Reports from the WHO regions and from ILO
Workers' health and primary health care
Ivan Dimov Ivanov, MD, PhD
Scientist, Occupational Health
World Health Organization
About half of the world's population is economically active. The health of workers is determined by a number of occupational hazards, individual risk factors and access to health services, which are modified by social factors and employment conditions. Though highly effective occupational health interventions exist, less than 15% of the global workforce, primarily in big enterprises in developed countries, have some access to occupational health services. Workers with precarious jobs, unemployed, migrants and those in informal economy and agriculture often do not have access to any preventive or curative health care.
The changing world of work features increasing mobility of the workforce, growing numbers of small and medium size enterprises, informal economy, sub-contracting, precarious forms of employment, rapid spread of new technologies and transfer of occupational hazards between and within countries. Unfortunately, health services for workers do not adapt quickly enough to the changing working conditions and in many cases are not fit anymore to respond adequately to the changing health needs of the workforce.
In many countries, occupational health services, if they exist at all, tend to focus on medical check ups, registration, treatment and compensation of occupational diseases and injuries. At the same time, general health services fail to detect and address health problems related to work. The linkages between occupational and general health care services are often very poor and in some countries there is a structural separation between the two. Such fragmentation of the health system results in insufficient primary prevention of work-related health problems, rising rates of sickness absenteeism, inability to reintegrate sick and injured workers back to the workplace, lack of continuity in care and inefficient use of human and financial resources.
The workplace provides ample opportunities to implement public health interventions, such as treatment of tuberculosis, immunizations against certain infectious diseases, as well as promotion of healthy diet, physical activity, well-being and mental health. However, because of the poor integration of occupational health services in primary care many public health programmes, for instance tobacco control, can not reach working populations.
The Alma Ata Declaration on Primary Health Care from 1978 emphasized the importance of bringing health care as close as possible to "where people live and work." Furthermore, resolution 60.26 "Workers' Health: Global Plan of Action", adopted by the World Health Assembly in 2007, urged 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."
The concepts of Primary Health Care (PHC) as they were expressed 30 years ago are still valid today. The 2008 World Health Report proposes four inter-linked goals for health systems strengthening based on a revitalized PHC approach for today:
- achieve universal coverage by giving everyone fair access to health services;
- re-organize health services around peoples' full range of life-long health needs and expectations and with their involvement;
- include health in all public policies and in health considerations with all external partners to create healthier and more stable communities.
- make regulation of the health sector more effective and include other sectors, NGOs, civil society and the private sector in health decision making.
This renewed attention to development of primary health care provides plentiful opportunities to scale up occupational health services using the values of equity, solidarity and social justice and the principles of multisectoral action and community participation. Such a process could allow for an adequate response by health systems to the specific health needs of a large group of workers who are currently left out, particularly by providing channels to participation and inter-sectoral action, covering working populations in a given territory, and integrated approaches to health in working and family life.
Therefore, the Government of Chile in collaboration with the World Health Organization has convened a global consultation in May 2009 to identify directions for integrating workers' health into the strategies of primary health care. The experience of the participating countries (Brazil, Chile, China, Finland, Italy, the Netherlands, South Africa, Thailand, United Kingdom, United States of America) demonstrated that this is feasible.
The meeting recommended to study systematically the lessons learned from the development of primary health policies in the context of workers'' health. The discourse on renewing primary health care that is going on at the global, regional and national levels should engage workplace actors. At the local level there is a need to improve the performance of primary care services in addressing the health needs of workers. Ministries of health have a very important role to play in protecting and promoting the health of all workers by integrating occupational health services into primary care. Occupational health could strengthen primary prevention and health promotion of primary health care policies and services. Key factors for success include: strengthening the regulatory base; building of human and institutional capacities for occupational health at the primary care level, and providing adequate financing mechanisms that stimulate the delivery of essential occupational health interventions to all workers.
WHO will work with ministries of health and WHO Collaborating Centres to develop case studies and policy options for integrating workers' health into the strategies of primary health care in different socio-economic and geographical contexts. Such work will be carried out in collaboration with international partners, such as International Labour Office, International Social Security Association, International Trade Unions Confederation and International Organization of Employers. The active involvement of the professional associations such as the International Commission on Occupational health (ICOH) and the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (Wonca).