MINISTRY OF LABOUR & SOCIAL SECURITY DIRECTORATE GENERAL OF OHS

1. MINISTRY OF LABOUR & SOCIAL SECURITY DIRECTORATE GENERAL OF OHS Dr. Buhara Önal OHS INSTITUTE (ISGUM) May 2010 Ankara - TURKEY

2. BASIC OCCUPATIONAL HEALTH SERVICES

3. CONTENT • Policy background • ILO Convention 161 • EU Legislation on OHS • WHO Worker’s health: Global Plan of Action • Basic Occupational Health Services (BOHS)

4. OCCUPATIONAL HEALTH ASA FUNDAMENTAL HUMAN RIGHT Every worker has the right to working conditions whichrespect his or her health, safety anddignity. (Art. 31 of the European Charter)

5. IMPACT OF THE OCCUPATIONALENVIRONMENT ON HEALTH • 300 000 workers die of work-related diseases • 27 000 workers die in occupational accidents (5% of all deaths due to accidents) • Loss of 4% GDP

6. POLICY BACKGROUND • ILO • EU • WHO

7. ILO • Joint Committees 1950-2003 • Related Conventions and Recommendations, Convention161, Recommendation 171, in particular • Ethics in workers' health surveillance guidelines • Numerous Codes of Practice • Global Strategy • Promotional Framework for Occupational Safety and Health Convention 187 • Fair globalization-Decent Work

8. ILO CONVENTION 161 OH SERVICES Article 1: For the purpose of this Convention- (a) the term occupational health services means services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking on- (i) the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work; (ii) the adaptation of work to the capabilities of workers in the light of their state of physical and mental health; (b) the term workers' representatives in the undertaking means persons who are recognised as such under national law or practice.

9. ILO CONVENTION 161(cont.) Article 2 • In the light of national conditions and practice and in consultation with the most representative organisations of employers and workers, where they exist, each Member shall formulate, implement and periodically review a coherent national policy on occupational health services.

10. ILO CONVENTION 161(cont.) • Article 3 1. Each Member undertakes to develop progressively occupational health services for all workers, including those in the public sector and the members of production co-operatives, in all branches of economic activity and all undertakings. The provision made should be adequate and appropriate to the specific risks of the undertakings. 2. If occupational health services cannot be immediately established for all undertakings, each Member concerned shall draw up plans for the establishment of such services in consultation with the most representative organisations of employers and workers, where they exist.

11. ILO CONVENTION 161(cont.) Article 5 • …….occupational health services shall have such of the following functions as are adequate and appropriate to the occupational risks of the undertaking: (a) identification and assessment of the risks from health hazards in the workplace; (b) surveillance of the factors in the working environment and working practices which may affect workers' health, including sanitary installations, canteens and housing where these facilities are provided by the employer; (c) advice on planning and organisation of work, including the design of workplaces, on the choice, maintenance and condition of machinery and other equipment and on substances used in work;

12. ILO CONVENTION 161(cont.) (d) participation in the development of programmes for the improvement of working practices as well as testing and evaluation of health aspects of new equipment; (e) advice on occupational health, safety and hygiene and on ergonomics and individual and collective protective equipment; f) surveillance of workers' health in relation to work; (g) promoting the adaptation of work to the worker; (h) contribution to measures of vocational rehabilitation; (i) collaboration in providing information, training and education in the fields of occupational health and hygiene and ergonomics; (j) organising of first aid and emergency treatment; (k) participation in analysis of occupational accidents and occupational diseases.

13. ILO CONVENTION 161(cont.) Article 7 1. Occupational health services may be organised as a service for a single undertaking or as a service common to a number of undertakings, as appropriate. 2. In accordance with national conditions and practice, occupational health services may be organised by- (a) the undertakings or groups of undertakings concerned; (b) public authorities or official services; (c) social security institutions; (d) any other bodies authorised by the competent authority; (e) a combination of any of the above.

14. ILO CONVENTION 161(cont.) Article 9 1. In accordance with national law and practice, occupational health services should be multidisciplinary. The composition of the personnel shall be determined by the nature of the duties to be performed. 2. Occupational health services shall carry out their functions in co-operation with the other services in the undertaking. 3. Measures shall be taken, in accordance with national law and practice, to ensure adequate co-operation and co-ordination between occupational health services and, as appropriate, other bodies concerned with the provision of health services.

15. EU • Framework Directive 89/391-preventive and protective services • Occupational health and safety strategy 2008-2012 • Workplace health promotion • Economic loss/productivity

16. PRINCIPLES OF EU LEGISLATION ON OCCUPATIONAL HEALTH AND SAFETY  Prevention  Hierarchy of prevention measures  Continuous improvement  Health and Safety  Employers’ responsibility  Social dialogue and participation of employees  Multidisciplinarity in preventive services & holistic approach to work

17. FRAMEWORK DİRECTİVE 89/391/EEC • Its scope is large: all sectors of activity, both public and private, with very few clearly described exceptions. • Article 5 (1), the Directive's fundamental provision, states that "the employer shall have a duty to ensure the safety and health of workers in every aspect related to the work."

18. 89/391/EHS – Framework Directive on the introduction of measures to encourage improvements in the safety and health of workers at work Using of the work equipment 89/655/EEC Work Equipment (2) Specific group of workers 92/85/EEC Pregnant and breastfeeding workers and worker who have recently given birth (10) Specific activities 90/269/EEC Manual Handling of Loads (4) 90/270/EEC Display Screen Equipments (5) 92/91/EEC Drilling (11) Personal protection 89/656/EEC Personal Protective Equipment (3) Exposure to agents 90/394/EEC Carcinogens (6) 2000/54/EC Biological Agents (7) 98/24/EC Chemical Agents (14) 2000/44/EC Vibrations (16) 2003/10/EC Noise (17) 2004/40/EC Electromagnetic Fields (18) Workplace 89/654/EEC Workplace (1) 92/57/EEC Temporary/Mobile Construction Sites (8) 92/58/EEC Safety and/or Health Signs (9) 92/104/EEC Surface and Underground Mineral-extracting Industries (12) 93/103/EC Fishing Wessels (13) 1999/92/EC Explosive Athmospheres (15) 2000/39/EC Indicative occupational exposure limit values

19. OHS directives which are not directly under Framework Directive 89/391/EEC 91/383/EEC Temporary Workers 94/33/EC Young Workers 93/104/EC 2000/34/EC 2000/79/EC 2002/15/EC Working Time 1983/477/EC 1999/77/EC 2003/18/EC Asbestos

20. WHO • WHO HFA 2000 and HFA21 • Alma Ata: Primary Health Care • Health sector reform • Public health policy: Prevent the preventable • Equity: odd distribution of risks • Social determinants of health • Global Strategy on OH for All • Workers’ Health - Global Action Plan

21. WHO’S CONCEPT ON WORKERS’ HEALTH AS A PUBLIC HEALTH ISSUE The Labour Approach The Public Health Approach Occupational Health Labour Contract Employer's responsibility Only at the workplace Only work-related health Negotiation between workers and employers Workers Health All workers beyond the workplace Responsibility of everyone All health determinants Other stakeholders Health protection not subject to collective negotiation

22. 60TH WORLD HEALTH ASSEMBLY"WORKERS' HEALTH: GLOBAL PLAN OF ACTİON" • The Global Plan of Action developed by the Member States, May 2007 • Consensus by all 192 Member States of WHO • Global plan of action on workers' health (2008-2017) • WHA60 urged Member States to take an number of measures on workers' health

23. OBJECTIVE 1: TO DEVELOP AND IMPLEMENT POLICY INSTRUMENTS ON WORKERS HEALTH • National policy frameworks • legislation • intersectoral collaboration • funding and resource mobilization • strengthening the ministries of health • National action on workers’ health (taking into consideration also ILO Promotional Framework for OSH Convention) • national profiles and priorities for action • objectives, targets and actions • mechanism for implementation, monitoring and evaluation • human and financial resources • National approaches for prevention of priority occupational diseases and accidents • Minimizing gaps – high risk sectors, vulnerable groups, gender aspects • WHO assistance to strengthen the capacities of ministries of health; global campaigns: elimination of asbestos-related diseases and immunization of healthcare workers against HBV

24. OBJECTIVE 2:TO PROTECT AND PROMOTE HEALTH AT THE WORKPLACE • Improving assessment and management of health risks at workplace: • Essential interventions for prevention occupational hazards • Integrated management of chemicals • Elimination of smoking from all indoor workplaces • Health impact assessment of new technologies • Basic set of occupational health standards • Minimum requirements for health and safety protection • Enforcement and inspection • Capacities for primary prevention of occupational hazards, diseases and injuries: methodologies, training, healthy workplaces • Health promotion and prevention of noncommunicable diseases at workplace: diet, physical activity, mental health, family health • Prevention and control HIV/AIDS, malaria, TB etc. in workplace

25. OBJECTIVE 3:TO IMPROVE THE PERFORMANCE OF AND ACCESS TO OCCUPATIONAL HEALTH SERVICES • Coverage and quality of occupational health services • Linkage to national health strategies and health sector reforms • Standards for organization and coverage • Mechanisms for resources and financing of the delivery • Sufficient and competent human resources • Quality assurance systems • Basic occupational health services for all workers • Building core institutional capacities – national and local levels • Development of human resources for occupational health • Post graduate training • Capacities for basic occupational health services • workers-’health in training of primary health care • Attracting and retaining human resources

26. OBJECTIVE 4:TO PROVIDE ANDCOMMUNICATE EVIDENCEFOR ACTION AND PRACTICE • Systems for surveillance of workers' health • National information systems • Capacities to estimate burden of diseases and injuries • Registries of exposures, diseases and accidents • Early reporting and detection • Research • Special agendas • Practical and participatory research • Communication and awareness raising • Workers and employers • Policy makers, media • Health practitioners • WHO action: indicators for workers' health; incorporation of occupational causes of diseases in ICD11; diagnostic and exposure criteria for occupational diseases

27. OBJECTIVE 5:TO INCORPORATE WORKERS’ HEALTH INTO OTHER POLICIES • Economic development policies and poverty reduction strategies • Collaboration with private sectors to avoid international transfer of risks • National plans and programmes for sustainable development • Consider workers' health in the context of trade policies • Assess health impacts of employment policies • Environmental protection in relation to workers' health: • Strategic approach to International Chemicals Management • Multilateral environmental agreements • Environmental management systems • Emergency preparedness and response • Sectoral policies for branches with highest health risks • Primary, secondary and higher level of education and vocational training

28. ESSENTIAL PUBLIC HEALTH FUNCTIONS IN THE AREA OF OCCUPATIONAL HEALTH • Assessment and management of occupational risks • Monitoring and surveillance of workers' health • Workplace health promotion • Participation of workers and employers • Development of policies and institutional capacity • Strengthening of institutional capacity for regulation and enforcement in occupational health • Evaluation and promotion of equitable access to OH services • Human resources development and training in OH • Quality assurance in OH services • Research in OH • Reduction of the impact of industrial accidents and technological disasters on health WHO PAHO “Public Health in the Americas. Conceptual Renewal, Performance Assessment, and Bases for Action” 2002

29. BOHS • Occupational health services are available to only 10%–15% of workers worldwide. • In industrialized countries, the coverage variesbetween 15% and 90% and in developing countries between a fewpercent and 20%, even where services are available, their quality andrelevance may be low. • The needs of occupational health servicesgrow continuously and new challenges are set by theglobalization of work life. • To provide a response to such a globalchallenge the WHO/ILO/ICOH jointeffort on the development of BOHSwaslaunched.

30. COVERAGE OF OHS Workers without OHS

31. BOHS • The ultimate objective of the BOHSinitiative is to provide occupational health services for all workingpeople in the world, regardless of economic sector, mode ofemployment, size of workplace or geographic location i.e. accordingto the principle of universal services provision

32. BOHS • There is a challenge to provide good practice guidelines and toolboxes for service providers on a number of specific activities,such as planning of occupational health services, risk assessment andmanagement, ergonomics and safety, assessment of psychologicalconditions and stress, and diagnosis of occupational diseases.

33. BOHS • BOHS are most needed for countriesand sectors that do not have services at all or which are seriouslyunderserved. • Particularly high-risk sectors such as agriculture,mining, fishery, forestry and construction have to be given priority. • Governments, in collaboration with social partners and with supportand guidance by international organizations, should strengthen theirpolicies and clarify priorities with regard to organization and development of service infrastructures.

34. BOHS CYCLE Workers health Orientation and planning Evaluation Evaluation Monitoring & Surveillance of WE Record keeping Surveillance of worker's health Individual health record Worker Assessing WE Risk Assessment General health service Assessment of individual's health risk Emergency preparedness First aid Health education and health information Dg of ODs and WRDs Action Information Accident prevention Initiatives Interaction & Education Prevention of OH hazards Initiatives Work Organization Work environment

35. HIERARCHY OF PREVENTIVE MEASURES Structural prevention Lack of hazard Engineering controls Minimising emissions Control technology Ventilation, exhaustion Working practices, wet processes, cleanliness, order Personal protection, respirators Preventive power Limiting exposure times Decontamination, health surveillance, early diagnosis, treatment Burden to health

36. A STEPWISE STRATEGY FOR OCCUPATIONAL HEALTH SERVICES Stage IV Comprehensive Service • In-company or external • special OHS units • Comprehensive content: • prevention, curative and promotion & development services Stage III International Standard Service Continuous development Objective for all! Stage II Basic Service • OHS Infrastructure • ILO No. 161, 155 • Multidisciplinary • content • Prevention plus • curative services Stage I Starting level • PHC Infrastructure • Basic OHS content • Toolboxes • Advice in OH • Accidents and ODs • Acute ill-health • PHC Multidisciplinary team with special training Field nurse Safety agent Physician and nurse with short special training Multidisciplinary specialists' team Starting point for Big industries and well organised SMEs Big industries and Big OHS Centres SMEs,SSEs,SEs,IFS SMEs,SSEs,SEs,IFS

37. MODELS OF SERVICES PROVISION • Primary health care model • Big company model • Group services • Social security model • Private physician • Private health centre • Local or regional hospitals

38. CONTENT OF BOHS The content of basic occupational health services includes, as a minimum, the following activities: • surveillance of work environment and risk assessment • health surveillance and health examinations • advice on preventive and control measures • health education and health promotion and promotion of work ability • first aid and treatment of acute illnesses • diagnosis of occupational diseases.

39. MODERN OCCUPATIONAL HEALTH SYSTEM Competent authority in central government labour health Secondary support level IOH or RESP LABOURINSPECTORATE OMCLINICS OM Hyg, Erg, Psych, Safety, W-org, OM Frontline level PHC Private center GROUP OHS IN-COMPANY OHS Big company SME Company SE SME SSE SME SE SE SE IFS IFS IFS IFS IFS IFS IFS BOHS IFS

40. Example: OH service providers in Finland Enterprise Enterprise Enterprise Enterprise Satellite Enterprise Enterprise Enterprise Farmers Räsänen et al 2002 Enterprises 61% Employees 37% OHS units 31% Costs 16% MUNICIPAL HEALTH CENTRE Self-employed Enterprises 2% Employees 25% OHS units 38% Costs 43% BIG ENTERPRISE OHS Enterprises 4% Employees 6% OHS units 7% Costs 2% Enterprise GROUP OHS Enterprise Enterprises 33% Employees 32% OHS units 24% Costs 39% PIVATE OHS CENTER

41. CONCLUSION • Development of the whole occupational health system (policy, legislation, infrastructures, human resources, information systems and registration) • Occupational health services should be provided by well-established service provision units with a sufficient size to be able to provide multiprofessional services • Training of multiprofessional expert resources for occupational health is recommended by upgrading and re-orienting the existing expert resources and by training new experts for broadening the scope of competence of occupational health services.

42. CONCLUSION • Drawing up a National Policy and Strategy and systematic curricula for training in occupational health and their adjustment to European curriculum systems is recommended. • Utilization of Basic Occupational Health Service (BOHS) model is recommended for expansion of coverage of occupational healthservices and particularly for serving the small enterprise, self-employed and informal sector workplaces.

43. CONCLUSION • The implementation of existing regulations is recommended to be supported by production of appropriate standards and good practice guidelines for practical implementation of occupational health services. • Infrastructures for occupational health services are recommended to be institutionalized and developed on a multi-model basis: coverage of all working people!

44. CONCLUSION • An important part of infrastructure consists of the Institute of Occupational HealthandSafety • A special information strategy on occupational health, including the development of national information service and dissemination system: - National ILO CIS Center - Focal Point for EU OSHA - WHO Collaborating Centre

45. THANK YOU… Dr. Buhara ÖNAL bonal@csgb.gov.tr 00 90 312 2571690/200