Occupational Health Education

for Primary Care Physicians in India

Mission BOHS

Dr. Suvarna Moti Technical Expert

Indian Association of Occupational Health

Mission BOHS

________________________________________

Public Health & Performance Analytics Specialist

Reliance Industries Limited, India

Zagreb

October 27, 2017

Labor Force Projections Based on the Annual Average Growth Rate (1983 to 2009-10) (in Million)

Report of the Working Group on Employment, Planning & Policy for the Twelfth Five Year Plan (2012-2017), 2011

Workforce Distribution

63% of 1.3 billion people in India – productive age group

Projected to rise to 68% of total population between 2015-2040

487 million workers – 84% in unorganized,16% in organized

sector

91% of unorganized sector workers are informal workers; 5% are

in formal non-agricultural employment and earn wages and

salaries

Agriculture employs 47% of informal workers

NCEUS, Kolli 2011; Kannan, Charu Garg - Barriers to and inequities in coverage and financing of health of the informal workers in India

Employment Scenario

84

16

Sectorwise Percentage Distribution of Workers (2011-2012)

Unorganised Organised

Informal Worker 4.5%

Formal Worker 95.5%

Formal Sector

Informal Worker 91.2%

Formal Worker 8.8%

Informal Sector

Occupational Health Service System

DGFASLI

Assistance to state

enforcement, training and education in

OSH

Advisory body

NIOH, ITRC, RLI

Research, epidemiological

studies

Occupational diseases’

prevalence surveys

DISH

Medical Inspector

supervises state level OH

services for organized

sector workers

ESIC OH Center OH

Physician

At

hazardous

process

units, large

scale

enterprises

For

formal

sector Curative

health care to

8 million

employees,

early detection

and diagnosis

of OH issues

among its

beneficiaries

Status of Occupational Healthcare

Decentralized, fragmented OH delivery system; not integrated with primary health care

OH in the domain of Ministry of Labor, not under Ministry of Health & Family Welfare

National OH Policy is on paper, awaiting structure and execution by Ministry of Labor

Safety & Health statutes for regulating OSH of persons exist only in four sectors – mining,

factories, ports & construction; OH & S legislation is not mandatory for all economic activities;

OHS provisions are not highly prioritized in Trade Agreements

No OH clinics in public/private hospitals or ESI facilities; OH in Factories guided by statutory

requirement under Factories’ Act; available in medium scale and large scale enterprises

Unorganized sector does not have dedicated OH delivery system; organized sector is monitored

by various enforcement agencies, unorganized sector is neglected

21 training institutes, currently 1125 OH

Physicians and 100 Occupational Hygienists,

Ergonomists, few Occupational Psychologists

Existing capacity for training 460 occupational

medicine & 50 occupational hygiene

specialists

6953 factory medical officers (FMOs) and 2308

safety officers (SOs) available

Manufacturing projected to require 16,728 FMOs

and 5619 SOs - deficit of 58% for FMOs, 59%

for SOs

Current OH Professional Capacity

Training & Research in Occupational Health

Medical Colleges - postgraduate diplomas like DIH, DIM; brief orientation in

undergraduate medical studies under Preventive & Social Medicine

Central Labor Institute under Ministry of Labor - three month certificate

course, Associate Fellow in Industrial Health statutory certification

Private institutes SRM University, IIPH, BHEL - AFIH

Labor institutes, All-India Institute of Local Self-Government

Indian Association of Occupational Health (IAOH)

Occupational Hygiene training for CIH certification

OH Nursing lacks formal training program

Competencies for BOHS Physicians

Competencies for Basic OH

Physician

Orientation & clinical competency in occupational

medicine and shop-floor level clinical

internship experience Knowledge of

occupations & relevant

occupational exposures

Exposure to trades, local work practices

in formal and informal sector

Detection of occupational

hazards, knowledge about primary

prevention, personal protection

Awareness of patients’ perceptions

of diseases, therapies, stigma and ambiguity of clinical conditions

Management & Communication skills to manage relationships with

employer, workforce and unions

Knowledge about environmental

health, regulations & statutory

requirements

Occupational Morbidity & Mortality

Annual incidence of occupational disease

between 9,24,700 – 19,02,300; 1,21,000

occupational disease caused deaths (Leigh

et al)

Agriculture: an annual incidence of 17

million injuries and 53,000 deaths per year

Silicosis, musculoskeletal injuries,

asbestosis, byssinosis, coal workers’

pneumoconiosis, COPD, pesticide

poisoning and noise-induced hearing loss

are common

Leigh J, Macaskill P, Kuosma E, Mandryk J. Global burden of disease and injury due to occupational factors. Epidemiology 1999;10:pp 626–631

Basic Occupational Health Service for Informal Sector Through Primary Care Ecosystem

IAOH : Agenda for Next Decade

Routing occupational healthcare delivery through primary care providers - IAOH Mission BOHS for

training primary care providers considers

- Each primary health center (PHC) physician serves 20,000-25,000 population in rural areas

- General physicians are available readily in urban areas

- Creating awareness and necessary attitude could achieve 75% success as per global experience

- Cost-beneficial proposition

Delivery of BOHS for Informal Sector Via Primary Care System involves training primary care providers

in the Primary Care ecosystem comprising of PHC Medical Officers, General Practitioners, ESIC physicians

who are, particularly accessible to the workers of informal industry, for provision of BOHS

Capacity Building: Consensus

Mission BOHS

Goal

Improved health care for informal workers delivered through Primary Health Care Providers (PCPs) to control work-related illnesses and injuries

Project Objectives

Increase capacity of primary health care to provide basic occupational health care

Develop knowledge and capacity of staff to initiate occupational health care services in Primary Health Centers

Outcomes Expected

75% PHC staff in project areas are formally certified trained in OHS care

Trained PHC staff and private primary care providers actively manage 90% OHS complaints in rural project areas

End-users at informal worksites undergo basic training in safe working under certified PHC staff

Mission BOHS Implementation

BOHS - tailored according to the national

conditions and needs of target groups

Flow

Task Force to identify informal occupations

Preparation of Training Manual for Primary

Care Providers

Capacity building for Basic Occupational

Health Physicians (BOHP)

Impact evaluation

BOHS Manual

• Addresses 22 informal trades

• Reporting about economic data, regional distributions,

numbers of workers and employment conditions

• Details of work processes and working conditions

• Work-related health problems and specific diseases

• Potential causative sources at work

• Preventive work practices

Capacity Development Programs for BOHS

- eSAT Learning Initiative for PHC/CHC medical

officers across the state of Gujarat

from IAOH website with YouTube link

- Training session for PHC, ESI medical officers at

Jamnagar focusing on agriculture workers, fishermen and artisans

- Training session for medical college staff at Kanpur focusing on tannery

workers

- Training session for IMA doctors, Factory Inspectors and Tea

estate medical officers at Jalpaiguri focusing on tea plantation workers, Goa Health Service

physicians

Assessment of BOHS Training

Satisfaction with content – relevance, information and quality of training

Request for enhanced learning about occupational history taking, respiratory

conditions and behavioral issues among informal workers

Gujarat distance learning initiative has been able to successfully communicate the

importance of occupational history taking

Lack of ownership for the program at the state level can adversely impact its

sustainability

Game based assessment of this training program reflected the urban audience’s

interest in behavioral conditions

Way Forward – Mission BOHS

Ministry of Health & Family Welfare

- NIOH ICMR

State Health Ministry Public Health System

Teaching Institutions/Universities

- AIIPH

SRM

NGOs & Physician Associations

- IMA PHFI

IAPSM

Others

Ministry of Labour -DGFASLI

ESIS State Labour Ministry

DISH

NSC

Ministries of Science &

Technology Education

Agriculture &

Industry

Informal & Unorganized

Sector

Workforce

Industry Associations

- CII ASSOCHAM

ICMA

Small & Medium Scale

Industry Associations

Strengthening Mission BOHS

• Not limiting to capacity development alone – change from curative to preventive mindset

• Multi-sectoral Stakeholder involvement – MOUs with DGFASLI, Labor Ministry, PHFI in

process; with Health Services, Maharashtra; proposed for agriculture & industry ministries

• Advocacy for provision of BOHS in all economic sectors

• Introduction of OSH in secondary, vocational, technical and professional education

sectors; OH module for academic programs in clinical & toxicological sciences

• Collaborations with employer - industry bodies, employee welfare & professional networks

• Stimulate development of relevant legislation, regulatory and enforcement apparatus

National Policy on Safety, Health & Environment at Workplace

Focus on informal sector OH practice should address: –

Cadre of Basic OH Physicians for informal sector through

competency & skills’ enhancement of formal health service physicians

Development of national OSH database

Broad-based policy measures to reduce the barriers in continuum of

care

Investment in workers’ and employers’ education programs

National Policy on Safety, Health & Environment at Workplace

Focus on OH education to create generalist OH physicians -

Occupational Health education to be reinforced with,

Knowledge of informal workplace hazards and safe work practices with focus on

local workplace exposures rather than generic content

Contextual and effective low cost interventions

Systems for surveillance and notification of occupational diseases

Subject-specific training & familiarization with risk assessment techniques

Psychology as a separate module with hands-on training in counseling techniques

Focus on community approach for NCD control

Soft skills and Communication module towards practice of Behaviour Based Safety

(BBS)

National Policy on Safety, Health & Environment at Workplace

Rotating internship/ elective program in household/ informal industry, SMEs besides,

organized industry

Distance learning programs through digital platforms for e-learning and content

updates

National Board for Occupational Health & Safety to foster multidisciplinary collaborative

networks for standardization, accreditation and promotion of cross-functional

professional OH practice

Technical boards to facilitate knowledge transfer for ergonomic, occupational hygiene

and other subspecialties academic programs

Acknowledgement

Dr. Ramnik Parekh, Chairman BOHS Core Committee, IAOH

Dr. S. M. Shanbhag, Vice Chairman BOHS Core Committee, IAOH

Dr. R. Rajesh, Group Medical Advisor, Reliance Industries Limited