thailand's work and health...

International Labour Review Vol 1 49 (201 O) No 3

Thailands work and health transition

By Matthew KELLY Lyndall STRAZDINS Tarie DELLORA Suwanee KHAMMAN Sam-ang SEUBSMAN

and Adrian C SLEIGH

Abstract Thailand has experienced a rapid economic transition from agriculture to manufacturing and services and to more formal employment Its labour market regulation and worker representation however are much weaker than they are in developed counlries which underwent rhese transitions more slowly and sequen- tially decades earlier The authors examine the s~rengthening of Thailands policy and legislation o n occupationalsafety and health itt response lo international stand- a r h a new democratic Constitution fear of foreign trade embargoes and fatal workplace disasters In concluding they identifi key challenges remaining for policy-makers including enjorcement o f legislation and measurement of new mental and physical health effects

ow people work and the conditions in which they work are critical determinants of population health Yet while much attention has been de-

voted to interconnections between work and health in affluent developed countries far less is known about this topic in transitional economies (CSDH 2008) This case study of Thailand illustrates a contemporary work and health transition in a middle-income country It occasionally uses data from Australia for

National Center for Epidemiology and Population Health the Australian National Uni- versity Canberra email matthewkellyanueduau National Economic and Social Devel- opment Board Bangkok email Suwaneenesdbgoth School of Human Ecology and Thai Health Promotion Centre Sukhothai Thammathirat Open University Nonthaburi email Sam- angseubsmananueduau

This study was supported by the Thai Health-Risk Transition project with joint grants from Wellcome Trust UK and the Australian National Health and Medical Research Council under the International Collaborative Grants Scheme The authors wish to acknowledge the helpful advice and encouragement of Dr Chaiyuth Chavalilnitikul

Responsibility for opinions expressed in signed articles rests solely with their authors and publication does not constitute an endorsement by the ILO

Copyright O The authors 2010 Journal compilation O International Labour Organization 2010

374 International Labour Review

comparison to contrast the situations in transitional and developed economies In concluding the paper identifies the challenges confronting Thailand as it strives for a healthy and productive workforce

Economic transitions work and health

As traditional rural occupations give way to manufacturing service and knowledge jobs population health is affected by rising incomes changing safety risks and working conditions and employment insecurity (Benach Muntaner and Santana 2007) The resulting health transition is marked by shifts in environmental risks and human ecology (McMichael 2001) diet and nutrition (Drewnowski and Popkin 1997) and morbidity and longevity (Caldwell and Caldwell 1991 Frenk et al 1991 Caldwell 1993 Jamison et al 1993)

Jobs affect health through exposure to occupational hazards The greatest risks occur in construction manufacturing and industrialized agriculture owing to atmospheric pollutants heart diseases caused by emissions or stress and injuries due to noise and poor ergonomics Workers in the service sector particularly office environments generally face the lowest risk of injury or disease (Ezzati et al 2004) The service and knowledge sectors however also pose health risks - especially to mental health - as a result of work organization job insecurity work pressures and shift work

In affluent countries the transition to a service and knowledge economy widened wage inequality (Goos and Manning 2007) - a factor which may also affect health outcomes In these countries the transition has been sequential and relatively gradual accompanied by a process of state regulation of working conditions and worker representation Developing and transitional economies by contrast are changing at a faster pace without any tradition of worker representation which limits capacity for regulation to protect workers health Furthermore the context of accelerating globalization - with capital moving freely across borders and labour markets competing globally - is placing downward pressure on wages and conditions (Slaughter and Swagel 1997) In other words the pace and context of change in developing and transitional countries differ from what todays developed economies experienced previ- ously and it is not clear whether these countries will reap the same health benefits from development

Thailands labour market and health transition

When Thailand entered its transformative stage its state regulation of working conditions social security and employment policies were obviously much less advanced than those of developed countries And such regulations and policies as were in place applied only to specific segments of the labour force (eg civil servants) To this day most Thai workers are still employed in the informal economy where work is contingent and conditions largely unregulated Con- currently unionization rates are low and few workers are aware of their rights

Thailands work and health transition 375

Although Thailands speedy economic transition has created a modern sector of service and knowledge industries a sizeable proportion of the labour force continues to work in the traditional sectors of agriculture and industry In todays developed countries by contrast there was a more sequential shift from one dominant sector to the next over centuries Thailands health transition is thus characterized by the coexistence of modern and traditional sectors with different work-related hazards pay and working conditions

In the course of Thailands transition over the past 50 years many of its health indicators have shown improvement life expectancy has increased while mortality and the incidence of communicable diseases and malnutrition have decreased From 1964 to 2006 for example life expectancy increased from 56 to 70 years for males and 62 to 78 for females From 1962 to 2006 the maternal mortality ratio fell from 3743 to 98 per 100000 live births And from 1980 to 2004 the infant mortality rate fell from 49 to 21 per 1000 live births (Wibulpol- prasert 2008)

Over the past 20 years however Thais have begun to experience many of the health problems prevalent in developed economies including cardiovascu- lar disorders diabetes obesity cancer and traffic injuries This health transition is quite advanced with the incidence of say obesity and other nutrition-related diseases approaching developed-country levels (Banwell et al 2008) By 2005 eight of the top ten causes of death in Thailand were strongly linked to aspects of modem work and life (ESCAP 2008)

Structural drivers of Thailands labour market transition

Trends in workforce composition Thailands sectoral employment trends illustrate the speed of its economic transformation (see figure 1) In 1960 agriculture occupied 82 per cent of the labour force in 1980 just before Thailands economic transformation took off the proportion was still over 70 per cent but by 2008 it had fallen to around 35 per cent (NSO 2008a and 2005a) By way of comparison Australias agricultural employment had already fallen below 20 per cent in 1948 (figure 2) This reflects the different structural factors facing policy-makers in the two countries unlike Australia where employment has long been dominated by one sector Thailand shows a fairly even distribution of employment across sectors (figures 1 and 2) Indeed while its agricultural workforce shrank between 1980 and 2008 the proportion of Thai workers employed in the manufacturing and service sectors more than doubled from 11 to 24 per cent and from 19 to 41 per cent respectively (NSO 2008a)

The informal sector Thailands National Statistics Office (NSO) defines informal workers as those primarily self-employed who are not covered by existing workplace laws regulations and protections (NSO 1994) Informal workers operate at a low level of


Figure 1 Employment in Thailand by sector ()

80

70 +P Industrial

60

50

40

30

20

10

Source NSO 2008a

organization [ with labour relations] based mostly on casual employment kin- ship or personal or social relations rather than contractual arrangements with formal guarantees (ILO 1993 art 5(1)) In other words informal-sector employment is insecure unregulated and low-paid and it generates more stress workplace injuries and related ill health than work in the formal sector (Florey Galea and Wilson 2007) Furthermore when a large proportion of the labour

Figure 2 Employment in Australia by sector ()

Source OECD 2008

377 Thailands work and health transition

force is informally employed government tax revenues are substantially reduced constraining investment in health infrastructure (Sujjapongse 2005)

From 80 per cent two decades ago the proportion of Thailands labour force in informal employment fell to 71 per cent in 2000 and 627 per cent in 2007 (NSO 2007) A little over half of these informal workers were employed in agriculture with the remainder running small businesses or market stalls or working in factories or construction Although the proportion of the labour force employed informally is still high it is falling rapidly with modernization and development particularly in Bangkok where it was only 317 per cent in 2007 (NSO 19942005b and 2007) For the foreseeable future however informal employment will remain an important mechanism for absorbing excess labour in economic downturns and providing jobs for new urban migrants

Inequity in the labour market Life expectancy infant mortality and other health indicators improve as incomes increase but socio-economic inequalities mean that not all people experience the same health benefits (Kawachi 2000 Coburn 2000) A concomitant of Thai- lands labour market transition and rapid economic growth has been an increase in income inequality Measured by the Gini coefficient Thailands income inequality rose from 0410 in 1962 to a peak of 0525 in 2000 before falling back to 0499 in 2007 (UNPAN 2003 Thailand 2007b) By comparison in Australia where the work transition occurred earlier the Gini coefficient has hovered around 0448 in recent years (ABS 2003)

Higher wages and safer working conditions in the growing service sector can also improve social cohesion and equity - including gender equality Thai- land differs from many countries at a similar stage of development in that its female labour force participation rate has always been relatively high (Ton- guthai 2002) At over 60 per cent it is comparable with the rates found in developed countries (NSO 2009) Most women in Thailand enjoy the opportunity to work for pay but they are more likely than men to be employed in the lowest- paid and most hazardous jobs created by economic development or to be in insecure informal and home-based employment (Tonguthai 2002) In 2005 for example 763 per cent of home-based workers in Thailand were women (NSO 200)

Work and family Change from a rural agriculture-based economy to a rapidly urbanizing one has affected family life as work has moved away from the village and the extended family while few alternative childcare options are available (Heymann 2003) In rural Thailand as men tend to work in urban areas women have to look after agricultural production as well as the household and children (Coyle and Kwong 2000) This extra workload is likely to have a damaging effect on the physical and mental health of mothers and children Furthermore womens long working hours have increased marital instability (Edwards et al 1992) -a further cause of psychological distress and related illness among parents and children


Working conditions in Thailand

Hours of work and productivity Thailands economic transition is characterized by persistently low labom productivity rooted in generally low levels of educational attainment among the labour force At present around 57 per cent of the Thai labour force have primary-school education at best (NSO 2008a) In the period of rapid growth that was largely driven by manufacturing an uneducated labour force was not a hindrance to the countrys economic success But jobs are now becoming in- creasingly skilled service-oriented and knowledge-based leaving Thailand with both a shortage of skilled workers and a large pool of unskilled labourers who cannot get good-quality jobs

The Government has responded by increasing spending on education and promulgating the 1999 National Education Act which provides for 12 years of free education The number of students proceeding beyond the primary level has increased sharply in recent years in 2006 approximately 59 per cent of students completed upper secondary school and 24 per cent went on to tertiary education (NSO 2008b) However the labour market effects of this trend are likely to occur with a persistent time-lag because of the large share of the labour force still having only primary education (Khoman 2005)

Meanwhile Thailands low labour productivity generates its own health risks as employers demand longer hours and pay lower rates The average working week is 48 hours in manufacturing and up to 54 hours in trade and service industries Almost 70 per cent of the labour force spend more than 40 hours a week at work (NSO 2008a) compared with only 30 per cent in Australia which is among the developed countries with the longest working hours (ABS 2007) Such long hours clearly exacerbate the health risks facing workers particularly women who have to combine long hours at work with family responsibilities

Social security systems Social security is also important for workers health Several schemes operate in Thailand namely

the Civil Servants Medical Benefit Scheme and Government Officials Pension Act of 1951 which provide generous benefits for government workers and their dependants (Reisman 1999)

the Workmans Compensation Scheme - an employer-funded scheme providing benefits for work-related sickness (ibid)

the Social Security Scheme which provides sickness benefits for conditions unrelated to work old-age pension and unemployment benefits (ibid Kanjanaphoomin 2004)

the Universal Coverage Scheme which since 2002 has been providing free medical care for a wide range of treatments based on a capitation model for the whole population (Tangcharoensathien and Jongudomsuk 2004)


Thailands social security system has thus progressed towards a universal safety net providing free health care to workers and their dependants thereby greatly reducing inequities in access to health care Legally registered foreign workers can also be covered by this scheme for a small fee Although informal workers are still excluded from other social security benefits - eg paid sick leave and unemployment benefits - a universal pension of 500 baht per month covering even informal workers was recently introduced

Unionization Trade unions play a pivotal role in securing both statutory labour protection and rights - including on occupational safety and health overtime and familylsick leave - and in the enforcement of those rights at the workplace (Mishel and Walters 2003) Averaging less than 4 per cent in 2006 Thailands overall rate of unionization is very low though it was more than 50 per cent among state-enterprise workers Likely reasons include the large percentage of workers informally employed (particularly casual migrant labourers) cultural factors and the lack of political support for unionization among the countrys leadership (Brown 2001) Besides many Thai workers are also reluctant to upset the traditional family relationships typically found within workplaces because they provide them with protection

Until the mid-1970s unionization was actively suppressed Since then there have been improvements in freedom of association and trade unions now enjoy some statutory rights The 1975Labour Relations Act regulates the registration of unions and establishes labour-dispute resolution procedures It favours enterprise-level unions and limits industry-wide organization (Lawler and Suttawet 2000) However despite improved statutory rights during Thai- lands rapid economic transition union strength may have actually declined because of a combination of poor enforcement of the right to organize and private-sector employers active suppression of unionism (Brown 2001)

In developed countries trade unions have been key players in setting hours of work and minimum wages reducing exposure to occupational hazards and securing paid sick leave and holidays and other benefits for workers The weakness of trade unions may thus be another reason for Thailands long hours of work and low wages It has been estimated that up to 40 per cent of factories do not honour their minimum-wage obligations (Charoenloet 1998)

National planning for labour and workplace safety

changes in labour policy The past 15 years have brought unprecedented openness in Thai politics

together with stronger government policy on workplace conditions and workers health and safety Partly driven by a newly empowered civil society a Peoples Constitution was promulgated in 1997 This new Constitutions numerous pro- visions for individual and collective rights led to the establishment of a National


Human Rights Commission (Baker and Phongpaichit 2005) Reform of labour legislation can be seen as part of this process

Two other reasons may explain policy interest in workplace health and safety The first was the series of industrial accidents that occurred in the 1990s notably the 1993 fire at the Kader toy factory where 188 workers were killed and some 500 injured This drew the attention of the media non-governmental organizations and public to the issue of worker safety putting pressure on policy-makers to take action (Brown 2001) Just like the 191 1Triangle Shirtwaist Factory fire that killed 146 garment workers in New York and led to a raft of new legislation aimed at protecting workers in the United States (McEvoy 1995) these industrial accidents appear to have marked a turning point in national attitudes towards worker safety in Thailand

The second related reason was the fear of embargoes on Thai exports that might result from international condemnation of Thailands labour standards (Brown 2001) Besides Thailand has been a member of the ILO since 1919 and although it has cautiously ratified only a few of the ILOs more than 180 Con- ventions it hosts the Organizations Regional Office for Asia and the Pacific with which its Ministry of Labour and Social Welfare has developed a close working relationship

An important channel for the implementation of Thailands new policy direction on labour has been its five-year National Economic and Social Devel- opment Plans formulated by the powerful National Economic and Social Development Board (NESDB) Since the eighth such plan spanning 1997-2001 policy guidelines have consistently emphasized reduction of the incidence of occupational injuries and illnesses The plans now set incidence targets and pre- scribe the measures to be implemented in order to achieve them They also pro- mote the registration of informal workers especially home-based workers and recognition of informal workers organizations thus providing them with greater protection and security NESDB policy has also been aimed at providing informal workers wit11 social security benefits similar to those enjoyed by the formal workforce (Thailand 2004)

Since 1997 these issues have been specifically addressed through the NESDBs Labour Development and Welfare Plans which also open up avenues for collective bargaining on workplace conditions (Ruphan 1999) These plans have provided for new safety regulations a national safety culture campaign better inspection systems embedded safety management systems improved reporting and participatory training These measures address both well-known occupational hazards and newly recognized biological psychosocial and musculoskeletal risks (Chavalitnitikul 2005)

Another channel for change was the 1998 Labour Protection Act which required all (formal) workplaces to set up an occupational safety committee made up of management and worker representatives trained in workplace health and safety This legislation also established a reporting system for employees to notify suspected breaches of safety rules which the Ministry is then obliged to investigate and rendered the general workplace inspection


process more rigorous (Seehavong 2006 Thailand 2007a) In addition the 1998 Act addressed working conditions and conditions of employment (eg maxi- mum working hours and minimum wages) and set up a separate reporting process for employees to report breaches of these conditions Penalties for breaches were increased and independent third parties were allowed to investigate disputes (Suthamasa and Buayaem 2001)

Since 2005 the Ministry of Labour and Social Welfare has openly supported regulation to require organizations employing 50 or more workers to develop an occupational safety and health management system (Chavalitni- tikul 2005) The prerequisite reforms and training procedures are still under way if successful they too should contribute to improved worker safety

Alongside the above measures the Ministry of Public Health has also con- ducted several nationwide campaigns and an active epidemiological surveillance programme The latter is part of a joint effort to set up a comprehensive occupational health and safety surveillance system pooling the resources of the Ministry of Public Health the Ministry of Labour and Social Welfare and the Ministry of Industry with a view to monitoring the incidence of target diseases (eg silicosis) identifying high-risk groups and developing policy interventions (Siriruttanapruk and Anantagulnathi 2004)

Workplace health and safety The Ministries of Health and of Labour and Social Welfare have addressed industrial health risks such as hazardous chemicals and unsafe manufacturing practices but there are new hazards that remain unregulated Indeed poor ergonomics and workplace design human resource practices and repetitive work also expose many unskilled or poorly educated workers to the risk of life- long health problems (Tonguthai 2002 Yingratanasuk Keifer and Barnhart 1998) But again the size and nature of the informal labour market limit the Governments ability to improve overall standards of occupational health and safety In particular the disease and injury rates reported for informal workers are most probably inaccurate because of under-reporting (Chavalitsakulchai and Shahnavaz 1993)

Nevertheless after peaking in 1990 the numbers of recorded workplace injuries and deaths have been falling in recent years as has the incidence of occupational disease Indeed statistics from the Office of the Workmens Com- pensation Fund reflect a downward trend in death and injury rates since 1994 reported deaths per 100000 workers fell from 192 in 1994 to 177 in 1997116 in 2004 and 95 in 2006 similar declines were reported in injury rates per 1000 workers from 438 in 1994 to 292 in 2004 and 24 in 2007 (see also Chavalitni- tikul 2005 Wilbulpolprasert 2008 Seehavong 2006 Thailand 2007a)

The role of globalization in Thailands transition As from 1987 rapid economic expansion was fuelled by massive growth in foreign direct investment Concomitantly the Thai Governments economic policies

382 International Labout-Review

promoted export-oriented development reduced trade barriers and privatized state enterprises in order to maximize international trade and the countrys com- petitiveness Thailands growing reliance on foreign investment and trade culmi- nated in the Asian financial crisis of 1997 triggered by a massive outflow of foreign capital (Warr 19931999 and 2005) The country has since tried to strike a better balance in its economic development by reducing its dependence on foreign capital and exports

This encounter with globalization occurred at a time when Thailand had neither policies nor structures in place to ensure that workplace health and safety rules were followed by international companies on its soil Nor did it yet have the economic capacity to protect workers (especially agricultural workers) from new pressures to produce for powerful global buyers On the positive side the Thai Government has been quite quick to adopt international standards of workplace safety refined over long years of industrial development in more advanced countries In contrast to the deregulation of many developed economies the Thai bureaucracy is thus demanding increased workplace safety based on the standards stipulated by the ILO

Indeed Thailand has not adopted neoliberal ideas uncritically and in full Since the 1980s a Buddhist model of economics has emerged notably under the influence of PA Payutto This approach emphasizes well-being moderation and self-reliance It has led to the concept of a sufficiency economy advo- cated by King Bhumiphol Adulyadej and now enshrined in the last two national economic development plans (Thailand UNEP and TEI 2008) What this actually means for the interaction between work and health in Thailand is unclear In rural Thailand at least there is a movement towards community rights over resources and empowerment along with emphasis on self-reliance and distrust of financial markets and industrialization (Hewison 2000 Reynolds 2001)

implications for a healthy and productive labour force Thailand is progressing towards a modern well-regulated labour market as employment moves steadily from agriculture towards the manufacturing and service sectors The labour force is formalizing workplace health and safety are improving and workers enjoy more rights than before These developments have coincided with globalization which has strengthened external influence on Thai policy-making This is particularly obvious in regard to workplace health and safety What is more growing openness and civil-society participation in politics have led to improved legislation protecting workers and granting them rights in accordance with international standards

Over the past few decades Thailand has experienced a health transition closely bound to its labour market transition Indicators linked to poverty such as infant mortality and life expectancy have shown improvements and recorded rates of workplace injuries and deaths and occupational disease have declined However Thai health statistics do not yet enable us clearly to correlate changes in injuries and diseases to changes in the nature of workplace hazards and given


the low unionization rates and large informal workforce occupational diseases are likely to continue to be a major public health burden Another unknown is the way changes in work organization workloads autonomy and job insecurity may affect the mental health of the Thai labour force both formal and informal In the developed world mental health problems such as depression - in which working conditions play an important role - are now one of the leading causes of morbidity (Stansfeld and Candy 2006)

Changes in government policy on workplace health and safety are relatively recent with little research on their benefits to workers7 health But new academic journals are being launched and new research alliances are being formed which may provide the evidence base needed by policy-makers in Thai- land and other transitional economies Indeed the bulk of the worlds working population lives in transitional and developing countries Hence the need for further research on the impact of heavy workloads work intensification low autonomy job insecurity and low work rewards in these countries Indeed in the context of economic downturns and frequent recourse to offshoring such working conditions may become even more widespread and important for public health in middle-income countries such as Thailand Developing this evidence base requires large-scale national monitoring arrangements as well as research on representative cohorts of workers and their families Given the impact of work on health investment in this research is urgent

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comparison to contrast the situations in transitional and developed economies In concluding the paper identifies the challenges confronting Thailand as it strives for a healthy and productive workforce

Economic transitions work and health

As traditional rural occupations give way to manufacturing service and knowledge jobs population health is affected by rising incomes changing safety risks and working conditions and employment insecurity (Benach Muntaner and Santana 2007) The resulting health transition is marked by shifts in environmental risks and human ecology (McMichael 2001) diet and nutrition (Drewnowski and Popkin 1997) and morbidity and longevity (Caldwell and Caldwell 1991 Frenk et al 1991 Caldwell 1993 Jamison et al 1993)

Jobs affect health through exposure to occupational hazards The greatest risks occur in construction manufacturing and industrialized agriculture owing to atmospheric pollutants heart diseases caused by emissions or stress and injuries due to noise and poor ergonomics Workers in the service sector particularly office environments generally face the lowest risk of injury or disease (Ezzati et al 2004) The service and knowledge sectors however also pose health risks - especially to mental health - as a result of work organization job insecurity work pressures and shift work

In affluent countries the transition to a service and knowledge economy widened wage inequality (Goos and Manning 2007) - a factor which may also affect health outcomes In these countries the transition has been sequential and relatively gradual accompanied by a process of state regulation of working conditions and worker representation Developing and transitional economies by contrast are changing at a faster pace without any tradition of worker representation which limits capacity for regulation to protect workers health Furthermore the context of accelerating globalization - with capital moving freely across borders and labour markets competing globally - is placing downward pressure on wages and conditions (Slaughter and Swagel 1997) In other words the pace and context of change in developing and transitional countries differ from what todays developed economies experienced previ- ously and it is not clear whether these countries will reap the same health benefits from development

Thailands labour market and health transition

When Thailand entered its transformative stage its state regulation of working conditions social security and employment policies were obviously much less advanced than those of developed countries And such regulations and policies as were in place applied only to specific segments of the labour force (eg civil servants) To this day most Thai workers are still employed in the informal economy where work is contingent and conditions largely unregulated Con- currently unionization rates are low and few workers are aware of their rights










80

70 +P Industrial

60

50

40

30

20

10

Source NSO 2008a



Source OECD 2008


















































































































80

70 +P Industrial

60

50

40

30

20

10

Source NSO 2008a



Source OECD 2008









































































































thailand's work and health...

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