MINISTRY OF LABOUR SOCIAL SECURITY DIRECTORATE GENERAL OF

MINISTRY OF LABOUR & SOCIAL SECURITY DIRECTORATE GENERAL OF OHS Dr. Buhara Önal OHS INSTITUTE (ISGUM) May 2010 Ankara - TURKEY

BASIC OCCUPATIONAL HEALTH SERVICES

CONTENT • Policy background • ILO Convention 161 • EU Legislation on OHS • WHO Worker’s health: Global Plan of Action • Basic Occupational Health Services (BOHS)

OCCUPATIONAL HEALTH AS A FUNDAMENTAL HUMAN RIGHT Every worker has the right to working conditions which respect his or health, safety and dignity. (Art. 31 of the European Charter)

IMPACT OF THE OCCUPATIONAL ENVIRONMENT ON HEALTH • 300 000 workers die of work-related diseases • 27 000 workers die in occupational accidents (5% of all deaths due to accidents) • Loss of 4% GDP

POLICY BACKGROUND • ILO • EU • WHO

ILO • Joint Committees 1950 -2003 • Related Conventions and Recommendations, Convention 161, Recommendation 171, in particular • Ethics in workers' health surveillance guidelines • Numerous Codes of Practice • Global Strategy • Promotional Framework for Occupational Safety and Health Convention 187 • Fair globalization-Decent Work

ILO CONVENTION 161 OH SERVICES Article 1: For the purpose of this Convention(a) the term occupational health services means services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking on(i) the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work; (ii) the adaptation of work to the capabilities of workers in the light of their state of physical and mental health; (b) the term workers' representatives in the undertaking means persons who are recognised as such under national law or practice.

ILO CONVENTION 161(cont. ) Article 2 • In the light of national conditions and practice and in consultation with the most representative organisations of employers and workers, where they exist, each Member shall formulate, implement and periodically review a coherent national policy on occupational health services.

ILO CONVENTION 161(cont. ) • Article 3 1. Each Member undertakes to develop progressively occupational health services for all workers, including those in the public sector and the members of production cooperatives, in all branches of economic activity and all undertakings. The provision made should be adequate and appropriate to the specific risks of the undertakings. 2. If occupational health services cannot be immediately established for all undertakings, each Member concerned shall draw up plans for the establishment of such services in consultation with the most representative organisations of employers and workers, where they exist.

ILO CONVENTION 161(cont. ) Article 5 • ……. occupational health services shall have such of the following functions as are adequate and appropriate to the occupational risks of the undertaking: (a) identification and assessment of the risks from health hazards in the workplace; (b) surveillance of the factors in the working environment and working practices which may affect workers' health, including sanitary installations, canteens and housing where these facilities are provided by the employer; (c) advice on planning and organisation of work, including the design of workplaces, on the choice, maintenance and condition of machinery and other equipment and on substances used in work;

ILO CONVENTION 161(cont. ) (d) participation in the development of programmes for the improvement of working practices as well as testing and evaluation of health aspects of new equipment; (e) advice on occupational health, safety and hygiene and on ergonomics and individual and collective protective equipment; f) surveillance of workers' health in relation to work; (g) promoting the adaptation of work to the worker; (h) contribution to measures of vocational rehabilitation; (i) collaboration in providing information, training and education in the fields of occupational health and hygiene and ergonomics; (j) organising of first aid and emergency treatment; (k) participation in analysis of occupational accidents and occupational diseases.

ILO CONVENTION 161(cont. ) Article 7 1. Occupational health services may be organised as a service for a single undertaking or as a service common to a number of undertakings, as appropriate. 2. In accordance with national conditions and practice, occupational health services may be organised by(a) the undertakings or groups of undertakings concerned; (b) public authorities or official services; (c) social security institutions; (d) any other bodies authorised by the competent authority; (e) a combination of any of the above.

ILO CONVENTION 161(cont. ) Article 9 1. In accordance with national law and practice, occupational health services should be multidisciplinary. The composition of the personnel shall be determined by the nature of the duties to be performed. 2. Occupational health services shall carry out their functions in co-operation with the other services in the undertaking. 3. Measures shall be taken, in accordance with national law and practice, to ensure adequate co-operation and co-ordination between occupational health services and, as appropriate, other bodies concerned with the provision of health services.

EU • Framework Directive 89/391 -preventive and protective services • Occupational health and safety strategy 2008 -2012 • Workplace health promotion • Economic loss/productivity

PRINCIPLES OF EU LEGISLATION ON OCCUPATIONAL HEALTH AND SAFETY Prevention Hierarchy of prevention measures Continuous improvement Health and Safety Employers’ responsibility Social dialogue and participation of employees Multidisciplinarity in preventive services & holistic approach to work

FRAMEWORK DİRECTİVE 89/391/EEC • Its scope is large: all sectors of activity, both public and private, with very few clearly described exceptions. • Article 5 (1), the Directive's fundamental provision, states that "the employer shall have a duty to ensure the safety and health of workers in every aspect related to the work. "

89/391/EHS – Framework Directive on the introduction of measures to encourage improvements in the safety and health of workers at work Using of the work equipment Specific group of workers 89/655/EEC Work Equipment (2) 92/85/EEC Pregnant and breastfeeding workers and worker who have recently given birth (10) Specific activities 90/269/EEC Manual Handling of Loads (4) Personal protection 90/270/EEC Display Screen Equipments (5) 89/656/EEC Personal Protective Equipment (3) 92/91/EEC Drilling (11) Workplace Exposure to agents 89/654/EEC Workplace (1) 92/57/EEC Temporary/Mobile Construction Sites (8) 90/394/EEC Carcinogens (6) 92/58/EEC Safety and/or Health Signs (9) 92/104/EEC Surface and Underground Mineralextracting Industries (12) 93/103/EC Fishing Wessels (13) 1999/92/EC Explosive Athmospheres (15) 2000/54/EC Biological Agents (7) 98/24/EC Chemical Agents (14) 2000/44/EC Vibrations (16) 2003/10/EC Noise (17) 2004/40/EC Electromagnetic Fields (18) 2000/39/EC Indicative occupational exposure limit values

OHS directives which are not directly under Framework Directive 89/391/EEC 91/383/EEC Temporary Workers 93/104/EC 2000/34/EC 2000/79/EC 2002/15/EC Working Time 94/33/EC Young Workers 1983/477/EC 1999/77/EC 2003/18/EC Asbestos

WHO • • WHO HFA 2000 and HFA 21 Alma Ata: Primary Health Care Health sector reform Public health policy: Prevent the preventable Equity: odd distribution of risks Social determinants of health Global Strategy on OH for All Workers’ Health - Global Action Plan

WHO’S CONCEPT ON WORKERS’ HEALTH AS A PUBLIC HEALTH ISSUE The Labour Approach Occupational Health Labour Contract Employer's responsibility Only at the workplace Only work-related health Negotiation between workers and employers The Public Health Approach Workers Health All workers beyond the workplace Responsibility of everyone All health determinants Other stakeholders Health protection not subject to collective negotiation

60 TH WORLD HEALTH ASSEMBLY "WORKERS' HEALTH: GLOBAL PLAN OF ACTİON" • The Global Plan of Action developed by the Member States, May 2007 • Consensus by all 192 Member States of WHO • Global plan of action on workers' health (2008 -2017) • WHA 60 urged Member States to take an number of measures on workers' health

OBJECTIVE 1: TO DEVELOP AND IMPLEMENT POLICY INSTRUMENTS ON WORKERS HEALTH • • • National policy frameworks – legislation – intersectoral collaboration – funding and resource mobilization – strengthening the ministries of health National action on workers’ health (taking into consideration also ILO Promotional Framework for OSH Convention) – national profiles and priorities for action – objectives, targets and actions – mechanism for implementation, monitoring and evaluation – human and financial resources National approaches for prevention of priority occupational diseases and accidents Minimizing gaps – high risk sectors, vulnerable groups, gender aspects WHO assistance to strengthen the capacities of ministries of health; global campaigns: elimination of asbestos-related diseases and immunization of healthcare workers against HBV

OBJECTIVE 2: TO PROTECT AND PROMOTE HEALTH AT THE WORKPLACE • Improving assessment and management of health risks at workplace: – Essential interventions for prevention occupational hazards – Integrated management of chemicals – Elimination of smoking from all indoor workplaces – Health impact assessment of new technologies • Basic set of occupational health standards – Minimum requirements for health and safety protection – Enforcement and inspection • Capacities for primary prevention of occupational hazards, diseases and injuries: methodologies, training, healthy workplaces • Health promotion and prevention of noncommunicable diseases at workplace: diet, physical activity, mental health, family health • Prevention and control HIV/AIDS, malaria, TB etc. in workplace

OBJECTIVE 3: TO IMPROVE THE PERFORMANCE OF AND ACCESS TO OCCUPATIONAL HEALTH SERVICES • Coverage and quality of occupational health services – Linkage to national health strategies and health sector reforms – – • • Standards for organization and coverage Mechanisms for resources and financing of the delivery Sufficient and competent human resources Quality assurance systems • Basic occupational health services for all workers Building core institutional capacities – national and local levels Development of human resources for occupational health – Post graduate training – Capacities for basic occupational health services – workers-’health in training of primary health care – Attracting and retaining human resources

OBJECTIVE 4: TO PROVIDE AND COMMUNICATE EVIDENCE FOR ACTION AND PRACTICE • Systems for surveillance of workers' health – National information systems – Capacities to estimate burden of diseases and injuries – Registries of exposures, diseases and accidents – Early reporting and detection • Research – Special agendas – Practical and participatory research • Communication and awareness raising – Workers and employers – Policy makers, media – Health practitioners • WHO action: indicators for workers' health; incorporation of occupational causes of diseases in ICD 11; diagnostic and exposure criteria for occupational diseases

OBJECTIVE 5: TO INCORPORATE WORKERS’ HEALTH INTO OTHER POLICIES • • Economic development policies and poverty reduction strategies Collaboration with private sectors to avoid international transfer of risks National plans and programmes for sustainable development Consider workers' health in the context of trade policies Assess health impacts of employment policies Environmental protection in relation to workers' health: – Strategic approach to International Chemicals Management – Multilateral environmental agreements – Environmental management systems – Emergency preparedness and response Sectoral policies for branches with highest health risks Primary, secondary and higher level of education and vocational training

ESSENTIAL PUBLIC HEALTH FUNCTIONS IN THE AREA OF OCCUPATIONAL HEALTH • • • Assessment and management of occupational risks Monitoring and surveillance of workers' health Workplace health promotion Participation of workers and employers Development of policies and institutional capacity Strengthening of institutional capacity for regulation and enforcement in occupational health Evaluation and promotion of equitable access to OH services Human resources development and training in OH Quality assurance in OH services Research in OH Reduction of the impact of industrial accidents and technological disasters on health WHO PAHO “Public Health in the Americas. Conceptual Renewal, Performance Assessment, and Bases for Action” 2002

BOHS • Occupational health services are available to only 10%– 15% of workers worldwide. • In industrialized countries, the coverage varies between 15% and 90% and in developing countries between a few percent and 20%, even where services are available, their quality and relevance may be low. • The needs of occupational health services grow continuously and new challenges are set by the globalization of work life. • To provide a response to such a global challenge the WHO/ILO/ICOH joint effort on the development of BOHS was launched.

COVERAGE OF OHS Workers without OHS

BOHS • The ultimate objective of the BOHS initiative is to provide occupational health services for all working people in the world, regardless of economic sector, mode of employment, size of workplace or geographic location i. e. according to the principle of universal services provision

BOHS • There is a challenge to provide good practice guidelines and toolboxes for service providers on a number of specific activities, such as planning of occupational health services, risk assessment and management, ergonomics and safety, assessment of psychological conditions and stress, and diagnosis of occupational diseases.

BOHS • BOHS are most needed for countries and sectors that do not have services at all or which are seriously underserved. • Particularly high-risk sectors such as agriculture, mining, fishery, forestry and construction have to be given priority. • Governments, in collaboration with social partners and with support and guidance by international organizations, should strengthen their policies and clarify priorities with regard to organization and development of service infrastructures.

BOHS CYCLE Workers health Orientation and planning Evaluatio n a alu v E Record keeping Mo nit ing Surveillance of WE & Surveillance of worker's health Worker Emergency preparedness WE Risk Assessment First aid Ac Work environment n Prevention of OH hazards tio Accident prevention Assessment of individual's health risk ing General health service ess Ass Individual health record or Dg of ODs and WRDs Health education and health es v information ti tia i In on & cti ra Inte Initiative s Informatio n Education Work Organization

HIERARCHY OF PREVENTIVE MEASURES Structural prevention Lack of hazard Engineering controls Minimising emissions Preventive power Control technology Ventilation, exhaustion Working practices, wet processes, cleanliness, order Personal protection, respirators Limiting exposure times Burden to health Decontamination, health surveillance, early diagnosis, treatment

A STEPWISE STRATEGY FOR OCCUPATIONAL HEALTH SERVICES m t en s ou u n ti n Co d p lo e ev Stage IV Comprehensive Service • In-company or Stage III external International special OHS units Standard Service • Comprehensive content: prevention, Stage II curative and Basic Service promotion & • OHS Infrastructure development services • ILO No. 161, 155 Objective for all! Stage I Starting level • PHC Infrastructure • Multidisciplinary content • Basic OHS content • Prevention plus • Advice in OH • Toolboxes curative services • Accidents and ODs • Acute ill-health • PHC Field nurse Physician and nurse. Multidisciplinary Safety agent with short special team with special training Starting point for SMEs, SSEs, IFS Big industries and well organised SMEs Multidisciplinary specialists' team Big industries and Big OHS Centres

MODELS OF SERVICES PROVISION 1. Primary health care model 2. Big company model 3. Group services 4. Social security model 5. Private physician 6. Private health centre 7. Local or regional hospitals

CONTENT OF BOHS The content of basic occupational health services includes, as a minimum, the following activities: • surveillance of work environment and risk assessment • health surveillance and health examinations • advice on preventive and control measures • health education and health promotion and promotion of work ability • first aid and treatment of acute illnesses • diagnosis of occupational diseases.

MODERN OCCUPATIONAL HEALTH SYSTEM labour Competent authority in central government health Secondary support level IOH or RESP OM LABOUR INSPECTORATE OM CLINICS Hyg, Erg, Psych, Safety, W-org, OM Frontline level IN-COMPANY OHS Big company PHC GROUP OHS SME Company SE SME Private center SSE SE SE IFS IFS BOHS SME IFS IFS SE IFS

Example: OH service providers in Finland Räsänen et al 2002 Enterprises 61% Employees 37% OHS units 31% Costs 16% MUNICIPAL HEALTH CENTRE Enterprise Farmers Self-employed Enterprises Employees OHS units Costs 2% 25% 38% 43% Enterprises Employees OHS units Costs 4% 6% 7% 2% Enterprises Employees OHS units Costs 33% 32% 24% 39% BIG ENTERPRISE OHS Satellite Enterprise GROUP OHS Enterprise PIVATE OHS CENTER Enterprise

CONCLUSION • Development of the whole occupational health system (policy, legislation, infrastructures, human resources, information systems and registration) • Occupational health services should be provided by wellestablished service provision units with a sufficient size to be able to provide multiprofessional services • Training of multiprofessional expert resources for occupational health is recommended by upgrading and reorienting the existing expert resources and by training new experts for broadening the scope of competence of occupational health services.

CONCLUSION • Drawing up a National Policy and Strategy and systematic curricula for training in occupational health and their adjustment to European curriculum systems is recommended. • Utilization of Basic Occupational Health Service (BOHS) model is recommended for expansion of coverage of occupational health services and particularly for serving the small enterprise, self-employed and informal sector workplaces.

CONCLUSION – The implementation of existing regulations is recommended to be supported by production of appropriate standards and good practice guidelines for practical implementation of occupational health services. – Infrastructures for occupational health services are recommended to be institutionalized and developed on a multi-model basis: coverage of all working people!

CONCLUSION • An important part of infrastructure consists of the Institute of Occupational Health and Safety • A special information strategy on occupational health, including the development of national information service and dissemination system: - National ILO CIS Center - Focal Point for EU OSHA - WHO Collaborating Centre

THANK YOU… Dr. Buhara ÖNAL bonal@csgb. gov. tr 00 90 312 2571690/200