Global strategy on occupational health for all: The way to health at work
Recommendation of the second meeting of the WHO Collaborating Centres in Occupational Health, 11-14 October 1994, Beijing, China
A proposed Global Strategy on Occupational Health for All
Basis for the strategy
The Constitution of WHO stipulates the fundamental right of all people to the highest attainable standard of health. In addition, article 2 of Chapter II - of the Constitution specifies prevention of accidental injuries and the pro- motion of improvement of working conditions as functions of WHO. WHO has had a special programme for occupational health since 1950 and close coordination and collaboration has taken place with ILO. The Alma Ata Declaration emphasized the need to organize primary health care services (both preventive and curative) "as close as possible to where people live and work". The Declaration emphasized that in the organization of such services, high priority should be given to the people most in need, including the working populations at high risk. In 1979 a new strategy for the further development of occupational health was launched when the World Health Assembly adopted Resolution WHA32.14 on the Comprehensive Workers’ Health Programme. In 1980, Resolution WHA33.31 encouraged countries to integrate occupational health and primary health care services to cover underserved populations, particularly in developing countries. In the same resolution a need for further development of occupational health services, training and research was emphasized.
Several WHO programmes and other initiatives have relevance to occupational health, the International Programme on Chemical Safety (IPCS) and its WHO element, the Programme on Chemical Safety (PCS) and the Programme for Promotion of Environmental Health (PEH), programmes on communicable diseases, non-communicable diseases and human resources development, and so on. The support of these programmes for the Workers’ Health Programme should be ensured.
The WHO VIII General Programme of Work for the Years 1990-1995 - recognized the seriousness of the health problems of working populations, of particularly the underserved in developing countries. So far little attention has been given to workers in agriculture, small-scale industries, construction and mining. The Programme of Work called for extension of primary health care to the underserved working populations, as well as providing guiding principles for supporting legislation for primary health care action in the workplace. But occupational health means far more than providing conventional primary health care to workers (and at the workplace). Occupational health is a preventive activity aiming at identification, assessment and control of hazardous factors at the workplace and generation of competent and effective actions to ensure a healthy work environment and 38.healthy workers. Such activity cannot be carried out with primary health care competence alone; specialized occupational health competence and knowledge of the real needs (e.g. knowledge on industrial and other chemicals, physical factors at work, ergonomics, safety, work psychology, occupational medicine) of the working life are needed.
The ambitious target of having at least 70% of countries develop occupational health programmes was set by the VIII General Programme of Work. To achieve this target, the WHO Workers’ Health Programme in collaboration with IL0 and countries called for identification and control of health hazards at work, identification of national priorities, evaluation of occupational health measures, provision of information to employers and workers, and efforts to meet the needs of high-risk groups, child workers, agricultural workers, mining and small-scale industry workers, and those working in construction and home industries. Training of both occupational health personnel and primary health care workers in issues of occupational health was also encouraged. In addition, a global data system for monitoring morbidity and mortality trends in major occupational and work-related diseases and injuries was also requested, standard guidelines were set up for data collection and reporting. Guiding principles and standards for occupational exposure limits were also anticipated. Much emphasis was given to the communication of information on occupational health between the Member States and to the development of the Network of Collaborating Centres in Occupational Health.
Most valuable information on health hazards of chemicals and on their risk assessment is produced by the IPCS in the form of Environmental Health Criteria, Health and Safety Guides and International Chemical Safety Cards. These outputs can be effectively used in occupational health programmes and should be distributed widely to occupational health experts.
The right to health and safety at work has been stipulated in the Constitution of WHO and IL0 and is supported by a number of other United Nations documents. No country has so far been fully successful in achieving this objective for all workers. Thus occupational health infrastructures and programmes should be further developed in every country.
Though major efforts have been invested by WHO, its Regional Offices and Collaborating Centres together with Member Countries, the ambitious targets of the VIII General Programme of Work are likely to be only partly achieved. There are several reasons for this, the most evident being the extremely limited resources available from WHO for the implementation of the Workers’ Health Programme and the economic constraints in most Member States. Rapid structural changes in economies and changes in the political priorities are reported by several industrialized and developing countries. For example, the alleviation of problems related to severe unemployment in the Member States have consumed many of the resources that otherwise could have been used for development. All this has happened at a time when occupational health activities are needed even more than before, particularly in countries where transition of economic systems and development of employment has been turbulent.
The Agenda 21 of the United Nations Conference on Environment and Development (UNCED), as well as the recommendations of the WHO Commission on Health and Environment and the European Charter on Environment and Health contain several items that directly or indirectly concern occupational health. In addition to general aspects of chemical exposures, chemical safety and risk assessment, the documents also ad-dress specific issues such as surveillance of occupational exposures, the setting of exposure limits, the epidemiology of occupational diseases in terms of the dose-response relationship between exposure and outcome, the control of toxic exposures, the prevention of occupational accidents and injuries. These recommendations are expected to guide the relevant plans and programmes of WHO and IL0 up to the year 2000 and beyond. Many of the targets for occupational health and safety, chemical safety and environmental health cannot be achieved without full participation of occupational health experts.
The European Union (EU) has paid much attention to occupational health and safety in its efforts to develop the so-called social dimension of working life. A comprehensive Framework Directive (No. 391/89) on the minimum requirements for health and safety at work has been approved and has been supplemented with some 16 special directives. The EU Fourth General Programme of Work for occupational health and safety has recently been passed and is currently being implemented.
The North American Free Trade Association (NAFTA) of the USA, Canada and Mexico has initiated a programme for occupational health and is planning to improve the collection of information, the conduction of re-search, and the training and education of experts, workers and employers within the framework of the new Association.
The International Commission on Occupational Health (ICOH) is a non-governmental expert body in the field of occupational health. It focuses primarily on research, training and information activities among the more than 2 000 experts in occupational health in about 80 countries. ICOH has also prepared an International Code of Ethics for Occupational Health Professionals. The International Occupational Hygiene Association (IOHA) with its 20 national associations carries out respective activities in the field of occupational hygiene.
The proposed Global Strategy on Occupational Health for All is based on the WHO Constitution, the Health for All Strategy, previous policy objectives adopted by the World Health Assembly, UNCED Agenda 2 1, the call for leadership and collaboration from countries and several other organizations and especially on the scientifically documented special needs regarding health at work in all parts of the world, in all sectors of the economy and in all occupations. These needs have been further aggravated by the rapid changes in economies, technologies, health and demography and should be effectively met at all levels: international, national and workplace.
The proposed Global Strategy on Occupational Health for All is based on the WHO Constitution, Health for All Strategy, previous policy objectives adopted by the World Health Assembly, the UNCED Agenda 21, the call for leadership and collaboration from countries and several other organizations and especially on the scientifically documented needs regarding health at work in all parts of the world, in all sectors of the economy and in all occupations.
Principles of occupational health and safety
Several definitions of occupational health and safety and occupational health services have been produced by professional bodies, international organizations such as WHO and IL0 and national bodies and authorities. If one summarizes those definitions, occupational health is considered to be multidisciplinary activity aiming at:
- protection and promotion of the health of workers by preventing and controlling occupational diseases and accidents and by eliminating occupational factors and conditions hazardous to health and safety at work
- development and promotion of healthy and safe work, work environments and work organizations.
- enhancement of physical, mental and social well-being of workers and support for the development and maintenance of their working capacity, as well as professional and social development at work
- enablement of workers to conduct socially and economically productive lives and to contribute positively to sustainable development.
Thus occupational health has gradually developed from a monodisciplinary risk-oriented activity to a multidisciplinary and comprehensive approach that considers individual’s physical, mental and social well-being, general health and personal development.
The most successful economies have demonstrated that workplaces designed according to good principles of occupational health, safety and ergonomics are also the most sustainable and productive. Furthermore, wide experience from countries show that a healthy economy, high quality of products or services and long-term productivity are difficult to achieve in poor working conditions with workers who are exposed to health and safety hazards. The available scientific knowledge and practical experiences of enterprises and countries which have achieved the best results in the development of occupational health indicate the value of several principles. These principles are common denominators in occupational set-tings that have shown the best results in health, safety, social relations and economic success. Enterprises with such occupational settings are also the most stable in times of crisis.
The following principles are found in international instruments on occupational health and safety and in the legislation of the countries with the strongest occupational health and safety traditions: avoidance of hazards (primary prevention) and use of safe technology; government responsibility; authority and competence to regulate and control working conditions; optimization of working conditions; integration of production and health and safety activities; primary responsibility of the employer or entrepreneur for health and safety at the workplace; recognition of employees’ own interest in health at work; cooperation and collaboration on an equal basis: participation, right to know and transparency; continuous follow-up and development of working conditions.
The key strategy principles of international and national occupational health and safety policies are:
- avoidance of hazards (primary prevention)
- safe technology
- optimization of working conditions
- integration of production and health and safety activities
- government’s responsibility, authority and competence in the development and control of working conditions
- primary responsibility of the employer and entrepreneur for health and safety at the workplace
- recognition of employees’ own interest in occupational health and safety
- cooperation and collaboration on an equal basis by employers and workers
- right to participate in decisions concerning one’s own work
- right to know and principle of transparency
- continuous follow-up and development of occupational health and safety.
Implementation of such principles requires appropriate legal provisions, administrative enforcement and service systems for occupational safety and health and occupational health services.
For occupational health services, the following functional principles are recognized; prevention and promotion; adaptation and adjustment of working conditions to the worker; rehabilitation; curative services and acute response (first aid and emergency response).
By implementing such principles occupational health serves as a catalyst for change at the workplace towards the development of better management of production and better control of hazards at work.
Occupational health problems are not only problems for the worker, but above all they are problems of work and the work environment. The work environment varies greatly according to type of economic activity, occupation, company and size of workplace. Geographic and climatic conditions also have a great impact on the work environment, particularly in outdoor activities such as fishing, forestry and agriculture. However, due to differences between the work environments in different countries with otherwise similar socio-economic and climatic conditions and between different companies with similar types of production, it has been concluded that a major part (varying according to the activity and the method of esti-43.mate, SO-900/,) of occupational health hazards are in principle prevent-able. Thus, there is much room for prevention in virtually all countries and particularly in countries with lower standards of occupational health and safety.
Many industrialized countries with the strongest traditions in occupational health and safety can show constantly declining trends of occupational accidents and traditional occupational diseases as an impact of adopting the above principles.
Some national and international industries have adopted a strategy setting zero risk as an objective in the work environment. Though not totally achievable such a strategy has stimulated programmes and actions for planning and designing the work environment and working practices ac-cording to the best available technology and principles and carrying out production according to good practices, operation and maintenance. This has led to substantial reduction of hazardous exposures at work, elimination or decrease in occupational injuries and diseases, and saving of costs by reduction of disturbed production and costs of sickness. Such experiences demonstrate that a safe and healthy work environment can be planned, constructed, organized and maintained if the best occupational health and safety standards are applied. They also demonstrate that a healthy and safe work environment is a realistic and achievable objective, a positive investment rather than a burden for economy.
Occupational health problems are not only problems of individual workers’ health, but they are also problems relating to the healthiness and safety of work and the work environment, the organization of work and the management philosophy of the enterprise and workplace.
The way that work is organized, the management style, and the extent to which the worker can determine or regulate his or her work and participate in decisions about it have been shown in several studies to make a positive impact on health, prevent overload at work, counteract stress and promote work motivation and productivity. In the midst of rapid change, the need to learn new jobs and new skills requires an environment which is conducive to learning and adaptation. Effective management of such changes re-quires further development of the principles of right to know, transparency, openness and participation. A number of studies have shown that organizing work in this way tends to be supportive of health and well-being, provides social contacts and gives opportunity for the development of personal abilities and skills. Such an approach also aims at adjustment 44.of the workload and other work requirements to match the personal needs and capacities of the individual worker. This latter objective is particularly important for enabling older individuals, handicapped persons, chronically ill individuals, pregnant workers and others with special needs or vulnerability to participate in work. Meeting such multiple criteria for a "good workplace" also meets the best occupational health standards. There is also recent evidence on better management of crises caused by economic difficulties of the companies, uncertainty of jobs, and threat of unemployment in organizations which have adopted new participatory and collaborative principles as a part of organization’s management culture.
Successful prevention requires: a) information on the causal relationship the between risk factor and health outcome, b) knowledge of the mechanism of action of hazardous factors and conditions, c) knowledge of how the causal relationship can be broken, d) resources, tools and mechanisms for he implementation of preventive measures, and e) political, managerial and target group support for the preventive programme. Many of these conditions are met in the modem occupational health approach and realistic opportunities for effective prevention do prevail provided point e) can be assured. Obtaining such support requires effective information and education of several actors and decision-makers and implies a need to raise awareness on the importance of occupational health. Knowledge of mechanisms of action and of the causal relationship between exposure and outcome call for extensive research efforts. One of the leading principles in the industrialized countries and international organizations, including WHO, is that all policy and practical actions should be founded on a "sound scientific basis.
Successful prevention requires scientific knowledge of the sources, mechanisms of generation, transmission and magnitude of problems together with technical knowledge and practical skills for the prevention and control. Thus multidisciplinary expert competence and practical technical competence should collaborate.
Empowerment of the community
In well-organized industrial settings, local activities in occupational health are initiated at plant level by managers, foremen or workers’ representatives. In many countries such activities are institutionalized in occupational health and safety committees. Various service systems, such as in-plant occupational health services, external occupational health units or 45.primary health care units, may provide expert services and advice in the development of occupational health and safety. This corresponds to the community approach in public health.
In the case of small and medium-sized enterprises, the self-employed and the agricultural sector, organized service systems are rare and other approaches should be adopted. The community-based approach may be relevant by providing training, information and expert advisory support to the local actors in the community. Two major experiments have been made in this field. One is the training intervention among the small and medium-sized enterprises in Asia, Africa and Finland by the IL0 WISE approach, in which the owners of small industries are invited to learn better management by combining the objectives for productivity, quality and occupational health and safety. Interactive group learning methods have been used and found to be successful. For planning, implementation and follow- up of such activities, advice from external experts is needed. Another experimental approach, using primary health care units for initiating local activities for occupational health, has been tried in Thailand, Malaysia, Finland and Tanzania. Special training in occupational health is needed for the staff of primary health care units in order to make the programmes something more than just the provision of general health services for people at the workplace. In particular, interventions directed towards working methods and workplace exposures require special training that differs from the type of training that primary health care staff receive.
In the informal sector it may be very difficult to reach the workers, entrepreneurs and the self-employed. Such groups may be reached with the help of information and training, but usually the access should be organized in connection with other activities such as agricultural extension work, small enterprise promotion programmes, family health programmes and so on. In some limited areas, such as the prevention of poisoning and the provision of first aid training, voluntary organizations and NGOs may be able to help. Some trade unions have initiated projects on women’s work and work conditions in the informal sector, for example as a part of the FINNIDA-supported development collaboration programmes in India and in the countries of South-East Asia. These programmes can be used as a vehicle for occupational health programmes as well.
The awareness of politicians, the authorities, employers, workers and the general public of occupational health and safety issues should be increased by using various ways to disseminate information. This creates a basis for strengthening political will to create the prerequisites for improvement of working conditions, and thereby workers’ health. A system of participation 46.and positive incentives would further ensure the development of health at work in all societies.
Objectives and actions
Goals and objectives of occupational health are based on the WHO definition of health as a "state of physical, mental and social well-being" that provides the individual with an opportunity to conduct a "socially and economically productive life". Both the WHO Health-for-All strategy and the IL0 Conventions on Occupational Safety and Health (No. 155) and on Occupational Health Services (No. 161) start from the principle that occupational health and safety services should be available and are the right of each individual taking part in work, irrespective of the sector of the economy, size of the company or type of assignment. This objective covers also the self-employed, agriculture, home industries and other workplaces in the so-called informal sector, as well as workers in cooperatives and the public sector. It aims, therefore, at occupational health for all working persons everywhere.
Not only the health problems directly related to work, but also the so-called work-related diseases, problems of general health and working capacity, and the potentially positive impact of occupational health on environmental health should be considered in setting objectives for occupational health.
To identify occupational health hazards, to provide appropriate advice on their control and prevention, to contribute to the development of healthy and safe workplaces and to follow up and take the necessary actions for the health of workers, a comprehensive and competent occupational health service is necessary. Such a service should be available at each workplace and accessible by each worker. For this purpose, many industrialized countries have developed a special, often legislation-based system for occupational health services (OHS). Comprehensive OHS are understood as front-line services, active at the workplace, containing preventive, curative and promotional elements and using, where appropriate, the primary health care approach. OHS constitute the health component of comprehensive occupational safety and health programmes aiming at progressive development of working conditions. In their most advanced forms, comprehensive OHS focus on workers and working populations, to the work environment and its hazardous factors, exposures and structures, and work organization. Such OHS contain preventive, control, curative, treatment, rehabilitation and promotion activities for the improvement of working conditions, protection of health and for the maintenance and promotion of working capacity.
According to the WHO Health for All principles and ILO Conventions on Occupational Safety and Health (No. 155) and on Occupational Health Services (No. 161) every worker has the right of access to occupational health and safety services, irrespective of the sector of the economy, size of the company, or type of assignment and occupation.
In line with the new strategies of the United Nations organizations, particularly WHO, and strategies adopted in many of the Member States, and in view of the constraints on financial and human resources, a global strategy on occupational health for all should be implemented as far as possible in collaboration with other relevant bodies, programmes and actors. Strategic alliances, networking, division of labour and collaboration with other units of WHO, particularly PCS/IPCS and with other organizations, particularly ILO, are of utmost importance.
To make cost-effective use of available resources, careful coordination and collaborative links with other relevant programmes will be considered by following WHO’s new integrated approach for programme implementation. Full use and participation of the Network of 52 Collaborating Centres in Occupational Health is foreseen.
The following 10 objectives requiring special action are proposed as a basis for the Global Strategy on Occupational Health for All. Some of the objectives have been included in previous WHO Programmes and particularly in the VIII General Programme of Work, but either the activity is still very relevant or previous objectives have so far not been met.
It is the objective in this Strategy that, by the year 2000, the countries where trends in occupational health and safety are already positive should demonstrate a further improvement of occupational health and safety indicators, showing a reduction of the difference between levels of health and safety of low-risk and high-risk occupations and enterprises. In countries where the present trends are negative, positive development is expected, and the legal and other actions, including the development of necessary resources and infrastructures, should be taken to make such positive trend possible. All countries should show a progressive development of occupational health services with the ultimate objective of covering all workers with such services irrespective of the sector of the economy, size of company, occupation, mode of employment, or nature of self-employment.
The development of occupational health and safety calls for full utilization of all the expertise and knowledge found in WHO. In planning new projects in occupational health, collaboration with and participation of other units within WHO is encouraged. Also vital is clearly-defined leadership in global occupational health. This should be demonstrated by giving a high priority to occupational health and by elevating the status of OCH within the Organization and within its regular budget.
As the resources for activities are scarce in every country, effective net-working of the existing educational, research and information resources, progranunes and institutions should be fully utilized. Such networking should aim to avoid duplication of work and waste of human and financial resources, to increase motivation and to improve quick and immediate transfer of knowledge. The Network of WHO Collaborating Centres in Occupational Health offers a good model and forum for development of this collaboration.
Many ethical problems are encountered in the practice of occupational health and in occupational health research. These should be tackled by tri-partite review of the study protocols, avoidance of perceived compromises in results, and by following faithfully generally-accepted ethical guide-lines and scientific methods in all work practices. The ethical code of ICOH for occupational health personnel is a valuable guideline which should be effectively distributed to all concerned.
Continuous improvement of quality is also closely related to the ethics of occupational health. WHO should take a leadership in introducing quality management systems for occupational health.