asian-pacific newsletter 3/2014, ohs and primary health care

Asian-Pacific NewsletterVolume 21, number 3, December 2014

O N O C C U P A T I O N A L H E A L T H A N D S A F E T Y

Occupational health services and primary health care

Contents43 Editorial Occupationalhealthservicesandprimaryhealthcare

Somkiat Siriruttanapruk, Thailand

44 Challengesandopportunitiesinoccupational healthservicesinIndia–Aperceptionalstudyfrom southernIndia

S Jeremiah Chinnadurai, Vidhya Venugopal, P Kumaravel, K Paari, Krishnendu Mukhopadhyay, India

48 OccupationalhealthservicesandprimaryhealthcareinSriLanka

Rohini de Alwis Seneviratne, Sri Lanka

50 DeliveryofbasicoccupationalhealthservicesinThaiPCUs

Orrapan Untimanon, Somkiat Siriruttanapruk, Thailand

53 Healthyworkplaceintervention:Scopeofbasicoccupationalhealthservices(BOHS) ininformaloccupationsinIndia

J Majumder, RR Tiwari, SM Kotadiya, India

56 Occupationalhealthservicesandprimaryhealthcarein Indonesia

Hanifa M. Denny, Indonesia

58 SafelynavigatingyourperfectOSHinformationworld

Sheila Pantry, UK

Asian-Pacific Newsletter OnOCCUPATIOnALHEALTHAnDSAfETy

Volume21,number3,December2014Occupational health services and primary health care

Published byfinnishInstituteofOccupationalHealthTopeliuksenkatu41aAfI-00250Helsinki,finlandEditor-in-ChiefSuviLehtinenEditorInkeriHaatajaLinguistic EditingAliceLehtinenLayoutKirjapainoUusimaa,Studio

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Printed publication:ISSn1237-0843On-line publication:ISSn1458-5944©finnishInstituteofOccupationalHealth,2014 Theresponsibilityforopinionsexpressedinsignedarticles,studies

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Workers’ health is one of the most important public health issues. It can lead not only to work-ers’ well-being, but also to increasing productivity and expanding the economy. Occupational health services (OHS) are essential for improving workers’ health. According to ILO Conven-tion No. 161 on OHS, the functions of OHS focus on the prevention of occupational diseases

through, for example, health risk assessments at workplaces, surveillance of workers’ health, and advice on the implementation of proper preventive measures. However, in spite of its importance, in many countries only a few workers have access to OHS, especially in under-developed or developing countries. The reasons for this are a lack of policy support, poor national health service systems, a lack of occupational health per-sonnel, and a lack of awareness among employers and workers themselves. In addition, the workers who do have access to such services are in large-scale enterprises. Workers with precarious jobs, informal workers, agricultural workers, and immigrants often have no access to OHS at all.

Since the declaration of Alma-Ata in 1978, primary health care (PHC) has played an important part in the health system to achieve health for all. PHC is a fundamental health service system that focuses on “put-ting people at the centre of health care”. Up to now, the development of PHC has progressed extensively in many countries. PHC activities in some countries include the treatment of common diseases with essential drugs; the provision of a basic package of health interventions; and improvement of hygiene, water, sanita-tion, and health education. The majority of these activities are run by health personnel, with support from medical doctors. Although PHC has proved to be successful, it still faces many limitations and needs to be improved. WHO’s 2008 World Health Report, ‘Primary Health Care: Now More Than Ever”, stated that PHC must be renewed in order to respond effectively to the health challenges of today’s world. WHO also recom-mended four sets of PHC reforms for policy-makers and relevant agencies to use as a guideline in the new development process. These consist of universal coverage reforms, service delivery reforms, public policy re-forms, and leadership reforms.

To enhance the access of workers to OHS, the 13th Session of the Joint ILO/WHO Committee on Oc-cupational Health in 2003 recommended a “basic services” approach by introducing Basic Occupational Health Services (BOHS). In addition, Resolution 60.26, “Workers’ Health: Global Plan of Action (GPA)”, of the World Health Assembly (WHA) in 2007 also urged Member States to work towards full coverage of all workers through essential interventions and BOHS. The GPA drew attention to improving the performance of and accessing OHS through integration with PHC. With support from WHO and the ILO, the Internation-al Commission on Occupational Health (ICOH) and the Finnish Institute of Occupational Health (FIOH) have developed guidelines for establishing BOHS provision. Meanwhile, several countries, including Brazil, Chile, China, South Africa, and Thailand, have started conducting and developing BOHS models in PHC.

From our experience in Thailand, integrating BOHS with PHC is feasible and successful. A well-designed pilot project for integrating BOHS into existing PHC structure had been ongoing since 2004. The project was divided into four phases: planning, model development, implementation and expansion, and quality assur-ance. The conceptual model of BOHS provision included a pro-active OHS approach integrated with PHC, workers’ participation, and the application of suitable tools and interventions, such as the ILO WISE (Work Improvements in Small Enterprises) technique. Capacity-building was also arranged for PHC personnel by providing practical guidelines and a five-day training course. In their evaluation of the project, most prima-ry care unit staff stressed that limited financial and human resources, a lack of advanced knowledge on OH, and weak support from upper-level policy-makers were the main obstacles. Currently, the model is being implemented into other PHC units throughout the country. Although the project can achieve its objectives, the model has to be further improved and all limitations have to be overcome. Finally, sharing experiences regarding this issue among national and international agencies is essential in order to develop and improve OHS for all workers’ health.

Dr. Somkiat SiriruttanaprukSeniorExpertinPreventiveMedicine(OccupationalandEnvironmentalHealth)DepartmentofDiseaseControl,MinistryofPublicHealthTivanontRoad,nonthaburi11000,ThailandEmail:[email protected]

Asian-PacificnewslettonOccupHealthandSafety2014;21:43 • 43

Occupational health services and primary health care

Introduction

Rapid industrialization and new technological develop-ment is exposing workers to a wide spectrum of hazards at workplaces as well as associated occupational health risks, which, if overlooked, will lead to an increased dis-ease burden in India. Occupational health in India is a complex issue due to child labour, poor labour legisla-tion, lack of control over the vast informal sector, insuffi-cient industrial hygiene practices, and poor surveillance data (1). The burden of occupational diseases affects not only workers, but also the employer, society, and families through, for example, “take-home lead” (2).

Independent studies by the National Institute of Oc-cupational Health (NIOH) on the prevalence of occupa-tional lung diseases reported that morbidity due to silicosis is 54.5% in the slate pencil sector, 38% in agate polishing, 21% in stone quarries, and 15.2% in potteries. Morbid-ity due to asbestosis is 11% in open cast asbestos mines (3). Many cases of occupational disease go unreported, especially in informal sectors, for reasons such as lack of awareness due to the non-availability of occupational health services at workplaces, fear of losing one’s job etc.

According to the 2001 census of India, 14 446 224

SJeremiahChinnadurai,VidhyaVenugopal,PKumaravel,KPaari,KrishnenduMukhopadhyay,India

Challenges and opportunities in occupational health services in India – A perceptional study from southern India

people migrated for employment. This accounts for about 40.8% of the total migrant workers (4) who find employ-ment in jobs that involve very heavy physical work and high exposure to environmental and occupational stress-ors. The work is on a temporary basis and makes the work-ers’ livelihoods uncertain in terms of pay and living, which is in temporary settlements without basic amenities such as proper sanitation and living space. This makes the workers even more vulnerable to other health and psychological risks. Labour in India is cheap and easily replaceable (4) and workers do not worry about maintaining their health and well-being in order to sustain their jobs.

Occupational Health Services (OHS) in India currently remain restricted mostly to the enlightened employers in the formal sectors, as there is no legislation to mandate provision or clear visible return on expenditure on OHS. However, making OHS mandatory for all workers would create a huge void due to lack of infrastructure, resources, qualified health professionals, and a system framework that sustains itself and caters to millions of workers in the informal sectors.

The changes in work practices due to globalization also create additional challenges to OHS practitioners, through changes in hazard trends and the intensity of outcomes.

Industrial hy-giene, occupa-tional health sur-veys and ques-tionnaire adminis-tration conducted by authors in vari-ous industries

44 • Asian-PacificnewslettonOccupHealthandSafety2014;21:44–47

The study aimed to understand occupa-tional health practitioners’ perceptions of the challenges they face in providing basic OHS in formal sectors and to seek their opinion on the opportunities for making improvements to the current OHS sys-tem. An insight into the challenges faced by current OHS professionals in formal sectors would help modify the way OHS services are provided, rather than pro-viding more of the same, which in turn might not help to meet the growing OHS requirements of a workforce that is as di-verse and large as that in India.

MethodologyFrom 2011 to 2014, the authors conducted the Industrial Hygiene survey in 89 indus-tries which were formally registered un-der the Factories Act. Some of these had occupational health centres manned by qualified OH (Occupational Health) prac-titioners and personnel trained to han-dle occupational health issues. A ques-tionnaire was developed on the basis of the limited available literature in order to conduct a perceptional survey among the qualified OH practitioners and occu-pational nurses in the selected industries (45). It included questions on their per-ceptions of the status of OHS in India, pol-icies, infrastructure, trained personnel, functionality, and challenges and oppor-tunities in the provision of OHS services. OH specialists/occupational nurses/safety officers responded from 32 industries in person or by telephone and email, and the results are presented here.

Current status of OHS in IndiaFigure 1 depicts the strategy of WHO (World Health Organization) for provid-ing basic health services (5). Statistics indi-cate that 7464 factory medical officers are available for the totally registered 325 209 factories in India, which have 11 634 070 employees altogether (6). All the com-ponents mentioned above are highly in-adequate for providing satisfactory OHS for India’s ever-growing workforce. The current status of OHS in India and the results of the survey are briefly discussed in the following sections in line with the WHO strategy.

Results and discussionAccording to the 2011 Indian census,

the country has 481.7 million workers (7). The existing policies and legislation support only about 18.3 million of these (3.8%), who are employed in registered industries. Only about 300 factory in-spectors are responsible for checking the industrial hygiene and safety of about 56 334 960 workers, which is grossly in-adequate (8). The status of OHS in the 45 industries surveyed by the authors is de-picted in Figure 2.

Policy and good practicesIn 1987, after the Bhopal gas tragedy, the Factories Act (1948) was amended to pro-tect the health and safety of workers. The Factories Act has made pre-employment, periodic medical examinations and work-place monitoring mandatory for the in-dustries defined as hazardous under the Act, and is applicable only to factories that employ over 10 employees on a perma-nent basis (4). It covers about 13 million workers employed in registered industries (4). Many small and medium-sized en-terprises (SMEs) employ fewer than 10 employees on a permanent regular ba-sis, and the rest of the workers are con-tract employees: this means that they can avoid providing benefits such as Employ-

ees State Insurance or Health services. Al-though the Factories Act has a Permissible Limit of Exposures (PLEs) to chemicals, heat stress and ventilation, in practice, this is rarely followed, and more chem-icals are handled in the industries than the 117 listed under the second schedule of the Factories Act. This needs updat-ing by dedicated organizations. The Di-rector General of the Factory Advisory Services & Labour Institutes (DGFASLI) and NIOH deal with labour issues, but it must be understood that these issues are numerous and the agencies responsi-ble are limited in their ability to upkeep OHS in industries. Very little information is documented regarding new emerging issues or that deals with the OH issues of the millions of workers engaged in the informal sectors, who are left to be han-dled by the government health care sys-tem, which is not equipped for and does not have trained personnel to handle OH matters.

The participants (doctors and nurses) were unanimous (100%) in their opinion that policies should be more stringent. One of the major challenges in providing effective OHS, as felt by about 81% of the survey participants, was the lack of clear

Figure 1. WHO/ILO/ICOH strategy for basic occupational health services

AvailabilityofOHcentre

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DoctorsspecializedinOHS

Availabilityofnurses

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Figure 2. OHS statistics in 45 industries in Southern India

12.4%

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10.1%

15.7%

14.6%

0 4 8 12 16 20

Asian-PacificnewslettonOccupHealthandSafety2014;21:44–47 • 45

legislation and guidance on many occupa-tional health issues. A total of 59% of the doctors who are in charge of OHS report-ed difficulties in obtaining clear informa-tion regarding how to deal with and doc-ument occupational diseases other than the notifiable diseases listed in the Facto-ries Act in sections 89 and 90. Moreover, following international guidance such as that issued by OSHA, NIOSH & ACGIH is often impossible in the Indian context, as the law does not mandate it.

Adopting best practices to protect workers’ health is gaining popularity in Indian industries, encouraged by global trade requirements and increasing aware-ness among both employers and employ-ees. This is also due to reduced employee injuries, absenteeism, costs for medical care, and disability benefit. Among the 45 industries surveyed, 7 were OHSAS 18001 certified and 3 were in the process of certification. OHSAS certification was viewed as a positive step in OHS manage-ment; a structured system to propel OSH management in the industries. Only 21% of the participants had knowledge of the OHSAS concept, as training was mostly given to the safety officers of the indus-tries. Only 4 out of the 39 medical offic-ers who responded were OHSAS trained and 23 medical officers felt that safety of-ficers and industrial hygienists are better suited for roles in OHSAS than occupa-tional health physicians.

Industrial hygiene (IH) is still in its in-fancy in India, and lack of knowledge in this area is widely prevalent among OHS professionals; those who are aware of the linkage between IH and health find diffi-culties in convincing management to in-vest in hygiene services in their industries due to various limiting factors. Lack of

policies and legislations for mandatory IH services in industries was cited as a chal-lenge (44%) and about 66% of the partic-ipants were partially aware of the impor-tance of applying a “Hierarchy of controls” to protect workers from ensuing occupa-tional hazards. As much as 47% felt that a strong safety culture in conjunction with IH was a major opportunity for improv-ing the status of OHS in India.

InfrastructureAlmost all survey participants were of the opinion that OH centres are often only equipped to provide first aid. Basic health services and anything beyond small inju-ries were difficult to manage due to the lack of trained personnel and equipment. The industries have agreements with near-

by hospitals for handling complicated is-sues such as fatal injuries. A total of 78% responded (Figure 3) that having lifesav-ing medical facilities is mandatory for hazardous and accident-prone indus-tries, as the lag time in availing ambulance services was sometimes a life-threatening factor. For better OHS services, 86% felt that a fully-equipped community OH cen-tre in an industrial cluster, supported by the industries, could be a viable solution for effective OHS.

Human resourcesDGFASLI reported 1509 fatal injuries and 33 093 non-fatal injuries in 2009 among registered factories with a total workforce of about 5% of the total workforce in In-dia (6). To meet the regulations, many in-

Figure 3. Perception of occupational health and safety personnel in basic occupational health services

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References

1. AgnihotramRV.AnoverviewofoccupationalhealthresearchinIndia.IndianJOccupEnvironMed2005;9:10–4.

2. KhanFJOkla.Takehomeleadexposureinchildrenofoilfieldworkers.StateMedAssoc2011Jun;104(6):252–3.

3. Saiyed.OccupationalHealthResearchinIndia.IndustrialHealth2004;141–2.4. PingleS.OccupationalSafetyandHealthinIndia:NowandtheFuture.IndustrialHealth2012;50:167–

71.5. RantanenJ.Basicoccupationalhealthservices–theirstructure,contentandobjectives.SJWEHSuppl

2005;no1:5–15.6. SafetyStatistics,http://www.dgfasli.nic.in/info1.htm7. CensusofIndia2001,http://www.censusindia.net/.8. ParekhR.Futureoccupationalhealthprospection.IndianJOccupEnvironMed2004;8:5–6.9. SaiyedHN,TiwariRR.OccupationalHealthResearchinIndia.IndustrialHealth2004;42:141–8.10. OSHA.PersonalProtectiveEquipmentbooklet.OSHA2003;3151–12R.11. HealthandSafetyExecutive.Personalprotectiveequipment(PPE)atwork,Abriefguide,2013.12. AbbateC,PolitoI,PuglisiA,BrecciaroliR,TanzarielloA,German¢D.Dermatosisfromresorcinalintyre

makers.BrJIndMed1989;46:212–4.

dustries appoint medical officers who are regular physicians, lack knowledge of oc-cupational health diseases, and are una-ware of the occupational exposures caus-ing them. These physicians visit the indus-try’s OH centres twice a week for com-pliance purposes, which is inadequate, and does not help in cases of emergen-cies. Musculoskeletal disorders (MSD) were a major concern in the industries, and one of the issues that ranked highest among workers frequenting the OH Cen-tre. Longer consultation times and waits for dealing with MSDs when referred to external consultants was reported by 76% of the participants as another major con-cern, and lack of an onsite physiotherapist and ergonomist for dealing with MSDs was quoted as a cause of employee dis-satisfaction with OH facilities by 46% of the surveyed (Figure 4).

A limited safety and health budget has driven many Indian industries to employ factory medical officers on a contractual basis, and being a contract employee lim-its the officers’ influence on implementing worker-protective measures. At the same time, there is a tendency to incriminate the contract medical officers in cases of fatal injuries to avoid legal actions against the industry and the permanent employ-ees. This has gradually led to a culture of medical officers preferring to work on a consulting basis rather than full-time.

India has about 2652 safety officers and 6800 qualified occupational health physicians (4). There are no statistics on qualified hygienists. These may be in their few hundreds, due to recent voluntary ef-forts arising from global markets advo-cating the importance of IH in industrial settings. The huge mismatch between the 324 761 registered industries (4) and the number of professionals is clear, and ef-forts by the government and private insti-tutions for conducting short-term courses on occupational health and hygiene has helped bridge some of the gaps (9).

The participants felt that safety officers emphasize personal protective equipment such as wearing safety shoes and respira-tors more than occupational exposures and ways in which to eliminate them. In the absence of engineering and adminis-trative controls, the employers must pro-vide PPE to their employees and must ensure its proper use (10) and suitability

(11). Most medical officers treat only the health problems of the employees, and are unaware of the exposures that cause the diseases. Moreover, safety officers are also unaware of the health issues and the implications of the exposures on work-ers’ health. Many epidemiological studies have reported excess deaths from differ-ent types of cancers, attributed to expo-sures to a mixture of chemicals with no occupational standards (12). Twenty per cent of the respondents thought that the medical officer and safety officer/indus-trial hygienist should be empowered by the authorities to order biological moni-toring for assessing chronic exposure and health effects, the results of which would give them the evidence to convince man-agement to implement specific adminis-trative controls to protect employees. A majority of 66% of the survey participants felt it was important to have a dedicated budget for an IH programme, and that working with industrial hygienists could prevent the occurrence of occupational diseases, which is currently not the case in many industries. Only 2 of the 39 in-dustries that responded had a trained in-dustrial hygienist; the rest hired IH con-sultants periodically, an option preferred by management.

ConclusionThe statistics undoubtedly show that In-dia needs to improve occupational health, hygiene and safety services. The survey also clearly highlights the mismatch in OHS supply and demand, which has led to

differing levels of effectiveness in provid-ing basic OHS in industries. OHS onsite or closer to workplaces is an important target, which will help provide effective, timely OHS to those in need. Challenges in dealing with the OHS needs of unregis-tered industries and those in the informal sectors, especially in rural regions, cause a dark cloud to loom over the OHS frame-work of India. Research efforts in OHS and industry-specific epidemiological studies are desperately needed for driv-ing policy decisions. Training all levels of people and making them aware of the importance of OHS for the health and future of the employee, businesses and the economy of the country is the key to the success of an effective OHS culture in India. A unified national occupation-al health and safety agency (all-in-one), guidance and implementation could set India on the road to success as regards its ever-growing OHS needs.

S Jeremiah Chinnadurai Vidhya Venugopal* P Kumaravel K Paari Krishnendu Mukhopadhyay DepartmentofEnvironmentalHealthEngineeringSriRamachandraUniversityChennai,IndiaEmail:[email protected]

*Correspondingauthor


The recent global employment situation has been affected by the successive downward revisions of economic growth projections. The result has been an increase in the unem-ployed around the world, reflecting an insufficient expan-sion of employment that is too slow to keep pace with the growing labour force (1). Of the additional job seekers in 2013, 45% were from the East Asia and South Asian re-gions; the two regions that have the bulk of the increase in global unemployment. Vulnerable employment, that is, either self-employment or work by contributing fam-ily workers, accounts for almost 48% of total employment, and more than half of the developing world’s workers ac-count for about 1.5 billion workers (2). Informal employ-ment is common in most developing countries, with re-gional variations. In Eastern Europe, CIS countries, and a few advanced economies, informal employment still ac-counts for over 20% of total employment. In Latin Amer-ica, informal employment rates vary from under 50% to over 70% in low-income Andean and Central American countries. In the economies in South and South-East Asia, informality rates reach 90% of total employment in some countries. In Sri Lanka, a low middle income developing country of South Asia, informal employment accounts for 64% of employment. The workers in informal work are more likely than wage and salaried workers to have limited or no access to social security or a secure income. Their level of education is lower and unlikely to benefit from legal enactments ensuring health, safety and welfare at the workplace. They are also unlikely to have had training for employment or workplace-based training for the job.

The provision of occupational health services (OHS) should be an essential health service, provided as a part of overall health care to all citizens. It has been estimated that no more than 5‒10% of the working population in many developing and newly industrialized countries, and less than 20‒50% in several industrialized countries have access to OHS, despite the evident need (3). Globally, only 15% of the workforce has been identified as having access to any kind of OHS.

Industrialized countries have used different approach-es, such as workplace insurance, social protection through public taxation and in-house OHS. Well-established large-scale industries have been able to provide on-site OHS to

RohinideAlwisSeneviratne,SriLanka

Occupational health services and primary health care in Sri Lanka

workers, while others have engaged full-time or part-time general practitioners. Small-scale workplaces refer work-ers, when necessary, to the existing state sector health fa-cilities.

Given the fact that in most developing countries, a large proportion of workers are in the informal sector, a feasible option for the provision of health care needs ur-gent consideration. In this context, the primary health care (PHC) approach emerges as a feasible and sustainable op-tion. PHC varies in different countries.

PHC, as defined at the Alma Ata 1978 Conference is “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination (4).” Its strength lies in its underlying concepts. Embodied in the concept are the features of quality care and its scientific backing, univer-sality, accessibility, essentiality, social acceptability, equity, affordability, autonomy, and community participation.

The PHC provided through the state sector in Sri Lan-ka is a good example of the potential strengths and ben-

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efits of the PHC system for providing ba-sic occupational health and safety (OHS) services to all employees. PHC has been in place since 1926 in Sri Lanka, and is well accepted, trusted, and utilized by the people. It is available through the Ministry of Health to all citizens free of charge at point of delivery, and is financed through public taxation. A network of geographi-cally-defined areas known as health units cover the entire island of Sri Lanka, en-suring coverage and accessibility through PHC. Coverage is well over 95% for estab-lished services such as maternal care, child health and immunization. Since PHC has adopted a life cycle approach of providing services from womb to tomb, including antenatal, postnatal, pre and school child care, and well women and health life clin-ics for adults, it is justifiable and only right that occupational health should also be a component of PHC. A similar opinion was voiced at and emerged as a key mes-sage from the WHO global conference on occupational health and primary health care in 2011 (5).

PHC is community-based and has several categories of trained field health care workers. In Sri Lanka, a category of PHC staff called public health inspectors have been assigned responsibility for oc-cupational and environmental health. This provides them with the opportunity to visit work settings. Walk-through sur-veys, identifying problems in the work environment, and providing simple ad-vice and corrective measures are feasible. Issues such as poor electrical safety and fire safety practices, poor housekeeping and the non-use of and non-compliance with personal protective devices can be addressed. The Ministry of Labour and other sectors can provide more expert ad-vice where necessary. Employees also rep-resent a captive audience for workplace health education and health promotion interventions. Health and safety educa-tion is more meaningful when provided at the workplace itself.

Developing countries are recently fac-ing problems in local communities, re-lated to the unsafe disposal of solid and liquid waste from industries. These have led to the contamination of natural lo-cal water resources used for drinking and personal use. There is an urgent need to provide these industries with support

through referrals to correct this. Effec-tive and practical approaches for indus-trial waste disposal, such as reduction, re-using and recycling should be advocated.

Health promotion to address risk factors of non-communicable diseases, a major global public health issue, is also a practical option. Approaches to imple-menting health promotion, such as ad-vocating healthy canteen policies and a non-smoking work environment, and em-powering workers to select healthy op-tions in day-to-day life issues have been implemented. PHC clinics provide sim-ple screening facilities for common non-communicable diseases. In addition, workers can be referred to lifestyle clin-ics for pre-employment screening and pe-riodic screening. The screening offered to those over 35 years of age for hyperten-sion, diabetes mellitus, cervical and breast cancer can be easily offered to all work-ers at pre-determined intervals through the programme already on offer by the non-communicable diseases control pro-gramme of the Ministry of Health.

Workers can be referred through ex-isting referral practices to primary care clinics for simple health problems and in-jury management. Through this system, even tertiary referral care can be obtained when necessary for occupational health problems and injuries.

However, a few factors must be con-sidered for the effective utilization of PHC approaches in the provision of OHS ser-vices, A policy directive and policy instru-ments regarding the provision of OHS services would greatly facilitate efforts towards using the PHC approach. In Sri Lanka, the recently formulated National Occupational Safety and Health Policy (2014) states that, ‘initiatives are needed to strengthen the linkage between the pri-mary health care system and OHS, and the Ministry of Health is encouraged to set up a national body and to strengthen it to oversee this’. Appropriate regulations and standards need to be drawn up and approval obtained to support the success-ful implementation of OHS programmes.

PHC workers who are designated to carry out OHS activities need training in OHS issues, which include practical ex-posure. Including OHS modules in their basic curriculum would greatly facilitate this. PHC clinics also need to be expand-

ed or reorganized to include OSH clinics and to accommodate workers in lifestyle clinics. The health system will need to in-crease staff and other clinical resources as well as facilities to cater for the increase in the numbers of clients.

Unavoidably, this approach has cer-tain shortcomings. Without legal provi-sion, it is not possible to gain access to work settings, to encourage employers to allow workers to attend clinics or to rec-tify problems in the work environment. It is therefore necessary that policy di-rectives, instruments, and a suitable le-gal framework be identified, and that em-ployers are encouraged to build a good relationship with the local PHC manage-ment. The workers themselves also need to understand that safeguarding their own health by utilizing services is for their own benefit.

Professor Rohini de Alwis SeneviratneDirector,WHOCollaboratingCentreforTrainingandResearchinOccupationalHealthSeniorProfessorinCommunityMedicinefacultyofMedicineUniversityofColomboKynseyRoadColombo08SriLankaEmail:[email protected]

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1. GlobalEmploymentTrends2014:RiskofJoblessRecovery.Geneva:InternationalLabourOffice,2014.

2. WorldofWorkReport2014:DevelopingwithJobs.Geneva:InternationalLabourOffice,2014.

3. Globalstrategyonoccupationalhealthforall:Thewaytohealthatwork.Recommen-dationofthesecondmeetingoftheWHOCollaboratingCentresinOccupationalHealth,11–14October1994,Beijing,China.

4. PrimaryHealthCare.AlmaAtaWorldHealthOrganizationandUnitedNationsChildren’sFund,1979.

5. WorldHealthOrganization.Connect-ingHealthandLabour:BringingTogetherOccupationalHealthandPrimaryCaretoimprovethehealthofworkers.Geneva:WHO,2012.



Background

Thailand started a primary health care programme as part of the Fourth National Health Development Plan (1977–1981) by restructuring the health system and setting up primary care units for health services in the community. In 2000, the health sector was reformed. The most outstand-ing change resulting from this reform was the Universal Coverage (UC) health care scheme in 2001. This policy was practically supported by determining primary care as a key mechanism for providing health services for all. Primary care was located in the best setting close to the community. Primary Care Units (PCUs) have to be sup-ported by the Contracting Unit for primary care. Com-munity hospitals are part of a network of PCUs.

The Bureau of Occupational and Environmental Dis-eases (BOED), Department of Disease Control, is a nation-al authority under the Ministry of Public Health (MoPH) which is responsible for occupational health activities in Thailand. The major roles of the bureau include policy development, setting up standards and guidelines for oc-

OrrapanUntimanon,SomkiatSiriruttanapruk,Thailand

Delivery of basic occupational health services in Thai PCUs

cupational hazards, and the development of occupational health services at all levels of the health service system in the country. A total of 9770 PCUs have provided many health care services, such as the improvement of nutri-tion of young children, immunization, investigations of communicable diseases, etc. OHS were not launched into PCUs due to limitations such as a lack of knowledge among health care personnel, an indefinite occupational health policy, and a small number of reported occupational dis-eases. However, OHS is important in the PCUs because these units are close to informal workers who work in the communities and are exposed to several occupational haz-ards. Moreover, the health welfare of this group is not cov-ered by the Social Security Scheme. In 2013, the number of informal workers was about 25.1 million or 64.2% of the total employed population. As regards the economic activities of informal employment, more than half of this group worked in the agriculture sector (15.1 million per-sons or 61.4%) followed by 29.7% in the trade and service sector and 8.9% in the manufacturing sector (1).

Primary Care Unit building

PhotosbyOrrapanUntimanon


Chronological project implementationIn 2008, a pilot project aimed to devel-op OHS in 16 PCUs was established. Ca-pacity building, training and supervision were the main activities for strengthen-ing the health team and network. After the project ended, the PCUs were able to provide OHS for informal workers. Pas-sive OHS, such as screening of occupa-tional diseases, health examinations, and the treatment of diseases and injuries con-tinued. Pro-active OHS, including walk-through surveys at workplaces using an observation checklist, and risk assessment using a structured-questionnaire were al-so performed.

In 2010, the development of OHS in PCUs was extended and 300 PCUs par-ticipated in the project. Through these, 113 400 informal workers could access the services, 72% of which were farmers. As farmers make up such a large proportion of the informal sector, in 2011 the MoPH documented a policy to enforce OHS de-livery in PCUs for farmers. Three depart-ments, including the Department of Dis-ease Control, the Department of Mental Health and the Department of Develop-ment of Thai Traditional and Alternative Medicine collaborated to provide these services through a project called “Healthy farmers; Safety consumers”. Finally, 3602 PCUs (36.9% of total PCUs) participat-ed in this project. As a result, 716 571 farmers underwent risk assessment and 533 524 were entitled to blood tests for cholinesterase screening. Pesticide poi-soning treatments using Thai traditional medicine were provided to farmers whose blood test level was too high. The mental health of 575 573 farmers was assessed. Of these, 75 830 obtained counselling to reduce stress. (2)

In 2012, the farmer clinic model was launched in 18 PCUs in three pilot prov-inces, Uthaithani, Supanburi and Bur-irum, to increase the screening and di-agnosis of occupational diseases, and to provide holistic health care for farmers. Farmer clinics had to: (3)

1) Regularly deliver services, for example, once a week or twice a month, and maintain public rela- tions to also target the rest of the population.

2) Assess farmers’ health problems resulting either from work or underlying diseases. Carry out two questionnaires, including a musculoskeletal disorder assessment and pesticide use assessment. 3) Provide diagnosis, treatment and health education.4) Record occupational disease cases in the existing data system. 5) Collaborate with related agencies to prevent occupational diseases or injuries. In 2013, the farmer clinic project was

extended nationwide. PCUs with expe-rience of OHS delivery were requested to participate in the project. The BOED’s goal for development of farmer clinics is at least 2 PCUs per province. At the end of this year, a total of 1092 PCUs were par-ticipating in the project. Most of PCUs could provide OHS following such crite-ria. However, there were few farmers who went to the clinic on the day that PCU was open on OHS issues (once a week); there-fore, the OHS for farmers or other infor-

mal workers should provide everyday by integration with other health services. There are still some limitations, such as 1) the PCU staff ’s capacity for early diag-nosis of occupational diseases is still lim-ited, thus the occupational disease record is incomplete, 2) common hazards related to health problems have been identified, but risks must still be managed, and 3) er-gonomic problems still need to be evalu-ated using the simple tool.

In 2014, criteria were developed for evaluating OHS delivery in PCUs. This involved 13 interventions (Table 1). The evaluation levels are as follows: • Startinglevel (6 of 13 interventions conducted) • Good (7−9 interventions conducted) • Verygood (≥10 interventions conducted)

In 2014, an OHS delivery standard is being developed and will be used as a guideline for PCUs to carry out OHS interventions. The standard will address

Table 1. Farmer clinic/community worker clinic criteria

NO. Interventions Yes No

1 farmerclinicopenoneday/week

2 Databaseofoccupationsofpopulation incommunity

3 Riskassessment

4 Screeningofotherdiseasese.g.diabetesor hypertension

5 Reportingtootherrelatedagencies

6 ProvisionofpreventiveOHSinatleast oneintervention

7 Occupationaldiseasesdiagnosis

8 Trainingofoccupationalhealthvolunteer

9 Occupationalhealthinformationtothecommunity

10 Occupationalhealthknowledgeto strengthenthecommunity

11 OHSdeliveryplandocumentedtogetherwiththe SubdistrictAdministrativeOrganization/ municipality

12 ObtainingfundsforOHSdeliveryfromSub-district healthfunds

13 Implementationofriskmanagementproject

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References

1. NationalStatisticalOffice.Theinformalemploymentsurvey2013.

StatisticalForecastingBureau,2014.2. ChancharoenS,SiriruttanaprukS,Unti-

manonO.BasicOccupationalHealthServicesandtheNationalProgrammeforfarmers.OH&SForum2011Proceedings,Espoo,Finland,2011:136–9.

3. BureauofOccupationalandEnvironmentalDiseases.GuidelineofOHSdeliveryinPCUs.(Thaiversion),2012.

Farmer clinic

not only interventions for other commu-nity workers, but also for health workers (PCUs staff).

ConclusionsThe BOED has continuously developed the project on OHS delivery in PCUs for over 10 years. However, although the pro-ject has been evaluated as satisfactory, it still has several limitations. The future development of OHS delivery in PCUs should be addressed through six issues, as follows: 1) policy-maker support for operational resources and personnel, 2) training to enhance PCUs staff compe-tency for effective OHS delivery, 3) im-provement of data systems for recording and reporting occupational disease cases or other OHS interventions, 4) collabo-

Occupational diseases prevention board

Manuscripts addressing the above themes and other topics in the field of occupational health and safety are welcome. If you plan to submit a manuscript, kindly contact the Editorial Office in advance. Readers may also send proposals on potential authors and articles.

Contact:Asian-Pacific Newsletter on Occupational Health and SafetyFinnish Institute of Occupational HealthTopeliuksenkatu 41 a AFI-00250 Helsinki, FinlandEmail: [email protected]

www.ttl.fi/Asian-PacificNewsletter See “Instructions for contributors”

ration among related agencies, especially the local authority and health volunteers in the community to sustain and extend the service, 5) provision of OHS for health workers who work in PCUs, and 6) spec-ification of OHS interventions in local health funds and a benefit package for the universal coverage scheme.

Orrapan Untimanon Somkiat Siriruttanapruk BureauofOccupationalandEnvironmentalDiseasesDepartmentofDiseaseControlMinistryofPublicHealthnonthaburi11000,ThailandEmail:[email protected]

Asian-Pacific Newsletter themes in 2015The themes of the Newsletters to be published in 2015 are:

1/2015 NetworkingManuscripts by 1 March 2015

2/2015 Emerging infectious diseasesManuscripts by 15 June 2015

3/2015 Textile sectorManuscripts by 1 October 2015


Background

The informal sector today provides sources of livelihood to a substantial section of the workforce. As livelihood opportunities in the formal sector are shrinking, the in-formal sector provides opportunities for a large segment of a country’s workforce and significantly contributes to the national product.

The informal sector in the world comprises 1/6 of the global workforce, spread over around 100 million small enterprises. India has around 482 million workers and over 94% of these, farmers included, are engaged in the informal sector (1, 2), with around 70% of the population in rural areas. Of this huge workforce, under 10% is or-ganized, 60% self-employed and 30% do not have regu-lar jobs (3, 4).

In India, the informal sector is broadly character-ized by small-scale units, connected to the formal sector by sub-contracting the production and distribution of goods and services via powerlooms, goldsmiths, iron works, stone quar-ries, ceramics, glass works, block printing, etc. However, household-based sub-sector activities (e.g., the production of incense and match-sticks, and handloom and tobacco products) as well as the independ-ent service sector (domestic help-ers, street vendors, transportation, construction, forestry, fishing, ag-riculture and allied activities, etc.) are also considered to belong to the informal work zone (5). The World Bank employment report (2004–05) estimated that about 26% of the total share of Indian gross national prod-uct comes from the informal econo-my. However, this sector of employ-ment is not organized systematically and is devoid of mandatory registra-tion or licenses and thus the legisla-tion to cover it.

JMajumder,RRTiwari,SMKotadiya,India

Healthy workplace intervention: Scope of basic occupational health

services (BOHS) in informal occupations in India

The literature reports ILO data of indecent working conditions and work-related exposures in informal sec-tors, with about 270 million non-fatal accidents, 2.2 mil-lion fatalities and 160 million work-related diseases in the world (6). Due to occupational exposure, unintentional injuries at the workplace, exposures to carcinogens, air-borne particulates, ergonomic stressors and noise that lead to mortalities, respiratory ailments and hearing loss account for nearly 75% of the years of healthy life lost (7). These morbidity and mortality numbers indicate the po-tential risk posed by the informal sectors of occupation to safety, health and the economy.

Indecent work, an unhygienic work environment, ex-posure to various work-related hazards, and the absence of occupational training and personal protective devices lead to health-related morbidity (8). The health of self-

Vegetable vendors – working in unhygienic workplace.

PhotobyJMajum

der


employed workers and those in decen-tralized and rural industries is at a high-er risk (9). Working in occupations such as mining, construction, transportation, agriculture, forestry and fishing increases the risk to health and safety (10). Occupa-tional stressors are aggravated by labour-intensive practices, poor knowledge re-garding hazards, extreme tropical climate, less sophisticated machinery, and exten-sive use of hazardous chemicals without personal protective equipment (6). Pain and discomfort, respiratory problems, skin-related allergies, stress symptoms, and poor well-being are differently dis-tributed in the informal workforce (8). In spite of the dangers associated with these occupations, poor social dynam-ics such as poverty and low literacy lev-els force workers to hold on to their jobs (11, 12). Communicable diseases, mal-nutrition, poor sanitation, environmental concerns, and inadequate medical care are sustained health issues in India (13). Ab-sence of occupational training and safety training and exposure to hazardous sub-

stances increase work-related accidents, injuries and death rates (14). Thus tropi-cal climate, unhygienic conditions and crowded work environment and work pat-tern make the specific occupations of the informal sector distinctive.

Improving these workplaces requires evolving and implementing management frameworks for the development and de-livery of occupational safety and health (OSH). Over 80% of workers (organized as well as unorganized) all over the globe have no access to occupational health ser-vices (OHS) (15). This is mainly due to the increased labour force and demand of ser-vices. The World Health Organization, the International Labour Office and the In-ternational Commission on Occupation-al Health developed the concept of Basic Occupational Health Services (BOHS) in 2003, to provide essential services for the health of workers in small and medi-um-sized enterprises, the informal sector and agriculture, as well as self-employed workers, through a primary health care approach. The main focus is on the elim-

ination, prevention, and control of fac-tors hazardous to health in the work en-vironment, as well as on providing basic health care services to all working people irrespective of occupation, type of work contract, or mode of employment and lo-cation of workplace (16).

Approach to addressing the problemAmple studies have been carried out on OSH in the organized sector. India has al-so defined an OSH regulatory framework, called the Factories Act, which covers the organized sectors of industries and mines. However, as the huge workforce in the informal sector continued to suffer from the lack of occupational health and safety delivery, eventually, the Bureau of Indian Standards formulated an Indian Stand-ard on OHS management systems – IS 18001:2000 – Occupational Health and Safety Management Systems – Specifica-tion with Guidance for use. Because this standard was formulated on the basis of demand from the industry for a compre-hensive framework of OHS, the coverage of the workers in the unorganized sector still remained an issue. However, the pri-orities and circumstances of OSH pro-grammes in informal sectors differ from the organized sectors, and workers in the informal sector could not be covered by such regulations as regards the protection of their health and safety at workplaces or protection from work-related hazards. Some legislation that protects the rights

Fish sellers – injury prone informal work among fisher women.

PhotobyJMajumder

Slate pencil cutting – chiseling plates from slate stone.

PhotobyRRTiwari


References

1. CensusofIndia2011.OfficeoftheRegistrarGeneral&CensusCommissioner,India,2011.2. MinistryofLabourandEmployment.ReportoftheWorkinggrouponSocialSecurityforTwelfthFive

YearPlan2012–17.MinistryofLabourandEmployment,GovtofIndia,2012.3. PingleS.OccupationalSafetyandHealthinIndia:NowandtheFuture.IndHealth,2012;50:167–71.4. PingleS.Basicoccupationalhealthservices.IndianJOccupEnvironMed2009;13(1):1–2.5. MitraA.InFocusProgrammeonSkills,KnowledgeandEmployabilityInformalEconomyTrainingand

SkillFormationforDecentWorkintheInformalSector:CaseStudiesfromSouthIndia,ILOWorkingpaper.InternationalLabourOrganization,Geneva,2002.

6. TakalaJ.Globalestimatesoftraditionaloccupationalrisks.ScandJWorkEnvHealth,2005;1:62–7.7. Concha-BarrientosM,NelsonD,DriscollT,SteenlandN,PunnettL,FingerhutM,etal.Selectedoc-

cupationalriskfactors.In:EzzatiM,LopezA,RodgersA,MurrayC,editors.Comparativequantificationofhealthrisks:globalandregionalburdenofdiseaseattributabletoselectedmajorriskfactorsGeneva:WorldHealthOrganization,2004;1651–802.

8. NagA.IdentifyingProgrammeElementsforOSHDevelopmentinSelectedinformalOccupationinRuralIndia.NationalInstituteofOccupationalHealth,Ahmedabad,2009.

9. LoomisD,RichardsonD,WolfS,RunyanJ.FatalOccupationalInjuriesinaSouthernState.AmJEpide-miol,1997;145:1089–99.

10. VillanuevaV,GarciaAM.Individualandoccupationalfactorsrelatedtofataloccupationalinjuries:Acase-controlstudy.AccidentAnnalPrev2011;43(1):123–7.

11. DashSK,KjellstromT.WorkplaceheatstressinthecontextofrisingtemperatureinIndia.CurrSciIndia2011;101(4):496–502.

12. AhasanM.Work-relatedproblemsinmetalhandlingtasksinBangladesh:Obstaclestothedevelop-mentofsafety.Ergonomics,1999;42:385–96.

13. SaiyedH,TiwariR.OccupationalHealthResearchinIndia.IndHealth2004;44:218–24.14. InternationalLabourOrganization.Safetyinnumbers:Pointersforglobalsafetycultureatwork.Inter-

nationalLabourOrganization,Geneva,2003.15. ChenY,ChenJ,SunY,LiuY,WuL,WangY,YuS.BasicOccupationalHealthServicesinBaoan,China.

JOccupHealth2010;52:82–8.16. RantanenJ.Basicoccupationalhealthservices–theirstructure,contentandobjectives.ScandJWork

EnvironHealthSuppl2005;1:5–15.17. NagA,NagP.Dotheworkstressfactorsofwomentelephoneoperatorschangewiththeshiftsched-

ules?IntJIndErgonom2004;33:449–61.

of workers in the informal sector are the Minimum Wages Act, 1948 and Payment of Wages Act, 1936, which help fix mini-mum wages and protect workers from ille-gal wage deductions or unjustified delays in the payment of wages. The Unorgan-ized Sector Workers (Conditions of Work and Livelihood Promotion) Bill, 2005 as-sures basic minimum standards on work-ing conditions such as hours and wages, providing old age pension and insurance, the right to organize non-discrimination in payment and settle disputes between wage workers and employers in the in-formal economy.

Further, the development of an OSH programme or the execution of the ba-sic occupational health services in the informal sector remains a complex ac-tivity, requiring organizational structure, functional inter-agency communication, and large technical, personnel and finan-cial input. A serious research approach is required for micro-level factors such as measuring work processes and hazards, workgroup cohesiveness and co-opera-tion, and the approach of the employer and employees towards OSH manage-ment, as well as macro-level variables that measure local government commit-ment to occupational safety and socio-economic support mechanisms. The ob-jective of an OSH programme is to devel-op a planned, verifiable process for man-aging the hazards and risks of health and safety at workplaces, by reducing the di-rect and indirect costs associated with accidents, and increasing the quality of products and services (17). In brief, the identification of the management tool is essential in designing OSH for the infor-mal sector. The informal sector is devoid of a management system and is thereby deprived of the conventional assessment of an OSH programme. The non-exist-ence of a health care delivery manage-ment system in the unorganized sector does not implicate the non-feasibility of developing a safety, health and environ-ment programme in this sector, but rather that developing a BOHS model for this group will be challenging.

This suggests that diverse work-relat-ed stressors and poor work environments pose risks to workers’ health and safety, and that there is a genuine need to embed a management framework in the existing

social and health delivery machinery in order to develop OSH programmes.

PracticalitiesThe objective is to analyse the possibility of developing a BOHS model for informal occupations. This should include (a) the development of a surveillance system to monitor the OSH issues of the informal workforce for health risk assessment, with suitable adaptation of a survey instrument to assess work-related health morbidities such as injuries, disorders, job stress etc., and to retrieve OSH information for ap-plying BOHS to the informal workforce, (b) carrying out surveys in rural and semi-urban areas using the surveillance system, (c) examining the basic structure of exist-ing systems and exploring the prospect of applying BOHS as a universal OSH pro-gramme for the informal occupation, with due component analysis of the work pro-cesses with the retrieved analysed OSH data and possible interaction with human systems.

An initiative has been taken by the Na-tional Institute of Occupational Health in the state of Gujarat to analyse the possi-bility of implementing the BOHS model through a wide network of primary health centres. We regard this as an initial step in exploring the existing infrastructure for the implementation and in examining the stakeholders’ need for BOHS. Awareness and training of the stakeholders would further help in understanding the utility of such services. We are hopeful that in the future we will be able to expand the scope of the pilot BOHS through primary health care systems in other states of India.

J Majumder, RR Tiwari, SM KotadiyanationalInstituteofOccupationalHealth(IndianCouncilofMedicalResearch)MeghaninagarAhmedabad380016,IndiaEmail:[email protected],[email protected],[email protected]

PhotobyMsK

adek,courtesyofPUSK

ESMA

SGianyar


Indonesia is considered one of countries with the biggest universal health coverage. The health services are well structured through community health centres (PUSKES-MAS), City Health Offices and Provincial Health Offices. Occupational health services (OHS) are expanded into Occupational Health Posts or POS UKK at the grass-root level by actively involving workers as volunteers. The POS UKK consist of basic OHS to promote and improve work-ers’ awareness of occupational health. The main targets are workers in informal and small-scale enterprises. However, despite some notable success stories, the sustainability of the programme remains a concern.

An overview of IndonesiaIndonesia, located in south-east Asia is a member of the Association of Southeast Asian Nations (ASEAN), and according to current 2014 International Monetary Fund’s (IMF) calculations, is the largest Southeast Asian economy by GDP, fourth in Asia major and ninth largest worldwide. According to the Indonesian Central Bureau of Statistics (BPS), 2011, its citizens benefit from a rising per capita income of USD 3600. (1)

Indonesia’s population is the world’s fourth largest with 237 641 326 inhabitants according to the 2011 census, and is increasing. A recent 2014 estimate by Bank Indonesia sets the figure as high as 252 164 800. The population density is 123.76 people per square kilometre (323.05 per square mile). With Indonesia’s rising economic success, the health and well-being of the population has become a major issue for long-term sustainability and prosperity. (1)

Hierarchy of health services in IndonesiaThere are currently 5000 POS UKK units in Indonesia. Occupational health posts (OHPs) at the village level are the units that promote occupational health as part of the initiative to empower communities through participation. Establishing a POS UKK is deemed feasible whenever there is a substantiated need, requirement and willing-ness to adopt and engage workers through volunteerism. This includes workers in informal sectors, home indus-tries and small-scale enterprises with similar production.

PUSKESMAS or Community Health Centers (CHC), with inpatient and /or outpatient services, serve an average population of 30 000, with some 9655 operational CHC units in Indonesia. BKKM is the Center for Occupational Health Services (COSHS) for OHS referrals, and currently has four operational units in the West Java Province and one in the Makassar-South Sulawesi Province. (2)

HanifaM.Denny,Indonesia

Occupational health services and primary health care in Indonesia

Policies (3)

1. Decree of the Minister of Health of the Republic of Indonesia number: 758/MENKES/SK/XII/2003 concerning the Basic Occupational Health Services Stand- ard: The Occupational Health Post is one of the basic OHS units located in the workplace area and managed by volunteer workers.2. Law No. 36 of 2009: Health, Chapter XII Article 164 to 166: OHS cover workers in the formal and informal sectors, and the Center for Occupational Health’s scope within the Ministry of Health, Republic of Indonesia was expanded under the new Directorate of Occupa- tional Health (Dit.OH) in December 2005.3. Decree of the Minister of Health of the Republic of Indonesia: Republic Indonesia’s Presidential Instruc- tion number: 15/2011 concerning Health Protection of Fishermen. This recommends building and operating health service infrastructures within fishing communities, to facilitate health service access for fishermen and their families, and to help with health insurance claims. •TheMinistryofStateEmployeesEmpowermentand Bureaucratic Reform enacted Decree number 13/2013 concerning the creation, functioning, responsibility and mission of the Occupational Health Supervisor operating under the Directorate of Occupational Health & Sports within the Indonesian Ministry of Health.

Role of primary healthcare in Indonesia (4)What started as Pilot Projects for the Establishment of Occupational Health Posts (POS UKK) in 2002 and 2006, has to date resulted in 5518 operational posts. The initial pilot project focusing on the establishment of OHS cen-


tres in 2002, has resulted in five opera-tional BKKMs. Occupational Health Risk Mapping procedures were implemented and performed by the Directorate of Oc-cupational Health (Dit.OH) together with some Provincial Health Offices at select-ed provinces and workplaces, including those in the informal sectors, home in-dustries and small-scale enterprises. Over time, these pilot projects have taken on primary roles such as:1. Training for Volunteers of POS UKK (e.g. farmers, craftsmen, fishermen, traditional divers, etc.), conducted by Dit.OH together with some Provincial Health Offices2. Occupational health training for PUSKESMAS’ staff, covering 3000 PUSKESMASes in Indonesia.3. Training and technical assistance on occupational health for traditional divers and fishermen at Riau Is- land, Maluku, Seribu Island, Cilacap, Semarang, and Situbondo.4. Diagnosis of Occupational Diseases training, in which general physicians participated, who worked at PUSKES- MASes in Indonesia.5. The distribution of Occupational Health guidelines and Information & Education & Communication mate- rials for specific occupations in informal sectors, for example, farmers, traditional fishermen, traditional divers, and footwear workers. 6. Free medical services in Indonesia since the enactment of the universal health care programme in 2014, as long as a person has obtained a “BPJS” or a Social Security card. The BPJS means universal health coverage, which will cover the whole Indonesian population by 2019. Considering that the Indonesian Universal Health In- surance will cover be 170 million people, it will be the highest coverage in the world.

Financing and collaboration (4,5)The annual budget for the Occupation-al Health Program administered by the Directorate of Occupational Health and Sports (MOH, RI) has increased three-fold from Rp.15 000 000 000 (± $1.5 M) in 2005 to the present Rp.50 000 000 000 (± $5M). Fifty per cent of the budget was utilized to deliver OHS to informal sec-tors. In addition to direct spending by

the central government, a discretionary spending budget was made available to Provincial Health Offices; so called De-concentration Budgeting. Local govern-ment’s contributions are generally patchy and mostly engaged at the pilot project level.

The Directorate of Occupational Health & Sports is a leading actor in OHS delivery for workers in informal sectors, home industries and small-scale enter-prises. It serves as the consolidating link for all health-related affairs, and engages other ministries through influence and collaboration. In contrast, the Ministry of Manpower and Transmigration, for exam-ple, is involved in selected projects in part-nership with the ILO. It should be noted that its main focus is its OHS inspection programme for medium and large-scale companies.

On a collaborative level, the Ministry of Agriculture, for instance, has partnered with the Ministry of Health’s initiative for safe pesticide use by farmers and pesti-cide handlers. The Ministry of Industries has participated and collaborated with the Ministry of Health for an Occupational Health and Safety Program at some small-scale batik industries.

Financing is and remains the main is-sue in delivering OHS to informal sectors. Some examples of other factors potential-ly hindering progress are the maintenance of the programme and the partnership. Firstly, if the PUSKESMAS does not con-tinue its supervisory role, informal sectors have difficulties in sustaining occupation-al health promotion when the assigned Technical Assistant (TA) has left. Second-ly, partnership with local large-scale com-panies as regards OHS for the informal sectors’ workers has not been promoted widely. Thirdly, as no occupational health programme has been included in the Na-tional Minimum Standard of Health Ser-vices Delivery in PUSKESMAS, its sus-tainability depends on the funding assis-tance, willingness and awareness of the PUSKESMAS’ manager.

Success storiesThe key to success is and remains to be the Dit.OH supervision and the assistance of PUSKESMASes, which in turn enables the PUSKESMASes to assist POS UKKs. This improves collaboration and efficiency on a national level, bridges interests and sets

a precedent for the success of future ac-tivities among the different interdepend-ent tiers. The ability and empowerment of PUSKESMASes to provide assistance to POS UKKs has improved the work-ers’ skills in identifying workplace hazards and their respective solutions. For exam-ple, a BKKM health promotion outreach programme succeeded in transforming home industries owners’ perspectives and practices of unsafe food processing (i.e. switching from the use of textiles for food colouring to the use of legal food colour-ing products).

Other occupational health promotion activities through PUSKESMAS and POS UKK have directly contributed to a posi-tive behavioural change amongst informal sector workers and in their workplace hy-giene and PPE practices. Credit must be given to the notable effort to make home industry owners believe that they them-selves and their workers will work better because they are healthier due to provi-sion of occupational health services.

Current barriersAlthough progress and success are the norm, difficulties in cross-sector col-laboration, a lack of record-keeping and reporting on the part of OHS, workers’ job loss and frequent job rotation among health officers still pose significant barri-ers. Other obstructions also persist, such as informal sector workers’ non-perma-nent status and difficulty in tracking them. Last but not least, sustainability efforts for maintaining the Occupational Health pro-gramme when funding ends are lacking.

Current limitationsDespite the overall vision and will for im-provements in the health of Indonesia’s population, major influencing limitations such as the lack of human resources to deliver OHS, and difficulties gaining ac-cess to certain villages due to geograph-ical barriers, remain an issue. The time constraints of workers and difficulties in mapping the type of production neces-sary to establish a POS UKK also play a significant role and are currently limit-ing progress.

A solution to the limited funding for covering all underserved working popu-lations in Indonesia has yet to be found. Future plans for the expansion of univer-sal coverage beyond health care coverage


Ever wondered if your usual occupational safety and health (OSH) sources are vali-dated, authoritative and up to date and, if electronic, are consistently available whenever you need access?

Since the advent of the internet almost 25 years ago, many people now firmly be-lieve that “ALL information is out there and free of charge”.

Although it is useful that information can easily be made available by an author anywhere in the world by uploading it onto the internet, many significant things need to be checked before you can use the data safely at your workplace.

What is not really understood is how information is actually produced, who writes and edits it, and who checks to see if it is up to date and contains reliable, ac-curate content.

Questions about OSH informationFirst, consider how often you need OSH information. Is it daily, weekly, monthly or just occasionally?

Secondly, where do you routinely go for information?

a) Own collection – does it contain current subscriber services?b) Google?c) Colleagues/friends –is knowledge up to date and comprehen- sive?d) An organization that you are a member of, that will obtain answers for you?e) Well-known organizations’ web pages; for example the Health and Safety Executive (HSE)?If you do search for information

yourself, do you know how much time you spend doing this per day/week. You should also recognize other expenses, for example, equipment and telephone us-age costs.

SheilaPantry,UK

Safely navigating your perfect OSH

information worldDo you need worldwide information?

If so what kind: legislation, datasheets, guidance, advice?

Another question is how much would you pay for authoritative and vali-dated information?

Searching the World Wide Web The internet is one of the world’s fastest growing communication developments, and has created many information re-sources that can be of value to everyone who needs to stay ahead in their own spe-cialization.

Making the best use of these resources takes time. Just as no one book will give all the answers to a question, you may not find all the information you need from looking at just one website.

How to search effectively Getting the best results from your searches.

The following may help when search-ing for information on occupational, safe-ty, health, fire, chemical and environment (OSHE) on the internet.

1. Clear thinking Develop a clear understanding of what you need from your information search. Are you looking for general information or something very specific?

2. Terms, keywords etc. • Whensearching,thinkof: related terms (both broader and narrower)• synonyms• otherchemicalnamesplusunique chemical number• legislation• differencesinBritishandAmerican terminology, for example, fume cup- boards and fume hoods

through the national programme in the National Social Security scheme has not yet been implemented and remains sub-ject to debate.

StrengthsA common strength is that community participation and engagement in social activities is a strongly ingrained part of In-donesian culture. Furthermore, all stake-holders and beneficiaries remain deeply engaged and vested, as the roadmap to national success is now supported and en-forced by enacted laws and regulations to support OHS delivery. Other significant contributing strengths that will eventually lead to Indonesia’s improved health and economic success are increased funding from the central government for the de-livery of OHS programmes, better-quality, continuous improvement policies in OHS, and a vision supported by a plan for uni-versal health coverage that has been well structured and implemented.

Hanifa M. Denny, Ph.D.AssociateProfessor(LektorKepala)DepartmentofOccupationalSafetyandHealthCollegeofPublicHealthDiponegoroUniversityJl.Prof.Sudharto,SH,KampusUndipTembalangSemarang50239,IndonesiaEmail:[email protected]

References

1. StatisticsIndonesia,availableat: http://www.bps.go.id/eng/tab_sub/

view.php?kat=1&tabel=1&daftar=1&id_subyek=12&notab=1

2. http://www.iom.edu/Activities/Global/PublicPrivatePartnershipsForum/2014-JUL-29/Day%202/Panel%206/35-Denny-Video.aspx

3. DennyH.ImpactofOccupationalHealthInterventionsinIndonesia.UMI3549179,ProQuestLLC,USA2013).Availableat:http://pqdtopen.proquest.com/pqdtopen/doc/1283390488.html?FMT=AI

4. WagnerN,DennyH.ConsultationfortheDirectorateofOccupationalHealth,Minis-tryofHealth,RepublicofIndonesia,fundedbyGTZ-PAF,2006.

5. AnnualReportofOccupationalHealthProgramoftheDirectorateofOccupationalHealthandSportsin2010–2013,Unpub-lished.


3. Search tips Using what is known as Boolean opera-tors – the words AND, OR and NOT can make a big difference to the results of your search. You will get much closer to what you are seeking by using these sophisti-cated operators.

Read the help or search tips when you are using any of the electronic services, for example, OSHUPDATE+FIRE www.oshupdate.com, or websites (see Search Engines), because many people only look at the first 10 ‘hits’ on any retrieved lists.

Search operators are used differently by different search engines or electronic services. Searchers may benefit from look-ing at Google’s advice, for example (see https://support.google.com/websearch/answer/136861), before embarking on a search.

4. Spelling If you are unsure of the spelling, think about the variations, especially the differ-ent spellings found in American and Brit-ish English, for example, centre/center; sulphur/sulfur.

5. Authors Do you know any author(s) on this subject? By using the author’s name, you may re-trieve other references to similar work on the subject of your choice.

6. Institutions Do you know of an institution, competent authority/ies or research organizations that have done some work in this area? Again try using the name, you may re-trieve even more references.

7. Other sources Do you know of any journals/indexing/abstracting service(s) that specialize in the subject? Again you can add these to your search.

8. Any information centre(s) that spe-cialize in the subject? This is similar to author searches because these information centres may well have produced a publication on the subject you are seeking.

9. Other databases, databanks, CD-ROMs, either full text or bibliographi-cal information

If you cannot find anything, look on an-other search engine or similar site which has lots of links. This will act as a ‘hot link’ for you to explore other materi-al you may not otherwise have found.

10. Search strategy Work out a search strategy before start-ing your search. Many search engines of-fer ways of refining your search and this will save time and money in the long run, for example, decide:• howfarbackintimedoyouneedto go? You will save time by limiting your search.• onwhichauthoritativesitesyouwish to search• onlanguage;forexampleEnglishonly, which again will save time and money• onthewordsandphrasestobeused. Remember to use both English and the language of the site• whetherornottorefineyoursearch. Most search engines offer two types of search - “basic”, and “advanced” or “refined”. In the “basic” search, just enter a keyword without going through any additional options. Some search engines are so powerful that you often get good results with a minimum number of keywords.• whetherornottoautomaticallyex- clude common words. Most search engines ignore common words and characters such as “where” and “how”, as well as certain single digits and single letters, because they tend to slow down the search without improving the results. Some search engines such as Google will indicate if a common word has been excluded by display- ing details on the results page below the search box.

• whetheracommonwordisessential for getting the results you want. You can include it by putting a “+” sign in front of it. (Be sure to include a space before the “+” sign.) The one excep- tion to this is “the”, which is so common that it is not considered in searches. Note that some search engines only search for exactly the words you enter in the search box and do not offer “stem” or “wildcard” word searching. If in doubt, enter both singular and plural, e.g. “air-line” and “airlines”. Read the “hints and tips” information for each of the differ-ent search engines.

11. If you cannot find a page There may be a number of reasons why you cannot locate a “home page” that you have used before. It may have been re-moved completely, or changed its name, or be temporarily unavailable. Try the fol-lowing:• Makesureyouhavetypedinthehome page correctly: you may have made a spelling mistake• Ifsomespecificpageissuddenlynot available, open the main home page and then look for the link: it may have been re-linked• Iftheaboveactionsfail,gointoone of the search engines, for example, www.google.com and look for the information again.

12. Presentation of documentsThe results may offer you the full text of the documents presented in different file formats.

•AdobeAcrobatPDF(.pdf)•AdobePostscript(.ps)•MicrosoftWord(.doc)•MicrosoftExcel(.xls)•MicrosoftPowerpoint(.ppt)•RichTextFormat(.rtf)

Sheila Pantry, OBE BA FCLIPSheilaPantryAssociatesLtd85TheMeadows,Todwick,SheffieldS261JG,UKEmail:[email protected]

Editorial Boardas of 1 September 2014

Nancy Leppink ChiefofLABADMIn/OSHInternationalLabourOffice4,routedesMorillonsCH-1211Geneva22SWITZERLAnD

Evelyn KortumTechnicalOfficer,OccupationalHealthInterventionsforHealthyEnvironmentsDepartmentofPublicHealthandEnvironmentWorldHealthOrganization20,avenueAppiaCH-1211Geneva27SWITZERLAnD

Jorma RantanenICOH,PastPresidentfInLAnD

Harri VainioDirectorGeneralfinnishInstituteofOccupationalHealthTopeliuksenkatu41aAfI-00250HelsinkifInLAnD

Chimi DorjiLicencing/MonitoringIndustriesDivisionMinistryofTradeandIndustryThimphuBHUTAn

N.B.P. BalallaHeadOccupationalHealthDivisionBlock2G5-03JalanOngSumPingBandarSeriBegawanBA1311BSBBRUnEIDARUSSALAM

Yang NailiannationalILO/CISCentreforChinaChinaAcademyofSafetySciencesandTechnology17HuixinXijieChaoyangDistrictBeijing100029PEOPLE’SREPUBLICOfCHInA

Ho Ho-leungDeputyChiefOccupationalSafetyOfficerDevelopmentUnitOccupationalSafetyandHealthBranchLabourDepartment14/f,HarbourBuilding38PierRoad,CentrumHOnGKOnG,CHInA

K. ChandramouliJointSecretaryMinistryofLabourRoomno.115ShramShaktiBhawanRafiMargnewDelhi-110001InDIA

Lee Hock SiangDirectorOSHSpecialistDepartmentOccupationalSafetyandHealthDivision#04-02,MinistryofManpowerServicesCentre1500BendemeerRoadSingapore339946SInGAPORE

John FoteliwaleDeputyCommissionerofLabour(Ag)LabourDivisionP.O.BoxG26HoniaraSOLOMOnISLAnDS

Le Van TrinhDirectornationalInstituteofLabourProtection99TranQuocToanStr.Hoankiem,HanoiVIETnAM

asian-pacific newsletter 3/2014, ohs and primary health care

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