Policy and Legislation

In Japan, the sole administrative body of occupational health is the Ministry of Labour, and the core law is the Industrial Safety and Health Law enacted in 1972 (this law will be termed “the Health Law” for the purposes of this article). The Health Law and its enforcement orders specify the employer’s responsibility to provide occupational safety and health services, including the appointment of an occupational health physician (OP), according to the size of the workplace. It is a requirement that all workplaces employing 50 or more workers appoint an OP (a full-time OP for workplaces that employ 1,000 or more workers). In addition, all workplaces, regardless of employee number, are mandated to provide health examinations for their workers. The mandatory health examinations include pre-employment and periodic general health examinations for full-time workers and specific health examinations for full-time workers engaged in activity described as “harmful work”. Compliance with the above legal requirements is generally good, although a gradient in compliance rate exists according to workplace size.

Organization and Service Provision Models

Organization and service provision models vary considerably according to the size of the workplace. Large-scale workplaces often embody full-size occupational health units, such as a health administration department, a department of health promotion or a clinic/hospital on the premises. These functional units may take the form of independent institutions, especially if they emphasize curative activities, but many are units subordinate to departments such as the labour department or the general affairs department. In some cases, the occupational health unit is run by a corporate health insurance union. The full-time OP is very often appointed to a directorial position of the unit, sometimes nominally matching a managerial post within the corporate hierarchy. The co-medical staff may consist of a variable combination of general nurses, occupational health nurses and x-ray and/or medical technologists.

In contrast, many small-scale workplaces lack the human and facility resources to carry out occupational health functions. In this sector, part-time OPs are recruited from among private general practitioners, hospital- or university-affiliated physicians and independent or non-independent occupational health practitioners. The part-time OPs engage in a variable range of occupational health activities depending on the needs of the workplace and the physician’s expertise. An occupational health organization (OHO), which is defined as an organization delivering occupational health services on a profit-earning basis, have played an essential role in the provision of occupational health services to small-scale workplaces. Services purchasable from OHOs cover provision and follow-up of various health examinations, implementation of environmental measurements and even the dispatch of OPs and nurses. Many small-scale workplaces appoint a part-time OP and contract with an OHO to meet specific legal requirements imposed on the workplace.

Activities and Content

Nationwide questionnaire surveys focusing on the activities of full-time and part-time OPs have been conducted periodically by the Occupational Health Promotion Foundation, an auxiliary non-profit-making organization of the Ministry of Labour. According to the 1991 survey, to which 620 full-time OPs responded, average time allocation was longest for curative activities (495 hours/year) followed by periodic health examinations (136) and health consultations (107). Time allocation to workplace patrols averaged 26.5 hours/year. In the survey, 340 part-time OPs also responded; the average time allocated by part-time OPs was proportionately less than that of full-time OPs. However, a detailed observation reveals that the activities of part-time OPs vary widely in quantity and quality, depending on several inter-related factors:

1. size and characteristics of the workplace
2. main job and other appointments of the physician
3. work commitment.

Personnel Resources

There are no legal provisions on the qualifications of the OP: simply stated, the OP (whether full-time or part-time) can be appointed “from among physicians” (the Health Law). As of 1995, the total number of physicians is estimated to be 225,000, with an annual increase of about 5,000 (i.e., an increase of 7,000 qualifying from graduates of 80 medical schools in Japan and a decrease of 2,000 due to death). The estimated number of OPs as of 1991 was about 34,000 (2,000 full-time and 32,000 part-time), which was equivalent to 16.6% of the total number of physicians (205,000). In addition, an estimated several thousand nurses across the nation play an active part in the field of occupational health, although there is no legal definition of an occupational health nurse. A health supervisor, which is defined by the Health Law as a person who takes charge of technical matters related to health, is recruited from among the workers. The OP interacts closely with the health supervisor, to whom the OP may “give guidance or advice” under the Health Law.

Administration

Within the Ministry of Labour, occupational health is administered directly by the Industrial Safety and Health Department, which is subordinate to the Labour Standards Bureau. The Bureau’s functional units at the local level include the Prefectural Labour Standards Offices (of which there are 47) and the Labour Standards Inspection Offices (there are 347 of these) distributed nationwide and staffed by a total of about 3,200 “Labour Standards Inspectors”, 390 “Industrial Safety Expert Officers” and 300 “Industrial Health Expert Officers”.

The Ministry of Labour has been implementing consecutive five-year plans for the prevention of industrial accidents; the most recent of these (the eighth) was associated with the slogan “realizing a healthier and safer working life on both mental and physical aspects”. Accordingly, the Ministry is pursuing a Total Health Promotion (THP) plan. Under the THP plan, the OP prescribes an exercise menu for each worker based on health measurement data. Training programmes accommodating company representatives are organized by the government to develop necessary skills. The government also gives recognition to OHOs that are capable of providing services related to THP implementation.

Financing Systems

When occupational health services are provided on the premises, as is the case in large-scale workplaces, they will often take the form of an intracorporate department and will thus be placed under the financial constraints of the employer. Another variation involves the presence of an affiliated but self-supporting unit (clinic, hospital or OHO) which employs an occupational health staff. In some cases, the unit is run by a corporate health insurance union. Many small-scale workplaces, lacking the human, facility and financial resources, but under the requirement to appoint a part-time OP, will often do so by contracting with general practitioners, hospital- or university-affiliated physicians and others. As stated previously, the part-time OP will engage in a variable range of occupational health activities depending on the needs of the workplace and the physician’s expertise. The requirements imposed on the workplace, such as provision of periodic health examinations to all employees, often exceed the time capacity and/or the willingness of the contracted physician. This creates a demand-supply gap which is often filled by OHOs.

Research

The Japan Society for Occupational Health (JSOH) is an academic society comprising OPs, occupational health nurses and researchers. Its present membership exceeds 6,000 and is increasing at a rapid rate. The JSOH holds annual scientific meetings at national and regional levels and recently started publishing an English scientific periodical entitled Journal of Occupational Health. Some core research institutes are the National Institute of Industrial Health (periodical: Industrial Health, biannual, English), the Institute for Science of Labour (periodical: Journal of Science of Labour, monthly, Japanese and English), the Japan Industrial Safety and Health Association (publications: Industrial Safety Yearbook and so on) and the Institute of the Industrial Ecological Sciences of the University of Occupational and Environmental Health, Japan (periodical: Journal of UOEH, bimonthly, Japanese and English).

Future Developments

The Ministry of Labour recently launched a comprehensive plan aimed at disease prevention and health promotion for the nation’s workers. It plans to establish government-subsidized occupational health centres (OHCs) at prefectural and regional levels throughout the country within an eight-year plan. Prefectural OHCs are planned to be established for each of the 47 prefectures, and each will be staffed by about 15 personnel, including one administrative full-time physician and three or four part-time physicians. Their primary function will be the provision of training and dissemination of information to OPs working within the vicinity. Regional OHCs are planned for 347 sites nationwide in affiliation with the local divisions of the Japan Medical Association (JMA). They will focus on providing occupational health services to the under-served sector, that is, workers in small-scale industries. The initial budget for the fiscal year 1993 was 2.3 billion yen ($US20 million) for the establishment of six prefectural and 50 regional OHCs. The prefectural and regional OHCs will function interactively as well as with the administration, the JMA, the workers’ hospitals and so on. Collaboration between these various institutions will be the key to the success of this plan.

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The organization of labour protection that was inherited by the Russian Federation from previous times represented a hierarchical structure that had been built up under the former society and functioned under rigorous administrative control accompanied by planning and allocation of resources. Recent changes in the country’s economic and social systems caused by the transition to a market economy have necessitated both the revision of the existing labour legislation and the reorganization of the whole system of labour protection and particularly the provision of occupational health services to the working population.

Labour Legislation

Labour protection in Russia is recognized as a complex system for ensuring safe and healthy working conditions, which includes legal, socio-economic, organizational, preventive, safety, hygienic, technical and other measures.

Labour legislation in the Russian Federation comprises certain provisions of the Russian Constitution, the Labour Code, the Basic Law on Labour Protection, and enabling legislation, which consists of the relevant legal acts, regulations and directives, as well as guidelines, instructions, state standards and various standards approved by the appropriate authorities of the Russian Federation and those of the republics in the territory of Russia.

Article 37 of the Constitution of the Russian Federation stipulates that each citizen has the right to work in an environment that meets occupational safety and health requirements, to remuneration for work that is paid without any discrimination at a rate that is not less than the minimum established by the federal government, and to be protected from unemployment.

The Basic Law on Labour Protection, adopted in August 1993, contains provisions ensuring workers’ rights to protection of their health. It also regulates labour relations between employers and workers in all branches of the economy regardless of the forms of property. According to Article 4 of this Law, workers have the right to:

• safe and healthy working conditions

• workplaces that are protected against occupational hazards that may cause occupational accidents or diseases or decrease working capacity

• compensation for occupational injuries and occupational diseases

• information on existing occupational hazards and health risks and the measures undertaken by the employer to control them

• provision of personal protective equipment at the expense of the employer.

Article 9 of the Basic Law on Labour Protection makes management responsible for ensuring safe and healthy working conditions, while Article 16 specifies economic penalties for allowing unsafe and unhealthy working conditions, as well as for the impairment of workers’ health resulting from occupational exposures, injuries or diseases.

Chapter 10 of the Labour Code of the Russian Federation concerns occupational safety and health in industry. Article 139 stipulates the responsibility of management for the provision of safe and healthy working conditions through the introduction of up-to-date safety procedures and accident prevention measures that will ensure appropriate hazard control and the prevention of occupational accidents and diseases.

Article 143 of the Labour Code requires management to equip worksites with safe machinery and equipment and create safe working conditions in conformity with technical and hygienic standards as well as inter-industry and sectoral regulations on occupational safety and health that have been developed and adopted in accordance with the existing labour legislation.

The inter-industry occupational safety and health regulations cover all branches of industry. They consist of legal requirements applicable to all enterprises regardless of the types of their economic activity (e.g., hygienic norms SN 245-71 for the design of industrial enterprises). The inter-industry regulations are adopted by the Council of Ministries of the Russian Federation, or by other appropriate authorities if requested by the Council of Ministers.

The sectoral occupational safety and health regulations define requirements for diverse industrial processes, types of works and equipment specific for particular branches of industry (e.g., regulations on safety rules for welding operations in construction, or for the operation of loading cranes in dockworks). They take into account specific characteristics of particular branches of the economy and are adopted by respective ministries, state committees, state supervision bodies and other appropriate authorities.

Ministries also issue safety and health guidelines, instructions and technical standards for their respective fields of economic activities. Other instructions such as those that oblige employers to organize in-plant safety and health training for workers or those that oblige workers to comply with safety requirements are subject to consultations with employers’ and workers’ organizations.

Employers have the obligation to provide workers with proper clothing or uniforms and personal and collective protective equipment as specified by the regulations. They are also responsible for the organization of periodic health examinations for certain specific categories of workers, such as those doing heavy work or in hazardous occupations, transport workers and some others.

Along with the duties and responsibilities of the employers (when the state owns the property, the management of the enterprise represents the employer), labour legislation makes workers responsible for complying with the occupational safety and health requirements specified by relevant regulations and instructions. For example, they are required to participate in occupational safety and health training, properly maintain and use personal protective equipment, be trained in fire prevention, maintain the machinery and equipment they use and keep their workplaces clean.

At the enterprise level, everyday supervision of occupational safety and health standards and requirements is the responsibility of the occupational safety and health bureau, which is an integral unit of the enterprise, and enjoys an independent status. Its main functions include evaluation of occupational hazards, risk assessment, recommendation of safety and control measures, prevention of industrial accidents, analysis of the causes of occupational accidents, cooperation with other units of the enterprise in preventing work accidents and injuries, control of machinery and equipment and the implementation of safety programmes. The bureau has the authority to halt the operation of certain machinery or processes or the performance of jobs that may endanger workers’ life and health.

Small-scale enterprises are usually not in a position to organize an occupational safety and health bureau (see “Occupational health services in small-scale enterprises”). Article 8 of the Basic Law on Labour Protection gives them the right to consult external occupational safety and health specialists and to employ them on a contract basis.

In order to make the regulations covering the protection of workers in the Russian Federation more effective, there exists a system for establishing state standards on occupational safety and health (GOST). The state standards have the force of law and appropriate state authorities enforce their implementation.

In all, there are now more than 2,000 regulations, directives, instructions, hygienic norms and state standards on occupational safety and health, most of which had been developed by the various ministries, state committees and other authorities of the former USSR. These rules and regulations are still in effect, even though 700 had been established before 1981 and were intended to be applicable for a period of only five years. Most of them need reconsideration and modification in the light of the new economic situation.

As part of the reorganization of the system of labour protection in Russia, the Presidential Decree of 4 May 1994 created the Federal Labour Inspectorate (Rostrudinspekcija) under the Ministry of Labour and made it responsible for enforcing labour legislation in all territories of the Russian Federation. This established the system of state control and supervision in the field of labour protection. (Before this, the enforcement of labour legislation was the responsibility of trade union inspectors.) Regional Inspectorates with a networking structure are to be set up in all constituent regions of the Russian Federation to complete the organizational structure of the Federal Labour Inspectorate.

Health Legislation

Health legislation of the Russian Federation represents an instrument for the realization of the state policy on public health and epidemiological welfare. The Federal Hygienic and Epidemiological Service of the Russian Federation performs its activities in accordance with health legislation and plays an important role in activities aimed at the promotion of safety and health at work and public health in general.

Health legislation consists of the Hygienic and Epidemiological Welfare of the Population Act, adopted on 13 April 1992 by the Supreme Council of the Russian Federation, and of relevant directives and regulations adopted by respective competent authorities by virtue of this Act.

Article 1 of the Act defines the term hygienic and epidemiological welfare as “such a state of public health and the environment under which there is no hazardous influence of environmental factors on the health of the populations and there exist favourable conditions for creative activities.”

Health legislation establishes hygienic standards for enterprises, new types of machinery and equipment, and new technological processes and materials. It also stipulates the enforcement of existing norms and standards.

State hygienic supervision has two forms:

• Preventive hygienic supervision includes the enforcement of hygienic standards in the design, construction and reconstruction of enterprises, introduction of new technologies, manufacturing of machinery and equipment, and monitoring the environment.

• Routine hygienic supervision involves regular surveillance of the working environment of the enterprises using hygienic methods of exposure monitoring, sampling and analysis. It also includes control of the application of hygienic standards in the operation of machinery and equipment and the maintenance of the enterprise in general.

Article 9 of the Act requires enterprises to comply with health legislation by complying with established hygienic standards and by exercising control over their industrial environment. They are required to prevent environmental pollution and to develop and implement safety and health programmes that are aimed at the improvement of the working environment and the prevention of work accidents and injuries.

Chapter 4 of the Act determines the various degrees of liability for infringement of the Russian health legislation. Persons responsible for breaking the law may be prosecuted either under civil or criminal law (Article 27) of the Russian Federation.

Chapter 5 of the Act stipulates functions of the state hygienic and epidemiological supervision. It includes:

• assessment and prognosis of environmental health for the public

• identification of occurrences of communicable diseases, wide-spread non-communicable diseases and poisonings, and their causes

• development of mandatory measures to ensure hygienic and epidemiological welfare of the population

• supervision of the compliance of enterprises with health legislation and hygienic standards

• prosecution of organizations and persons for non-compliance with health legislation and hygienic standards

• compiling statistics on communicable diseases, occupational diseases, widespread non-communicable diseases and poisonings resulting from adverse environmental factors.

As a result of the structural changes taking place in employment patterns, the Act, for the first time, places obligation for the observance of health legislation, hygienic standards, hygienic quality of products and the prevention of environmental pollution not only on management and workers but also on self-employed persons who are involved in full-time employment (Article 34).

According to Article 32 of the Act, the Federal Hygienic and Epidemiological Service of the Russian Federation is assigned responsibility for enforcement of the health legislation. In addition, the Council of Ministers of the Russian Federation approved Directive No. 375, which reorganized the former hygienic and epidemiological stations into Centres for State Hygienic and Epidemiological Supervision (CSHES), operating in all territories of the Russian Federation.

The new health legislation is a crucial development in the legal regulation of the hygienic and epidemiological welfare of the population, as is the radical restructuring of the Federal Hygienic and Epidemiological Service of the Russian Federation to implement it. The Service has recently received the status of a Federal Service and is now included in the federal bodies of state control. As a result, the Federal Committee of the Russian Federation for Hygienic and Epidemiological Supervision has been established to provide overall supervision of this Service.

The Federal Hygienic and Epidemiological Service of the Russian Federation is made up of the following bodies:

• The Federal Committee of the Russian Federation for Hygienic and Epidemiological Supervision

• Centres for State Hygienic and Epidemiological Supervision (CSHES) at the republic, regional, municipal, district and local levels

• linear CSHES in water and air transport

• Information and Analytical Centre of the Russian Federation

• medical institutes and specialized training centres for the education and training of specialists to staff the CSHES

• research institutes specializing in occupational hygiene and epidemiology

• specialized medical establishments producing vaccines

• disinfection centres.

As defined in Directive No. 375, the main functions of the Federal Hygienic and Epidemiological Service include:

• enforcement of health legislation

• development of hygienic norms and standards

• elaboration of federal, republic, regional and local programmes for health protection and health promotion

• provision of technical information to appropriate authorities, enterprises, employers’ and workers’ organizations and other institutions involved in occupational safety and health activities, including information about hygienic and epidemiological conditions in the country, statistics on population morbidity and interpretation of legal documents relating to health legislation

• coordination of the activities of enterprises, employers’ and workers’ organizations, scientific associations and other institutions and organizations with respect to both the development and implementation of hygienic standards.

CSHES specialists have the right to visit and inspect enterprises in order to enforce health legislation. They investigate causes of occupational diseases and identify potential environmental and occupational hazards that may give rise to work-related diseases, injuries and poisonings. Ideally, where necessary, they cooperate with the occupational physicians and nurses staffing the occupational health services.

CSHES funds are provided directly from the federal budget of the Russian Federation. In addition, the CSHES may provide specialized services and advice under contract to enterprises and any others who may need their expertise. The list of specialized services provided by CSHES is approved by the Federal Committee for Hygienic and Epidemiological Supervision.

Health legislation is enforced through the application of relevant directives, regulations, instructions, norms and standards and legal requirements. These include:

• hygienic regulations, hygienic standards and requirements intended to create safe and healthy working conditions, protect the environment and promote public health in general

• hygienic standards establishing occupational exposure limits and maximum permissible levels for potential hazards encountered in workplaces and the environment

• hygienic norms establishing criteria for specific factors that may affect the health of future generations

• uniform hygienic regulations that combine different norms and standards.

Protection of workers’ health

Article 41 of the Constitution of the Russian Federation states that each citizen has the right to health protection and medical care. New legal acts provide for the development of municipal and private health care systems to supplement the state health care system. Health care in the state and municipal medical settings is provided without charge to patients, the costs being met by federal and local budgetary funds, health insurance funds and other sources.

The Hygienic and Epidemiological Welfare of the Population Act includes the following provisions aimed at the protection of workers’ health:

• Workers at enterprises shall undergo pre-placement and periodic health examinations.

• Pre-placement and periodic health examinations shall be required for all workers exposed to specific occupational hazards and hazardous types of work included in a list approved by the Federal Committee for Hygienic and Epidemiological Supervision and the Ministry of Health of the Russian Federation in consultation with representative organizations of employers and workers.

• Enterprises shall undertake all necessary measures to provide health examinations for workers.

A feature of the country’s health care system is the introduction, in 1991, of compulsory health insurance, which was amended in 1993. The Health Insurance of the Citizens of the Russian Federation Law encompasses a new insurance model under which employers contribute premiums amounting to 3.6% of their total payrolls to local administrations to meet health insurance needs. In 1996, about 40 million workers were covered by the Federal Compulsory Health Insurance Fund of the Russian Federation.

The main aim of the introduction of the compulsory health insurance was to ensure the financing of health care in the post-Soviet economic system based on insurance principles, using funds contributed through compulsory and voluntary dues. Compulsory health insurance introduced two types of public relationships into the health care system of the Russian Federation that had not existed before: the involvement of insurers, represented by local authorities that are responsible for the health insurance covering public employees and the unemployed; and the involvement of industrial insurers represented by the employers and enterprises that are responsible for the coverage of workers. According to Article 23, Health and Epidemiological Welfare of the Population Act health examinations of workers are included in the list of services covered by the compulsory health insurance.

In accordance with the Basic Law on the Health Protection of the Citizens of the Russian Federation, adopted by the Supreme Council of the Russian Federation on 22 July 1993, the basic principles of health protection are:

• observance of human rights in the field of health protection that are guaranteed by the government

• priority of prevention in health protection

• universal access to social and medical care

• social protection of workers in case of disability

• responsibility of the state, appropriate authorities, enterprises regardless of their forms of property, and the management of institutions and organizations for the protection and promotion of workers’ health.

The Basic Law specifies the relationships with respect to health protection and health promotion between the working population and the appropriate authorities, state enterprises, private sector establishments, and the state, municipal and private medical settings providing health care services.

In practice, occupational health services are provided to workers by public health care settings (hospitals and polyclinics) that are located near their residences, and by the specialized occupational health services located for the most part in large enterprises. The objective of this arrangement is to bring qualified health care services as close as possible to the workers and their workplaces.

Occupational health services are normally organized at large enterprises employing over 4,000 workers and in chemical, petrochemical, mining and quarrying industries with over 2,000 employees. An in-plant unit staffed by an occupational physician and an occupational nurse is required for all enterprises with more than 800 workers; those with 300 to 800 workers are required to have only an occupational nurse; the minimal number for enterprises with chemical, petrochemical, mining and quarrying operations is 200 employees. These in-plant units are part of the public health care system.

Small-scale enterprises rely for occupational health services on the hospitals and polyclinics of the public health care system, which are expected to provide an occupational physician to perform the health examinations of workers.

The occupational health service at very large enterprises usually includes a hospital providing inpatient services, a polyclinic providing outpatient services, occupational nursing services and a dispensary. Its services may be “closed” (i.e., limited to individuals working in the enterprise), or “open” (i.e., also providing services to workers’ families and, sometimes, to individuals living in the neighbourhood of the plant).

Conclusions

Significant transformations in Russia’s economic and social systems reflect the transition to a market economy, the appearance of various forms of property, the granting of economic independence to enterprises and the abolition of state administrative control, all of which have resulted in a great many changes in the society.

The system of labour protection in the Russian Federation described above, while preserving its general features, is still undergoing major reorganization to conform with changing realities and to be able to respond effectively to emerging issues. Although well under way, this process is also just beginning.

The provision of occupational health services to the working populations needs special attention because of the partial disintegration of the old network of occupational health services resulting from well-known economic problems, and also because of such innovations as the appearance of a private sector, the introduction of compulsory health insurance, and the integration of private medical settings into the country’s health care system.

Although some progress has been made in reducing the numbers of work accidents and the incidence of occupational injuries and diseases, the rates remain unacceptably high, which may have serious consequences in terms of the deterioration of workers’ health and its resultant impact on the economy. The improvement of working conditions and the working environment and the protection and promotion of workers’ health consequently command a high priority in revising the social policy of the state. Active participation of knowledgeable occupational safety and health professionals in this process is critical.

Some prerequisites for the improvement of the system of labour protection in Russia include:

• creation of economic stimuli for the improvement of working conditions and the working environment

• formulation of a coherent national policy on occupational health, occupational safety and the working environment

• revision of existing labour legislation and the establishment of a solid legislative basis for occupational safety and health practice

• effective enforcement of labour legislation

• wider cooperation of employers and workers on matters related to occupational safety and health

• authorizing state control bodies to close down enterprises with unsafe and unhealthy working conditions, as well as those polluting the environment

• emphasizing the improvement of working environment together with the protection of the general environment

• detailed analysis and prognosis of possible effects of the design and construction of new enterprises on workers’ health and the environment

• providing more options for workers in the procurement of occupational health services and increasing professional independence of occupational health professionals

• providing access to a “standard” package of health care services for all workers

• establishing comprehensive, multidisciplinary occupational health services at large-scale enterprises that are capable of providing a full range of services, including treatment and rehabilitation, to workers and their families

• upgrading the technical facilities of occupational health services and CSHES and enhancing the levels of the expertise of their staff

• organizing and deploying health centres to provide occupational health services for small-scale enterprises

• providing recommended types of health examinations to all workers, including workers in agriculture and the informal sector, through the most efficient use of various medical settings

• upgrading the education and training of occupational health professionals

• emphasizing workers’ education and training in occupational safety and health.

Back

China, the world’s largest developing country, is striving to accomplish unprecedented modernization. The “opening-up” policy to outside interests and the economic reform in effect since 1979 have brought profound changes to China’s economy and to every aspect of its society. The GNP increased from 358.8 billion yuan RMB in 1978 to 2,403.6 billion in 1992, an increase of more than three times in terms of constant money value. The average annual growth rate of GNP was 9.0%. The gross industrial output value was 3,706.6 billion in 1992, an average annual growth of 13.2% from 1979 to 1992 (National Statistics Bureau 1993). China is being increasingly regarded as a “potential centre of economic activity” and has attracted 40% of all of the direct foreign investment in the developing world. By the end of 1993, 174,000 foreign-funded projects had been approved, bringing US$63.9 billion into the country, and the total cumulatively pledged foreign input was $224 billion (China Daily 1994a, 1994b).

In order to advance current reforms in a comprehensive manner ensuring harmonious progress in all economic sectors, an in-depth reform decision has been made. The objective of this reform of the economic structure is to establish a socialist market economy that will further liberate and expand China’s productive forces. The centrally planned economy which has been favoured for 40 years is being transformed into a market system. Whatever the market can manage itself should be left to be controlled by the market. The government should guide the growth of the market by economic policies, regulations, planning and necessary administrative means.

During the period of rapid social change and industrialization, especially the transition from a centrally planned economic system to a market-oriented economy, great challenges had to be faced by China’s traditional occupational health service. At the same time, many new occupational health problems are continually emerging while older ones have not yet been solved.

Reviewing the history of over 40 years of development of occupational health in China, one can observe that great achievements have been made and many efforts have proved to be successful. However, there is still a big gap between the growing need for occupational health capabilities and the currently limited service capacity. Like many other aspects of Chinese life, occupational health service is undergoing a tremendous reform.

Historical Review

Occupational health service, as a subsystem of China’s public health services, was established in the early 1950s. In 1949, when the People’s Republic of China was founded, the health status of the Chinese people was poor. Life expectancy at birth was 35 years. The occupational safety and health status of workers presented an even worse picture. The prevalence of occupational diseases, communicable diseases and injuries among workers was high. Workers were generally prematurely withdrawn from their jobs. To counter the hazardous working conditions and poor sanitation left over in the factories of the “old China”, the new government took three measures (Zhu 1990): (1) the establishment of health service institutions in large-scale industrial enterprises; (2) an extensive investigation of sanitation and safety in the factories; and (3) the improvement of sanitary conditions at the workplace and of worker’s living facilities.

The statistical data relating to China’s oldest industrial bases showed that, by 1952, 28 factory hospitals, 795 clinics and 30 sanatoria had been established in eastern China; in the northeastern region, the level of medical and health services in industrial enterprises had increased 27.6%, the number of health workers increased 53.2% and the number of hospital beds increased 12%—all these improvements took place in the three-year period from 1950 through 1952. Most of the seriously unsafe working conditions found in state-run enterprises by governmental checkups were improved through the joint endeavours of government and workers’ participation. The government also gave financial support to the construction of housing and sanitary facilities. By 1952, workers’ housing had increased ten times compared to 1950, the number of bathroom facilities increased 216%, restrooms increased 844% and workers’ clubs increased 207% (from the northeastern region statistics). Nutrition subsidies have been given to workers exposed to occupational hazards since 1950. These developments greatly promoted the resumption of industrial production at the time.

Since 1954, following Chairman Mao Ze-dong’s call for “approaching a socialist industrialized nation step by step”, China speeded up its industrial development. The government’s priorities for workers’ health started to be transferred from sanitation to occupational and environmental health and concentrated on the prevention and control of serious occupational diseases and injuries. The first Constitution of the People’s Republic of China stipulated that labourers should enjoy the right of protection by government and that the health and welfare of all labourers must be improved.

The central government—State Council—has paid great attention to the serious situation of occupational health problems. The First National Conference on Silica Dust Control in Working Environments was jointly convened by the Ministries of Public Health (MOPH) and Labour (MOL), and the All-China Federation of Trade Unions (ACFTU) in Beijing in 1954, just four years after the founding of the People’s Republic of China. The Second Conference on Silica Dust Control was convened five years later by the above-mentioned three agencies in conjunction with such industrial administration sectors as the Ministry of the Coal Industry and the Ministry of Constructive Material Manufacture, among others.

At the same time, heat stress, occupational poisoning, industrial noise injuries and other illnesses induced by physical factors as well as pesticide poisoning in agriculture were put on the agenda of occupational health. Through the active recommendations to the State Council expressed through the joint efforts of MOPH, MOL, ACFTU and the Ministry of Industrial Administration (MOIA), a series of decisions, policies and strategies to strengthen the occupational health programme have been made by the State Council, including those relating to labour insurance, health and safety requirements for working environments, medical care for occupational illnesses, health examinations for workers engaged in hazardous work, establishing “health inspection” systems, and also the large amount of financial support needed to improve working conditions.

Organizational Structure of Occupational Health Delivery

The occupational health service network in China was initially established in the 1950s and has gradually taken shape over forty years. It can be seen at different levels:

In-plant service

As early as 1957, MOPH (1957) published a Recommendation on Establishing and Staffing Medical and Health Institutions in Industrial Enterprises. The principles of the document were adopted as national standards in the Hygienic Standards for Design of Industrial Premises (MOPH 1979) (see table 1). There should be a health department or a health and safety department at the management level of the enterprise, which should also be under the supervision of the local public health authority of the government. A workers’ hospital affiliated with the department functions as a medical/health centre, which provides preventive and curative services, including health surveillance of workers for occupational safety and health purposes, evaluation of working capacity from the medical point of view and approval of sick leaves of workers. There are health care stations near the workshops, which, under the management of and with the technical support of the workers’ hospital, play an important role in first aid, occupational health education for workers, collection of health information of workers at the workplaces and supervision of occupational safety and health jointly with trade unions and safety engineering departments.

Table 1. Minimum requirements of an in-plant health facility

^* Industrial enterprises with more than 3,000 employees can establish an in-plant hospital if they have high-risk productive processes, are located at far distances from a city or are situated in mountain areas with poor transportation.

Administrative division-based occupational health delivery

Providing health service is one of the responsibilities of governments. In the early 1950s, to prevent and control serious communicable diseases and to improve environment health, Health and Epidemic Prevention Stations (HEPSs) were established in every administrative division from provinces down to counties. The functions of the HEPSs were expanded with the growing needs of society and economic development to include preventive medical services, which covered occupational health, environmental health, food hygiene, school health, radiation protection as well as control of communicable and some non-communicable diseases. With health legislation being emphasized, the HEPSs are authorized to enforce the public health regulations and standards promulgated by the state or local governments and to implement inspection. The HEPSs, especially those at the provincial level, also provide public health technical assistance and services to the community and are involved in in-service training and scientific research.

The industrialization drive in China in the 1950s and early 1960s greatly accelerated the development of the occupational health service programme, which became one of the biggest departments in the HEPS system. Most medium and small industrial enterprises which were not able to maintain in-plant occupational health and industrial hygiene services could be covered by the HEPSs occupational health services, most of which were free of charge.

During the “Cultural Revolution” from 1966 to 1976, the occupational health service network and its activities were seriously damaged. This is one of the important reasons why some occupational diseases are still seriously prevalent in China. The reconstruction of the occupational health programme started in the late 1970s, when China began to realize once again the importance of economic development. Since the beginning of the 1980s, hospitals for occupational disease prevention and treatment and institutes of occupational health, called occupational health institutions (OHIs) have rapidly been established in most provinces and some industrial administrative sectors under the favourable policy of the government. OHIs were formed mainly on the basis of utilizing occupational health personnel in HEPS integrated with occupational physicians from hospitals. During the period 1983 to 1991, the central and local governments invested 33.8 million yuan RMB in total to support building OHIs. At provincial and prefecture levels, 138 OHIs were set up, with appropriate laboratory or clinical equipment. At present, the number of OHIs has reached 204, of which there are 60 established by the industrial sector. Another 110 million yuan RMB have been invested to equip 1,789 health and epidemic prevention stations at the county level (He 1993). The occupational health programmes in county HEPSs were one of the important parts of the project to be first equipped. To strengthen the national capacity of research, training and coordination of occupational health service, a National Centre for Occupational Disease Prevention and Treatment (NCODPT) was set up in the Institute of Occupational Medicine, Chinese Academy of Preventive Medicine (IOM/CAPM), and seven regional centres of occupational health, located in Beijing, Shanghai, Shenyang, Lanzhou, Chengdu, Changsa and Guangzhou, were also established. The current national network of occupational health services is illustrated in figure 1.

Figure 1. National network of occupational health services

So far, 34 schools or departments of public health have been established in the medical colleges or medical universities. These are the main resources of occupational health personnel. Six national occupational health in-service training centres were established in 1983. The total professional occupational health personnel, including physicians, industrial hygienists, technicians in laboratories and other health workers involved in occupational health programmes, reached about 30,000 in 1992.

Occupational Health Standards and Legislation.

To encourage research in hygienic standards and in their establishment, a National Technical Committee of Hygienic Standards (NTCHS) was set up in 1981 as a consultative and technical reviewing agency of MOPH in hygienic standard setting. At present, NTCHS has eight subcommittees, which are responsible for occupational health, environmental health, school hygiene, food hygiene, radiation protection, occupational disease diagnosis, communicable disease and endemic disease prevention (figure 2). The members of NTCHS are experts from universities, research institutes, governmental agencies and the trade unions. The Hygienic Standards for Design of Industrial Premises (HSDIP) was first formulated in the 1950s and revised and promulgated again in 1979, so that it now contains a list of occupational exposure limits in terms of maximum allowable concentrations (MACs) for 120 toxic agents and dusts, and other requirements for hazards control measures in workplaces, sanitary and health facilities in plants and so forth. Also, there were 50 occupational hygienic standards for hazardous chemical and physical agents in the workplace promulgated by the Ministry of Public Health. Another 127 occupational hygienic standards are being reviewed. Diagnostic criteria for 50 compensable occupational diseases were issued by the Ministry of Public Health.

Figure 2. The management of health standard setting

As is known to all, China has had a centrally planned economic system and has been a country controlled by a unified central government for more than 40 years. So, most regulatory requirements in occupational safety and health at the national level were stipulated in the form of “Red Title” documents of the central government. These documents had, indeed, the highest legal effect and have constituted the basic regulatory framework of China’s occupational health. There are more than 20 documents of this kind promulgated by the State Council or its ministries. The major differences between these documents and legislation are that there are no stipulations for penalties in the documents, the compulsory effect is not as high as it is with laws and enforcement is weak.

Since economic reform has favoured the market-oriented system following the opening-up policy, national legislation has been greatly emphasized. Occupational health management is also being transformed from traditional administration to regulation-based approaches. One of the most important legal documents is the Regulation on Pneumoconioses Prevention and Control, issued by the State Council in 1987. Another milestone in protecting workers’ rights is the promulgation of the Labour Law by the National People’s Congress, with an anticipated effect date of 1 January 1995. The occupational safety and health of workers, as one of the major aims of this measure, is stipulated in the Law. To implement the Labour Law for occupational disease control, a draft law for occupational disease prevention and control was submitted to the Bureau of Legislation of the State Council by the Ministry of Public Health, in which most of the successful occupational health policies basic to occupational institutions, and experiences both in China and abroad. The draft must undergo further review and be submitted to the Standing Committee of the National People’s Congress.

Health Inspection System

“Putting prevention first” has been emphasized by the government and has become an important national basic public health principle. As early as 1954, when industrialization had just begun, the central government made the decision to establish a health inspection system to enforce the national health regulations and policies of industrial hygiene. HEPSs were authorized to implement health inspection on behalf of the public health authorities of the government. The main tasks of health inspection of enterprises include the following:

• to inspect the enterprise for hazard control in workplaces so that the concentrations/intensities of occupational hazards meet national industrial hygienic standards

• to check whether or not the pre-placement and periodic health examinations of exposed workers have been conducted in compliance with related national regulations or local governmental requirements

• to ensure that workers who are suffering from occupational diseases be properly treated, allowed to recuperate, transferred to other jobs or offered some other suitable option in line with related regulations

• to conduct hygienic evaluation and to supervise hazard control measures in workplaces

• to supervise occupational health record keeping, occupational disease reporting and working environmental monitoring in enterprises.

• The above activities are part of “regular health inspection” and are considered routine inspecting tasks that should be carried out periodically. To continue, the remaining chief tasks of health inspection are:

• preventive health inspection on industrial construction projects (prior to a new industrial construction or reconstruc-ting/expanding of old industrial enterprises, all engineering designs, hazard control facilities, medical/health and workers’ living facilities must pass an initial inspection for occupational health purposes)

• toxicological assessment of new industrial chemical substances.

Health inspection, especially preventive health inspection as a fundamental principle of public health intervention measures, has been stipulated in a number of laws and public health regulations. Since the 1970s, as great attention has been paid to the control of environmental pollution, preventive occupational health inspection has further been expanded to whole process inspection. The principle that “hazard control installations must be simultaneously designed, constructed and put into use/operation with the principal part of the project” was one of the important requirements in the Regulation on Pneumoconiosis Prevention and Control and the Environmental Protection Law.

Comprehensive Prevention Strategy for Occupational Diseases

Along the way to controlling pneumoconioses and serious dust contamination in the working environment, comprehensive prevention was emphasized, which was summed up in eight Chinese characters, and so called the “Eight Characters” strategy. The meanings are translated in English as follows:

• innovation: technological improvement, such as using safe or low-risk materials and more productive processes, and replacing outmoded productive methods by appropriate advanced techniques

• keep it wet: keeping a dusty worksite wet to decrease the concentration of dust, especially for drilling and grinding in mining industries

• enclosure: segregating workers, equipment and environmental areas to prevent the escape of dust and operators’ subsequent contamination

• ventilation: improving natural and mechanical ventilation

• protection: providing personal protection for exposed workers

• supervision: setting up regulations and safe operating rules, and supervising workers to ensure that they follow them strictly

• education: implementing health and safety education programmes to promote workers’ participation and enhance their awareness and skills with regard to personal protection

• checking up: inspecting the working environments to meet national standards and regularly examining the workers’ health in line with national requirements.

It has been proved by the practices of many enterprises that the “Eight Characters” strategy is important and effective in improving working conditions.

Environmental Monitoring in Workplaces

Enterprises with hazardous working environments should periodically monitor the concentrations or intensities of the hazards at worksites and take measures to control risks to meet national industrial hygienic standards (for example, with reference to values of MACs). If the enterprises are not able to conduct environmental monitoring by themselves, local OHIs or HEPSs can provide services.

To control the quality of workplace monitoring conducted by enterprises, OHIs or HEPSs must conduct inspection regularly or whenever necessary. NCODPT is responsible for the nationwide quality control of workplace hazard monitoring. A number of technical regulations for air monitoring in the workplace have been promulgated by MOPH or been published as national recommendations by NCODPT—for example, Methods for Airborne Dust Measurement in the Workplace (GB 5748–85) (MOPH 1985) and Methods for Monitoring and Analysis of Chemical Hazards in Air of Workplace (Institute of Occupational Medicine 1987).

To control further the quality of environmental monitoring in workplaces a set of quality assurance norms for measurement of hazardous substances in the working environment has been submitted to MOPH for further review and approval. The qualifications of institutions which undertake workplace monitoring would be reviewed and licensed, requiring:

• professional ability on the part of the person who takes the samples or engages in analytical work

• necessary equipment for sampling and analysis and their proper calibration

• reagents and standard solutions

• quality assurances for air and biological material sampling

• inter-laboratory quality assurances and similar checks.

At present, a pilot study on assessment of the laboratories is being conducting in 200 laboratories or institutions. This is the first step to implement the Quality Assurance Norm.

Health Examinations of Workers

Workers exposed to occupational hazards in workplaces should have occupational health examinations. This was first required for workers exposed to dust in the 1950s. It quickly expanded to cover workers exposed to toxic chemicals and physical hazards.

The health examinations include a pre-employment or fitness-to-work examination and periodic examinations. These medical examinations must be carried out by OHIs or competent medical/health institutions licensed by government public health administrations.

Pre-employment examination

A pre-employment examination is required for new workers or workers newly transferred to hazardous workplaces. The medical examinations focus on assessment of the health of workers in relation to the workplace conditions to ensure that the specific job they intend to hold will be of no damage to their health, and those who are not fit for a given job are excluded. Health criteria to determine job contraindications for different hazardous work conditions have been stipulated in detail in the National Diagnostic Criteria and Principles of Management of Occupational Diseases (Health Standards Office 1993) and Guideline of Occupational Health Service and Inspection promulgated by MOPH (1991b).

Periodic examination

Workers exposed to different hazards have different intervals of medical examinations. The period of examination for workers exposed to dust, for example, is illustrated in table 2. Workers suffering from pneumoconioses should have annual physical examinations.

Table 2. Periodic examination requirement for workers exposed to dust

All medical records should be well secured both in enterprises and in local OHIs, and should be reported annually to the local government public health authority, and then to the NCODPT and the MOPH.

When anyone transfers to an enterprise from a plant involving risks of hazardous exposure, a health examination must be given by a local OHI to clarify whether his or her health has been damaged by exposure, and the health records must be sent to the new enterprise with the worker (MOPH 1987).

Table 3 shows the statistics of workers’ health examinations in the period 1988-1993. A total of 64 million workers were covered by the network of the occupational health service, which included state-owned and city collective-owned enterprises, and a part of rural industries at the township level. The workers exposed to occupational hazards account for 30% of the total workers. Nearly 4 million exposed workers, about 20% of the total, had medical examinations every year. In 1993, for example, the total number of the industrial population was 64,345,193, according to the report from the National Centre of Occupational Health Reporting (NCOHR 1994) (there was, however, a lack of data from Neimeng, Tibet and Taiwan). The proportion of workers exposed to occupational hazards accounted for 31.28% (20,126,929), of which 3,982,940 were examined, accounting for 19.79%. The total rate of detected compensable occupational diseases was 0.46% in 1993 (MOPH 1994).

Table 3. Physical examinations for workers exposed to occupational hazards

The Management of Occupational Diseases

Compensable occupational diseases

Generally speaking, any illnesses caused by exposure to hazardous factors present in the workplace or resulting from processes of production is considered an occupational disease. However, for compensation purposes, a list of occupational diseases has been issued by the MOPH, the MOL, the Ministry of Finance and the ACFTU (MOPH 1987). The list covers nine categories, including pneumoconioses; acute and chronic occupational poisonings; diseases induced by physical factors; occupational communicable diseases; occupational dermatoses; occupational eye impairments; occupational ear, nose and throat diseases; and occupational tumours. The total is 99 diseases. If any other disease is proposed by local governments or governmental sectors to supplement the list, it should be submitted to the MOPH for approval.

Diagnosis of compensable occupational diseases

According to stipulations of the Administrative Rule of Occupational Disease Diagnosis issued by the MOPH, at the provincial and prefecture levels, compensable occupational diseases must be diagnosed by OHIs or by medical/health institutions licensed by the public health departments of local governments. In order to control the quality of diagnosis and to provide technical assistance for confirmation of complicated cases and adjudications of diagnostic disputes, expert committees on occupational disease diagnosis have been established at the national, provincial and prefecture/municipal levels (figure 3) (MOPH 1984).

Figure 3. The management of occupational disease diagnosis in China

The National Committee on Occupational Disease Diagnosis (NCODD) consists of five subcommittees concerned with occupational poisoning, pneumoconiosis, physical factor-induced occupational disease, radiation sickness and pneumoconiosis pathology, respectively. The headquarters of the Committee is in the Department of Inspection of the MOPH. The executive office of the NCODD is in the IOM/CAPM. All members of the Committee were appointed by the MOPH.

Diagnostic Criteria of occupational illnesses are promulgated by the MOPH. There are such criteria for 66 occupational diseases in effect right now. For other compensable occupational diseases without national diagnostic criteria, the provincial public health departments could formulate temporary diagnostic criteria to be put into effect in their own provinces after being submitted to the MOPH for the records.

According to the Diagnostic Criteria, the diagnosis of occupational disease must be based on the following sorts of evidence: a history of exposure, clinical symptoms and signs, laboratory findings and results of working environmental monitoring, and reasonable exclusion of other diseases. Once the diagnosis is made, an Occupational Disease Certification (ODC) must be issued by the OHI. Three copies of the ODC should be sent: one to the worker, one to the enterprise for proper compensation arrangements and one should be kept in the OHI for further medical treatment and working capacity evaluation.

Management of occupational disease patients

Compensation and other welfare for patients suffering from occupational diseases must be provided by the enterprises according to the Labour Insurance Regulations (LIR). The management, labour union and committee of working capacity evaluation in the enterprise must jointly take part in the discussion and decision on proper treatment and compensation for the patients based on the ODC and the degree of working capacity loss. For those who are proved to be not suitable for doing their original jobs after the completion of proper medical treatment, the enterprise should transfer them to other worksites or make proper employment arrangements according to their health conditions within two months, and for special cases, at the latest in six months. When a worker suffering from occupational disease moves to another enterprise, his or her occupational disease benefits should be borne by the original enterprise where the occupational disease was caused, or shared by both enterprises after they have come to an agreement. All the health records, the ODC and other information relating to the health care of the worker must be transferred to the new enterprise from the original one, and the transfer should be reported by both enterprises to their local OHIs for record-keeping and further follow-up purposes.

If the diagnosis of an occupational disease is made after the worker has moved to a new enterprise, all the compensation or benefits should be paid by the new enterprise where the worker is currently working, regardless of whether or not the affliction is connected with the present working conditions. For a contracted worker or temporarily employed worker, if the occupational disease is diagnosed during unemployed periods and there is evidence proving exposure to related hazardous working environments when he or she was hired by any enterprise, the compensation and medical care should be paid by the enterprise (MOPH 1987).

Achievements in Occupational Disease Prevention and Control

Improvement of working environments

The concentration or intensity of occupational hazards in the workplace has declined significantly. The statistics of working environmental monitoring as supplied from the NCOHR showed that the proportion of worksites in compliance with national standards has increased 15% from 1986 to 1993 (NCOHR 1994). This is particularly true for state-owned and urban collective-owned industrial enterprises, of whose working environments nearly 70% had met the national standards. The situation in rural industrial enterprises is also improving. The compliance rate for occupational hazards increased from 42.5% in 1986 to 54.8% in 1993 (table 4). It is important to note that the estimation of the compliance rates of township industries might be higher than the actual situation, because this routine report can cover only about 15% of the rural industries every year, and most of them are located near cities which have well-developed health service facilities.

Table 4. Results of environmental monitoring for hazards in the workplace

^* Exclusive of data from 1988: Yunnan, Xinjiang; 1989: Tibet, Taiwan; 1990: Tibet, Taiwan; 1991: Tibet, Taiwan; 1992: Tibet, Taiwan; 1993: Neimeng, Tibet, Taiwan.

The prevalence of some serious occupational diseases andthe implementation of comprehensive preventive measures

The national occupational health report data indicated that the prevalence of compensable occupational diseases maintained itself at a rate of 0.4 to 0.6%, although industries developed very quickly in recent years. Silicosis, for example, has been controlled for years in some large state-owned industrial or mining enterprises. Tables 5 and 6illustrate the success of Yiao Gang Xian Tungsten Mine and Anshan Steel Company in controlling silicosis (Zhu 1990).

Table 5. Dust exposure and prevalences of silicosis in Yiao Gang Xian Tungsten Mine

Table 6. Detection rate of silicosis in Anshan Steel Company

The nationwide epidemiological survey of pneumoconiosis in 1987-90 has also shown that the average working time of patients from their first exposure to silica dust to the appearance of signs of pneumoconiosis had been significantly prolonged, from 9.54 years in the 1950s to 26.25 years in the 1980s for those with silicosis, and 16.24 years to 24.72 years for those with coal worker’s pneumoconiosis in the same period of time. The average age of patients suffering from silicosis at death had also been increased from 36.64 years to 60.64, and for patients with coal pneumoconiosis from 44.80 years to 61.43 years (MOPH 1992). These improvements could be partly attributed to the successful occupational health policies and interventions of governmental policies as well as to the great efforts of occupational health professionals.

Promoting occupational health programmes in small-scale industries

Facing the continuing rapid development of small-scale industries, especially of township industries, and the growing gap between occupational health services and practical needs, the Ministry of Public Health decided to conduct a further comprehensive intervention field study. This study is important not only for helping to solve occupational health problems in rural industries, but also for exploring approaches to reform the occupational health service system in state-owned enterprises in order to match the changing requirements of the market economic system that is being established. Therefore, in December 1992, the Expert Group for the Field Study of Occupational Health Service Policies for Small-scale Industries was set up in the Department of Health Inspection, Ministry of Public Health. The Group was formed to support provinces in developing occupational health service programmes and approaches to effective intervention in hazardous situations. As the first step, the Group has drafted a “Recommended National Field Study Program” for provincial governments, which was approved and issued by the MOPH in 1992. The primary strategy of the programme is described as follows:

The enterprise, the provider of occupational health and the local government are the three key parts of the programme. The programme focuses on readjusting the relationship among the three parts to establish a new model of development. The basic objectives of the programme are to strengthen the regulatory control of government, to change the attitudes to health and the behaviours of the productive and operation functions of enterprises and to enlarge the coverage of minimum occupational health service while improving working conditions with appropriate technological measures (figure 4). Four counties (or districts) have been selected by the MOPH as national trial areas prior to the nationwide implementation of the programme, which include the Zhangdian district in Zibo municipality, Shandong province; the Baoshan District in Shanghai municipality; Jinhua County in Zhejiang province; and the Yuhong District in Shenyang municipality, Liaoning province.

Figure 4. The strategy of the pilot study on OHS in township enterprises

Seven spheres of policy interventions have been emphasized in the programme:

• strengthening the supervision and inspection provided by local governments of the occupational health of small-scale industries

• exploring how to integrate occupational health services for rural industries, with the goal “Health for All by the Year 2000” in China

• improving grass roots health organization networks to deliver occupational health services, management and supervision to the enterprises

• exploring practical approaches to enforce and implement occupational health inspection and service for township enterprises

• searching for and recommending appropriate technology for hazard control and personal protection for township enterprises

• implementing occupational health education programmes in township industries

• developing occupational health manpower and improving occupational health service working conditions to strengthen the occupational health service network, especially at the township and county levels.

Some preliminary results have been obtained in these four trial areas, and the basic ideas of the programme are being introduced to other areas in China and was scheduled for final evaluation in 1996.

The author thanks Prof. F. S. He for her assistance in reviewing this article.

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Geopolitical Background

The predominant development of heavy industry (the iron and steel industry, smelting and refinery plants), metalworking and machinery industries, and the emphasis on the production of energy in Central and Eastern Europe, have significantly predetermined the structure of the economies in the region for the last four decades. This state of affairs has resulted in the relatively high exposures to certain types of occupational hazards in the workplace. Current efforts to transform the existing economies along the lines of the market economy model and to improve occupational safety and health have been considerably successful so far, given the short period of time for such an endeavour.

Until recently, ensuring the prevention of adverse health effects of chemicals present in occupational settings and in the environment, the drinking water and the food basket of the population was provided for by the compulsory observance of hygienic and sanitary standards and occupational exposure limits such as Maximum Allowable Concentrations (MACs), Threshold Limit Values (TLVs) and Acceptable Daily Intake (ADI). The principles of toxicity testing and exposure evaluation recommended by various international organizations, including standards applied in the countries of the European Union, will become more and more compatible with those used in the Central and Eastern European countries as the latter gradually integrate with other European economies.

During the 1980s the need was increasingly recognized to harmonize the methodologies and scientific approaches in the field of toxicology and hygienic standardization applied in the OECD countries with those used in the member countries of the Council of Mutual Economic Assistance (CMEA). This was mainly due to growing levels of production and trade, including industrial and agricultural chemicals. A contributing factor favouring the urgency with which these considerations were viewed was a growing problem of air and river pollution across national boundaries in Europe (Bencko and Ungváry 1994).

The Eastern and Central European economic model was based on a centrally planned economic policy oriented to the development of basic metal industries and the energy sector. As of 1994, except for minor changes, the economies of the Russian Federation, Ukraine, Belarus, Poland, and the Czech and the Slovak Republics had preserved their old structures (Pokrovsky 1993).

Coal mining is a widely developed industry in the Czech Republic. At the same time, black coal mining (e.g., in the northern Moravian region of the Czech Republic) is a cause of 67% of all new cases of pneumoconioses in the country. Brown coal is extracted in opencast mines in northern Bohemia, southern Silesia and neighbouring parts of Germany. Thermal power stations, chemical plants and brown coal mining heavily contributed to the environmental pollution of this region, forming the so-called “black” or “dirty triangle” of Europe. Uncontrolled use of pesticides and fertilizers in agriculture was not exceptional (Czech and Slovak Federal Republic 1991b).

The labour force of the Czech Republic numbers some 5 million employees. About 405,500 workers (that is, 8.1% of the working population) are involved in hazardous operations (Ministry of Health of the Czech Republic 1992). Figure 1 presents data on the number of workers exposed to different occupational hazards and the proportion of women among them.

Figure 1. Number of workers in the Czech Republic exposed to the most serious occupational risks

Changing Needs

The occupational health system of the Czech Republic underwent three consecutive stages in its development and was influenced by the political and economic changes in the country (Pelclová, Weinstein and Vejlupková 1994).

Stage 1: 1932-48. This period was marked by the foundation of the first Department of Occupational Medicine by Professor J. Teisinger at the oldest university in Central Europe—Charles University (founded in 1348). Later, in 1953, this department became the Clinic of Occupational Medicine, with 27 beds. Professor Teisinger also founded the Research Institute of Occupational Health and in 1962 the Poison Information Centre at the Clinic. He was granted several international awards, including an award from the American Association of Industrial Hygienists in 1972 for his personal contribution to occupational health development.

Stage 2: 1949-88. This period exhibited numerous inconsistencies, in some respects being marked by notable deficiencies and in others showing distinct advantages. It was recognized that the existing system of occupational health, in many ways reliable and well developed, nevertheless had to be reorganized. Health care was considered as a basic civil right guaranteed by the Constitution. The six basic principles of the health system (Czech and Slovak Federal Republic 1991a) were:

• planned integration of health care into the society

• promotion of a healthy lifestyle

• scientific and technical development

• prevention of physical and mental illnesses

• free and universal access to health care services

• concern on the part of the state for a healthy environment.

Despite certain progress none of these goals had been fully achieved. Life expectancy (67 years for men and 76 years for women) is the shortest among the industrialized countries. There is a high mortality rate from cardiovascular diseases and cancer. About 26% of adult Czechs are obese and 44% of them have cholesterol levels above 250 mg/dl. The diet contains much animal fat and is low in fresh vegetables and fruits. Alcohol consumption is relatively high, and around 45% of adults smoke; smoking kills about 23,000 persons a year.

Medical care, dental care and medicines were provided free of charge. The numbers of physicians (36.6 per 10,000 inhabitants) and nurses (68.2 per 10,000) were among the highest in the world. But in the course of time the government became unable to cover the continually increasing and abundant expenses needed for public health. There had been temporary shortages of some drugs and equipment as well as difficulties in providing health care services and rehabilitation. The existing structure, which did not allow a patient to choose his primary health care physician, created many problems. Medical staff working in the state-run hospitals received low fixed salaries and had no incentives to provide more health care services. A private health care system did not exist. In hospitals, the main criterion of acceptable functioning was the “percentage of occupied beds” and not the quality of the health care provided.

However, there were positive features of the state-run centralized system of occupational health. One of them was an almost complete registration of hazardous workplaces and a well-organized system of hygienic control provided by the Hygienic Service. In-plant occupational health services established in large industrial enterprises facilitated the provision of comprehensive health care services, including periodic medical examinations and treatment of workers. Small private enterprises, which usually pose many problems to occupational health programmes, did not exist.

The situation was similar in agriculture, where there were no small private farms, but large-scale cooperative ones: an occupational physician working in a health centre of a factory or a cooperative farm provided occupational health services for the workers.

Enforcement of occupational safety and health legislation was sometimes contradictory. After an inspection of a hazardous workplace was carried out by an industrial hygienist or factory inspector, who had required the reduction of the level of occupational exposure and the enforcement of prescribed health and safety standards, rather than correct the hazards the workers would receive monetary compensation instead. Besides the fact that enterprises often took no action at all to improve working conditions, the workers themselves were not interested in improving their working conditions but opted to continue receiving bonuses in lieu of changes in the working environment. Furthermore, a worker who contracted an occupational disease received a substantial monetary recompense according to the severity of the disease and to the level of his or her previous salary. Such a situation produced conflicts of interests among industrial hygienists, occupational physicians, trade unions and enterprises. As many of the benefits were paid by the state and not by the enterprise, the latter often found it cheaper not to improve safety and health in the workplace.

Strange as it may seem, some hygienic standards, including permissible levels and occupational exposure limits, were more rigorous than those in the United States and in the western European countries. Thus, it was sometimes impossible not to exceed them with outdated machinery and equipment. Workplaces exceeding the limits were classified under “category 4”, or most hazardous, but for economic reasons manufacturing was not stopped and workers were offered compensatory benefits instead.

Stage 3: 1989–the present. The “velvet revolution” of 1989 enabled an inevitable change of the public health care system. The reorganization has been rather complex and sometimes difficult to accomplish: consider, for example, that the health care system has more beds in hospitals and doctors per 10,000 inhabitants than any industrialized country while it uses disproportionately less financial resources.

The Current Status of Occupational Safety and Health

The most frequent occupational hazard at the workplace in the Czech Republic is noise—about 65.8% of all workers at risk are exposed to this occupational hazard (Figure 8). The second major work-related hazard is fibrogenic dust, which represents an occupational hazard to about 21.3% of all workers at risk. Approximately 14.3% of workers are exposed to toxic chemicals. More than one thousand of these are exposed to toluene, carbon monoxide, lead, gasoline, benzene, xylene, organophosphorus compounds, cadmium, mercury, manganese, trichlorethylene, styrene, tetrachloroethylene, aniline and nitrobenzene. Another physical hazard—local hand-arm vibration—is a danger for 10.5% of all workers at risk. Other workers are exposed to chemical carcinogens, ionizing radiation and dangerous substances causing skin lesions.

The number of acknowledged cases of occupational disease in the Czech Republic in 1981-92 is presented in figure 2.

Figure 2. Occupational diseases in the Czech Republic in the period 1981-1992

The increase of morbidity from occupational diseases in 1990–91 had been due to the process of reclassification of occupational illnesses requested by miners and workers in other occupations and by their trade unions. They asked to change the status of “being endangered with an occupational disease”, used for less obvious forms of occupational impairment with low compensation, to fully compensated disease. The status of “endangerment” was reconsidered by the Ministry of Health in 1990 for the following kinds of occupational pathology:

• mild forms of pneumoconioses

• mild forms of chronic musculoskeletal disorders due to overload and vibration

• mild forms of occupational hearing loss.

Reclassification was done for all cases before 1990 and concerned 6,272 cases in 1990 and 3,222 cases in 1991 (figure 2). After that the status of “endangerment” was abolished. Figure 3 presents data on 3,406 new cases of occupational diseases by category diagnosed in the Czech Republic in 1992; 1,022 cases of these occupational diseases were diagnosed in women (Urban, Hamsova and Neecek 1993).

Figure 3. Occupational diseases in the Czech Republic in 1992

Some shortages in the supply of measuring equipment for sampling and analysis of toxic substances make it difficult to conduct occupational hygiene evaluations in the workplace. On the other hand, the use of biomarkers in exposure tests for the monitoring of workers in hazardous occupations is practised for a variety of dangerous substances according to the regulations of the Czech Republic. Similar tests have already been legally codified in Hungary, Slovakia, Slovenia, Croatia, Poland, and in some other countries of Central and Eastern Europe. The use of exposure tests for periodic medical examinations has proved to be a very efficient tool for personnel exposure monitoring. This practice has enabled early detection of some occupational diseases and permitted their prevention, thus decreasing compensation costs.

The transition to the market economy and the rising costs of health care services in the Czech Republic have had their influence on occupational health services. In the past, the in-plant based occupational health service or centre provided both health surveillance and treatment for workers. Nowadays, these activities are subjected to some restrictions. This has resulted in reduced activities in health surveillance and hazard control and in an increased number of occupational accidents and diseases. Workers in rapidly emerging small-scale enterprises, which often operate with unreliable machinery and equipment, are practically out of the reach of occupational health professionals.

Projects for the Future

A new system of public health in the Czech Republic is expected to incorporate the following principles:

• prevention and health promotion

• overall access to “standard” health care

• decentralized policy determining delivery of services

• integration of health services in a territorial network

• increased autonomy of health care professionals

• emphasis on outpatient care

• compulsory health insurance

• community participation

• more options for patients

• new public/private sector partnership to provide an “above standard” health care no longer offered by the public sector.

The introduction of the compulsory health insurance system and the creation of the General Health Insurance Office, which began operating in January 1993, as well as minor health insurance companies in the Czech Republic have marked the beginning of reform in the public health sector. These changes have brought some problems to the occupational health services, given their preventive character and the high cost of treatment in hospitals. Thus, the role of outpatient medical settings in treating patients with conventional as well as work-related diseases is steadily increasing.

The Potential Impact of Continuing Changes on Occupational Safety and Health

The growth of reform in the public health sector has created a need for change for occupational physicians, industrial hygienists and in-patient medical settings, and has also led to a focus on prevention. The ability to focus on prevention and milder forms of disease is partly explained by earlier positive results and by the relatively good functioning of the previous occupational health system, which had worked effectively towards eliminating major serious occupational diseases. The changes have involved a shift of attention from severe forms of occupational pathology that needed urgent treatment (such as industrial poisoning and pneumoconioses with respiratory and right-heart failure) to mild forms of disease. The change in the activities of the occupational health services from a curative orientation to early diagnosis now concerns such conditions as mild forms of pneumoconioses, farmer’s lung, chronic liver illnesses and chronic musculoskeletal disorders due to overload or vibration. Preventive measures at the earlier stages of occupational diseases also should be undertaken.

Industrial hygiene activities are not covered by the health insurance system, and the industrial hygienists in the hygienic stations are still paid by the government. Lowering their number and the reorganization of hygienic stations are also expected.

Another change in the health care system is the privatization of some health services. The privatization of small out-patient medical centres has already started. Hospitals—including university hospitals—are not involved in this process at present and details of their privatization still need to be clarified. New legislation concerning the duties of the enterprises, workers and occupational health services is being gradually created.

Occupational Health at the Crossroads

Thanks to the advanced system of occupational health founded by Professor Teisinger in 1932, the Czech Republic does not face a serious problem of education in occupational health for university students, even though in some countries of Central and Eastern Europe the rate of recognized occupational diseases is about five times less than that of the Czech Republic. The Czech List of Occupational Diseases does not differ notably from that appended to the ILO Employment Injury Benefits Convention, (No. 121), (ILO 1964). The proportion of unrecognized principal occupational diseases is low.

The occupational health system in the Czech Republic is now at the crossroads and there is an obvious need for its reorganization. But it is necessary at the same time to preserve whatever positive features have been acquired from experience with the previous occupational health system, namely:

• registration of working conditions at the workplaces

• maintaining in operation a broad system of periodic medical examinations of employees

• provision of curative health care services at large-scale enterprises

• offering a system of vaccination and communicable disease control

• preserving the system whereby occupational health services admit patients with various occupational illnesses, a system that would involve the university hospitals in providing treatment to patients as well as education and training to medical students and graduates.

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