Ohs paper initial draft for comments 22.05.2011

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 ● Occupational health services
instruments ● Research on OSH
● One or more authorities or bodies responsible for ● A mechanism for the collection and analysis of
OSH data on occupational injuries and diseases
● Regulatory compliance mechanisms, including ● Provisions for collaboration with relevant
systems of inspection insurance or social security schemes covering
● A national tripartite advisory mechanism occupational injuries and diseases
addressing OSH issues ● Support mechanisms for a progressive
● Arrangements to promote at the enterprise improvement of OSH conditions in micro, small and
level, cooperation between employers and medium-sized enterprises, and in the informal
workers economy
● OSH information and advisory services
● Systems for the provision of OSH training

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
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
Suppl 2005: no 1:5-15

Figure 1: Key Components of Basic Occupational Safety and Health

Risk assessment and Health education and Provision of basic
monitoring of the work health promotion curative services
environment including first aid

 Identification of workers  Workers provided with  Provision of first aid as
or groups of workers appropriate information required
exposed to specific on workplace risks and  Identification of
hazards hazards exposure(s) which may
 Control of causal agents  Workers understand the cause occupational
such as dust, harmful nature and severity of disease
chemicals or heat. the risks to which they  Diagnosis of occupation
 Suggestions for the are exposed related disease
control of occupational  Workers given  Provision of basic
health related risks information to manage, curative health services
 Identification and control mitigate and avoid those to treat occupation
of occupational health risks by making their related diseases
hazards through the use working practices safer  Reporting of
of personal protective occupational disease
equipment etc. and injuries

Adapted from a paper on Basic Occupational Health Services developed by Professor Jorma Rantanen of the Finnish Institute of Occupational Health.

Formatted: Bullets and Numbering
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

Community based
Contribution from Contributions from
insurance
Social Fund? workers
Organisation (e.g. SEWA
India)

Defined package of OSH
care and prevention
offered through network of
own providers

SEWA Care SEWA Care SEWA Care
provider provider provider

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

Model 2: Publicly funded BOSH interventions delivered by NGOs and private providers

MoH and/or MoL
Tax revenues &  Sets norms and standards for BOSH
user fees  Provides funding and capacity building Donor funds
 Manages/regulates provision of
services by third party providers

BOSH funding,
capacity building Information
and oversight

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

Contract management Information
and funding

CSOs or
private
providers
BOSH
services

Informal & Informal &
vulnerable workers vulnerable workers

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

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

MoH
Tax revenues &  Sets norms and standards for BOSH in
user fees partnership with Min of Labour? Donor funds
 Provides funding and capacity building
 Manages provision of services through
own network of facilities and CHWs

BOSH funding,
capacity building Information
and oversight

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

Training, capacity
building & supervision Information

Primary Health Care Facility
BOSH integrated with PHC

BOSH
services –
preventive &
curative
Community
health workers

Preventive interventions

Informal & Informal &
vulnerable workers vulnerable workers

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

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

Figure 1: Integrating Basic Occupational Safety and Health Service Delivery
with PHC

Basic OSH
services

Entry level
services
PHC Infrastructure
Basic OSH services
Practical Guides
Advice on OH
Training for community
Accidents and
health workers and
Occupational
volunteers
diseases
PHC

Doctor or nurse with
Community Health special training based
workers / volunteers at health centre

Services Services
provided to provided to
workers in workers in
SMEs, & SMEs, &
informal sector informal sector

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

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

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.

Formatted: Bullets and Numbering
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

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

Ohs paper initial draft for comments 22.05.2011

Ohs paper initial draft for comments 22.05.2011

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