Every employer is contractually obligated to take precautions to guarantee the safety of his employees. The labour-related rules and regulations to which attention must be paid are of necessity just as various as the dangers present in the workplace. For this reason, the Occupational Safety Act (ASiG) of the Federal Republic of Germany includes among the duties of employers a legal obligation to consult specialist professionals on matters of occupational safety. This means that the employer is required to appoint not only specialist staff (particularly for technical solutions) but also company doctors for medical aspects of occupational safety.

The Occupational Safety Act has been in effect since December 1973. There were in the FRG at that time only about 500 doctors trained in what was called occupational medicine. The system of statutory accident insurance has played a decisive role in the development and construction of the present system, by means of which occupational medicine has established itself in companies in the persons of company doctors.

Dual Occupational Health and Safety System in the Federal Republic of Germany

As one of five branches of social insurance, the statutory accident insurance system makes a priority the task of taking all appropriate measures to ensure prevention of work accidents and occupational diseases through detection and elimination of work-related health hazards. In order to fulfil this legal mandate, legislators have granted extensive authority to a self-governing accident insurance system to enact its own rules and regulations concretizing and shaping the requisite preventive precautions. For this reason, the statutory accident insurance system has—within the bounds of existing public law—taken over the role of determining when an employer is required to take on a company doctor, what expert qualifications in occupational medicine the employer may demand of the company doctor and how much time the employer may estimate that the doctor will have to spend on the care of his employees.

The first draft of this accident prevention regulation dates from 1978. At that time, the number of available doctors with expertise in occupational medicine did not appear sufficient to provide all businesses with the care of company doctors. Thus the decision was made at first to establish concrete conditions for the larger businesses. At that time, to be sure, the businesses belonging to large-scale industry had often already made their own arrangements for company doctors, arrangements which already met or even exceeded the requirements stated in the accident prevention regulations.

Employment of a Company Doctor

The hours allocated in firms for the care of employees—called assignment times—are established by the statutory accident insurance system. Knowledge available to insurers concerning the existing risks to health in the various branches formed the basis for the calculation of the assignment times. The classification of firms with regard to particular insurers and the evaluation of possible health risks undertaken by them were thus the basis for the assignment of a company doctor.

Since the care rendered by company doctors is an occupational safety measure, the employer must cover the costs of assignment for such doctors. The number of employees within each of the several areas of hazard multiplied by the time allocated for care determine the sum of financial expenses. The result is a range of different forms of care, since it can pay—depending on the size of a firm—either to employ a doctor or doctors full-time, that is as the company’s own, or part-time, with services rendered on an hourly basis. This variety of requirements has led to a variety of organizational forms in which occupational medical services are offered.

The Duties of a Company Doctor

In principle, a distinction should be made, for legal reasons, between the provisions made by companies to provide care for employees and the work done by the doctors in the public health system responsible for the general medical care of the population.

In order to differentiate clearly which services of occupational medicine employers are responsible for, which are given in figure 1, the Occupational Safety Act has already anchored in law a catalogue of duties for company doctors. The company doctor is not subject to the orders of the employer in the fulfilment of these tasks; still, company doctors have had to fight the image of an employer-appointed doctor up to the present day.

Figure 1. The duties of occupational physicians employed by companies in Germany

One of the essential duties of the company doctor is the occupational medical examination of employees. This examination can become necessary according to the specific features of a given concern, if particular working conditions exist which lead the company doctor to offer, of his own accord, an examination to the employees involved. He cannot, however, force an employee to allow himself to be examined by him, but must rather convince him through trust.

Special Preventive Checkups in Occupational Medicine

There exists, in addition to this kind of examination, the special preventive check-up, participation in which by the employee is expected by the employer on legal grounds. These special preventive checkups end in the issuance of a doctor’s certificate, in which the examining doctor certifies that, based on the examination conducted, he has no objection to the employee’s engaging in work at the workplace in question. The employer may assign the employee only once for each certificate issued.

Special preventive checkups in occupational medicine are legally prescribed if exposure to particular hazardous materials occurs in the workplace or if particular hazardous activities belong to job practice and such health risks cannot be excluded through appropriate occupational safety precautions. Only in exceptional circumstances—as is the case, for example, with radiation protection checkups—is the legal requirement that an examination be performed supplemented by legal regulations concerning what the doctor carrying out the examination must pay attention to, which methods he must apply, which criteria he must use to interpret the outcome of the examination and which criteria he must apply in judging health status with regard to work assignments.

This is why in 1972 the Berufsgenossenschaften, made up of commercial trade associations which provide the accident insurance for trade and industry, authorized a committee of experts to work out commensurate recommendations to doctors working in occupational medicine. Such recommendations have existed for more than 20 years. The Berufsgenossenschaften Guidelines for Special Preventive Checkups, listed in figure 2, now show a total of 43 examination procedures for the various health hazards which can be countered, on the grounds of present knowledge, with appropriate medical precautionary measures so as to prevent diseases from developing.

Figure 2. A summary information on external services of the Berufgenossenschaften in the German building industry

The Berufsgenossenschaften deduce the mandate to make available such recommendations from their duty to take all appropriate measures to prevent occupational diseases from arising. These Guidelines for Special Preventive Checkups are a standard work in the field of occupational medicine. They find application in all spheres of activity, not only in enterprises in the sphere of trade and industry.

In connection with the provision of such occupational medical recommendations, the Berufsgenossenschaften also took steps early on to ensure that in businesses lacking their own company doctor the employer would be required to arrange for these preventive checkups. Subject to certain basic requirements having to do primarily with the specialized knowledge of the doctor, but also with the facilities available in his or her practice, even doctors without expertise in occupational medicine can acquire the authority to offer companies their services in performing preventive checkups, contingent on a policy administered by the Berufsgenossenschaften. This was the precondition for the current availability of the total of 13,000 authorized doctors in Germany who perform the 3.8 million preventive checkups performed annually.

It was the supply of a sufficient number of doctors that also made it possible legally to require that employers initiate these special preventive checkups in complete independence of the question of whether or not the company employs a doctor prepared to do such checkups. In this way, it became possible to use the statutory accident insurance system to ensure enforcement of certain measures of health protection at work, even at the level of small businesses. The relevant legal regulations may be found in the Ordinance on Hazardous Substances and, comprehensively, in the accident prevention regulation, which regulates the rights and duties of the employer and the examined employee and the function of the licensed doctor.

Care Provided by Company Doctors

The statistics released annually by the Federal Board of Doctors (Bundesärztekammer) show that for the year 1994 more than 11,500 doctors fulfil the prerequisites, in the form of specialist knowledge in industrial medicine, to be company doctors (see table 1). In the Federal Republic of Germany, the organization Standesvertretung representing the medical profession regulates autonomously which qualifications must be met by doctors as regards study and subsequent professional development before they may become active as doctors in a given field of medicine.

Table 1.  Doctors with specialist knowledge in occupational medicine

^* As of 31 December 1995.

The satisfaction of these prerequisites for the activity of a company doctor represents either the attainment of the field designation “occupational medicine” or of the additional designation “corporate medicine”—that is, either four years’ further study after the licence to practice in order to be active exclusively as a work physician, or three years’ further study, after which activity as a company doctor is allowed only in so far as it is connected with medical activity in another field (e.g., as an internist). Doctors tend to prefer the second variant. This means, however, that they themselves see the chief emphasis of their professional work as physicians in a classical field of medical activity, not in occupational medical practice.

For these doctors, occupational medicine has the significance of an auxiliary source of income. This explains at the same time why the medical element of the examination by doctors continues to dominate the practical exercise of the profession of company doctor, although the legislature and the statutory accident insurance system themselves emphasize inspection of companies and medical advice given to employers and employees.

In addition, there still exists a group of doctors who, having acquired specialist knowledge in occupational medicine in earlier years, met different requirements at that time. Of particular significance in this regard are the standards which doctors in the former German Democratic Republic were required to meet in order to be allowed to practice as company doctors.

Organization of Care Provided by Company Doctors

In principle, it is left up to the employer to choose freely a company doctor for the firm from among those offering occupational medical services. Since this supply was not yet available subsequent to the establishment, in the early 1970s, of the relevant legal preconditions, the statutory accident insurance system took the initiative in regulating the market economy of supply and demand.

The Berufsgenossenschaften of the building industry instituted their own occupational medical services by engaging doctors with specialist knowledge in occupational medicine in contracts to provide care, as company doctors, to the firms affiliated with them. Via their statutes, the Berufsgenossenschaften arranged for each of their firms to be cared for by its own occupational medical service. The costs incurred were distributed among all the firms through appropriate forms of financing. A summary of information concerning external occupational medical services of the Berufsgenossenschaften of the building industry is given in table 2.

Table 2. Company medical care provided by external occupational medical services,1994

¹ ARGE Bau = Workers’ Community of the Berufgenossenschaften of Building Industry Trade Associations.
² BAD = Occupational Medical Service of the Berufgenossenschaften.
³ IAS = Institute for Occupational and Social Medicine.
⁴ TÜV = Technical Control Association.
⁵ AMD Würzburg = Occupational Medical Service of the Berufgenossenschaften.

The Berufsgenossenschaften for the maritime industry and that for domestic shipping also founded their own occupational medical services for their businesses. It is a characteristic of all of them that the idiosyncrasies of the businesses in their trade—non-stationary enterprises with special vocational requirements—were a decisive factor in their taking the initiative to make clear to their companies the necessity for company doctors.

Similar considerations occasioned the remaining Berufsgenossenschaften to unite themselves in a confederation in order to found the Occupational Medical Service of the Berufsgenossenschaften (BAD). This service organization, which offers its services to every enterprise in the market, was enabled at an early stage by the financial collateral provided by the Berufsgenossenschaften to be present over the entire area of the Federal Republic of Germany. Its broad coverage, as far as representation goes, was meant to ensure that even those businesses located in the Federal states, or states of relatively poor economic activity, of the Federal Republic would have access to a company doctor in their area. This principle has been maintained up to the present time. The BAD is considered, meanwhile, the largest provider of occupational medical services. Nonetheless, it is forced by the market economy to assert itself against competition from other providers, particularly within urban agglomerations, by maintaining a high level of quality in what it provides.

The occupational medical services of the Technical Control Association (TÜV) and of the Institute for Occupational and Social Medicine (IAS) are the second- and third-largest transregional providers. There are in addition numerous smaller, regionally active enterprises in all of the Federated States of Germany.

Cooperation with Other Providers of Services in Occupational Health and Safety

The Occupational Safety Act, as a legal foundation for care provided to companies by company doctors, provides also for professional supervision of occupational safety, particularly in order to ensure that aspects of occupational safety be handled by personnel schooled in technical precautions. The requirements of industrial practice have changed meanwhile to such an extent that technical knowledge regarding questions of occupational safety must now be supplemented more and more by familiarity with questions of the toxicology of materials used. In addition, questions of ergonomic organization of work conditions and of the physiological effects of biological agents play an increasing role in evaluations of stresses in a place of work.

The requisite knowledge may be mustered only through interdisciplinary cooperation of experts in the field of health and safety at work. Therefore, the statutory accident insurance system supports particularly the development of forms of organization which take such interdisciplinary cooperation into account at the organizational stage, and creates within its own structure the preconditions for this cooperation by redesigning its administrative departments in a suitable fashion. What was once called the Technical Inspection Service of the statutory accident insurance system turns into a field of prevention, within which not only technical engineers but also chemists, biologists and, increasingly, physicians are active together in designing solutions for problems of labour safety.

This is one of the indispensable prerequisites for creating a basis for the type of organization of interdisciplinary cooperation—within businesses and between safety technology service organizations and company doctors—required for efficient solution of the immediate problems of occupational health and safety.

In addition, supervision in respect of safety technology should be advanced, in all companies, just as much as supervision by company doctors. Safety specialists are to be employed by businesses on the same legal basis—the Occupational Safety Act—or appropriately trained personnel affiliated with the industry are to be supplied by the businesses themselves. Just as in the case of the supervision provided by company doctors, the accident prevention regulation, Specialists for Occupational Safety (VBG 122), has formulated the requirements according to which businesses must employ safety specialists. In the case of safety-technical supervision of businesses as well, these requirements take all necessary precautions to incorporate each of the 2.6 million firms currently comprising the commercial economy as well as those in the public sector.

Around two million of these firms have fewer than 20 employees and are classed as small industry. With the full supervision of all enterprises, that is, including the smaller and smallest of businesses, the statutory accident insurance system creates for itself a platform for the establishment of occupational health and safety in all areas.

Back

The coverage of workers in small-scale enterprises (SSEs) is perhaps the most daunting challenge to systems for delivering occupational health services. In most countries, SSEs comprise the vast majority of the business and industrial undertakings—reaching as high as 90% in some of the developing and newly industrialized countries—and they are found in every sector of the economy. They employ on average nearly 40% of the workforce in the industrialized countries belonging to the Organization for Economic Cooperation and Development and up to 60% of the workforce in developing and newly industrialized countries. Although their workers are exposed to perhaps an even greater range of hazards than their counterparts in large enterprises (Reverente 1992; Hasle et al. 1986), they usually have little if any access to modern occupational health and safety services.

Defining Small-Scale Enterprises

Enterprises are categorized as small-scale on the basis of such characteristics as the size of their capital investment, the amount of their annual revenues or the number of their employees. Depending on the context, the number for the last category has ranged from one to 500 employees. In this article, the term SSE will be applied to enterprises having 50 or fewer employees, the most widely accepted definition (ILO 1986).

SSEs are gaining importance in national economies. They are employment-intensive, flexible in adapting to rapidly changing market situations, and provide job opportunities for many who would otherwise be unemployed. Their capital requirements are often low and they can produce goods and services near the consumer or client.

They also present disadvantages. Their lifetime is often brief, making their activities difficult to monitor and, frequently, their small margins of profits are achieved only at the expense of their workers (who are often also their owners) in terms of hours and intensity of workloads and exposure to occupational health risks.

The Workforce of SSEs

The workforce of SSEs is characterized by its diversity. In many instances, it comprises the manager as well as members of his or her family. SSEs provide entry to the world of work for young people and meaningful activities to elderly and redundant workers who have been separated from larger enterprises. As a result, they often expose such vulnerable groups as children, pregnant women and the elderly to occupational health risks. Further, since many SSEs are carried out in or near the home, they often expose family members and neighbours to the physical and chemical hazards of their workplaces and present public health problems through contamination of air or water or of food grown near the premises.

The educational level and socio-economic status of SSE workers vary widely but are often lower than the averages for the entire workforce. Of particular relevance is the fact that their owners/managers may have had little training in operation and management and even less in the recognition, prevention and control of occupational health risks. Even where appropriate educational resources are made available, they often lack the time, energy and financial resources to make use of them.

Occupational Hazards in SSEs and the Health Statusof their Workers

Like all other aspects of SSEs, their working conditions vary widely depending on the general nature of the enterprise, the type of production, the ownership and location. In general, the occupational health and safety hazards are much the same as those encountered in larger enterprises, but as noted above, the exposures to them are often substantially higher than in large enterprises. Occasionally, however, the working conditions in SSEs may be much better than those in larger enterprises with a similar type of production (Paoli 1992).

Although very few studies have been reported, it is not surprising that surveys of the health of workers in SSEs in such industrialized countries as Finland (Huuskonen and Rantala 1985) and Germany (Hauss 1992) have disclosed a relatively high incidence of health problems, many of which were associated with lowered capacity for work and/or were work-related in origin. In SSEs in developing countries an even higher prevalence of occupational diseases and work-related health problems has been reported (Reverente 1992).

Barriers to Occupational Health Services for SSEs

There are formidable structural, economic and psychological barriers to the provision of occupational health services to SSEs. They include the following:

1. Traditionally, occupational safety and health legislation in most countries has exempted SSEs and is generally applicable only to manufacturing industries. The “informal sector” (this would include, say, the self-employed) and agriculture were not covered. Even where the legislation had wider coverage, it was not applicable to enterprises with small numbers of employees—500 employees was the usual lower limit. Re-cently, some countries (e.g., France, Belgium and the Nordic countries) have enacted legislation requiring the provision of occupational health service for all enterprises regardless of size or sector of the economy (Rantanen 1990).
2. SSEs, as defined for this article, are too small to justify an in-plant occupational health service. Their wide diversity with respect to type of industry and methods of production as well as style of organization and operation, along with the fact that they are spread over wide geographic areas, makes it difficult to organize occupational health services that will meet all their needs.
3. Economic barriers are substantial. Many SSEs hover on the edge of survival and just cannot afford any additions to their operating costs even though they may promise significant savings in the future. Further, they may not be able to afford education and training in hazard recognition, prevention and control for their owners/managers, much less their employees. Some countries have addressed the economic problem by providing subsidies either from governmental agencies or social security institutions (Rantanen 1994), or have included occupational health services in programmes promoting the general economic and social development of SSEs (Kogi, Phoon and Thurman 1988).
4. Even when financial constraints are not inhibiting, there is often a disinclination among the owners/managers of SSEs to devote the time and energy needed to acquire the necessary basic understanding of the relationships between work and health. Once acquired, however, SSEs may be very successful in applying the information and abilities in their workplaces (Niemi and Notkola 1991; Niemi et al. 1991).
5. Enterprises in the informal sector and small farming are seldom registered, and their formal links with official agencies may be weak or non-existent. Activities carried out as a business may be difficult to distinguish from those involving the private household and family. As a result, there may be concerns about privacy and resistance to interventions by “outsiders”. SSEs often resist becoming involved in trade associations and community organizations, and in perhaps the majority of instances their employees are not members of unions. To overcome such barriers, some countries have used extension organizations for the distribution of information, the creation of special training opportunities for the SSEs by official occupational safety and health agencies, and the adoption of the primary care model for the provision of occupational health services (Jeyaratnam 1992).
6. Many SSEs are located in communities providing ready access to emergency and primary care services. However, the physicians’ and nurses’ lack of knowledge and experience with respect to occupational hazards and their effects often results in failure to recognize occupational diseases and, probably more important, loss of opportunities to install the necessary prevention and control measures.

International Instruments Covering OccupationalSafety and Health Services

In some countries, occupational safety and health activities are in the jurisdiction of labour ministries and are regulated by a special occupational safety and health authority; in others, this responsibility is shared by their ministries of labour, health and/or social affairs. In some countries, such as Italy, regulations covering occupational health services are embodied in health legislation or, as in Finland, in a special act. In the United States and in England, provision of occupational health services rests on a voluntary basis, while in Sweden, among others, it was once regulated by collective agreement.

The ILO Occupational Safety and Health Convention (No. 155) (ILO 1981a) requires governments to organize a policy for occupational safety and health to be applicable to all enterprises in all sectors of the economy that is to be implemented by a competent authority. This Convention stipulates the responsibilities of the authorities, employers and workers and, supplemented by the concomitant Recommendation No. 164, defines the key occupational safety and health activities of all relevant actors at both national and local levels.

The ILO supplemented these in 1985 by the International Convention No. 161 and Recommendation No. 171 on Occupational Health Services. These contain provisions on policy design, administration, inspection and collaboration of occupational health services, activities by occupational safety and health teams, conditions of operation, and responsibilities of employers and workers, and they furthermore offer guidelines for organizing occupational health services at the level of the enterprise. While they do not specify SSEs, they were developed with these in mind since no size limits were set for occupational health services and the necessary flexibility in their organization was emphasized.

Unfortunately, ratification of these ILO instruments has been limited, particularly in developing countries. On the basis of experience from the industrialized countries, it is likely that without special actions and support by government authorities, the implementation of the ILO principles will not take place in SSEs.

The WHO has been active in promoting the development of occupational health services. Examination of the legal requirements was carried out in a consultation in 1989 (WHO 1989a), and a series of about 20 technical documents on various aspects of occupational health services has been published by WHO headquarters. In 1985 and again in 1992, the WHO Regional Office in Europe carried out and reported surveys of occupational health services in Europe, while the Pan American Health Organization designated 1992 as a special year for occupational health by promoting occupational health activities in general and conducting a special programme in Central and South America.

The European Union has issued 16 directives concerning occupational safety and health, the most important of which is Directive 391/1989, which has been called the “Framework Directive” (CEC 1989). These contain provisions for specific measures such as requiring employers to organize health risk assessments of different technical facilities or to provide health examinations of workers exposed to special hazards. They also cover the protection of workers against physical, chemical and biological hazards including the handling of heavy loads and working at video display units.

While all of these international instruments and efforts were developed with SSEs in mind, the fact is that most of their provisions are practical only for larger enterprises. Effective models for organizing a similar level of occupational health services for SSEs remain to be developed.

Organizing Occupational Health Services for SSEs

As noted above, their small size, geographic dispersion and wide variation in types and conditions of work, coupled with great limitations in economic and human resources, make it difficult to efficiently organize occupational health services for SSEs. Only a few of the various models for delivering occupational health services described in detail in this chapter are adaptable to SSEs.

Perhaps the only exceptions are SSEs that are dispersed operating units of large enterprises. These usually are governed by policies established for the entire organization, participate in company-wide educational and training activities, and have access to a multidisciplinary team of specialists in occupational health located in a central occupational health service that is usually based at the headquarters of the enterprise. A major factor in the success of this model is having all of the costs of occupational safety and health activities covered by the central occupational health unit or the general corporate budget. When, as is increasingly common, the costs are allocated to the operating budget of the SSE, there may be difficulty in enlisting the full cooperation of its local manager, whose performance may be judged on the basis of the profitability of that particular enterprise.

Group services organized jointly by several small or medium-sized enterprises have been successfully implemented in several European countries—Finland, Sweden, Norway, Denmark, the Netherlands and France. In some other countries they have been experimented with, with the help of government subsidies or private foundations, but they have not survived after termination of subsidies.

An interesting modification of the group service model is the branch-oriented service, which provides services for a high number of enterprises operating all in the same type of industry, such as construction, forestry, agriculture, food industry and so on. The model enables the service units to specialize in the problems typical for the branch and thus accumulate high competence in the sector that they serve. A famous example of such a model is the Swedish Bygghälsan, which provides services for construction industries.

A notable exception is the arrangement organized by a trade union whose members are employed in widely scattered SSEs in a single industry (e.g., health care workers, meat cutters, office workers and garment workers). Usually organized under a collective agreement, they are financed by employers’ contributions but are usually governed by a board comprising representatives of both employers and workers. Some operate local health centres providing a broad range of primary and specialist clinical services not only for workers but often for their dependants as well.

In some instances, occupational health services are being provided by hospital outpatient clinics, private health centres and community primary care centres. They tend to focus on the treatment of acute work-related injuries and illnesses and, except perhaps for routine medical examinations, provide little in the way of preventive services. Their staffs often have a low level of sophistication in occupational safety and health, and the fact that they are usually paid on a fee-for-service basis provides no great incentive for their involvement in the surveillance, prevention and control of workplace hazards.

A particular disadvantage of these “external services” arrangements is that the customer or client relationship with those using them generally precludes the participation and collaboration of employers and workers in the planning and monitoring of these services that are stipulated in the ILO Conventions and the other international instruments created to guide occupational safety and health services.

Another variant is the “social security model”, in which occupational health services are provided by the same organization that is responsible for the cost of compensation for occupational diseases and injuries. This facilitates the availability of resources to finance the services in which, although curative and rehabilitative services are featured, preventive services are often prioritized.

An extensive study carried out in Finland (Kalimo et al. 1989), one of the very few attempts to evaluate occupational health services, showed that municipal health centres and private health centres were the dominant providers of occupational health services to SSEs, followed by the group or shared centres. The smaller the enterprise, the more likely it was to use the municipal health centre; up to 70% of SSEs with one to five workers were served by municipal health centres. Significant findings of the study included verification of the value of workplace visits by the personnel of the centres serving the SSEs to gain knowledge (1) of the working conditions and the particular occupational health problems of the client enterprises, and (2) of the need to provide them with special training in occupational safety and health before they undertake the provision of the services.

Types of Activities for Occupational Health Services for SSEs

The occupational health services designed for SSEs vary widely according to national laws and practices, the types of work and work environments involved, the characteristics and health status of the workers and the availability of resources (both in terms of the ability of the SSEs to afford the occupational health services and the availability of health care facilities and personnel in the locality). Based on the international instruments cited above and regional seminars and consultations, a list of activities for comprehensive occupational health services has been developed (Rantanen 1989; WHO 1989a, 1989b). A number of key activities that should always be found in an occupational health services programme, and that are relevant for SSEs, can be picked up from those reports. They include for example:

Assessment of occupational health needs of the enterprise

• preliminary analysis of the activities of the enterprise and identification of the health and safety hazards common to such workplaces

• inspection and surveillance of the workplace to identify and quantify the hazards actually present in the particular enterprise

• assessment of the extent of the risks they present and ranking them in order of their urgency and priority

• repeating the hazard assessment whenever there are changes in production methods, equipment and materials.

Prevention and control activities in the workplace

• communication of the results of the assessment to the owners/managers and the workers’ representatives

• identification of the prevention and control measures that are needed and available, assigning relative priority to them in terms of urgency and feasibility

• overseeing their installation and implementation

• monitoring their continuing effectiveness.

Preventive activities oriented to workers

• assessment and surveillance of workers’ health status by pre-placement, screening and periodic examinations which may be general as well as focused on the biological effects of particular hazards to which the workers may have been exposed

• adaptation of the job, the work station and the workplace environment to promote workers’ ongoing health and safety with special attention to such vulnerable groups as the very young, the elderly and those with acquired diseases and disabilities

• providing workers with health education and training in proper work practices

• providing education and training for owners/managers and supervisors that will inculcate awareness of the health needs of workers and motivation to initiate appropriate prevention and control measures.

Curative activities

• provide or arrange the delivery of the appropriate diagnostic, therapeutic and rehabilitative services for occupational injuries and diseases

• provide or arrange for early rehabilitation to obviate avoidable disability and encourage and oversee adjustments in the job that will permit early return to work

• provide education and training (and periodic retraining) in first aid and emergency procedures

• establish procedures and conduct training drills for coping with major emergencies such as spills, fires, explosions and so on

• provide or arrange for workers’ involvement in programmes that promote general health and well-being.

Record keeping and evaluation

• make and retain appropriate records on occupational accidents, injuries and diseases and if possible on exposure; evaluate the overall health and safety status of the enterprise on the basis of such data

• monitor the effectiveness of hazard prevention and control measures.

Implicit in the above list of core activities is the appropriate availability of advice and consultations in such occupational safety and health specialities as occupational hygiene, ergonomics, work physiology, safety engineering, occupational psychiatry and psychology and so on. Such specialists are not likely to be represented in the personnel of the facilities providing occupational health services to SSEs but, when needed, they can usually be provided by governmental agencies, universities and private consulting resources.

Because of their lack of sophistication and time, owners/managers of SSEs are forced to rely more heavily on the purveyors of safety equipment for the effectiveness and reliability of their products, and on the suppliers of chemicals and other production materials for complete and clear information (e.g., data sheets) about the hazards they may present and how these may be prevented or controlled. It is important, therefore, that there be national laws and regulations covering proper labelling, product quality and reliability, and the provision of easily understood information (in the local language) about equipment use and maintenance as well as product use and storage. As a backup, the trade and community organizations of which SSEs are often members should feature information about the prevention and control of potentially hazardous exposures in their newsletters and other communications.

Conclusions

In spite of their importance for the national economy and their role as employer of a majority of the nation’s workforce, SSEs, the self-employed and agriculture are sectors that are typically underserved by occupational health services. ILO Convention No. 161 and Recommendation No. 171 provide relevant guidelines for the development of such services for SSEs and should be ratified and implemented by all countries. National governments should develop the requisite legal, administrative and financial mechanisms to provide all workplaces with occupational safety and health services that will effectively identify, prevent and control exposures to potential hazards and promote the enhancement and maintenance of optimal levels of health status, well-being and productive capacity of all workers. Collaboration at international, regional and subregional levels, such as that provided by the ILO and the WHO, should be encouraged to foster the exchange of information and experience, the development of appropriate standards and guidelines and the undertaking of relevant training and research programmes.

SSEs may in many instances be reluctant to seek actively the services of occupational health units even though they might be the best beneficiaries of such services. Considering this, some governments and institutions, particularly in Nordic countries, have adopted a new strategy by starting wide-scale interventions for establishment or development of services. For instance the Finnish Institute of Occupational Health currently implements an Action Programme, for 600 SSEs employing 16,000 workers, aimed at the development of occupational health services, maintenance of work ability, prevention of environmental hazards in the neighbourhood and improving the competence of SSEs in occupational health and safety.

Back

History

In the 1930s, the application in France of certain clauses of the labour code concerning occupational hygiene demonstrated the value of providing workplace inspectors with access to consulting physicians.

The laws of 17 July 1937 and 10 May 1946 (articles L 611-7 and R 611-4) empowered the Department of Workplace Inspection to order temporary medical interventions. Over time, these interventions, originally conceived of as intermittent, evolved into ongoing activities complementary to and conducted simultaneously with workplace inspection.

The promulgation of the law of 11 October 1946 concerning occupational medicine was soon followed by the establishment of a permanent technical framework for the medical inspection of workplaces and workers. The decree of 16 January 1947 established the context, pay scales, status and functions of medical inspectors of workplaces and workers.

Since 1947, however, technical development in this area has been irregular and sporadic, and the number of medical inspectors has sometimes failed to keep pace with the number of inspection tasks; the latter has also been true of workplace inspections. Thus, while medical departments created in accordance with the law of 11 October 1946 increased in prevalence and importance, the number of medical inspectors was gradually reduced from 44, the number originally called for in 1947, to 21. These contradictory trends partially explain some of the criticism the occupational medicine system has had to face.

However, since 1970, and particularly since 1975, there has been a significant effort to create a Department of Workplace Medical Inspection capable of responding to the needs of the approximately 6,000 physicians responsible for over 12 million workers. In 1980, inspection services were allocated 39 paid positions, of which 36 were actually filled. In 1995, 43 positions were available. Priority Action Plan Number 12 of the VIIth Plan provides for 45 medical inspectors; this will bring staffing levels up to the levels originally envisaged in 1947.

At the same time that French officials were recognizing the necessity of establishing a specialized inspection department responsible for the application of legislative and regulatory directives concerning occupational hygiene and medicine, identical conclusions were being drawn in other countries. In response to this growing consensus, the ILO, in collaboration with the WHO, convened an international colloquium on the medical inspection of workplaces, in Geneva in 1963. Among the noteworthy outcomes of the colloquium were the definition of the responsibilities, duties, and knowledge and training requirements of medical inspectors, and the techniques and methods of medical inspection.

General Organization

The central office of the Department of Workplace and Worker Medical Inspection is part of the Industrial Relations Department and reports directly to the Regional Director of Industrial Relations and Medical Inspection. The Regional Director, in turn, is part of the Regional Labour and Employment Board and reports directly to the Regional Director of Labour and Employment. The number of professionals and workers in France in 1995 were:

• 12.5 million workers benefiting from general coverage

• 6,337 physicians, of which 2,500 are full-time

• 4,000 nurses

• 1,500 medical departments

• 90% of workers are followed up by sectoral medical departments.

The number of medical inspectors in each region depends on the number of salaried occupational medicine positions in that region. In general, each regional medical inspector should be responsible for approximately 300,000 workers. This general rule is, however, subject to modification in either direction, depending on the size and geography of each region.

Mission

Although many of its clauses are no longer relevant or have lapsed, it is nevertheless useful to review the responsibilities of medical inspectors prescribed by the aforementioned decree of 16 January 1947.

The physician in charge of the department is responsible, among other things, for the coordination of all medical problems in the various departments of the Ministry of Labour and Social Security. His or her functions can be extended by decree.

The Medical Inspector of Workplaces and Workers will:

1. maintain, with the Technical Committees of the Social Security Credit Unions, direct and permanent contact with the Workplace Inspection Department, and ensure the application of legislation concerning occupational hygiene and the protection of worker health
2. carry out, on an ongoing basis, activities designed to protect worker health in the workplace; these activities will include, among other things, the supervision of the Occupational Medical Departments established by virtue of the law of 11 October 1946
3. supervise, in close collaboration with psychotechnical departments, medical examinations aimed at determining workers’ fitness for work, and reclassifying and referring workers who are temporarily unfit for work or physically handicapped to rehabilitation centres
4. supervise, in collaboration with the Technical Committees of the Social Security Credit Unions, the preparation, compilation and use of statistics concerning the physiopathological characteristics of the workforce.

The Medical Inspector of Workplaces will communicate information he or she possesses concerning the risk of occupational disease and accidents in different companies to the Technical Committees of the Social Security Credit Unions. The note of 15 September 1976 concerning the organization of Industrial Relations Departments assigns the following responsibilities to the Department of Workplace and Worker Medical Inspection:

• the investigation of technical aspects of occupational medicine, pathology, work physiology and ergonomics

• the investigation of questions related to the protection of wor-kers’ health and to work conditions

• the investigation of medical aspects of work

• the monitoring of progress in medicine, physiology and erg-onomics

• the coordination of regional information gathering.

Management of medical inspectors involves:

• the coordination of regional medical inspectors

• the development and application of reports, technical studies and research conducted regionally or transregionally, and ulti-mately, of specialized work groups

• the organization of meetings which provide members of the Department of Workplace and Worker Medical Inspection with an opportunity to compare experiences and define consistent approaches to new problems

• the preparation of recruitment and training procedures for medical inspectors of workplaces and workers

• the continuing education of all regional medical inspectors.

In addition to these core activities, the Department of Workplace and Worker Medical Inspection also collaborates with industrial relations and human resources departments in all cases involving medical aspects of work (especially those involving handicapped workers, candidates for continuing education and job applicants) and is responsible for managing, coordinating, recruiting and training regional medical inspectors and ensuring their continuing technical education. Finally, the central office of the Department also engages in consulting activities and is the government’s official representative in matters concerning occupational medicine.

The Department of Labour’s central or regional Departments of Workplace and Worker Medical Inspection may be called upon to intervene when other governmental departments without their own medical inspection services (most notably the Department of Health and Social Security) find themselves faced with problems related to the prevention or correction of occupational health hazards; these departments of the Department of Labour may also assist in the establishment of a department of medical prevention. Except in cases where the requesting party is another governmental work-inspection service, the Department’s role is usually limited to an advisory one.

From 7 to 10 June 1994, almost 1,500 people attended the XIIIth Journées nationales de médecine du travail (the 23rd National Occupational Medicine Conference) organized by the Société et l’Institut de médecine du travail et d’ergonomie de Franche-Comté (the Society and Institute of Occupational Medicine and Ergonomics of Franche-Comté). The following subjects were discussed:

• neurotoxicity of low-level solvent exposure

• health and the precariousness of health and work

• stress and strain of contemporary work—the role of the occup-ational physician.

The Department is the government’s representative in medicosocial, scientific and professional agencies or institutions in the field of occupational medicine. These include the Conseil National de l’Ordre des Médecins (the National Council of the Order of Physicians), le Haut Comité d’Études et d’Information contre l’alcoolisme (the High Commission for Alcoholism Research and Information) and various university and scientific institutions. In addition, the central Department of Workplace and Worker Medical Inspection is frequently called upon to present the French government’s position on medical questions to the European Economic Community, the WHO and the ILO. Regional departments have similar responsibilities, in accordance with Circular DRT No. 18-79, of 6 July 1979, on the role of cooperation between workplace inspectors and medical inspectors of workplaces in the prevention of occupational hazards. The circular identifies orientation, informational, supervisory, management and intervention activities to be carried out, as needed, in collaboration with the regional, departmental or local workplace inspection departments.

Although both workplace inspectors and medical inspectors share common goals—the prevention of occupational health ha-zards—their specific interventions may differ, depending on the technical expertise required. Other circumstances may, on the other hand, require their collaboration.

Proposed New Circular

A circular in preparation reiterates and updates the clauses of the circular of 6 July 1979. It should be noted that on 1 January 1995, the Departments of Occupational Training assumed the responsibilities of the regional Departments of Labour and Employment. The function, role and mission of medical inspectors of workplaces must therefore be reviewed.

In summary, we can say that by 1980, medical inspection departments had, for all intents and purposes, regained the role and functions originally foreseen for them in the period 1946-47. The most likely next step in medical inspection is towards increasing emphasis on promotion, management and research in workplaces. This evolution, it should be noted, parallels that of occupational medicine itself. Following a long period of development and implementation that may now be considered practically completed, occupational medicine must now embark upon a new era of qualitative improvement and scientific advance.

Back

Infrastructures, Practice and Approaches in Occupational Health

While much progress has been made since the 1980s towards a comprehensive approach in occupational health where the protection and promotion of workers’ health are pursued together with the maintenance and promotion of their working capacity, with a special emphasis on the establishment and maintenance of a safe and healthy working environment for all, there is much room for discussion as to the manner in which occupational health is actually implemented. The expression occupational health practice is currently used to cover the whole spectrum of activities undertaken by employers, workers and their organizations, designers and architects, manufacturers and suppliers, legislators and parliamentarians, labour and health inspectors, work analysts and work organization specialists, standardization organizations, universities and research institutions to protect health and to promote occupational safety and health.

The expression occupational health practice includes the contribution of occupational health professionals, but it is not limited to their practice of occupational health.

Confusion often occurs because the term occupational health services may be used to denote:

• the provision of occupational health services (i.e., the contribution of occupational health professionals to occupational safety and health)

• the institutionalized organizational arrangements to provide such services (i.e., the occupational health services which are part of the infrastructure to protect and promote workers’ health).

In order to overcome this difficulty and several other common causes of misunderstanding, the following wording was used for the second point on the agenda of the Twelfth Session of the Joint ILO/WHO Committee on Occupational Health: “Infrastructures for occupational health practice: options and models for national policies, primary health care approaches, strategies and programmes, and functions of occupational health services” (1995b) with the following understanding of the terms:

• Occupational health practice encompasses the activities of all those who contribute to the protection and promotion of workers’ health and to the improvement of working conditions and environment; these terms should not be understood as merely the practice of occupational health professionals.

• Occupational health approaches embodies a number of principles and approaches to guide action, such as the general principle of primary health care advocated by the WHO and the improvement of the working conditions and environment advocated by the ILO.

• Infrastructures for occupational health practice means the organizational arrangements to implement a national policy and to conduct action at the enterprise level; infrastructures may take the form of “institutionalized” occupational health services and include many other bodies such as national institutes for occupational safety and health.

The use of the key words infrastructures, practice and approaches permits the various actors and partners in prevention to play their individual roles in their respective fields of competence and to act jointly, as well.

Occupational health services contribute to the occupational health practice, which is intrinsically multidisciplinary and intersectoral and involves other specialists both in the enterprise and outside in addition to occupational health and safety professionals, as well as the appropriate governmental authorities, employers, workers and their representatives. Functionally, occupational health services must be considered both a part of country-level health infrastructures as well as of the infrastructures that exist for the implementation of relevant legislation on occupational safety and health. It is a national decision to determine whether such services should be under the supervision of the ministry of labour, the ministry of health, the social security institutions, a tripartite national committee or other bodies.

There are a large number of models for occupational health services. One of them enjoys the support of a large consensus at the international level: the model proposed by the ILO Occupational Health Services Convention (No. 161) and Recommendation (No. 171) adopted by the International Labour Conference in 1985. Countries should consider this model as an objective towards which progress should be made, taking into account, of course, local differences and the availability of specialized personnel and financial resources. A national policy should be adopted to develop progressively occupational health services for all workers, taking into account the specific risks of the undertakings. Such policy should be formulated, implemented and periodically reviewed in the light of national conditions and practice in consultation with the most representative organizations of employers and workers. Plans should be established indicating the steps which will be taken when occupational health services cannot be immediately established for all undertakings.

Multidisciplinary Cooperation and Intersectoral Collaboration: An Overall Perspective

The ILO and the WHO have a common definition of occupational health (see box), which was adopted by the Joint ILO/WHO Committee on Occupational Health at its first session (1950) and revised at its twelfth session (1995).

Governments, in collaboration with employers’ and workers’ organizations and professional organizations concerned, should design adequate and appropriate policies, programmes and plans of action for the development of occupational health with multidisciplinary content and comprehensive coverage. In each country, the scope and content of programmes should be adapted to national needs, should take into account local conditions and should be incorporated into national development plans. The Joint ILO/WHO Committee emphasized that the principles embodied in the ILO Conventions No. 155 and No. 161 and their accompanying Recommendations, as well as WHO resolutions, guidelines and approaches related to occupational health, provide a universally accepted guide for design of such policies and programmes (Joint ILO/WHO Committee on Occupational Health 1992).

There are similar features between the ILO strategy for the improvement of the working conditions and environment and the WHO general principle of primary health care. Both rest on similar technical, ethical and social considerations and they both:

• aim at all concerned, workers or the public

• define policies, strategies and means of action

• insist on the responsibility of each employer for the health and safety of the workers in his or her employment

• emphasize primary prevention and the control of risk at the source

• give special importance to information, health education and training

• indicate the need to develop an occupational health practice that is easily accessible to all and available at the workplace

• recognize the central place of participation, community participation in health programmes, inter-sectoral participation and workers’ participation in the improvement of the working conditions and the working environment

• highlight the interactions between health, environment and development, as well as between occupational safety and health and productive employment.

The main focus of ILO activity has been on the provision of international guidelines and a legal framework for the development of occupational health policies and infrastructures on a tripartite basis (including governments, employers and workers) and the practical support for improvement actions at the workplace, while the WHO has concentrated on the provision of scientific backgrounds, methodologies, technical support and on the training of health and related manpower for occupational health (Joint ILO/WHO Committee on Occupational Health 1992).

Multidisciplinary cooperation

For the WHO, occupational health includes safety at work. Hygiene is conceptualized as directed towards disease prevention while safety is thought of as the discipline that prevents bodily injuries due to accidents. For the ILO, occupational safety and health is considered as a discipline aiming at the prevention of work injuries (both occupational diseases and accidents) and at the improvement of working conditions and the environment. The terms occupational safety, occupational health, occupational medicine, occupational hygiene and occupational health nursing are used to acknowledge the contribution of different professions (e.g., engineers, physicians, nurses, hygienists) and in recognition of the fact that the organization of occupational safety and health at the enterprise level very often comprises separate occupational safety services and occupational health services, as well as safety and health committees.

To some extent, occupational safety and primary prevention are more directly linked to the technology which is used, to the process of production and to daily management than is occupational health, which focuses more on the relationships between work and health, in particular on the surveillance of the working environment and of workers’ health (secondary prevention), as well as on human factors and ergonomic aspects. Further, at the enterprise level, engineers are a necessary presence and are inte-gral to the management line (production engineers, maintenance, technicians and so on), while occupational health and hygiene requires the intervention of specialists in the health field who need not be present for the enterprise to function, but can be consultants or belong to an external occupational health service.

Whatever organizational arrangements and terminology are used, the most important thing is that occupational safety and health professionals work as a team. They need not necessarily be in the same unit or service, although this may be desirable where appropriate. The emphasis should not be on the structure of services but on the execution of their functions at the enterprise level in a sound manner (from a scientific, technical and ethical point of view). The emphasis should be on cooperation and coordination in the elaboration and implementation of a programme of action, as well as on the development of unifying concepts, such as “working cultures” (safety culture, labour protection culture, corporate culture) that are conducive to safety and health at work and “continuing quality improvement” of the working conditions and environment.

In 1992, the Joint ILO/WHO Committee emphasized that the scope of occupational health is very broad (as shown in table 1), encompassing disciplines such as occupational medicine, occupational nursing, occupational hygiene, occupational safety, ergonomics, engineering, toxicology, environmental hygiene, occupational psychology and personnel management. Collaboration and participation of employers and workers in occupational health programmes is an essential prerequisite for successful occupational health practice.

Table 1. Six principles and three levels for a sound occupational health practice

Note: The times (1910, 1920, etc.) are arbitrary. Dates are merely given to provide an idea of the time scale for the progressive development of a comprehensive approach in occupational health. Dates will vary from country to country and may indicate the beginning or the full development of a discipline or the appearance of new terms or approaches for a practice which has been carried out for many years. This table does not intend to delineate exact disciplines involved in the process but to present in a concise manner their relationships within the framework of a mutlidisciplinary approach and intersectoral cooperation, towards a safe and healthy working environment and health for all, with a participatory approach and the objective of new forms of development which should be equitable if they are to be sustainable.

The definition of a common goal is one of the solutions to avoid the trap of an excessive compartmentalization of disciplines. Such compartmentalization of disciplines may sometimes be an asset since it allows for a specialized in-depth analysis of the problems. It may often be a negative factor, because it prevents the development of a multidisciplinary approach. There is a need to develop unifying concepts which open fields of cooperation. The new definition of occupational health adopted by the Joint Committee in 1995 serves this purpose.

Sometimes there can be heated arguments as to whether occupational health is a discipline in itself, or is part of labour protection, of environmental health or of public health. When the issue is more than academic and involves such decisions as which organization or ministry is competent for specific subject areas, the outcome can have significant consequences with regard to the allocation of funds and distribution of resources available in the form of expertise and equipment.

One of the solutions to such a problem is to advocate convergent approaches based on the same values with a common objective. The WHO approach of primary health care and the ILO approach of improving the working conditions and environment can serve this purpose. With common values of equity, solidarity, health and social justice in mind, these approaches can be translated into strategies (the WHO’s strategy of occupational health for all) and programmes (the ILO International Programme for the Improvement of Working Conditions and Environment) as well as into plans of action and activities implemented or carried out at the enterprise, national and international levels by all partners in prevention, protection and promotion of workers’ health, independently or jointly.

There are other possibilities. The International Social Security Association (ISSA) proposes the “concept of prevention” as a golden path to social security to address “safety worldwide” at work and at home, on the road and during leisure time. The International Commission on Occupational Health (ICOH) is developing an approach of ethics in occupational health and catalyses a rapprochement and cross-fertilization between occupational health and environment health. A similar trend can be seen in many countries where, for example, professional associations now get together occupational health and environmental health specialists.

Intersectoral collaboration

In 1984, the ILO’s annual International Labour Conference adopted a resolution concerning the improvement of working conditions and environment incorporating the concept that the improvement of the working conditions and environment is an element essential to the promotion of social justice. It stressed that improved working conditions and environment are a positive contribution to national development and represent a measure of success of any economic and social policy. It spelled out three fundamental principles:

• Work should take place in a safe and healthy environment.

• Conditions of work should be consistent with workers’ well-being and human dignity.

• Work should offer real possibilities for personal achievement, self-fulfilment and service to society.

During the 1980s a shift occurred from the concept of development towards the concept of “sustainable development”, which includes “the right to a healthy and productive life in harmony with nature” as indicated in the first principle of the Rio Declaration (United Nations Conference on Environment and Development—UNCED 1992). The objective of a safe and healthy environment has thus become an integral part of the concept of sustainable development, which also implies balancing environment protection with generation of opportunity for employment, improved livelihoods and health for all. Both environmental health and occupational health contribute to make development sustainable, equitable and sound not only from an economic but also from a human, social and ethical point of view. This paradigm shift is illustrated in figure 1.

Figure 1. A multidisciplinary approach towards a sustainable and equitable development

The purpose of this figure is to illustrate the interaction between occupational health and environmental health and their mutually supportive contribution to a sustainable development. It identifies an area which represents the integration of the economic and social objectives which can be met while at the same time taking account of the environment, employment and health.

The WHO Commission on Health and Environment has further recognized that “the kind of development needed to safeguard health and welfare will depend on many conditions, including respect for the environment, while development without regard for the environment would inevitably result in impairment of human health” (WHO 1992). In the same vein, occupational health should be recognized as an “added value”, that is, a positive contribution to national development and a condition of its sustainability.

Of particular significance to the work of the ILO and the WHO are the Declaration and Programme of Action adopted by the World Summit for Social Development held in Copenhagen in 1995. The Declaration commits the nations of the world to pursuing the goal of full, productive and freely chosen employment as a basic priority of their economic and social policies. The Summit clearly indicated that the goal must not be to create just any sort of jobs, but quality jobs that safeguard the basic rights and interests of workers. It made clear that the creation of good quality jobs must include measures to achieve a healthy and safe working environment, to eliminate environmental health hazards and provide for occupational health and safety. This is an indication that the future of occupational health may well be active partnership in reconciling employment, health and environment towards an equitable and sustainable development.

The primary health care approach emphasizes social equity, affordability and accessibility, participation and community involvement, as noted by the Joint ILO/WHO Committee on Occupational Health in 1995. These basic moral and ethical values are common to the ILO and the WHO. The primary health care approach is innovative because it applies social values to preventive and curative health care. This complementarity has not always been clearly understood; sometimes confusion is due to the interpretation of common words, which has led to a degree of misunderstanding in discussing actual roles and activities to be undertaken by the ILO and the WHO, which are complementary and mutually supportive.

Primary health care can be considered to be based on principles of social equity, self-reliance and community development. It may also be considered to be a strategy for reorienting health systems, in order to promote individual and community involvement and collaboration between all sectors concerned with health. A general principle should be that primary health care should incorporate an occupational health component and specialized occupational health services should apply the general principle of primary health care, regardless of the structural model in place.

There are many partners in prevention, sharing the philosophy of both the ILO and the WHO, who should provide the necessary inputs to implement a good occupational practice. The Joint ILO/WHO Committee has indicated that the ILO and the WHO should promote an inclusive approach to occupational health in their member countries. If such an approach is used, occupational health can be seen as a multidisciplinary and integrated subject. Taken in this light, activities of different organizations and ministries will not be competitive or contradictory but will be complementary and mutually supportive, working towards an equitable and sustainable development. The emphasis should be on common goals, unified concepts and basic values.

As pointed out by the Joint ILO/WHO Committee in 1995, there is a need to develop occupational health indicators for the promotion and monitoring of the progression towards health and sustainable development. Forms of development which jeopardize health cannot claim the quality of being equitable or sustainable. Indicators towards “sustainability” necessarily include health indicators, since UNCED emphasized that the commitment of “protecting and promoting human health” is a fundamental principle for sustainable development (Agenda 21, Chapter 6). The WHO has taken a leading role in developing both the concept and use of environmental health indicators, some of which concern health and the working environment.

The WHO and the ILO are expected to develop occupational health indicators which could help countries in the evaluation, both retrospective and prospective, of their occupational health practice, and assist them in monitoring the progress made towards the objectives set by national policies on occupational safety, occupational health and the working environment. The development of such indicators focusing on the interactions between work and health could also assist occupational health services in evaluating and guiding their programmes and their activities to improve the working conditions and environment (i.e., in monitoring the efficiency and the manner in which they carry out their functions).

Standards and Guidance

The ILO Conventions and Recommendations on occupational safety and health define the rights of the workers and allocate duties and responsibilities to appropriate authorities, to the employers, and to the workers in the field of occupational safety and health. The ILO Conventions and Recommendations adopted by the International Labour Conference, taken as a whole, constitute the International Labour Code which defines minimum standards in the labour field.

The ILO policy on occupational health and safety is essentially contained in two international Conventions and their accompanying Recommendations. The ILO Occupational Safety and Health Convention (No. 155) and its Recommendation (No. 164), 1981, provide for the adoption of a national occupational safety and health policy at the national level and describe the actions needed at the national and at the enterprise levels to promote occupational safety and health and to improve the working environment. The ILO Occupational Health Services Convention (No. 161) and its Recommendation (No. 171), 1985, provide for the establishment of occupational health services which will contribute to the implementation of the occupational safety and health policy and will perform their functions at the enterprise level.

These instruments provide for a comprehensive approach to occupational health that includes primary, secondary and tertiary prevention and is consistent with general principles of primary health care. They indicate the manner in which occupational health care should ideally be delivered to the working populations, and propose a model that channels towards the workplace organized activities which require expert staff in order to catalyse an interaction between various disciplines to promote cooperation between all partners in prevention. These instruments also provide an organizational framework wherein occupational health professionals can deliver efficiently quality services to ensure workers’ health protection and promotion and contribute to the health of enterprises.

Functions

Convention No. 161 defines occupational health services as services dedicated to essentially preventive functions and responsible for advising employers, workers and their representatives at the enterprise on the requirements for establishing and maintaining a safe and healthy working environment that will optimize physical and mental health in relation to work and on the adaptation of work to the capabilities of workers, taking into consideration their state of physical and mental health.

The Convention specifies that occupational health services should include those of the following functions that are adequate and appropriate to the occupational risks at the worksite:

• identification and assessment of the risks from health hazards in the workplace

• 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

• advice on planning and organization of work, including the design of workplaces, on the choice, maintenance and condition of machinery and other equipment and on substances used in work

• participation in the development of programmes for the improvement of working practices, as well as testing and evaluation of health aspects of new equipment

• advice on occupational health, safety and hygiene and on ergonomics and individual and collective protective equipment

• surveillance of workers’ health in relation to work

• promoting the adaptation of work to the worker

• contributing to measures of vocational rehabilitation

• collaborating in providing information, training and education in the fields of occupational health and hygiene and ergonomics

• organizing first aid and emergency treatment

• participating in analysis of occupational accidents and occupational diseases.

The ILO Convention and Recommendation are very flexible with regard to the forms of organization of occupational health services. The establishment of occupational health services may be done by laws or regulations, by collective agreements, or in any other manner approved by the appropriate authority, after consultation with the representative organizations of concerned employers and workers. Occupational health services may be organized as a service for a single enterprise or as a service common to a number of enterprises. As far as possible, the occupational health services should be located near the place of employment or should be organized to ensure their proper functioning at the place of employment. They may be organized by the concerned enterprises, by the public authorities or official services, by social security institutions, by any other bodies authorized by the authorities or, indeed, by combination of any of these. This offers a large degree of flexibility and, even in the same country, several or all of these methods may be used, according to local conditions and practice.

The flexibility of the Convention demonstrates that the spirit of the ILO instruments on occupational health services is to place more emphasis on its objectives rather than on the administrative rules for achieving them. It is important to ensure occupational health to all workers, or at least to make progress towards this objective. Such progress is usually achievable by degrees but it is necessary to make some progress towards achieving these aims and to mobilize resources in the most efficient manner for this purpose.

Various methods of financing occupational health exist. In many countries the obligation of establishing and maintaining occupational health services rests with employers. In other countries they are part of national health schemes or public health services. Staffing, financing and training of personnel are not detailed in the Convention but are individual national approaches.

Many examples exist of occupational health services set up by social security institutions or financed by special workers’ insurance schemes. Sometimes their financing is governed by an arrangement agreed upon by the ministry of labour and the ministry of health or by the social security institutions. In some countries trade unions run occupational health services. There are also special arrangements wherein funds are collected from employers by a central institution or tripartite body and then disbursed to provide occupational health care or distributed to finance the functioning of occupational health services.

The sources of financing occupational health services may also vary according to their activities. For example, when they have curative activities, social security may contribute to their financing. If occupational health services take part in public health programmes and in health promotion or in research activities, other funding sources may be found or become available. Financing will depend not only on the structural model chosen to organize the occupational health services, but also on the value that society concedes to health protection and promotion and its willingness to invest in occupational health and in the prevention of occupational hazards.

Conditions of Operation

A special emphasis is placed on the conditions of operation of occupational health services. It is not only necessary for the occupational health services to execute a number of tasks but it is equally important that these tasks should be performed in an appropriate manner, taking into consideration technical and ethical aspects.

There are some basic requirements as regards the operation of occupational health services which are spelled out in the ILO Convention, and especially in the Recommendation on Occupational Health Services. These may be summarized as follows:

• The personnel in occupational health services should be qualified and benefit from a full professional independence.

• Confidentiality should be ensured.

• Workers should be informed of the activities of the services and of the results of their health assessments.

• Employers, workers and their representatives should participate in the operation of the services and in the design of their programmes.

Ethical dimensions of occupational health are increasingly taken into account, and emphasis is placed on the need for both quality and on-going evaluation of occupational health services. It is not only necessary to determine what should be done but also for which purpose and under which conditions. The ILO Recommendation on Occupational Health Services (No. 171) introduced a first set of principles in this respect. Further guidance is given by the International Code of Ethics for Occupational Health Professionals adopted by the International Commission on Occupational Health (ICOH 1992).

In 1995, the Joint ILO/WHO Committee on Occupational Health emphasized that “quality assurance of services must be an integral part of the occupational health services development. It is unethical to give poor quality of service”. The ICOH Code of Ethics prescribes that “occupational health professionals should institute a programme of professional audit of their own activities in order to ensure that appropriate standards have been set, that they are being met and that deficiencies, if any, are detected and corrected”.

Common Goals and Values

The role of institutionalized occupational health services should be seen within the broader framework of health and social policies and infrastructures. The functions of occupational health services contribute to the implementation of the national policies on occupational safety, occupational health and the working environment advocated by the ILO Occupational Safety and Health Convention (No. 155) and Recommendation (No. 164), 1981. Occupational health services contribute also to the attainment of the objectives embodied in the “Health For All” strategy advocated by the WHO as a policy for equity, solidarity and health.

There are signs of an increasing trend to mobilize expertise and resources within the framework of networking arrangements and joint ventures. At the international level, such is already the case for chemical safety, where there is an interorganization me-chanism for chemical safety: the Inter-Organization Programme for the Sound Management of Chemicals (IOMC). There are many other fields where new flexible forms of international cooperation among countries and international organizations are emerging or could be developed, such as radiation protection and biological safety.

Networking arrangements open new fields of cooperation which may be adapted in a flexible manner to the theme which is to be addressed, such as occupational stress, coordinating research or updating this Encyclopaedia. The emphasis is placed on interactions and not any more on vertical compartmentalization of disciplines. The concept of leadership gives way to active partnership. International networking for occupational safety and health is developing rapidly and could be further developed on the basis of existing structures which could be interconnected. The roles of the ILO and the WHO may well be to initiate international networks designed to fulfil the needs and demands of their constituents and to meet the common goal of protecting the people at work.

The social and ethical values agreed upon by the international community are incorporated into the ILO Conventions and Recommendations, as well as in the WHO policy on “Health For All”. Since the 1980s the concept of sustainable development has progressively emerged and, after the Rio Conference and the Social Summit in Copenhagen, now takes into account the interrelationships between employment, health and the environment. The common goal of a safe and healthy working environment for all will reinforce the determination of all those involved in occupational safety and health to better serve the health of workers and to contribute to a sustainable and equitable development for all. One of the main challenges in occupational health may well be to resolve the conflict between values such as the right to health and the right to work at the level both of the individual and all workers, with the aim of protecting health and allowing employment.

Back