The role of the health system in basic occupational health service provision for underserved groups – experiences and challenges Draft 22 May 2011

Table of Contents

1. Introduction ........................................................................................................................... 3

1.1. Purpose of this paper & target audience ...................................................................... 5 1.2. Scope and limitations of this paper .............................................................................. 5 1.3. Why do these target groups deserve special attention? .............................................. 5 1.4. Challenges of meeting the target groups ..................................................................... 7

2. The potential role of the health system in providing BOSH ................................................. 8 2.1. Essential components of BOSH ................................................................................... 8 2.2. Delivering BOSH services to informal and vulnerable Workers ................................ 10 2.3. Advantages of integrating BOSH into PHC ................................................................ 13 2.4. Development and delivery of OSH within PHC .......................................................... 15 2.5. Extending Healthcare Funding Mechanisms to include BOSH ................................. 17

3. Delivery of BOSH in practice - country experience ........................................................... 21 3.1. Thailand – an integrated PHC approach .................................................................... 21 3.2. Indonesia – a PHC Approach to BOSH ..................................................................... 22 3.3. China - piloting an integrated PHC/BOSH approach ................................................ 23 3.4. Brazil – an integrated PHC approach ......................................................................... 26 3.5. Indonesia – a PHC Approach to OSH ........................................................................ 26 3.6. Tanzania - UMASIDA Health Insurance Scheme, a community based insurance approach.................................................................................................................................. 27 3.7. India – SEWA, a community based insurance approach .......................................... 28 3.8. Chile – a dual social & private health insurance approach ........................................ 29

4. Conclusions and challenges ............................................................................................... 30

1. Introduction Basic occupational safety and health (BOSH) practice is firmly rooted in the principles of primary health care. Prevention is the primary focus of occupational health interventions. Rantanen1 argues that the “theoretical basis for BOSH lies in the general theory of public health…..The main focus is on the elimination, prevention and control of factors that are hazardous to health in the work environment”. The Alma Ata Declaration recognised that governments “have a responsibility for the health of their people which can only be fulfilled by the provision of adequate health and social measures”. The Declaration went on to emphasise that PHC should be based on practical, scientifically sound and socially acceptable methods that should be available to all. The importance of providing healthcare both where people live and where they work was recognised:

“PHC involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors…”

In practice however, the focus over the last 30 or so years of PHC implementation has been on providing health services where people live rather than where they work.

Traditional single cause – single effect public health approaches are still valid in certain circumstances such as when dealing with illness caused by bacterial infections or though chemical exposure. There is an acknowledgment that many of the challenges of occupational health are more complex and may involve complex interactions between a range of causal factors or determinants. There is also recognition that the occupational health approach must move beyond the large industrial or commercial environment and into a much broader range of settings if is to be effective in the modern world. Prevention should be at the centre of efforts to integrate BOSH and PHC – the greatest challenge for occupational health in developing countries is to eliminate hazards in the work environment. ILO Convention No. 187 (Promotional Framework for Occupational Safety and Health) agreed in 2006, sets out the essential elements of a national OSH system (see Table 1). Included is the requirement to “develop support mechanisms for a progressive improvement of OSH conditions in micro, small and medium-sized enterprises, and in the informal economy”. Table 1: Essential Elements of a National Occupational Safety and Health System ● Legislation and any other relevant OSH instruments ● One or more authorities or bodies responsible for OSH ● Regulatory compliance mechanisms, including systems of inspection ● A national tripartite advisory mechanism addressing OSH issues ● Arrangements to promote at the enterprise level, cooperation between employers and workers ● OSH information and advisory services ● Systems for the provision of OSH training

● Occupational health services ● Research on OSH ● A mechanism for the collection and analysis of data on occupational injuries and diseases ● Provisions for collaboration with relevant insurance or social security schemes covering occupational injuries and diseases ● Support mechanisms for a progressive improvement of OSH conditions in micro, small and medium-sized enterprises, and in the informal economy

ILO Convention No. 187

1 Basic occupational health services—their structure, content and objectives, Jorma Rantanen, SJWEH

Suppl 2005: no 1:5-15

OSH has traditionally had a ‘workplace’ orientation which has looked at workers in the context of the formal business, factory or office setting in which they are employed. However, the workplace has changed radically in the past few decades as home working, growing numbers of SMEs, sub-contracting & self-employment and work in informal or precarious settings (street vendors etc.) become increasingly common for hundred of millions of workers. All of these work settings fall outside the scope of most existing employment or labour legislation. In 2007, the 60th World Health Assembly, concerned at the lack of workers’ access to OSH health services called for the 193 WHO Member States “to work towards full coverage of all workers including those in the informal economy, small- and medium-sized enterprises, agriculture, and migrant and contractual workers, with essential interventions and basic occupational health services for primary prevention of occupational and work-related diseases and injuries”2. Attention was primarily focused on workers in agriculture, small and medium sized enterprises (SME), the informal economy and migrant workers. WHO was requested to develop guidance to countries on basic packages, tools, working methods and models of good practices for occupational health services and also to stimulate international efforts for capacity building as part of the Global Plan of Action on Workers’ Health 2008 – 2017 (GPAWH). A broad range of interventions to improve standards and access to OHS were outlined in the GPAWH. These included: the development of improved policies on workers health; improved assessment and management of workplace health risks; improving access and quality of occupational health services; developing and disseminating evidence for action and practice; and strengthened cross sectoral cooperation to promote the inclusion of workers’ health in other sectors policies3. The WHO Global Occupational Health Programme (GOHP) based in Geneva has responsibility for coordinating and overseeing the OSH agenda defined in the 2008 – 2017 Global Plan of Action on Workers’ Health (GPAWH). The GPAWH identified a number of key strategies including:

1) Establishing national policies for occupational health; and 2) Covering all workers with essential interventions and basic occupational safety and

health services (BOSH) for the primary prevention of work-related diseases and injuries.

The following principles were applied to the GPAWH BOSH service development:

Available to all working people

Address local needs

Adapted to local conditions

Affordable to providers and clients

Organized by the employer for employees

Provided by the public sector for the self-employed and the informal sector

Supported by intermediate level services. The GOHP is in the process of developing global guidance, policy options and recommendations for financing and delivering essential OHS interventions and basic occupational health services to underserved working populations and work settings in the context of integrated primary health care.

2 WHA Resolution 60.26, “Workers’ Health: Global Plan of Action”

3 Sixtieth World Health Assembly, Agenda item 12.13, May 2007

1.1. Purpose of this paper & target audience

The purpose of this paper is to look at some of the health systems implication of integrating basic occupational health services into PHC for poor and vulnerable groups and to contribute to the development of a WHO White Paper on occupational health. The principal target audiences for this paper are primarily health planners and policy makers, health economists and those officials with a responsibility for allocating and managing human and financial resources within ministries of health and ministries of finance.

1.2. Scope and limitations of this paper

This paper will draw upon recent published articles in English relating to approaches to organising and financing OHS programmes and interventions in a number of different country contexts from around the world. The focus of this paper is on looking at OHS interventions and services intended to serve workers in vulnerable employments, the unemployed, migrants, those employed in the informal economy and agriculture. There is very limited published literature on this topic and much of what is available is mainly descriptive. So the information base from which evidence has been extracted and conclusions drawn is relatively modest. Unpublished, grey literature has been used where this has been felt to be useful, available and appropriate.

1.3. Why do these target groups deserve special attention?

In 2009 it was estimated that worldwide there were 1.5 billion or 50 percent of all workers in informal or vulnerable employment out of a total of 3 billion people globally who were economically active. Of those, 1 billion worked in agriculture, 666 million in industry and the remaining 1.3 billion in the service sector4. Vulnerable employment has been defined by the ILO as a measure of individuals engaged under relatively precarious employment circumstances including the self-employed and their family members. As these workers are less likely to have formal work arrangements, access to benefits or social protection, their employment status is categorised as “vulnerable”5. Their access to occupational health and safety services will also be greatly reduced. Many workers in informal or vulnerable employments are engaged in hazardous activities such as mining, fishing or agriculture where workers are routinely exposed to dangerous chemicals. In total, it is estimated that there are 337 million work related accidents and up to 2.3 million work related deaths each year with 650,000 of those being due to exposure to hazardous substances – this figure has doubled in recent years. The economic cost of poor occupational safety and health (OSH) practices is substantial. It is calculated that $US1.25 trillion, representing 3 - 4% of global GDP, are lost every year due to costs such as lost working time, workers’ compensation, loss of production and medical expenses6. The 2002 World Health Report identified the following occupational health factors: work related risk factors for injuries, exposure to carcinogens and particulates, ergonomic stressors and noise as making the following contribution to global morbidity: 37 percent of back pain, 16 percent of hearing loss, 13 percent of chronic obstructive lung disease, 11 percent of asthma cases, 10 percent of injuries and 9 percent of cancers. Whilst industrialised countries have seen a steady reduction in the numbers of occupational accidents and diseases, the opposite trend is being seen in countries under-going rapid industrialisation or those too poor to maintain effective, national OSH systems. Developing countries have seen an increase in the numbers of work related accidents as OSH practices fall far below acceptable practices7.

4 Global Employment Trends 2011, ILO

5 Guide to the new Millennium Development Goals, Employment Indicators, ILO, 2009

6 World of Work, Number 63, August 2008, ILO

7 Ibid

Informal sector workers frequently live and work in difficult and dangerous conditions that render them more vulnerable to events such as illness, loss of assets and loss of income. Hazards that people may face at work are almost as varied as the different types of work that they may do, but will include: exposure to chemicals and biological agents, physical factors, adverse ergonomic conditions, and allergens. The consequences may result in a wide range of poor health outcomes, including injuries, cancer, hearing loss and respiratory, musculoskeletal, cardiovascular, reproductive, neurotoxic, skin and psychological disorders8. In addition, workers have little access to social safety nets such as insurance, pensions and social assistance. Basic services such as education, health care and adequate housing are frequently beyond the means of these workers as many of them cannot afford to join formal sector social insurance schemes whose benefits may not meet their principal needs9. Workers in vulnerable employment, the unemployed, migrants and those employed in the informal economy and agriculture frequently have little or no access to preventive or curative health services in their workplace10. This can have a dramatic impact on their income and future earning potential with potentially severe consequences for the worker and his/her family or dependents. There are a number of highly effective interventions for the prevention of occupational diseases and injuries. Whilst, some countries already provide at least basic OSH services and interventions, very few have managed to achieve universal coverage or the sustainable provision of such services. Many countries do not have health systems able to deliver these interventions to those workers in greatest need. It is estimated that less than 15% of the global workforce has some coverage of occupational health services. In Africa, the informal economy is extremely important and most people are employed within it. In those countries where employment statistics are collected, it is estimated that the formal economy can only provide jobs for 5-10 per cent of new entrants to the labour market – most new jobs are being generated by the informal economy. The key issues for workers in the informal economy relate to low productivity, low earning and high poverty levels. In China, rapid economic development has been accompanied by high rates of rural – urban migration as people seek to move out of agriculture to find more rewarding work in the rapidly growing towns and cities. Migrants have faced particular problems in accessing OSH services in China. The low skill level of migrants compared to urban workers and the barriers they face in accessing formal employment has led to migrants being concentrated in jobs with a high risk of occupational illness and disease, often in SMEs which are not adequately regulated and have poor access to basic OSH services. Migrants also tend to work longer hours, and have poorer living conditions than other workers in China11.

Whilst data on OSH are sparse and unreliable in India, it is believed that unsafe working conditions are one of the leading causes of death and disability among India’s working population. ILO data, which are incomplete and very probably underestimate the scale of the problem, suggest that as many as 400,000 people die each year as a result of work-related accidents12. As in many countries, there is very little reliable data available on occupational diseases

8 World Health Report 2002

9 Social Policy Framework for Africa, African Union, October 2008

10 Integration of workers’ health in strategies for primary health care, WHO/Government of Chile, May

2009 11

Holdaway, J; Krafft, T and Wuyi, W (2011) Migration and health in China: challenges and responses, International Human Dimensions of Programme on Global Environmental Change, Issue 1 12

Beyond deaths and injuries: The ILO’s role in promoting safe and healthy jobs’, the International Labour Organisation, 2008

1.4. Challenges of meeting the target groups

Those countries which have the greatest need for basic occupational health services, such as China, India and most of sub-Saharan Africa generally have very limited or no occupational health services. Sectors where workers are at particularly high risk such as construction, forestry, mining and agriculture often have very poor or no provision of services13. The nature of the informal sector – employment in small, medium sized and micro-enterprises, self employment, agricultural work in remote rural settings, a lack of worker organisation and the often poor education and income levels of informal workers has led to four principal areas of exclusion14. These include:

Exclusion from the inspection and safety regimes imposed on large, formal workplaces

Exclusion from social protection programmes including health services

Exclusion from labour legislation – laws on health and safety standards and workers’ rights are limited to those with an employer-employee relationship

Lack of access to resources and services Historically, there has been focus in OSH on gathering data in order to report headline numbers of occupation related injuries or illnesses. Efforts have also focused on identifying the links or relationships between workers’ health and working conditions. There has been very little research done in developing countries on measuring the impact of occupational illness or injury on the incomes and living standards of workers and their families or dependents. As importantly, a traditional OHS focus (medical check-ups, registration, treatment and compensation for occupational diseases and injuries) in large, formal enterprises means that information and data on those workers who are unable to work due to poor OHS practices outside of those settings are very frequently not collected. The workers on whom poor health and safety practices have had the greatest impact are therefore often not included in the statistics. The exclusion of informal workers from the basic OSH protections and services, preventative and curative, provided to workers in larger scale enterprises in the formal employment sector has played a significant role in increasing their exposure and vulnerability to workplace accidents and illnesses15. Mainstream health services are often not resourced or organised to identify and treat occupational health related sickness resulting from employment and working conditions. This is particularly relevant for those workers operating in the informal sector. Frequently, occupational health services and general health services operate as parallel systems with very few or no links and almost no communication. The consequences are a lack of effective prevention of workplace related health problems, untreated disease, absenteeism, an increasing lack of productivity and significant difficulties in re-integrating sick or injured workers back into the workplace. Losses in human, financial and economic terms are substantial16.

13

Basic occupational health services—their structure, content and objectives, Jorma Rantanen, SJWEH Suppl 2005: no 1:5-15 14

As cited in G. Litong, R. Lao, and J. Apolonio. An Assessment of the Situation of the Informal Sector in the Philippines: A Human Rights Perspective 15

Insecurities of Informal Workers in Gujarat, India, Unni J., U. Rani, ILO 2002 16

Integration of workers’ health in strategies for primary health care, WHO/Government of Chile, May 2009

2. The potential role of the health system in providing BOSH

2.1. Essential components of BOSH

The next section of this paper outlines some of the key factors that need to be considered when designing a package of BOSH services to fit within primary care provision in poor and middle income countries. Key components of Basic Occupational Safety and Health are adapted from a Finnish paper on the structure and content of basic occupational health services17. The Finnish paper develops the idea of BOSH in an essentially developed world context. Universal coverage of OHS services is a useful goal, but it may be too ambitious to be feasible. However, given the financial and human resource constraints found in almost every developing country, it is important to be realistic about what services can realistically be offered and delivered to informal and vulnerable workers in those very different contexts. Whilst there has been a significant amount of research done in the developed world to assess the costs, efficiency and effectiveness of OSH interventions, very little work has been done on these issues in the developing world. Many health systems in poor countries are heavily aid dependent. If OSH interventions are going to be included as part of a basic package of primary health care, it will be necessary to be able to demonstrate that they are effective in delivering health gain and can be delivered at a reasonable cost. The individual elements of BOSH to be included in a package of primary health care and delivered through local health providers will need to be developed to meet the specific needs of the local context in which the OSH services are being delivered. The needs of self-employed agricultural workers in remote locations are going to be very different from street vendors in an urban context. There is no “one size fits all” approach that will be successful. Given the very significant resource constraints, it will be extremely important to adopt a practical and realistic and localised approach, when developing a limited and effective package of OSH interventions to be delivered. The package of OSH interventions should be based on an evaluation of the burden of disease experienced by specific groups of informal and vulnerable workers in specific country contexts. Interventions of proven efficacy and cost effectiveness that can be delivered by health staff and community volunteers with minimal amounts of training and supervision and with the resources available should be identified in the first instance. As the capacity of the health system increases, health staff become more proficient and experienced in delivering OSH interventions, and finance becomes available, the package of care on offer could be gradually expanded to include additional interventions.

17

Basic occupational health services—their structure, content and objectives, Jorma Rantanen, SJWEH Suppl 2005: no 1:5-15

Adapted from a paper on Basic Occupational Health Services developed by Professor Jorma Rantanen of the Finnish Institute of Occupational Health.

Figure 1: Key Components of Basic Occupational Safety and Health

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

2.2.Delivering BOSH services to informal and vulnerable Workers

2.3.2.2.

Experience from a number of countries around the world in delivering integrated PHC and BOSH suggests that there are three main models for delivering health services to poor and vulnerable populations: Model 1: Financing and delivering BOSH interventions 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 weaknesses18. These included:

Exclusion of the most vulnerable groups leading to gaps in coverage and service provision particularly to the poorest

May require the support of donor or government financed Social Funds to be fully effective

CBI arrangements vulnerable to manipulation by local leaders especially in poor and isolated rural communities

18

Community-based Risk Management Arrangements: An Overview and Implications for Social Fund Programs, Bhattamishra R., Barrett C, World Bank Division of Social Protection and Labor, Oct 2008

Community based insurance

Organisation (e.g. SEWA India)

Contributions from workers

Contribution from Social Fund?

Defined package of OSH care and prevention

offered through network of

own providers

SEWA Care provider

SEWA Care provider

SEWA Care provider

Formatted: Bullets and Numbering

Model 2: Publicly funded BOSH interventions 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 areas19. However, there are certain pre-requisites if this approach is to be successful. These include: government capacity and commitment to the contracting out of services; capacity at the national and intermediate levels to manage contracts and monitor compliance with service level agreements etc; and the availability of NGOs or private sector providers with the capability to deliver contractually agreed services.

19

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)

BOSH funding, capacity building

and oversight

CSOs or private

providers

Contract management

and funding

Information

Informal & vulnerable workers

Informal & vulnerable workers

BOSH services

Information

MoH and/or MoL

Sets norms and standards for BOSH

Provides funding and capacity building

Manages/regulates provision of services by third party providers

Donor funds

Tax revenues & user fees

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”20. However, it was also noted that many countries which lack the capacity to organise 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 BOSH into state delivered primary health care Model 3 illustrates how BOSH services might be both funded and integrated into a PHC approach. MoH staff are responsible for developing a package of BOSH services in

20

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)

BOSH funding, capacity building

and oversight

Primary Health Care Facility BOSH integrated with PHC

Training, capacity building & supervision Information

Informal & vulnerable workers

BOSH services – preventive &

curative

Information

MoH

Sets norms and standards for BOSH 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

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 immunisation 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 OSH needs of agricultural workers in Africa are going to be very different from those of street vendors or rubbish collectors in India or artesanal fishermen in the Philippines. This implies that a creative and flexible approach to OSH design needs to be taken that takes into account the OSH 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 BOSH 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 BOSH can be integrated into PHC as health systems vary so widely from country to country. Model 3 attempts to provide a generalised outline of how integration could be organised. However, the existing structure of the health system in individual countries and the method of funding health services will in large part determine how BOSH services can be effectively integrated into PHC. BOSH 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 BOSH access. One size will not fit all and it will be important to adapt BOSH organisation and services to the local context.

2.4.2.3. Advantages of integrating BOSH into PHC

International evidence indicates that a well organised and managed 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 emphasises disease and accident prevention and health promotion.

In this context integration is defined as:

“The organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money22”

There are strong arguments for integrating BOSH services into existing arrangements for providing primary healthcare within the health sector. One of the principal advantages of an integrated PHC approach is that this will enable BOSH services to be provided closer to the locations where people live and work. A number of countries are testing models to integrate PHC and BOSH. Their experience is discussed in more detail later in this paper. However, experience gained to-date in a number of different countries indicates that it is possible to begin to combine PHC and BOHS in order to provide essential OHS services to poor, previously underserved informal sector workers. An integrated approach should not try to focus of all aspects of OSH – it is important to concentrate on those areas of OSH that will deliver the greatest return.

21

Is primary care essential? Starfield B., Lancet. 1994 22

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

A key advantage of integrating PHC and BOSH would be to bring BOSH services closer to the places where workers in the informal sector live and work. This potentially will make integrated services easier to access and should help to increase utilisation rates. PHC is offered at the community level through a combination of fixed facilities (health centres & health posts) and through outreach services offered by health workers and community health volunteers. Integrating BOSH into PHC will provide access to an already established network of health provision and could enable BOSH services to generate reach and impact reasonably quickly.

Existing public health programmes, such as HIV/Aids, Malaria, MNCH etc. have been demonstrated to be able to quickly reach at risk populations 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, BOSH effectively integrated into existing primary health care structures and systems could enable similar opportunities for providing target worker populations with a range of appropriate OSH services. Appropriate integrated BOSH/PHC models that identify systems, structures and health worker capacities need to be developed

An integrated BOSH/PHC 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 BOSH services should take careful account of what is really needed by informal workers Integrating BOSH into PHC could lead to more efficient service delivery and less costly utilisation by recipients than providing a standalone OSH system. There are a number of potential benefits from integration. These include:

Improved access

Integration would also assist with the reduction of OSH related illness through improved prevention practices and better access to education for workers through their local PHC system

Clients could make one visit to one practitioner or group of practitioners rather than having to travel between different teams of providers in various locations thus improving continuity of service provision and reducing the likelihood of dropout.

Informal sector workers would be more likely access BOSH services provided through their local health facility and may feel more comfortable in getting treatment in their normal healthcare setting rather than having to incur significant travel costs to be treated at a specialist facility in an urban centre

Greater health system efficiency

Specialist OSH workers are in very short supply in many countries; providing supplementary training in BOSH to existing health workers could be an effective strategy for rolling out these services into the community and providing prevention and treatment services for uncomplicated cases

Using existing but up-skilled networks of health volunteers or auxiliary health workers to provide BOSH services may prove to be an effective strategy for delivering these services right to the community level.

Integration of BOSH into PHC can avoid duplication in management and support costs. Separate programmes need separate staffing and infrastructure; and sometimes run separate supporting systems e.g. logistical and procurement systems. There is some evidence from studies of other programmes that have been integrated into PHC have demonstrated reduced overall costs and improved treatment practices23

23 Jenkins R, Strathdee G: The Integration of Mental Health Care with Primary Care. International Journal of Law and Psychiatry 2000, 23:277-291.

Integrating BOSH into PHC may be more cost effective. Duplicate implementation and management arrangements potentially increase the cost of programme delivery – however there is very little data on costs in the OSH studies that have been undertaken to date.

Better prevention of illness

Many of the disabling and costly OSH health conditions that health systems have to deal with are preventable. With appropriate support, additional complications can be avoided or their onset delayed and health outcomes for clients improved

Health systems can optimise the returns from scarce human and financial resources through offering new services in innovative ways and by emphasising those activities that help to prevent accidents and illness and which delay the onset of complications.

The existing evidence base describing the benefits of integrating PHC is limited. 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”24. 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

2.5.2.4. Development and delivery of OSH within PHC

OSH has to compete with many other spending priorities in the resource poor countries where the majority of the world’s vulnerable and informal workers are located. For that reason, in many areas of the world there has been insufficient investment in the development of effective systems of OSH. Rantonen argues that the returns from investment in OSH in countries which have developed good systems of OSH (mainly in the developed world) have been substantial, not only in terms of improved health for workers but also by increasing worker effectiveness and productivity25. He proposes a four tier system for delivering increasingly more complex OSH services. However, the last two stages are really only relevant in a developed country context and have been omitted from Figure 1 below. This represents one method for developing an integrated OSH / PHC delivery system approach – there will be others

24

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

Basic Occupational Health Services, Professor Jorma Rantanen, President of the International Commission on Occupational Health, Sep 2007

Integrated OSH services to be provided would include: Entry level OSH services - the starting point intended for those workers and workplaces that have no access to OHS. Simple OHS services are offered through community based health workers with limited training operating out of community based PHC facilities Activities would be focused on:

Reducing the risk of accidents

Basic training for heavy physical work (lifting etc)

Training on chemical hazards (pesticides etc.)

Referral Basic Occupational Safety and Health Services (BOSH). Delivered by trained PHC health workers (doctors and nurses) located as close to workplaces and communities as possible. Activities would include:

Surveillance of workers health and assessment of health risks

Provision of health education and information

Prevention of occupational health hazards

Training and provision of personal protective equipment

Diagnosis of occupational and work related disease

Accident prevention & emergency preparedness

First aid

Record keeping and reporting

PHC Infrastructure Basic OSH services Practical Guides Training for community health workers and volunteers

Community Health

workers / volunteers

Advice on OH Accidents and Occupational diseases PHC

Doctor or nurse with special training based at health centre

Services provided to workers in SMEs, & informal sector

Entry level

services

Basic OSH

services

Figure 1: Integrating Basic Occupational Safety and Health Service Delivery

with PHC

Adapted from a paper on Basic Occupational Health Services, by Professor Jorma Rantanen

Services provided to workers in SMEs, & informal sector

It is important to ensure the effective integration of BOSH services with existing PHC arrangements so that quality services are easily accessible and that they meet the OSH needs of working people, and particularly those in the informal sector. They also need to be delivered with sufficient levels of quality to be able to provide effective solutions to the OSH problems facing their recipients. Research looking at primary health care in developing countries has shown that frequently services are of poor quality and that access and coverage are still far from universal. Where OSH services are being delivered in a primary care setting, the doctor or the nurse responsible will need to have some specialist knowledge in order to be able to diagnose an OSH related condition and to prescribe effective treatment. Equally, the effective prevention of OSH related accidents and illness also requires specialist knowledge and training. To do this effectively will require health workers to receive a minimum amount of knowledge, training and supervision in OHS methods and approaches. The medicalisation of BOSH should be avoided in order that it can be successfully delivered by a range of health workers in the primary health care setting. Putting the systems and infrastructure in place to enable effective staff training and supervision at appropriate levels of the health system requires careful planning and will need to be tailored to the particular requirements of countries’ health systems. Additional resources will be required for training sufficient numbers of health workers, to enable them to provide BOSH services and to cover the costs of integrating a BOSH component into PHC Because of problems with quality and access to public health services people often use both qualified and unqualified private providers26 to meet their healthcare needs. This clearly has implications for the delivery of BOSH in so far as private providers of healthcare will be involved in delivering care but will not have received appropriate information and training to do so. The challenge for the public health system is to identify ways in which the capacity of the private sector can be increased and the quality of its services monitored and regulated. This is potentially a very large and complex task. The focus of initial efforts to integrate BOSH into PHC should be on developing the capacity of the public health system to deliver services.

2.5.Extending Healthcare Funding Mechanisms to include BOSH

2.7.2.5.

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 challenges that will need to be tackled when integrating OSH with PHC. There are five main health financing approaches which are used to fund healthcare27 (this analysis does not include financial transfers from donors) and which could potentially serve as funding mechanisms for OHS as it integrates with PHC. These are:

Taxation – public funding of healthcare is provided through the collection of a range of taxes including income tax, corporation tax, customs duties and licence fees etc.

Advantages – taxation is generally an inexpensive way of raising funds - most countries already have an existing revenue collection system which can be adapted or

26

The performance of different models of primary care provision in Southern Africa’, Mills A., Palmer N. Social

Science and Medicine 59, 2004 27

Understanding Health Economics for Development, HLSP CD Rom, 2010

Formatted: Bullets and Numbering

expanded. Taxation can be progressive meaning those who have the most pay the most (e.g. income tax) Disadvantages – tax revenues may be unpredictable due to fluctuations in the business cycles. The recent global financial crisis has had a significant impact on tax revenue collection in most countries around the world which has led to a reduction in the amount of funding available for public health systems and primary care. Taxes may be regressive - sales taxes and VAT have a disproportionate impact on the poor.

This is potentially a mechanism for funding BOSH although any new package of 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 collecting funds from the informal sector. Vulnerable groups of people are therefore likely to be excluded.

China is piloting the use of social insurance to fund BOSH interventions for informal 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 frequently28. 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 organised by local providers of health care). It has grown rapidly in recent years, particularly in West Africa.

28

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

Advantages - the success of community health insurance depends upon a number of factors, including: trust and solidarity, typically requiring significant community participation; a willingness to pay which depends on economic and social factors; subsidies - otherwise the approach will only meet some needs of the rural sector; good design (to counter adverse selection, moral hazard); and a strong marketing/business culture. Disadvantages - Although sometimes successful on a smaller scale, these approaches have rarely been taken to scale. Establishing schemes creates a dilemma. Initial subsidisation can be helpful in introducing the concept of insurance and reducing risks to those implementing any scheme, but this can be counterproductive and subsidies become difficult to remove. Sustainability is a key concern - access by the poor and vulnerable populations will invariably require subsides. The problem is that poor countries which have the greatest need to subsidise the poor are the very countries least able to provide such subsidies.

There is some evidence from the SEWA scheme in India of the successful application of 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 hospitals29 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 healthcare30:

by making regular contributions, the problem of indebtedness brought about by high medical bills can be overcome

the financial power of the group may enable its administrators to negotiate services of better quality or which represent better value for money from private health care providers; and

the group may be willing to spend on preventive and health promotion activities so as to keep down the cost of curative services.

Private health insurance - In low income countries, private insurance typically serves the rich, though it may enjoy both direct (tax relief) or indirect subsidies (e.g. through tax funding of the regulatory system).

Disadvantages – whilst private insurance provides choice and is responsive to patient needs it introduces serious problems of adverse selection, moral hazard, supports little risk pooling and has the potential to absorb resources from elsewhere in the system (either directly or indirectly. It has high administration costs and also provides an escape route for the middle classes who might otherwise press for better services for

29 The UMASIDA Mutual Health Care Scheme, A case study of an Urban based Community Health Fund, Kiwara A, Institute of Develoment Studies, May 2005 30

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

the population at large. There is no evidence that subsidising private insurance reduces the burden on the public sector as is often claimed.

This is not likely to be an effective approach for extending basic services to poor 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 formalising 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 utilisation, 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.

3. Delivery of BOSH in practice - country experience This section of the paper aims to look at the different approaches taken to delivering BOSH and integrating it with PHC in a number of countries looking at the challenges, problems and successes experienced. The literature on the implementation of BOSH is largely descriptive and there is little hard data or information available on key issues such as costs and health impact and outcomes.

3.1. Thailand – an integrated PHC approach

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 Myanmar31. 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 specialised services than health volunteers and who provide health care to the community. A PCU will service 10,000 people on average and its responsibilities will include disease prevention, health promotion, and treatment of illness.

Secondary level services provided by medical and health personnel based in community hospitals.

Tertiary level services which cover more specific and complicated cases provided by specialist medical and health care staff. These services are based in Regional, General, Specialised and University Hospitals.

Health system 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 public32. Occupational Safety and Health in Thailand Responsibility for OSH 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

31 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). 32 Integrating Occupational Health Services into Public Health Systems: A Model Developed with Thailand’s Primary Care Units, Dr. Somkiat Siriruttanapruk and team Ministry of Public Health, Thailand, ILO (2006)

surveillance; technical support; development of OSH guidelines; training of health care workers; and research and development. Traditionally, OSH 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 BOSH In order to improve the coverage and availability of OSH services an initial, strategy of using PCUs to deliver both PHC and basic OSH 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 OSH 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 difficulty in accessing OSH 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 BOSH services to workers in the informal sector (Agriculture, SMEs, Fisheries, Migrant workers and Home workers). BOSH services to be provided included:

Risk assessment and workplace improvement

Surveillance of work-related diseases and chronic diseases

Health promotion

Provision of safety equipment Health volunteers were used to deliver both PHC and basic OSH services in the community (Siriruttanapruk et al, 2009). The health volunteers (who receive a small stipend from 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 OSH 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.

3.2. Indonesia – a PHC Approach to BOSH

Indonesia is the fourth largest country in population terms after China, India and the USA. In 2008, its total population was 228 million33. 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 GDP34. 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 OSH services are co-funded by central and local governments. A

33

Indonesian Country Paper on the Informal Sector and its Measurement, BPS-Statistics Indonesia, May 2008 34

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

typical health centre is led by a medical doctor supported by a range of health and 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 empowerment35. 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 approach36. 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 administrations37. It is important to integrate OSH into the basic PHC package of care in oder 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.

3.3. China - piloting an integrated PHC/BOSH approach

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 country38. 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 work39. China lacks good quality, accessible primary care system. Traditionally, in urban areas, hospitals have provided PHC - there has been a widespread belief among the urban 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 200940. 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 standardise labour contracts and collective contracts41.

35

Revitalising Primary Health Care, Indonesia Country Experience, WHO Regional Conference, Aug 2008 36

Ibid 37

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) 38 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 39

Ibid 40

China’s primary health-care reform, Liu Q., Wang B., The Lancet, March 2011 41

Zhu, C (2008) Labour protection for women workers in China, Asian-Pacific Newsletter on Occupational Health and Safety;15:47

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. 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 utilise 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 city42 (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 201043. 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)44 . 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 training45. 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:

42

Health care utilisation amongst Shenzhen migrant workers: does being insured make a difference?, Mou J et al, BMC Health Services Research 2009, 9:214 43

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 44

Basic Occupational Health Services in Ba’oan, China, Chen, Y; Chen, J, Journal of Occupational Health; 52: 82-88 45

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

Tier 1 – (Lowest level) are the community health service centres which provide services to all workers. Services include:

o general health examination o first aid services o health promotion o OH education.

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

towns of Ba’oan which provides services to workers not exposed to serious occupational hazards. Services include:

o OH and general health examinations o surveillance of working environments o proposing prevention and control actions to eliminate health hazards o record keeping o health training for workers and education.

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

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

o OH examination and potential referral to specialist occupational medical clinics for treatment.

o surveillance of the working environment o dealing with major OH accidents o risk control and assessment o providing information and training for basic OHS personnel.

How is the pilot scheme funded? Under the BOSH scheme in Ba’oan, the cost is shared by the employer and the government with employers being responsible for the surveillance of workers health and the working environment. BOHS 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 disease46. 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 the bureaus of finance and industry was established. The group was responsible for organising 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

46

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

as much as three or more times a year47. 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.

3.4. Brazil – an integrated PHC approach

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 families48. 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 measures49.

3.5. Indonesia – a PHC Approach to OSH

Indonesia is the fourth largest country in population terms after China, India and the USA. In 2008, its total population was 228 million50. 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 GDP51. 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 OSH 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 empowerment52. 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 approach53. 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

47

Ibid 48

The Primary Health Care Strategy in Brazil, Dr Luis Rolim Sampaio, National Director of Primary Care, Nov 2006 49

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 50

Indonesian Country Paper on the Informal Sector and its Measurement, BPS-Statistics Indonesia, May 2008 51

The Informal Sector and Informal Employment in Indonesia, ADB Country Report, 2010 52

Revitalising Primary Health Care, Indonesia Country Experience, WHO Regional Conference, Aug 2008 53

Ibid

has been rather patchy both from the central level and through local administrations54. It is important to integrate OSH into the basic PHC package of care in oder 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.

3.6. Tanzania - UMASIDA Health Insurance Scheme, a community based insurance approach

“UMASIDA is an umbrella health insurance organization for the informal economy in Dar 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 schemes55. The main messages were:- For the beneficiaries:

Resist overuse of service.

Consult provider only when necessary

Overuse means higher premiums on your part

Don’t facilitate provision of care to unentitled people

Pay your premiums on time

Always present your identity at the point of services for you and your families if you observe the above factors.

For the providers

Always ask for identity before providing services

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

Restrict prescriptions to the WHO approved essential drugs list.

A functioning Health Insurance System is an assurance that you will continue to get patients whose services are prepaid.

54

Impact and Effectiveness of Occupational Health Interventions: a qualitative study on multiple stakeholders in occupational health for informal sectors in Indonesia, Hanifa M. Denny, College of Public Health, University of Florida (on-going research project) 55

The UMASIDA Mutual Health Care Scheme, A case study of an Urban based Community Health Fund, Kiwara A, Institute of Development Studies, May 2005

3.7. India – SEWA, a 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 million56. The majority of them are poor and have little or no access to social security or to healthcare. Provision of OSH services by the government is negligible 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. Is SEWA related to this? The main causes of occupational disease related morbidity and mortality in India are silicosis, musculoskeletal injuries, coal workers’ pneumoconiosis, obstructive lung diseases, asbestosis, byssinosis, pesticide poisoning and noise induced hearing loss57. Only workers in four sectors: mining, factories, ports and construction are currently covered 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. Government spending on occupational health in India is negligible. 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, 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, hospitalisation 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 protection58. 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. 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 problems59. Workers are more likely to access PHC/OSH services and seek appropriate preventive and curative services. Well integrated PHC/OSH 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 OSH 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).

56

CIA World Factbook, 2007 57

Do occupational health services really exisit in India?, Pingle S, Reliance Industries Ltd 58 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. 59 Francie Lund and Anna Marriott (2005) Occupational Health and Safety and the Poorest: Final report of a consultancy for the Department for International Development

OSH 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. Recognising 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. How relevant? 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”60. Some of SEWA’s poorest members may find even the low insurance premiums charged by the organisation beyond their means and are excluded from cover61. 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 effectively design preventive interventions. This is essential if an effective package of OSH interventions and care is to be delivered and integrated into SEWA’s community health programmes..

3.8. Chile – a dual social & private health insurance approach

PHC 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 uncovered62. 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; recognising 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 OSH35 .

60

Ibid 61

Livelihood security through community based health insurance in India, Chatterjee, M and M.K. Ranson, Global Health Challenges to Human Security, Harvard, 2003 62

Health care reform in Chile, Gabriel Bastias & Tomas Pantoja, Canadian Medical Association Journal, Dec 2008

4. Conclusions and challenges Over the last twenty years or so, a large variety of environmental, social, organisational and other determinants of workers’ health have been identified. Workplace settings have become more varied and complex and the determinants of occupational health have become multi-factorial. A number of models have been developed that explore the inter-dependent relationship between ill-health or disability and poverty. A number of these acknowledge the important role of workplace health and safety63. It is argued that there is an interdependent or cyclical relationship between workplace related ill health or disability and poverty. It is believed that chronic poverty reduces a worker’s options to refuse exposure to hazardous working conditions which then (together with other factors) increases the risk of illness, accident and disability. This may then further undermine the worker’s already precarious situation leading to an even weaker position and will contribute to reducing future earning potential64. Information and data on OSH in the developing world is sparse and unreliable. Patterns of employment, work contexts and conditions for informal and vulnerable workers vary enormously between countries and continents. The OSH challenges faced in sub-Saharan Africa are quite different to those found in China and India for example. It is evident from reviewing the studies that are available, that the nature of the OSH challenges for poor people varies enormously both between countries and across different work settings within those countries. However, given the limited financial and human resources available to provide occupational health and safety programmes particularly in developing countries, there is a real imperative to focus on the most important determinants of health and safety in the workplace65 and to deliver a limited range of proven and effective preventive and curative interventions to those workers most at risk of OSH related injury and disease. Conventional public health interventions such as immunisation 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 OSH needs of agricultural workers in Africa are going to be very different from those of street vendors or rubbish collectors in India or artesanal fishermen in the Philippines. This implies that a creative and flexible OSH design approach needs to be taken that takes into account the OSH 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 BOSH interventions. This will offer a particular challenge to the health sector. Moreover high level knowledge and skills will be needed to accomplish this task effectively. A review of the available OSH literature reveals that many countries are adopting an approach which integrates BOSH with PHC. The vast majority of the studies available are descriptive and describe the approach taken and some of the implementation challenges encountered when developing an integrated system. It was not possible to assess key issues such as costs, outcomes or impact of BOSH interventions from any of the studies reviewed. However this data will be a key determinant of the preparedness of health systems to extend their range

63

Occupational Health and Safety and the Poorest, Prof. Francie Lund & Anna Marriot, School of Development Studies, University of KwaZulu-Natal, March 2005 64

Chronic Poverty and Disability, Background Paper Number 4, Yeo R., Chronic Poverty Research Centre, UK, 2001 65

Basic occupational health services: a WHO/ILO/COH/FIOH guideline. 2nd

ed.

to include OHS, suggesting a research agenda which focuses on examining in greater detail the lessons learned from these examples. There is little reliable, empirical evidence on the impact of occupational injury or illness on informal or vulnerable workers. The information which is available suggests that OSH related morbidity and mortality has a significant impact on these groups and is a major cause of economic loss and poverty amongst these workers. There is a substantial literature on the design, content, costs, benefits and impact of OSH interventions in the developed world. However, there are very few high quality studies available relating to OSH interventions targeted at informal and vulnerable workers in the developing world. BOSH will need to compete for funding with other, far better researched and evidence based PHC interventions such as DOTS treatment for TB, HIV/Aids and malaria prevention and treatment. High quality research to demonstrate the benefits and cost effectiveness of BOSH interventions for informal and vulnerable workers in developing country contexts will need to be undertaken. Where efforts are being made to integrate BOSH with PHC (e.g. China and Thailand) these approaches need to be thoroughly evaluated and documented. Much more and better research is needed on the effectiveness of integrating BOSH into PHC. More information is required on the effectiveness of different approaches to funding BOSH that are being employed. It would be useful to compare the effectiveness of tax based, versus social insurance and community based insurance approaches in extending BOSH services to workers in the target groups. A great deal of thinking will be required on how to develop the capacities of health systems and health workers to develop effective packages of BOSH interventions tailored to the needs of specific groups of workers. Closely related is the requirement to be able to train and provide health workers at all levels of the health system with the appropriate knowledge and skills to deliver BOSH. Given the lack of knowledge about the causes and impact of occupational disease and accidents in the developing world, there is an urgent need to undertake high quality research n this area. The research agenda should include but not be limited to:

Developing a greater understanding of the disease burden of occupational related illness and accidents among informal and vulnerable workers

Prioritising OSH related risks and exposures in order to be able to identify the determinants of occupational disease and injury that are most prevalent and amenable to prevention and/or treatment

Identifying simple, low cost and effective interventions both preventive and curative that will have an impact on reducing the burden of disease

Developing greater understanding of the financing and organisational approaches required to implement effective BOSH programmes for the target groups of workers

More rigorous evaluation of existing BOSH programmes looking at key issues such as intervention design, delivery costs and impact in reducing the burden of disease.