Global strategy on occupational health for all: The way to health at work
Recommendation of the second meeting of the WHO Collaborating Centres in Occupational Health, 11-14 October 1994, Beijing, China
Global strategy objectives and actions for occupational health for all
Objective 1. Strengthening of international and national policies for health at work and development of policy tools
Description and justification: In spite of major efforts by international organizations, individual counties, enterprises, employers’ and workers’ unions and NGOs, many of the previous policy objectives on occupational health have not been met and are likely to remain unmet by the year 2000. Major traditional occupational health needs still prevail among the global workforce. In addition, due to the rapid changes in economic structures, technologies and demography, new occupational health needs have appeared and should be taken into consideration in policies. In spite of the evident needs, the majority of world’s workforce is still not served by competent occupational health services. The priority of occupational health should be elevated on both national and international social agendas and appropriate resources should be provided for strengthening occupational health programmes at both levels.
- A strong occupational health element should be included in all policy programmes and plans of WHO, including the IX General Programme of Work. The necessary financial, personnel and organizational resources should be allocated for the implementation of this element.
- WHO should provide stimuli and support for Member States in the preparation of appropriate occupational health policies and programmes by transmitting information from international experience and from other countries. This is needed particularly in the developing and newly industrialized countries and in the economies in transition.
National policy and programmes for the further development of occupational health should be reviewed and prepared in collaboration with government and social partners. Without prejudicing the primary responsibility of the employer for health and safety at work, government policy, legal actions and enforcement are needed to ensure minimum levels of health and safety in all sectors of the economy, including small-scale enterprises, the informal sector, agriculture and the self-employed. Occupational health programmes should be considered integral components of socio-economic development. Guidance given by the policy documents of WHO and IL0 should be used when appropriate. A national programme for developing occupational health should include:
- updating of legislation and standards
- definition and, if needed, strengthening of the role of the competent authority
- emphasis on the primary responsibility of the employer for health and safety at work
- establishment of mechanisms for tripartite collaboration between government, employers and trade unions for implementation of national occupational health programmes
- education, training and information of experts, employers and workers
- development of occupational health services
- analytical and advisory services
- development and, if needed, establishment of registration systems of occupational accidents, diseases and, if possible, exposures
- action to ensure collaboration between employers and workers at workplace and enterprise level.
The national occupational health system is realized at the level of the enterprise and at the local level in the form of OHS provided by occupational health teams in collaboration with employers and workers.
Objective 2. Developing the healthy work environment
Description and justification: Occupational health problems are to a great extent derived from hazardous factors in the work environment. In most countries, hazardous exposures and factors that have adverse effects on the health of workers are still found in high numbers of workplaces. The achievement of targets for equity in health stipulated in the WHO Health-for- All strategy requires intensive actions for better work environments in virtually every country. Most hazardous conditions at work are in principle preventable and the primary prevention approach is the most cost-effective strategy for their elimination and control. Criteria and actions for the planning and design of healthy and safe work environments that are conducive to physical, psychological and social well-being should be considered. With guidance and support from WHO, other international organizations and professional NGOs, countries should include in their national occupational health programmes a strong element for improvement of the physical and psychological work environment by using the primary prevention approach.
By using international scientific and expert support, together with support from other relevant programmes within WHO and outside, WHO should produce scientifically based guidelines for primary prevention of priority occupational hazards and should generate health-based criteria, standards and guidelines for the development of healthy work environments. Full use of the outputs of IPCS should be made. Collaboration between the WHO Workers’ Health Programme and professional NGOs such as the International Commission on Occupational Health (ICOH) and International Occupational Hygiene Association (IOHA) and International Ergonomic Association (IEA) is recommended.
- Every country should carry out national surveys representative of all workplaces and occupations and examine the occurrence, distribution and levels of occupational health and safety hazards and thus identify priority problems
- Within the framework of national occupational health policy and programme, strengthened national actions should be initiated with clear objectives for reduction and prevention of priority hazards at work, such as high-risk chemical and physical exposures and unreasonable physical workload or psychological workloads that lead to severe occupational accidents and diseases.
- For the establishment and planning of new work environments, health-based criteria should be given to planners, designers and builders.
Objective 3. Development of healthy work practices and promotion of health at work
Description and justification: Many occupational hazards can be effectively avoided and controlled through the adoption of appropriate working practices by the worker and through providing him or her with information, tools, work organization and work aids that enable the performing of work tasks without risk to health. This requires knowledge of health hazards at work and how to avoid them. In some instances, personal protective devices may be needed. Introduction of healthy and safe work practices requires the development, validation and distribution of guidelines, codes of practice, effective education and counseling methods.
Workers’ lifestyles may have specific or general impact on their occupational health and safety and working capacity. Health education on avoiding the combined effects of lifestyle factors and occupational exposures should be effectively provided. Health promotion that introduces healthy lifestyles and supports the maintenance of such lifestyles with appropriate information, counseling and educational measures should be undertaken and should preferably be included in OHS programme. This health promotion should be directed particularly to the maintenance of the working capacity of the worker.
The WHO Workers’ Health Programme should provide health education, information and health promotion, as well as information and training materials and model programmes for
- strengthening working capacity and providing guidance in healthy and safe working practices
- providing guidelines for general health education, information and promotion campaigns that introduce healthy lifestyles among the working population.
- The National Occupational Health Programme should encourage occupational health institutions and experts to include health promotion as an element of occupational health programmes in enterprises. The primary responsibility for this activity should lie with OHS and, where appropriate, collaboration with other bodies active in health promotion should be considered.
- Health education for the adoption of healthy and safe working practices and for avoiding lifestyles hazardous to health and working capacity should be provided to workers as an integral element of OHS.
- Occupational health personnel should be given training and education in health promotion to enable them to carry out these activities as a part of their occupational health practice.
Objective 4. Strengthening of occupational health services (OHS)
Description and justification: In many developing and newly industrialized countries no more than 5-10% of the working population, and in several industrialized countries less than 20-50%, have access to competent OHS in spite of the evident needs. Yet, the emerging problems of occupational health call for the development of OHS for all workers in all sectors of the economy and in all enterprises, as well as for the self-employed. Some industrialized countries have successfully achieved this objective in accordance with IL0 Convention No. 161 on Occupational Health Services and have found the programme both feasible in terms of health and sustainable from the point of view of the economy.
Modern occupational health services draw from each relevant profession, discipline or science - be it biomedical or environmental - all the required elements and integrates them into a comprehensive multidisciplinary approach aimed at the protection and promotion of workers’ health through actions related both to the work environment and to the workers them-selves. Disciplines relevant for OHS include occupational medicine and nursing, occupational hygiene, work physiology and physiotherapy, ergonomics, safety and work psychology.
- WHO will include in its Workers’ Health Programme a special element for the development of OHS for all working people
- Guidelines for both organization and implementation of such services will be provided by WHO in collaboration with other relevant bodies.
- Special emphasis will be given to the development of OHS for small-scale enterprises and the self-employed, including agricultural workers.
- International financial, technical and information support will be allocated through WHO Regional Offices to facilitate development of OHS at national level.
- In this action, various service provision models, including the primary health care approach, will be used where available and appropriate.
- Each country should include in its national occupational health policy and programme an objective and actions for the gradual development of OHS for all workers, starting from those at highest risk and those in underserved groups.
- The preventive approach should be given the highest priority.
- Countries are encouraged to provide the support services and other infrastructures needed for development of multidisciplinary OHS.
- Due consideration should be given to the needs of OHS for the self-employed, agricultural workers, persons employed in small-scale enterprises, migrant workers and those in the informal sector. In most instances such services can be provided by primary health care units specially trained in occupational health.
Objective 5. Establishment of support services for occupational health
Description and justification: Effective occupational health practice re-quires not only the front-line OHS at enterprise and local level, but also several expert services that individual companies or workplaces may not be afforded to sustain. Expert advisory and analytical services of occupational hygienists, ergonomists, psychologists, physiologists, safety engineers, and toxicologists, among others will be needed. Many countries have organized such services in institutes of occupational health but many others rely on services provided by universities, large industries or individual consultancies. However they are organized, these support services should be available for all practitioners in OHS. In all steps of occupational health practice the principles of total quality management and continuous quality improvement should be followed.
- WHO should give guidance and transmit experience and, if necessary, give advice to countries on why and how to organize the expert services for occupational health.
- International collaboration between experts providing these services should be encouraged to facilitate the development of their professional expertise.
- The need for research back-up for the development of expert services should be considered by WHO and other international organizations.
- Systems for developing and maintaining good scientific-technical quality in all services and methods employed in occupational health activities should be ensured by collaboration with WHO and the inter-national professional bodies.
- Governments and authorities responsible for occupational health should ensure the availability of expert services for OHS by guaranteeing the availability of expert institutions with the necessary capacity and manpower.
- Development of expert services should be a part of the National Programme for Occupational Health.
- The potential shortage of such experts should be considered in the planning of the training curricula and programmes for occupational health.
- A national quality assurance and quality management element should be included in occupational health programmes and appropriate training should be provided to responsible personnel.
Objective 6. Development of occupational health standards based on scientific risk assessment
Description and justification: To ensure minimum levels of health and safety at work, standards which define the safe levels of various exposures and other conditions of work are needed. The standards also serve as references for assessment of the results of monitoring and provide guidelines for planners. In the further development of standards the high variation in workers’ sensitivity to occupational exposures should be considered. The fact that many individuals are not what is considered to be "average" should be taken into account. A relevant scientific basis for setting standards should be ensured through collaboration with research organizations.
- WHO should continue its efforts to produce principles and scientific bases for health-based standards concerning the major occupational exposures and other conditions of work, including chemical, physical, biological and ergonomic factors. Full use of the outputs of other programmes, such as IPCS and various professional NGOs should be made.
- Guidelines should be provided on principles for the development of psychosocial quality of work.
- Research needed for setting standards should be strengthened.
- As far as appropriate and possible, WHO should facilitate and encourage international collaboration and international harmonization of standards.
- By using guidance and support from international organizations and relevant professional and scientific communities, each country should adopt a basic set of standards to be used as criteria for the evaluation of the occupational health and safety aspects of various exposures, including chemical, physical, biological and ergonomic factors. Where formal standards are not feasible or appropriate, guidelines and codes of practices should be prepared (e.g. on psychological factors).
- Production of standards and limit values for occupational exposures should be included as an element in national occupational health programmes.
- Collaboration with bodies responsible for occupational health and safety with employers’ and workers’ organizations should be ensured when standards are being set.
- Countries should collaborate in the production of a scientific basis for standards.
Objective 7. Development of human resources for occupational health
Description and justification: Occupational health is a broad expert activity that utilizes the basic knowledge of several other disciplines, such as medicine, chemistry, physics, toxicology, physiology, psychology and safety technology. Competent occupational health activities require appropriate training in these fields.
Many of the industrialized countries have trained sufficient numbers of occupational medical experts to provide one physician per 2 000-3 000 workers and about one nurse per 1 000-2 000 workers (with a wide range of variation). Many European countries and those of North America, as well as Australia and Japan, have established specialist or diploma curricula for occupational health and some countries require specialization or diploma as a condition for the right to carry out occupational health practices. Special training in occupational health is available for nurses in most countries.
The training of specialists other than the medical experts for the multidisciplinary occupational health team is much less systematically organized in most countries. Special curricula for occupational hygiene are available in six European countries and in the United States and Canada. WHO has defined the profile of the occupational hygienist on the basis of defined areas of knowledge in an effort to promote international harmonization of training curricula. Training of physiotherapists specialized in occupational health is also available in some’ countries while the special training of occupational psychologists is rare. For many Western European countries, the training of safety engineers is well organized. There is a universal shortage of both expert resources and training in developing and newly industrialized countries in the South. This is due to three main reasons:
- lack of effective legislation and lack of requests from authorities and employers make the employment opportunities for such experts minimal
- in the absence of requests, the vocational training institutions and universities have not organized and developed curricula for the training of experts in occupational health
- in some instances, where training is available, it is oriented to clinical occupational medicine only which, though important, does not give a full response to the needs for expertise in a preventive workplace-oriented occupational health service.
Equally important is the awareness and knowledge of managers and foremen of the key principles of occupational health because they make decisions about several aspects of work that determine health and safety. The awareness, knowledge and skills of workers and the self-employed are key factors for appropriate safety and health behaviour and for adopting safe working practices. There is a universal need for training in the basic principles of occupational health and safety for workers who need such knowledge in their everyday work and employers who decide on the organization of work and other working conditions. In such guidance the need for a multidisciplinary approach should be specially addressed.
- WHO should include in its Workers’ Health Programme a specific element on the training of various groups of experts in occupational health.
- In collaboration with scientific communities, other international bodies such as ILO, ICOH and IOHA, and by using support from the Network of WHO Collaborating Centres in Occupational Health and relevant professional associations, WHO should prepare appropriate guidelines for training curricula for the key expert groups in occupational health.
- Where individual countries are not able to carry out appropriate training programmes at national level WHO should establish through its Network of Collaborating Centres in Occupational Health and, when appropriate, through its special programmes such as EHG, GEENET and GETNET and particularly through its Regional Offices regional and subregional training programmes for training and education of experts in occupational health.
- Countries with well-established training capacities in occupational health should be encouraged to provide expert advice and support in the organization of such training programmes subregionally or bilaterally.
- Each country should include in its National Programme on Occupational Health an element of training of sufficient numbers of experts to implement the National Programme and to ensure sufficient personnel resources for OHS.
- Governments should ensure that the necessary elements of occupational health will be included in the basic training curricula of all who may in the future deal with occupational health issues.
- Training in occupational health should also be given in connection with vocational training and in training programmes for workers, employers and managers.
- In all training the need for a multidisciplinary approach in occupational health should be taken into consideration, ensuring involvement of occupational medicine and nursing, occupational hygiene, ergonomics and work physiology, occupational safety and other relevant fields.
Objective 8. Establishment of registration and data systems development
Description and justification: Analysis of reliable data and establishment of trends in occupational health as well as recognition of priorities at national and local levels are of utmost importance both for decision-making on policies and for occupational health practices.
There should be at least one well-developed focal point with sufficient library resources and modem data systems for the country. This focal point should be linked with international information and data networks. Progressive development of national networks is currently needed to provide technically feasible and cost-effective solutions.
Occupational health practice, training, research and communication are critically dependent on an effective supply of scientific and practical in-formation and the availability of relevant databases. Such databases and information services are needed for each country and for each occupational health team, CD-ROM technology is able to provide relevant inter-national data banks to individual experts at a reasonable cost. Several in-formation networks also serve experts in specific fields such as toxicology, medicine, chemistry and technology. Access to information systems for experts in each country should be taken as an objective of the national occupational health programme. Information networks can also be developed on a subregional or regional basis.
Provision of CD-ROM information services to the key institutions in each Member State is a realistic objective and could be realized through, for example, the Network of the WHO Collaborating Centres in Occupational Health and, if appropriate, in collaboration with IL0 International Safety and Health Information Centre (CIS), IPCS and the International Register of Potentially Toxic Chemicals (IRPTC). Multilateral and bilateral collaboration in transmission of information and sharing of experiences between countries and institutions will be further developed by the Net-work.
Much progress in the prevention of occupational health hazards has been made thanks to identification of adverse health effects by epidemiological research. It has usually taken a long time before sufficient numbers of cases have been noted and properly analyzed. Because of this, control actions have often been made post hoc, particularly in instances where the health outcome has been uncertain or unknown. New observations are occasionally made on occupational hazards, injuries and diseases that have not been reported before or that were not known to be work-related. Preventive actions are often delayed due to the uncertainty of the etiology of the problem. Collection of reports of new cases into an international data bank may help in planning and organizing multicentre studies or studies using pooled data. Such a data bank of interesting reports of new cases could be organized within the framework of the Network of WHO Collaborating Centres in Occupational Health.
Data on the demography of working populations, on economic activities and enterprises, on occupational diseases and accidents, and on the most important exposures and outcomes such as cancer are of vital importance for carrying out occupational health activities, for analyzing trends and setting priorities for prevention and control, and for carrying out epidemiological and other types of research. In most countries registers of data on occupational health and safety do not cover the whole working population and are not accurate enough for practical purposes. The development of occupational and environmental data registers for each country has been recommended recently by the Second European Conference on Health and Environment and by several working groups of WHO but further efforts should be made to meet the needs of occupational health.
Awareness of the needs and objectives of occupational health among the public at large, decision-makers, politicians, employers and workers is of utmost importance for getting the necessary political decisions taken and practical actions take. Several countries have established effective information activities for public information by using journals, other written in-formation and electronic communication media.
- WHO should, in collaboration with CIS/ILO and other relevant bodies, prepare guidelines for registration of occupational diseases and accidents and, if appropriate and feasible, for collection of data on other important aspects of occupational health, including priority exposures. Development of national data systems should be supported by appropriate training.
- Establishment of international data banks on new observations of occupational hazards and outcomes should be undertaken by the Net-work of WHO Collaborating Centres in Occupational Health.
- WHO should collaborate with CIS/ILO, IPCS and IRPTC to provide Member States with appropriate CD-ROM information systems by using the Network of WHO Collaborating Centres in Occupational Health, CIS focal points and IRPTC focal points.
- Each country should review its data and registration systems of occupational diseases and accidents and, if necessary, by the year 2000 develop them to cover fully the basic occupational health and safety data by taking the guidance given by international organizations. The comparability of data should be ensured by collaboration between the countries through WHO or bilaterally.
- Each country should, through its WHO Collaborating Centre, link into the WHO data bank of new occupational hazards and outcomes.
- Each country is encouraged to join the WHO/IL0 project for a CD-ROM data bank on occupational health and safety and distribute this data to its appropriate national networks. At least one focal point with such a data bank should be found in each country by the year 1997.
- A public information element should be included in the national programme for occupational health and information. Media should be effectively supplied with scientific information on occupational health and safety by national research institutions and professional bodies.
Objective 9. Strengthening of research
Description and justification: Research is critical to the development of occupational health administration and planning, training and education, risk identification, assessment and practice. Much support is obtained from international research centres on occupational health. Because many occupational health problems vary according to national circumstances and practices, and in order to ensure the effective transfer of the results of international research and practice to the national level, each country needs national research programmes in occupational health. Most industrialized countries have delegated responsibility for such research to a national institute of occupational health or to a special department of occupational health in a university. The oldest institutes of occupational health were established in the industrialized countries 50-70 years ago, while most developing countries do not have such a centre although their needs may be even more evident than those of the industrialized countries. The main tasks of such a centre are the following:
- to provide the necessary critical mass of scientific and expert human resources that can offer expert support to national programmes and transfer international knowledge into the country
- to provide scientific and advisory support for policy-makers and decision- makers in the development of occupational health
- to support and guide the development of provincial, local and company programmes in occupational health
- to provide research, training, information and service support for all involved in the development of occupational health. While well-established in many industrialized countries, also the experiences of such institutions in countries such as China, India and Thailand are highly positive.
- WHO should encourage countries to establish and strengthen the national centre of excellence for occupational health, such as the Institute of Occupational Health or other body. The centre could further facilitate the development of other centres within the country thus leading gradually to a national network.
- Where needed, WHO could transmit information and experience and provide expert assistance in the establishment of national centres.
- Each centre is encouraged to join the Network of WHO Collaborating Centres in Occupational Health.
- By the year 2000 all the countries that have not yet established a national centre of occupational health should have such an institution in operation and able to participate in the Network of WHO Collaborating Centres in Occupational Health.
- WHO should with help of the Network of Collaborating Centres in Occupational Health stimulate and coordinate research which has global importance in occupational health such as provision of scientific basis for standard setting and assessment of occupational health risks.
- Each government should establish or strengthen its national centre for occupational health and, if appropriate, the network of centres.
- Each country should have at least one such centre functional by the year 2000.
- Such a centre should be given the responsibility of carrying out re-search, information, training, and if appropriate, advisory and analytical and measurement services in support of occupational health practices.
- The national research programme for surveying the occupational health and safety situation, for developing competence and methodology in occupational health and for responding to national occupational health problems should be a part of the national occupational health programme.
- Effective international collaboration in research should be ensured by collaboration with the international scientific community, including the ICOH Scientific Committees and within the context of the Net-work of the WHO Collaborating Centres.
Objective 10. Development of collaboration in occupational health
Description and justification: Successful implementation of the proposed Global Strategy requires close collaboration between WHO/OHC and several other organizations, such as ILO, ICOH and many NGOs. Collaboration within WHO is necessary with counterparts including IPCS, the programmes for communicable and non-communicable diseases, environment and health, and health promotion, and above all with the Regional Offices.
Occupational health activities have several links with other parallel activities, such as occupational safety, environmental health and environmental protection, primary health care and specialized hospital-based health care. In certain special situations, such as emergency response, occupational health activities are expected to collaborate intensively with several other services, such as rescue groups, fire services and police. In all such collaborative links the role of occupational health experts is to provide expert knowledge on potential hazards in the work environment and their effects on the health of those exposed to them. Occupational health experts often also have much experience of the practical prevention of hazards. Collaborative arrangements with neighboring services may vary according to the country and local conditions, but such links should always be established and maintained for the benefit of all the collaborating partners.
In developing occupational health practices for special groups, such as farmers, the self-employed, small-scale industries and home industries, collaborative links may be needed with various extension organizations, industrial associations and several types of nongovernmental voluntary organization. Such links may facilitate the implementation of occupational health programmes among economic activities that are more informal and more difficult to reach than conventional well-organized industry and service enterprises,
- WHO should further develop its collaboration with IL0 by providing health-related input to ILO work and specifically to the joint ILO/WHO Committee on Occupational Health and to CIS/ILO. Collaboration with the International Social Security Association (ISSA) is also relevant for occupational health and related social security issues.
- WHO/OCH should develop and maintain its close working relations and practical collaboration with all relevant units of WHO, including PCS/IPCS and the Programme for Promotion of Environmental Health.
- WHO/OCH should maintain and develop the Network of WHO Collaborating Centres in Occupational Health and should encourage new countries to join it. A part of tasks of WHO’s Workers’ Health Programme and selected actions of this Global Strategy may be assigned to individual Collaborating Centres or the Network.
- Collaboration with UNCED activities, and particularly with CSD and UNEP, should be further developed.
- Collaboration of WHO with international NGOs, employers’ confederations, trade unions, businesses, industries, environmental groups and above all with international professional bodies such as ICOH, IEA and IOHA will be further developed and strengthened.
- Each country should establish a focal point for WHO occupational health programmes.
- Each country should establish a national body for ensuring multisectoral collaboration in occupational health and for encouraging all relevant bodies such as other health sectors, the Ministry of Labour, environmental health groups and relevant professional bodies to participate.
- Establishment of a national network of actors in occupational health is recommended and should be supported by the WHO Collaborating Centers with information, training, education and, if necessary, services. The WHO Collaborating Centres in Occupational Health have a central role in the development of occupational health and safety at both national and international levels.
- Collaboration of occupational health bodies with representatives of the national scientific community and the training and education institutions such as universities should be encouraged.
- Tripartite collaboration between government, employers and trade unions in implementation of occupational health activities should be ensured by the establishment of formal links with these bodies.
- Collaboration with national NGOs and professional bodies is envisaged.
- Collaboration should be encouraged with extension and promotion organizations and with industrial and trade associations.