

the point of delivery in health facilities or communities. Experience in many countries has

demonstrated that whilst this approach can be very effective it can also lead to a number of

important problems such as poor allocation of funding across programmes (some can be

greatly overfunded and vice-versa), inefficiency and duplication in the use of resources and

real difficulties in getting funding for training and operational costs down to the service

delivery level. These are all important challenges that will need to be tackled when

integrating OH with PHC.

47 21

There are five main health financing approaches which are used to fund healthcare30 (this

analysis does not include financial transfers from donors) and which could potentially serve

as 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 interventions

would have to compete with existing PHC interventions and services for resources. Public

funding of services frequently provides few incentives to improve staff performance and

under performing staff may be difficult to replace. Important issues such as the quality of

care are also difficult to address in a system that does not provide incentives (or

disincentives) 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 in

30

Understanding Health Economics for Development, HLSP CD Rom, 2010

47 22

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 for

informal and migrant workers delivered through a PHC network. Experience there, where

the cost of providing BOSH is shared between the government and employers has

demonstrated that this can be a reasonably effective system for providing services to the

majority of workers. An evaluation of the BOSH scheme in 2008 found that employers had

spent 200 RMB for each worker per year on OH per year (compared with 3000 RMB lost per

worker per year due to occupational disease). However, there were administrative problems

in keeping migrant workers enrolled in the system particularly when they moved jobs

frequently31

.

Community based health insurance - is an emerging approach, which addresses the health

care challenges faced in particular by the rural poor and which helps to address both health

financing and service provision simultaneously (many of the CBI schemes are organized by

local providers of health care). It has grown rapidly in recent years, particularly in West

Africa.

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 the

CBI approach to providing a limited range of OSH services. However, coverage of the scheme

is limited and there are challenges in taking this kind of approach to scale.

Tanzania has developed a social health insurance organization (UMASIDA) targeted at the

informal sector in Dar es Salaam. The scheme provides both health and occupational safety

and health services to its members. It was recognized that access to social services has a

large impact on productivity and organizations of informal workers would be an appropriate

mechanism for providing such services. PHC services are provided through its own network

of dispensaries and by private providers. Secondary level care is provide through

government funded hospitals32

31

Basic Occupational Health Services in Ba’oan, China, Chen Y., Chen J, Journal of Occupational Health, 2010

32 The UMASIDA Mutual Health Care Scheme, A case study of an Urban based Community Health Fund, Kiwara

A, Institute of Develoment Studies, May 2005

47 23

The main advantage of social or community health insurance schemes for informal workers

is that they improve health expenditure efficiency (the relationship between quality and cost

of health services. There are three main reasons why informal workers would prefer group

schemes 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 the

rich, though it may enjoy both direct (tax relief) or indirect subsidies (e.g. through tax

funding of the regulatory system).

Disadvantages – whilst private insurance provides choice and is responsive to patient

needs it introduces serious problems of adverse selection, moral hazard, supports

little risk pooling and has the potential to absorb resources from elsewhere in the

system (either directly or indirectly. It has high administration costs and also provides

an escape route for the middle classes who might otherwise press for better services

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 and

disadvantaged groups of workers given the scale of the costs involved and the disposable

incomes of the workers concerned.

User Fees - In the past user fees were seen as a way of raising revenue and deterring

frivolous 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 or

exemptions are almost always ineffective, although experience in Cambodia suggests that

exemptions may be possible. Recently there has been a strong political shift in favour of the

abolition of fees based, in part, on positive experiences in Uganda. In some countries – most

notably Uganda - the abolition of user fees has been associated with a large increase in

utilization, especially by the poor, although accompanying measures to improve the drug

supply and strengthen financial management also played key roles.

This is not likely to be an effective approach for extending basic OH services to poor and

disadvantaged groups of workers.

33

Working Paper on the Informal Economy The Informal Sector in Sub-Saharan Africa, ILO, 2002

47 24

VVVV.... EEEExamples from xamples from xamples from xamples from countrcountrcountrcountriesiesiesies

This section looks at the approaches taken by different countries to delivering essential

interventions and basic services for occupational health in the context of integrated primary

health care. The case studies were developed by the HLSP Institute and by experts who

participated in the inter-country consultation "Integration of Workers’ Health in the

Strategies for Primary Health Care" organized by WHO and the Government of Chile on 4–7

May 2009 in Santiago, Chile. The available evidence in this area was primarily from

descriptive publications and there was little quantitative data or information available on

key issues such as costs and health impact and outcomes.

United Kingdom United Kingdom United Kingdom United Kingdom ---- working for a healthier tomorrow working for a healthier tomorrow working for a healthier tomorrow working for a healthier tomorrow 34

The UK health-care system is universal and funded from taxation, free at the point of

delivery, and covers the entire population. The National Health Service (NHS) is divided into

primary and secondary care. Primary care is controlled by regional health authorities

through primary care trusts. Primary care is the first point of contact for the public and

includes 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 NHS

was founded, occupational health was not included, as it was seen to be of most value and

concern to industries and businesses, and so to be paid for by employers. The current

coverage of occupational health is about 30% of workers. The trend since the 1990s has

been to outsource in-house occupational health services to external contracted service

units. 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 system

diseases (6%), injury and poisoning (6%) and others (22%). The overall cost of working-age

ill-health is 100 billion pounds per year, and the cost of sickness absenteeism is 13 billion

pounds per year. In addition, there are social problems and consequences beyond the

workplace, e.g. for children in workless families.

At a time when rising dependency ratios and the effects of ever-greater global competition

place huge pressures on economic and welfare systems all around the world, acting to

prevent people from becoming ill at work – and supporting and rehabilitating those who do

become 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, the

economy and the very fabric of society.

Current occupational health structures in the UK may have been right when they were

created, but there is a need now to make sure that they are appropriate for the present and

the future. It is time to reposition and redefine the role of occupational health as an integral

part of the new public health policy for the 21st century, and to reconsider the relationship

34

Contribution from Professor Dame Carl Black, 2009

47 25

between occupational health and the NHS, especially primary care, together with the wider

contribution of occupational health to the national economy.

GPs are critically important colleagues, and need to be supported to change and enlarge

their attitude to work as a desirable outcome of a clinical encounter. There is now clear

evidence that work is generally good for health, and therefore the benefits of work must

feature more prominently in the advice that GPs give to their patients. But general

practitioners cannot be expected to change without being offered significantly more

support. Occupational health has a role in providing such support.

The challenge for a new paradigm of occupational Health is to examine the care pathways

for working people and find new ways to support them before, during and after illness at

work. This will require forging new partnerships and new ways of working across traditional

boundaries. There is a need to bring together at local level anyone with interest or expertise

in occupational health, to find locally tailored and ever more innovative ways to allow

occupational health to make its crucial contribution to the health of the national economy.

Carol Black's report to Government, Working for a healthier tomorrow, published in March

2008, 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 health

and 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 26

• 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 Black's report, entitled Improving health and work:

changing lives, was published in November 2008. The government accepted the broad thrust

and most of the detail of the recommendations in the report. The response sets out new

perspectives on health and work, improvement of workplaces, supporting people to work

and 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; national

standards for occupational health providers; a strategy for mental health and employment; a

national 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. By

improving health and work we will make a real difference to people’s lives.”

Thailand Thailand Thailand Thailand –––– primary care unitsprimary care unitsprimary care unitsprimary care units35

In 2003, the total Thai workforce was estimated at 33.8 million people. Of these, at least 51

per cent worked in the informal sector with approximately 40 per cent of the population

working in agriculture, 16 per cent in manufacturing and 6 per cent in construction. There

were 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 of

health 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, 2009

36 Labour Force Survey. National Statistics Office, Ministry of Information and Communication Technology,

Thailand. http://web.nso.go.th/eng/en/stat/lfs_e/lfse.htm (accessed 29 August, 2007).

47 27

• 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 financing

Following the launch of universal health care coverage in 2002, general health services are

available to all Thai citizens, funded through health insurance. More than 25 million Thais

however do not hold public health insurance (Siriruttanapruk et al, 2006). Migrants who are

registered are able to access general health services through the Compulsory Migrant Health

Insurance (CMHI) scheme but this is not available to migrants who are not registered.

Unregistered migrants pay for services out of pocket although hospital exemptions are

available and international donors provide health services in many areas where migrants are

concentrated in addition to some provinces providing voluntary health insurance schemes to

the unregistered (IOM/WHO, 2009).

Health services are also provided by private providers under the supervision of the MOPH

and other public agencies such as the Ministry of Defence who provide services to officials

and their families and the public37.

Occupational Safety and Health in Thailand

Responsibility for occupational health and safety in Thailand is divided between three

government ministries. The Ministry of Labour enforces OSH regulations and undertakes

workplace safety inspections. The Ministry of Industry is responsible for enforcing the

Factories Act which covers workplaces with large machines and/or more than seven

workers. The Ministry of Public Health provides technical support for occupational health

services in five main areas: occupational disease surveillance; technical support;

development of OSH guidelines; training of health care workers; and research and

development.

Traditionally, OH services in Thailand have been provided through provincial and regional

public 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 the

means available to monitor occupational safety risks in the workplace. The public health

office in each province has a specialist in occupational and environmental health that is

responsible for developing OSH strategies for each province.

Role of Primary Care Units (PCU) in providing basic occupational health

In order to improve the coverage and availability of OH services an initial, strategy of using

PCUs to deliver both PHC and basic OH services was developed. A pilot project was

established by the MOPH in 2004 to test a model which integrated occupational health

services into the existing public health system and which assessed the capacity of PCU staff

to deliver OSH services. The model was found to be reasonably effective and it was

demonstrated that staff in PCUs were able to effectively deliver both PHC and basic OSH

services.

PCU staff undertake OH outreach visits to workplaces - these tend to be mainly factories or

other formal work settings. However, workers in the informal sector would often still find

37

Integrating Occupational Health Services into Public Health Systems: A Model Developed with Thailand’s

Primary Care Units, Somkiat Siriruttanapruk and team Ministry of Public Health, Thailand, ILO (2006)

47 28

difficulty in accessing OH services due to their dispersed, sometimes difficult to reach work

locations 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 of

delivering 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 equipment

Health 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 the

government) were trained to work with occupational health teams to provide basic OSH

services in addition to PHC. The rationale behind the strategy is that by up-skilling the large

network of health volunteers to provide PHC and OH services, local needs can be met more

effectively and services provided more efficiently to workers in the informal economy. In

some of the test locations, health volunteers have been involved in providing workplace

safety improvements and in reducing the use of dangerous chemicals and pesticides.

Finland Finland Finland Finland ---- municipal health centresmunicipal health centresmunicipal health centresmunicipal health centres38

According to the Primary Health Care Act the entire Finnish population is covered by primary

health care services provided by municipal health centres. Finland has had a special

legislation on occupational health services since 1978 and it was revised in 2001. The law

obligates the employer to organize preventive OHS for his/her employees by using

competent occupational health personnel (OHP + OHN) and according to need other

experts, such as hygienists, psychologists, physiotherapists/ergonomists etc.. The obligation

is universal in all sectors, private and public, regardless of the size of company, geographical

location 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/she

has provided to employees.

The law requires preventive content of services, including among others workplace

surveillance, risk assessment, accident prevention, ergonomics, surveillance of health,

promotion of health and work ability of workers and advice, information and education of

occupational health, and safe and healthy working practices to workers and employers. The

employer is entitled to provide also GP level curative services for his/her employees in

connection with occupational health services and about 80% of them do so. The employer is

entitled to buy services from any of the competent and registered occupational health

service units, organize own in-company services, group services, or buy the services from a

private occupational health centre or from a municipal health centre.

The municipal health centres have a legal obligation to provide occupational health services

to anybody who is interested in getting them. Virtually all farmers and self-employed who

are covered by OHS are served by municipal health centres and for farmers the preventive

OHS workplace visits by experts are provided free of charge.

38

Contribution from Professor J. Rantanen, 2009

47 29

The coverage of Finnish OHS is one of the highest in the world, about 85% of all (including

self-employed) and about 90% of the workers employed by the employer. The coverage of

services is 90 to 100% of companies with 10 workers and more, while the coverage of

companies decreases substantially among the SMEs and self-employed being on average at

the level of 60%.

The municipal health centres (primary health care units) have occupational health physician

and 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 regional

offices of occupational health (FIOH).

The experiences from provision of services by PHC units are positive. The municipal health

centres accommodate 29% of all occupational health service units in Finland and provide

occupational health services for 32% of all workers covered by OHS and for 61% of all

enterprises.

Obstacles are the thin resources and shortage of service time of OHS personnel and

tendency to prioritize the worker-oriented health service provided from the centre at the

cost of preventive interventions to the work environment, which would require more active

visiting at the workplaces.

Indonesia Indonesia Indonesia Indonesia –––– occupationoccupationoccupationoccupational health posts in the informal sectoral health posts in the informal sectoral health posts in the informal sectoral health posts in the informal sector

Indonesia is the fourth largest country in population terms after China, India and the USA. In

2008, its total population was 228 million39. The total labour force (15 years and above) was

approximately 108 million in 2007. In 2006 it was estimated that about 63 percent of

Indonesia’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: health

centres (PUSKESMAS), sub-health centres, mobile units and community based activities at

the village level. PHC and OH services are co-funded by central and local governments. A

typical health centre is led by a medical doctor supported by a range of health and other

professionals. It is responsible for providing preventative and curative services to the

community including OH together with activities aimed at health promotion, education and

empowerment41.

In 1980 Indonesia introduced Occupational Health Posts (OHP) at the community level. It is a

self-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 related

disease together with preventive and educative interventions intended to encourage

workers to use appropriate safety equipment. Service provision is intended to be integrated

within the PHC approach. Significant progress has been reported to-date in rolling-out the

basic OSH training required by staff at all levels of the health system in order to implement

the OHP approach42.

39

Indonesian Country Paper on the Informal Sector and its Measurement, BPS-Statistics Indonesia, May 2008

40 The Informal Sector and Informal Employment in Indonesia, ADB Country Report, 2010

41 Revitalizing Primary Health Care, Indonesia Country Experience, WHO Regional Conference, Aug 2008

42 Ibid

47 30

By 2008 it was reported that over 8,000 OHPs had been established although problems with

funding had been experienced. The provision of occupational health has not yet been

included in the basic PHC package of care in Indonesia and the support and financing of basic

OSH 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 that

appropriate structures are in place to provide training and supervision and also that funding

for OSH is included in overall PHC allocations.

China China China China ---- pil pil pil piloting oting oting oting basic occupational health servicesbasic occupational health servicesbasic occupational health servicesbasic occupational health services44

The economic reforms and industrialization over the last 25 years in China have resulted in a

substantial increase in the numbers of migrants moving from rural to urban areas of the

country45

. A rigid system of household registration (Hukou) that only allowed people to

access social services in the areas where they are registered has been applied. Whilst this

has begun to be relaxed in a number of cities, it has still been identified as an area of

concern. As migrants generally retain their rural registration, they are often excluded from

accessing services in the areas to which they migrate, including health care and occupational

health services. In 2008 health insurance coverage was only 19% among rural migrants

compared to 58% of urban residents whose cover was generally linked to the place of

work46.

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 Chinese

that hospital is best and that the quality of care provided by hospital specialist is superior to

that of general practitioners. The creation of a comprehensive primary health care system is

the centre piece of China’s health care reform announced in 200947

.

The State Administration of Work Safety, a ministerial level national authority directly under

the State Council, is responsible for workplace safety and health inspection, and for ensuring

compliance with OSH provisions at provincial, city and country levels. The labour

inspectorates enforce the implementation of various laws and regulations through

supervising employers in order to establish and standardize labour contracts and collective

contracts48

.

Workers in SMEs, including migrants however have limited coverage of OSH which is

attributed 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 in

occupational health for informal sectors in Indonesia, Hanifa M. Denny, College of Public Health, University of

Florida (on-going research project)

44 HLSP analysis

45 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): 189–197

46 Ibid

47 China’s primary health-care reform, Liu Q., Wang B., The Lancet, March 2011

48 Zhu, C (2008) Labour protection for women workers in China, Asian-Pacific Newsletter on Occupational

Health and Safety;15:47

47 31

• The small scale of SMEs making it difficult to provide in house services like larger

companies.

• Human and financial resources constrain the government’s ability to provide OSH

services through the health system.

A gradual shift has been identified since 2000 where migrants are being increasingly seen as

a vulnerable group with growing support for improving their access to public services,

including OSH from the general public. Data on occupational health and injury rates in

general in China is unreliable as the information is collected by a number of agencies with

incomplete reporting. This is exacerbated among migrants who do not necessarily seek care

from hospitals (ibid). Clearly a major challenge in the Chinese context is in being able to

collect and utilize accurate data on OSH. This will require better integrated and more robust

data collection systems. These should enable improved identification of need and better

planning of services.

In China, migrant workers are not eligible for Government Employee Insurance which covers

public servants working in state institutions or Labour Insurance which is a work unit based

self-insurance system that covers medical costs for the workers and often their dependents

as well. (These are the main types of insurance available for employees with Hukou).

Migrant workers are also not eligible for the New Rural Cooperative Medical Insurance as

they live and work in the city49 (Mou et al, 2009).

In 2006, the Ministry of Labour and Social Security developed plans to expand health

insurance to include migrant workers with the aim of having 20 million migrant workers

enrolled by the end of 2006 and almost all by the end of 2008. Urban governments have

employed a variety of methods to greatly increase access of migrants to insurance although

this varies between cities. Monitoring and prevention of occupational health risks is included

as a goal of health system reform. China has piloted several schemes to extend the provision

of basic OSH to its large migrant population. In 2006, the MOH launched a Basic

Occupational Health Services programme in 19 pilot counties in 10 provinces. This was then

expanded to 46 counties in 19 provinces in 201050.

Bao’an county has a large migrant population who mainly work in SMEs (considered in China

to be enterprises with less than 2000 employees and an annual revenue of less than 400

million RMB)51 . A pilot scheme to test various models for providing OHS and primary care

services to groups including migrants at different levels was begun in 2008. The objectives of

the pilot were: to develop working mechanisms for resource allocation; improve multi-

sectoral cooperation and participation of workers; expand coverage of compulsory work-

related injury insurance; expand OSH service delivery; integrate occupational health service

into primary health care at county and community level and to provide OSH training52.

49

Health care utilisation amongst Shenzhen migrant workers: does being insured make a difference?, Mou J et

al, BMC Health Services Research 2009, 9:214

50 Migration and health in China: challenges and responses, Holdaway J, & Krafft T, International Human

Dimensions of the Programme on Global Environmental Change, Issue 1, 2011

51 Basic Occupational Health Services in Ba’oan, China, Chen, Y; Chen, J, Journal of Occupational Health; 52: 82-

88

52 Dr Jian, F (undated) Basic occupational health services in China, Reports from the WHO regions and from ILO,

WHO WPRO

47 32

Ba’oan is divided in to towns and communities with a Centre for Disease Control and

Prevention (CDC) at the district level, an institute of health care and prevention at the town

level and at least one health service centre at the community level42. This structure allows

BOSH to be integrated with the primary health care system which follows the same

structure. Three levels of service are provided:

• Tier 1 – (Lowest level) are the community health service centres which provide services

to all workers. Services include:

o general health examination

o first aid services

o health promotion

o OH education.

• Tier 2 (Intermediate level) comprises the institutes of healthcare and prevention in the

towns of Ba’oan which provides services to workers not exposed to serious

occupational hazards. Services include:

o OH and general health examinations

o surveillance of working environments

o proposing prevention and control actions to eliminate health hazards

o record keeping

o health training for workers and education.

• Tier 3 – (Upper level) - the Centre for Disease Control and Prevention (CDC). Its main

role is to provide services for workers in workplaces with serious potential risks and

those exposed to serious hazards

o OH examination and potential referral to specialist occupational medical

clinics for treatment.

o surveillance of the working environment

o dealing with major OH accidents

o risk control and assessment

o providing information and training for basic OHS personnel.

How is the pilot scheme funded?

Under the BOHS scheme in Ba’oan, the cost is shared by the employer and the government

with employers being responsible for the surveillance of workers health and the working

environment. Basic occupational health training, education and relevant tools were provided

by the government which also offered BOHS to those who were self-employed or working in

informal factories. An evaluation of the BOHS scheme in 2008 found that employers had

spent 200 RMB for each worker per year on OH per year compared with an estimated 3000

RMB lost per worker per year due to occupational disease53.

Level of integration with other parts of the health system

Under the Ba’oan scheme, OSH services were provided through a “primary health care

approach”. Specific OSH staff were appointed as occupational health personnel at all three

levels of the scheme although it is not clear if those staff had a wider health role. A

government steering group including the district governor, Bureau of Health leaders and

other government offices, such as finance and industry, was established. The group was

53

Basic Occupational Health Services in Ba’oan, China, Chen Y., Chen J, Journal of Occupational Health, 2010

47 33

responsible for organizing OHS and ensuring financial and human resources to support the

basic OSH system.

Information and reporting

Where community health service centre physicians and nurses decide that an illness might

be associated with work, it is reported to the Institutes of Health Care and Prevention to

investigate and make a definitive diagnosis. Where surveillance of workplaces has resulted in

the identification of serious hazards, they are reported and improvements required.

An evaluation of BOSH in Ba’oan found that knowledge and recognition of occupational

diseases had increased significantly in 2008 compared with 2006. Coverage rates of factories

with OHS increase from 35% in 2006 to 82% in 2008 while the coverage rate of workers with

health surveillance increased from 29% to 81%. However it was found to be difficult to

provide cover for all workers including those who changed their jobs and workplaces often

sometimes as much as three or more times a year54. The reasons for this were not explained

but it seems likely that the administrative complexities of transferring workers from one

workplace to another and possibly from one insurance scheme to another proved

overwhelming.

Brazil Brazil Brazil Brazil –––– family health family health family health family health teamsteamsteamsteams55

PHC is at the centre of the Brazilian health system and it is delivered by a government

funded Family Health Team (FHT) comprising a General Practitioner (GP), public health

nurse, dentist, community health agent and a nursing assistant. The FHT is responsible for

delivering PHC and OSH services to 800-1000 families56. All members of the FHT receive

training in OSH from OH trained physicians. The target groups for BOSH are mainly the self-

employed and the informal sector. Large enterprises in Brazil are responsible for organising

the delivery of OSH services to their employees.

The activities of FHTs however vary according to the local conditions and population. Health

promotion and prevention are the responsibility of the FHT health agent. By 2011, the aim is

to provide OSH services through 70% of the FHTs. Key OSH services provided by the FHTs

include: registering occupational accidents and diseases; following up on the health of

workers; visiting workplaces and implementing prevention measures57

.

Tanzania Tanzania Tanzania Tanzania ---- essential health interventions and essential health interventions and essential health interventions and essential health interventions and community based community based community based community based

insuranceinsuranceinsuranceinsurance

In 2000 the Ministry of Health adopted a national package of essential interventions58. The

package is an integrated collection of cost-effective interventions that address the main

54

Ibid

55 Contribution from Claunara Mendonça, 2009

56 The Primary Health Care Strategy in Brazil, Dr Luis Rolim Sampaio, National Director of Primary Care, Nov

2006

57 WHO/ Government of Chile (2009) Integration of workers health in strategies for primary health care, global

inter-country consultation, 4-7 May, Santiago de Chile

58 The United Republic of Tanzania, Ministry of Health, National Package of Essential Health Interventions in

Tanzania, Dar es Salaam, January 2000

47 34

diseases, injuries and risk factors, plus the corresponding diagnostic and health care services.

The interventions are clustered into five groups: (1) reproductive and child health; (2)

communicable disease control; (3) non-communicable disease control; (4) treatment and

care of other common diseases of local priority within the district, e.g. eye disease, oral

conditions; and (5) community health promotion and disease prevention. The latter covers

essential interventions for water hygiene and sanitation, health education, school health as

well as occupational health and safety. The essential occupational health and safety

interventions are defined according to the level of delivery:

• community - safety measures, such as wearing safety gears, substituting toxic to non-

toxic materials, establishing first aid service

• dispensary/health center - dissemination of education and information materials,

supervision and monitoring

• district hospital - periodic medical examinations of workers; treatment of

occupational diseases, training of safety officers in first aid, training of workplace

safety committee members in occupational safety measures.

For each level the package also defines the activities, inputs, outputs and indicators. The

package is a way of ensuring that the most important services get also the highest priority in

terms of financing.

The UMASIDA is an umbrella health insurance organization for the informal economy in Dar

es Salaam, Tanzania. UMASIDA is an abbreviation in ki-Swahili (Umoja wa Matibabu katika

Sekta Isiyo Ra smi Dar es Salaam), which means in English: health care community fund for

the informal sector in Dar es Salaam. It grew out of an ILO/UNDP project that, in 1994-96,

experimented with the provision of integrated services for the urban informal sector in

Bogota, Dar es Salaam and Manila.

The main objective of the scheme is to provide health care to all its members and their

families on an insurance basis. One of the innovations of the project was that it not only

concentrated on economic services, such as the provision of credit and training in finance,

production, management and marketing, but also on social services, such as access to health

care as well as occupational safety and health measures. The idea behind this concept is that

access to social services has a strong impact on productivity, and that organizations of

informal sector workers would be an appropriate vehicle for organizing such services.

Initially the scheme relied solely on private providers for care to its members. Contracts

which guided care contents were signed between UMASIDA and the providers. Now

UMASIDA has its own dispensaries in Dar es Salaam, Arusha and Moshi. Its members receive

care from this combined system. Secondary level care is provided through government

hospitals

Before the scheme could become operational it was necessary to train both the beneficiaries

and providers on the dos and don’ts of mutual health schemes59. The main messages were:-

For the beneficiaries:

• Resist overuse of service.

• Consult provider only when necessary

59

The UMASIDA Mutual Health Care Scheme, A case study of an Urban based Community Health Fund, Kiwara

A, Institute of Development Studies, May 2005

47 35

• Overuse means higher premiums on your part

• Don’t facilitate provision of care to unentitled people

• Pay your premiums on time

• Always present your identity at the point of services for you and your families if

you observe the above factors.

For the providers

• Always ask for identity before providing services

• It is necessary to fill all the forms presented to you by those seeking care.

• Restrict prescriptions to the WHO approved essential drugs list.

• A functioning Health Insurance System is an assurance that you will continue

to get patients whose services are prepaid.

IndiaIndiaIndiaIndia –––– SEWA, a SEWA, a SEWA, a SEWA, a community based insurance approach community based insurance approach community based insurance approach community based insurance approach

The informal sector in India employs an estimated 260 million workers out of a total working

population estimated to be 500 million60

. The majority of them are poor and have little or

no access to social security or to healthcare. The main causes of occupational disease related

morbidity and mortality in India are silicosis, musculoskeletal injuries, coal workers’

pneumoconiosis, obstructive lung diseases, asbestosis, bysinosis, pesticide poisoning and

noise induced hearing loss61.

Only workers in four sectors: mining, factories, ports and construction are currently covered

by existing OSH legislation and regulations in India. Factories and mines are the focus of the

major OSH legal provisions for workers’ health. However, the majority of workers in India do

not work in either of these work settings and so have little legal protection. There is clearly a

need to extend legal protection to include these unprotected workers.

Provision of public OSH services is very scarce although the Government of India’s Eleventh

Five Year Plan 2007-12 does include some ambitious objectives for improving OSH including

the introduction of no-fault insurance schemes for workers in the formal and informal

sectors. Government spending on occupational health in India is very low. The provision of

OSH services is not integrated with PHC and the responsibility for it lies with the Ministry of

Labour not the Ministry of Health.

SEWA was established in 1972 is a trade union for workers, mainly women, in the informal

sector. In 1992, SEWA Insurance, a community based insurance scheme was launched for its

members and provides; life, hospitalization and asset cover. The health insurance

component is the most popular service offered, although members find it more difficult to

access this component compared with life and asset protection62. However, as with many

health insurance schemes only hospital care is provided under the health insurance plan as

this tends to have the highest cost and potential to have a catastrophic impact on a poor

family’s finances.

60

CIA World Factbook, 2007

61 Do occupational health services really exisit in India?, Pingle S, Reliance Industries Ltd

62 Tara Sinha, M Kent Ranson, Mirai Chatterjee, Akash Acharya And Anne J Mills (2006) Barriers to accessing

benefits in a community-based insurance scheme: lessons learnt from SEWA Insurance, Gujarat, Health Policy

Plan. (March 2006) 21 (2): 132-142.

47 36

As it is impossible to prevent all occupational injury and sickness, SEWA has provided

insurance against occupational injury and illness since 1994 as part of its integrated

insurance scheme. The cost of seeking any medical treatment is met through the SEWA

health insurance package. The combined cover helps an injured person to avoid further loss

of income in addition to that already caused by the illness or injury.

Lowering the cost of medical treatment through the provision of a community based

insurance approach also provides a significant incentive for workers to seek medical

attention when required rather than continuing to work and potentially suffering additional

health problems63. Workers are more likely to access PHC/OH services and seek appropriate

preventive and curative services. Well integrated PHC/OH services that are easy to use and

which provide effective treatment and advice are much more likely to be used and to deliver

better health outcomes.

SEWA has also addressed a number of important OH issues through the training and

development of a cadre of its own, local health workers. These provide SEWA members with

OSH related health education and preventative health care and are also promoting the use

of personal protective work equipment . The SEWA health workers also provide curative

care from their homes or from a health centre run by them where low-cost generic drugs are

dispensed at cost to members (Raval 2000).

OH related activities include: tuberculosis screening for workers at risk from occupational

causes, eye check-ups and a monthly mobile van out-reach service to remotely located salt-

workers. Other activities such as improving access to water and the promotion of stress

relief activities are undertaken. These also indirectly reduce the risk of injury and illness

associated with fatigue and stress caused by paid and unpaid work activities which may have

an impact on occupational health.

Recognizing that the national compensation system fails to cover informal workers and that

SEWA in conjunction with KKPKP (an association of informal scrap collectors and waste

pickers) has collaborated with design institutes in India to produce equipment for informal

workers that better meets their needs. For example, gloves which do not get too hot have

been designed for waste pickers, together with handcarts suitable for use by women.

SEWA’s integrated insurance packages, together with its provision of low cost, high quality,

health care at the community level have helped to ensure that poor, working women are

able to afford and access PHC and basic OSH services where they live and work. “The health

insurance has helped to address members’ concerns that the majority of what they earned

was spent on health care and by reducing the personal income costs associated with

occupational injury and illness”64. Some of SEWA’s poorest members may find even the low

insurance premiums charged by the organization beyond their means and are excluded from

cover65.

However, there have been some concerns expressed regarding the extent to which

information collected on OSH injuries and diseases amongst SEWA members is used to

63

Francie Lund and Anna Marriott (2005) Occupational Health and Safety and the Poorest: Final report of a

consultancy for the Department for International Development

64 Ibid

65 Livelihood security through community based health insurance in India, Chatterjee, M and M.K. Ranson,

Global Health Challenges to Human Security, Harvard, 2003

47 37

effectively design preventive interventions. This is essential if an effective package of OH

interventions and care is to be delivered and integrated into SEWA’s community health

programmes.

ChileChileChileChile –––– a a a a dual social dual social dual social dual social and and and and private health insuranceprivate health insuranceprivate health insuranceprivate health insurance approach approach approach approach

Primary health care coverage in Chile is high. There is a dual healthcare system which allows

Chileans to opt to be covered by the government run National Health Insurance Fund (NHIF)

or by a private insurance provider. An estimated 68 percent of the population is covered by

the NHIF government, 18 percent by private insurance companies and the remaining 14

percent is provided by not-for-profit agencies or is uncovered66. Due to the multiple

provider arrangements, the public and private health systems in Chile operate almost

independently from one another – there is little coordination to achieve common health

objectives.

In contrast to the public sector, the private health care system has largely neglected the

development of PHC and instead has concentrated its resources in the hospital sector. PHC

services are provided by a network of health centres and health posts located in rural and

urban areas. Health posts are the first point of contact and refer patients to health centres.

OSH services in the formal sector are covered by mutual insurances (covering 40% of

workers), the rest are covered by PHC centres funded by the NHIF. Eighty eight percent of

enterprises in Chile employ less than 10 workers. There are a number of programmes being

developed by the public health sector which focus on integrating OSH and PHC services;

recognizing and diagnosing OH diseases; developing health education programmes; health

surveys and providing services to vulnerable groups.

The health sector is undergoing reform and OSH services are being increasingly integrated

into PHC. These reforms aim to improve equity, increase coverage to underserved groups,

prevent occupational disease and promote OSH.

The Netherlands The Netherlands The Netherlands The Netherlands ---- treatingtreatingtreatingtreating the the the the "blind spot""blind spot""blind spot""blind spot"67

During the 80s and 90s The Netherlands were often called ‘The sick man of Europe’, because

of the high percentages of sickness absence and work incapacity (almost 1 million for a

workforce of 6 million). Therefore, during the last two decades many legal and

organizational reforms were undertaken regarding social security, occupational health and

the general health systems. The Working Conditions (ARBO) Act from 1981 focused on

prevention.

The 1994 reform introduced the obligation for employers to take care of their employees

during sick leave. They were required to contract an occupational health service (OHS).

Within some years coverage rose from about 40% to more than 90%. Occupational health

services are general, regional, sector or company oriented and provide comprehensive,

multidisciplinary occupational health care, including primary prevention (advising employers

about working conditions), helping employers manage sickness absence and offering

66

Health care reform in Chile, Gabriel Bastias & Tomas Pantoja, Canadian Medical Association Journal, Dec

2008

67 Contribution from Peter Buijs,2009

47 38

support to employees on sick leave to return to work. 1994 also changed the OHS from

exclusively not-for-profit establishments to a mixed system of profit-oriented and not-for-

profit services. In 2005 the Arbo Act was liberalized, giving employers more choice and

making some services voluntary or subject to agreement between social partners. This

slightly diminished OHS coverage.

The social security system for work and health is regulated mainly by the Sickness Absence

Act (SAA) and Work Incapacity Act. This system was also reformed substantially during the

beginning of the 90s. A crucial feature of this reform was the shifting of costs of workers'

health from collective sickness absence funds to individual employers. Employers are now

paying the salaries during sick leave. Starting with six weeks for companies with more than

15 employees, and two weeks for the others (1994), that period has been extended in 1996

to one year and in 2004 to two years for all companies. This has substantially increased the

employers' interest in reduction/ prevention of sickness absence and premature work

disability through improving working conditions, better sickness absence management,

medico-social support to employees on sick leave and stimulating a return to work.

Unfortunately, some employers are reluctant to employ people with a possible medical

condition, despite a legal ban on medical pre-employment assessment (except for certain

high-risk functions/jobs).

When after two years an employee is still not capable of work because of health problems,

salary payment by the individual employer is taken over by the collective Work Incapacity

Act. This requires an independent assessment of the employee’s health and functional

capacity and of the employers’ efforts to facilitate work resumption e.g. by adapting specific

working conditions, hours etc. The 2004 Gatekeepers Act introduced duties of employers,

employees and the OHS during the first 4-6 weeks of sick leave. All these reforms led to a

dramatic decrease in the rates of sickness absence and work incapacity.

The 1994 reform caused some problems in occupational health care, such as

commercialization, high turnover of occupational physicians, lack of clarity about their tasks

and position, bias and ethical considerations of being too close to the (paying) employers.

There is still a wide gap between primary care/general medical practice and occupational

health care. This is on the agenda of the government employees, employers, and healthcare

organizations. There is already a consensus about the following major problems to be

addressed:

• Little attention and expertise on work - health problems (‘Blind Spot’);

• Poor coordination with occupational health care/physicians;

• Inefficiency (waiting lists, only ‘open’ Monday till Friday, 8-17 hrs etc.)

• Little attention for the worker’s perspective and empowerment.

Dutch workers with health problems do not have to visit a general practitioner for

certification of sick leave and have mostly free access to an occupational physician, or so

called ‘work health expert’. Nevertheless, they usually contact their GP first, often weeks

before seeing an occupational physician. Though GPs are in a good position for early

detection and intervention at work-related problems, many have that ‘Blind Spot’ for

occupational health. The result is incomplete medical history, false diagnosis, inadequate

therapy, referrals to health care providers with long waiting lists or without competence in

occupational health; unnecessary absence from work for clinical examination, and

medicalization of complaints without a medical cause, such as disturbed work relations.

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Combined with healthcare inefficiency, this can cause unnecessary and long sick leave, work

incapacity, unemployment, loss of health and well being, and eventually even premature

death.

In 1997 the Dutch Centre for Occupational Health TNO carried out a state-of-the art study on

occupational health care and general practice and presented the results to the ministers of

health and labour and to the presidents of the organizations of general practitioners and

occupational physicians. The study reconfirmed the existence of Blind Spot, poor

cooperation and indicated obstacles and prerequisites. It also found that more than 80% of

the occupational physicians and general practitioners want improvement.

Based on TNO's research, the professional organizations agreed to a common vision,

regional meetings and demonstration projects including occupational physicians in some

primary health care centres. Other pilot initiatives, funded mostly by the government,

included developing general or specific coordination guidelines, e.g. for fatigue and

musculoskeletal disorders (including modules for cooperation between occupational

physicians and general practitioners in medical curricula), an occupational history

questionnaire, and a guide for workers' empowerment. However, preliminary evaluations

found too little change in the daily practice of occupational and general health care

providers; financial support was discontinued and most instruments were not implemented.

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VIVIVIVI.... ConclusionConclusionConclusionConclusionssss and recommendationsand recommendationsand recommendationsand recommendations

The inter-country consultation "Integration of Workers’ Health in the Strategies for Primary

Health Care" was organized by WHO and the Government of Chile on 4–7 May 2009 in

Santiago, Chile with the purpose to review countries’ experiences in integrating occupational

health services and PHC to expand coverage among underserved sectors and workers. The

consultation was attended by 24 experts in occupational health and social determinants of

health representing government and academic institutions from twelve countries, WHO and

ILO68

.

Conclusions:

1. The working population, like any other subpopulation, has the right to the highest

attainable standard of physical and mental health. This right should not be limited to

conditions of formal employment. Almost half of the working population do not have

formal employment and are exposed to risks in the course of their work. Occupational

health is needed not only to increase their productivity but also to allow them to fully

exercise their right to health and to favourable working conditions.

2. The health of workers is an essential prerequisite for societal productivity, and

therefore services to protect and promote workers’ health contribute to overall

economic and human development.

3. Insufficient connections between the world of health and the world of work may

jeopardize the health and well-being of the working population. There is a gap in the

public policies for health and labour, and this requires strengthening the collaboration

between both sectors. There are some good examples of establishing institutional

arrangements for such collaboration.

4. Up to now primary care development has not paid much attention to the specific

health needs of workers. The development of health systems does not take sufficient

account of the needs of the working populations as opposed to other high-risk

populations.

5. The ongoing process of renewing PHC and reforming health systems provides an

opportunity to rethink and scale up the provision of health services to the working

population. Failure to consider the health needs of workers may have long-term

unfavourable consequences for public health.

6. PHC development can improve workers’ health by providing basic occupational health

services, referral services and specialized occupational health services to more people

than by traditional ways. There are a number of suitable models depending on the

characteristics of the working population and the types of health systems in the

countries.

68

Integration of workers’ health in strategies for primary health care. Report of Global Intercountry

Consultation organized jointly by WHO and the Government of Chile, 4–7 May 2009, Santiago, Chile. WHO,

Geneva, 2010

47 41

7. It is feasible to integrate the provision of occupational health services and primary

care. This has already been done widely in a number of countries as demonstrated by

the cases presented at the meeting. Policy support, capacity building, worker

participation and adequate resources are key factors for the success of such horizontal

integration.

8. The renewal of PHC is a process that allows for integration of occupational health at

the primary, secondary and tertiary levels of health service delivery. This process is

undertaken step by step; it may start with promotional activities and then move on to

service provision.

9. Providing comprehensive health care at the primary level requires an occupational

health component. This is an important tool also to address the social determinants of

health at working age.

10. Good occupational health can stimulate the development of PHC and health systems

strengthening. It can reduce the disease burden and provide opportunities to improve

public health and to implement essential health interventions, e.g. tobacco control and

HIV prevention and treatment.

11. Furthermore, providing occupational health services to all workers contributes to

achieving the goals of equity and universal coverage and brings prevention and

promotion to primary care

12. The majority of workers, such as those in the informal economy, are not covered by

occupational health services and even not with general health care services. The

increasing mobility of workers requires new solutions, such as networking, for

providing these services. Workplace-based services do not provide complete solutions.

A complementary territorial approach to providing health services to workers could

overcome this problem.

13. Strong public policies, infrastructure, competent human resources and adequate

financing mechanisms are features common to all countries that have achieved

satisfactory coverage of and access to occupational health services.

14. Improving the training of primary care providers in the area of occupational health and

employment-related health aspects is an essential first step in integrating occupational

health and primary care.

15. Research on organizing occupational health services and their integration with PHC

should be strengthened in order to provide sufficient evidence for implementation of

the WHO strategies in this field.

Recommendations

1. PHC policies should take into account workers’ health needs and are particularly well

placed to reach out to workers not covered by the current occupational health

services.

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2. Models and good practices for provision of PHC-based occupational health services

which were described at the meeting should be systematically analysed and

disseminated. Specific recommendations will be developed on integrating occupational

health and primary care, through regional meetings and reviews of experiences.

3. The broad spectrum of stakeholders should be engaged in the discourse on PHC and

occupational health, and governments need to take responsibility and be accountable

for addressing workers’ health, including inequalities.

4. Policy development at the national level should be stimulated through particular

efforts by ministries of health to improve PHC and develop it further, taking into

consideration the health needs of the working populations.

5. At the local level there is a need to improve the performance of primary care services

in addressing the health needs of workers, including:

• developing models and standards for providing occupational health services

under the primary care centres and community health services;

• building human resource and institutional capacities of primary care for

addressing the specific health needs of workers;

• establishing mechanisms for intersectoral collaboration on providing health

services to all workers;

• enhancing the participation of workers and working communities in the

planning, implementation and evaluation of health services.

6. Ministries of health have a very important role to play in protecting and promoting the

health of all workers by integrating occupational health services into primary care and

placing emphasis on primary prevention, including:

- developing PHC-based systems and structures that address the specific health

needs of working populations with emphasis on prevention and promotion;

- establishing national centres of excellence and capacities for preventing and

mitigating work- and employment-related health problems;

- developing human resources for occupational health;

- coordinating with other governmental agencies;

- providing for participation of workers and social partners in the development of

policies regarding workers’ health;

- stimulation and funding of research needed for implementing the WHO strategies

in this field

7. Other stakeholders, such as labour and social security, as well as the social partners,

should be fully engaged in the discourse on providing PHC-based services to all

workers, e.g. through a global stakeholder forum to be convened by WHO.

8. The lessons learned from developing PHC since 1978 and the reasons for failures with

regard to workers’ health should be further examined.

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9. Success stories on how workers’ health can be improved using PHC approaches should

be identified and disseminated.

10. Mechanisms and procedures should be established to take into account work-related

health issues at the first point of contact of individuals and communities to the health

system.

11. The experience of the participating countries in integrating occupational health and

primary care should be systematically described and made widely available.

12. Mechanisms for intercountry collaboration, exchange of experience and joint research

should be established at the regional and global levels.

13. WHO, ILO and other international organizations, including international professional

NGOs (nongovernmental organizations), the International Commission on Occupational

Health and Wonca (World family doctors Caring for people), are urged to provide

coherent support to national policymakers to integrate occupational health in the

policies for PHC.

14. WHO is invited to establish an international working group to develop concrete

recommendations for integrating occupational health in the policies for PHC based on

the available evidence, good practices and lessons learnt.