thailand's work and health transition

International Labour Review, Vol. 149 (2010), No. 3

Thailand’s 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 tomanufacturing and services, and to more formal employment. Its labour marketregulation and worker representation, however, are much weaker than they are indeveloped countries, which underwent these transitions more slowly and sequen-tially, decades earlier. The authors examine the strengthening of Thailand’s policyand legislation on occupational safety and health in response to international stand-ards, a new democratic Constitution, fear of foreign trade embargoes, and fatalworkplace disasters. In concluding, they identify key challenges remaining forpolicy-makers, including enforcement of legislation and measurement of new mentaland physical health effects.

ow people work and the conditions in which they work are critical deter-Hminants of population health. Yet, while much attention has been de-voted to interconnections between work and health in affluent developed coun-tries, far less is known about this topic in transitional economies (CSDH, 2008).This case study of Thailand illustrates a contemporary work and health tran-sition 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: [email protected]. ** National Economic and Social Devel-opment Board, Bangkok, email: [email protected]. *** School of Human Ecology and ThaiHealth Promotion Centre, Sukhothai Thammathirat Open University, Nonthaburi, email: [email protected].

This study was supported by the Thai Health-Risk Transition project with joint grants fromWellcome Trust UK and the Australian National Health and Medical Research Council under theInternational Collaborative Grants Scheme. The authors wish to acknowledge the helpful advice andencouragement of Dr Chaiyuth Chavalitnitikul.

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

Copyright © The authors 2010Journal compilation © 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 itstrives for a healthy and productive workforce.

Economic transitions, work and healthAs traditional rural occupations give way to manufacturing, service and know-ledge jobs, population health is affected by rising incomes, changing safety risksand working conditions, and employment insecurity (Benach, Muntaner andSantana, 2007). The resulting health transition is marked by shifts in environ-mental risks and human ecology (McMichael, 2001), diet and nutrition(Drewnowski and Popkin, 1997), and morbidity and longevity (Caldwell andCaldwell, 1991; Frenk et al., 1991; Caldwell, 1993; Jamison et al., 1993).

Jobs affect health through exposure to occupational hazards. The greatestrisks occur in construction, manufacturing, and industrialized agriculture owingto atmospheric pollutants, heart diseases caused by emissions or stress, andinjuries due to noise and poor ergonomics. Workers in the service sector, par-ticularly office environments, generally face the lowest risk of injury or disease(Ezzati et al., 2004). The service and knowledge sectors, however, also posehealth risks – especially to mental health – as a result of work organization, jobinsecurity, work pressures and shift work.

In affluent countries, the transition to a service and knowledge economywidened wage inequality (Goos and Manning, 2007) – a factor which may alsoaffect health outcomes. In these countries, the transition has been sequentialand relatively gradual, accompanied by a process of state regulation of workingconditions and worker representation. Developing and transitional economies,by contrast, are changing at a faster pace without any tradition of worker rep-resentation, which limits capacity for regulation to protect workers’ health.Furthermore, the context of accelerating globalization – with capital movingfreely across borders and labour markets competing globally – is placingdownward pressure on wages and conditions (Slaughter and Swagel, 1997). Inother words, the pace and context of change in developing and transitionalcountries differ from what today’s developed economies experienced previ-ously; and it is not clear whether these countries will reap the same healthbenefits from development.

Thailand’s labour market and health transitionWhen Thailand entered its transformative stage, its state regulation of workingconditions, social security and employment policies were obviously much lessadvanced than those of developed countries. And such regulations and policiesas were in place applied only to specific segments of the labour force (e.g. civilservants). To this day, most Thai workers are still employed in the informaleconomy, where work is contingent and conditions largely unregulated. Con-currently, unionization rates are low, and few workers are aware of their rights.

Thailand’s work and health transition 375

Although Thailand’s speedy economic transition has created a “modern” sectorof service and knowledge industries, a sizeable proportion of the labour forcecontinues to work in the traditional sectors of agriculture and industry. Intoday’s developed countries, by contrast, there was a more sequential shift fromone dominant sector to the next over centuries. Thailand’s health transition isthus characterized by the coexistence of modern and traditional sectors with dif-ferent work-related hazards, pay and working conditions.

In the course of Thailand’s transition over the past 50 years, many of itshealth indicators have shown improvement: life expectancy has increased, whilemortality and the incidence of communicable diseases and malnutrition havedecreased. From 1964 to 2006, for example, life expectancy increased from 56 to70 years for males and 62 to 78 for females. From 1962 to 2006, the maternalmortality ratio fell from 374.3 to 9.8 per 100,000 live births. And from 1980 to2004, the infant mortality rate fell from 49 to 21 per 1,000 live births (Wibulpol-prasert, 2008).

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

Structural drivers of Thailand’s labour market transition

Trends in workforce compositionThailand’s sectoral employment trends illustrate the speed of its economic trans-formation (see figure 1). In 1960, agriculture occupied 82 per cent of the labourforce; in 1980, just before Thailand’s economic transformation took off, the pro-portion 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, Australia’s agricultural employ-ment had already fallen below 20 per cent in 1948 (figure 2). This reflects the dif-ferent structural factors facing policy-makers in the two countries: unlikeAustralia, where employment has long been dominated by one sector, Thailandshows a fairly even distribution of employment across sectors (figures 1 and 2).Indeed, while its agricultural workforce shrank between 1980 and 2008, the pro-portion of Thai workers employed in the manufacturing and service sectors morethan doubled, from 11 to 24 per cent and from 19 to 41 per cent, respectively(NSO, 2008a).

The informal sectorThailand’s National Statistics Office (NSO) defines informal workers as those,primarily self-employed, who are not covered by existing workplace laws, regu-lations and protections (NSO, 1994). Informal workers operate at a low level of


organization, [… with labour relations] based mostly on casual employment, kin-ship or personal or social relations rather than contractual arrangements withformal guarantees” (ILO, 1993, art. 5(1)). In other words, informal-sector em-ployment 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


force is informally employed, government tax revenues are substantially re-duced, constraining investment in health infrastructure (Sujjapongse, 2005).

From 80 per cent two decades ago, the proportion of Thailand’s labourforce in informal employment fell to 71 per cent in 2000, and 62.7 per cent in2007 (NSO, 2007). A little over half of these informal workers were employed inagriculture, with the remainder running small businesses or market stalls, orworking in factories or construction. Although the proportion of the labourforce employed informally is still high, it is falling rapidly with modernizationand development, particularly in Bangkok, where it was only 31.7 per cent in2007 (NSO, 1994, 2005b and 2007). For the foreseeable future, however, infor-mal employment will remain an important mechanism for absorbing excesslabour in economic downturns and providing jobs for new urban migrants.

Inequity in the labour marketLife expectancy, infant mortality and other health indicators improve as incomesincrease, but socio-economic inequalities mean that not all people experience thesame health benefits (Kawachi, 2000; Coburn, 2000). A concomitant of Thai-land’s labour market transition and rapid economic growth has been an increasein income inequality. Measured by the Gini coefficient, Thailand’s income in-equality rose from 0.410 in 1962 to a peak of 0.525 in 2000, before falling back to0.499 in 2007 (UNPAN, 2003; Thailand, 2007b). By comparison, in Australiawhere the work transition occurred earlier, the Gini coefficient has hoveredaround 0.448 in recent years (ABS, 2003).

Higher wages and safer working conditions in the growing service sectorcan also improve social cohesion and equity – including gender equality. Thai-land differs from many countries at a similar stage of development in that itsfemale 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 devel-oped countries (NSO, 2009). Most women in Thailand enjoy the opportunity towork 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 in-secure, informal and home-based employment (Tonguthai, 2002). In 2005, forexample, 76.3 per cent of home-based workers in Thailand were women (NSO,2005c).

Work and familyChange from a rural, agriculture-based economy to a rapidly urbanizing one hasaffected family life, as work has moved away from the village and the extendedfamily, while few alternative childcare options are available (Heymann, 2003). Inrural Thailand, as men tend to work in urban areas, women have to look afteragricultural 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 andmental health of mothers and children. Furthermore, women’s long workinghours have increased marital instability (Edwards et al., 1992) – a further cause ofpsychological distress and related illness among parents and children.


Working conditions in Thailand

Hours of work and productivityThailand’s economic transition is characterized by persistently low labour pro-ductivity, rooted in generally low levels of educational attainment among thelabour force. At present, around 57 per cent of the Thai labour force haveprimary-school education at best (NSO, 2008a). In the period of rapid growththat was largely driven by manufacturing, an uneducated labour force was not ahindrance to the country’s economic success. But jobs are now becoming in-creasingly skilled, service-oriented and knowledge-based, leaving Thailand withboth a shortage of skilled workers and a large pool of unskilled labourers whocannot get good-quality jobs.

The Government has responded by increasing spending on education andpromulgating the 1999 National Education Act, which provides for 12 years offree education. The number of students proceeding beyond the primary levelhas increased sharply in recent years: in 2006, approximately 59 per cent of stu-dents completed upper secondary school and 24 per cent went on to tertiaryeducation (NSO, 2008b). However, the labour market effects of this trend arelikely to occur with a persistent time-lag because of the large share of the labourforce still having only primary education (Khoman, 2005).

Meanwhile, Thailand’s low labour productivity generates its own healthrisks, as employers demand longer hours and pay lower rates. The average work-ing week is 48 hours in manufacturing, and up to 54 hours in trade and serviceindustries. Almost 70 per cent of the labour force spend more than 40 hours aweek at work (NSO, 2008a), compared with only 30 per cent in Australia, whichis among the developed countries with the longest working hours (ABS, 2007).Such long hours clearly exacerbate the health risks facing workers, particularlywomen, who have to combine long hours at work with family responsibilities.

Social security systemsSocial security is also important for workers’ health. Several schemes operate inThailand, namely:

• the Civil Servants’ Medical Benefit Scheme and Government Officials’Pension Act of 1951, which provide generous benefits for governmentworkers and their dependants (Reisman, 1999);

• the Workman’s Compensation Scheme – an employer-funded scheme pro-viding benefits for work-related sickness (ibid.);

• the Social Security Scheme, which provides sickness benefits for conditionsunrelated to work, old-age pension and unemployment benefits (ibid.;Kanjanaphoomin, 2004);

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


Thailand’s social security system has thus progressed towards a universalsafety net providing free health care to workers and their dependants, therebygreatly reducing inequities in access to health care. Legally registered foreignworkers can also be covered by this scheme for a small fee. Although informalworkers are still excluded from other social security benefits – e.g. paid sickleave and unemployment benefits – a universal pension of 500 baht per monthcovering even informal workers was recently introduced.

UnionizationTrade unions play a pivotal role in securing both statutory labour protection andrights – including on occupational safety and health, overtime and family/sickleave – and in the enforcement of those rights at the workplace (Mishel andWalters, 2003). Averaging less than 4 per cent in 2006, Thailand’s overall rate ofunionization is very low, though it was more than 50 per cent among state-enter-prise workers. Likely reasons include the large percentage of workers infor-mally employed (particularly casual migrant labourers), cultural factors, and thelack of political support for unionization among the country’s leadership(Brown, 2001). Besides, many Thai workers are also reluctant to upset the tradi-tional family relationships typically found within workplaces because they pro-vide them with protection.

Until the mid-1970s, unionization was actively suppressed. Since then,there have been improvements in freedom of association, and trade unions nowenjoy some statutory rights. The 1975 Labour Relations Act regulates the regis-tration of unions and establishes labour-dispute resolution procedures. Itfavours enterprise-level unions and limits industry-wide organization (Lawlerand Suttawet, 2000). However, despite improved statutory rights during Thai-land’s rapid economic transition, union strength may have actually declinedbecause of a combination of poor enforcement of the right to organize andprivate-sector employers’ active suppression of unionism (Brown, 2001).

In developed countries, trade unions have been key players in settinghours of work and minimum wages, reducing exposure to occupational hazards,and securing paid sick leave and holidays and other benefits for workers. Theweakness of trade unions may thus be another reason for Thailand’s long hoursof work and low wages. It has been estimated that up to 40 per cent of factoriesdo not honour their minimum-wage obligations (Charoenloet, 1998).

National planning for labour and workplace safety

Changes in labour policyThe 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 “People’sConstitution” was promulgated in 1997. This new Constitution’s numerous pro-visions for individual and collective rights led to the establishment of a National


Human Rights Commission (Baker and Phongpaichit, 2005). Reform of labourlegislation can be seen as part of this process.

Two other reasons may explain policy interest in workplace health andsafety. 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 killedand some 500 injured. This drew the attention of the media, non-governmentalorganizations and public to the issue of worker safety, putting pressure on pol-icy-makers to take action (Brown, 2001). Just like the 1911 Triangle ShirtwaistFactory fire that killed 146 garment workers in New York and led to a raft ofnew legislation aimed at protecting workers in the United States (McEvoy,1995), these industrial accidents appear to have marked a turning point innational attitudes towards worker safety in Thailand.

The second, related reason was the fear of embargoes on Thai exports thatmight result from international condemnation of Thailand’s labour standards(Brown, 2001). Besides, Thailand has been a member of the ILO since 1919, andalthough it has cautiously ratified only a few of the ILO’s more than 180 Con-ventions, it hosts the Organization’s Regional Office for Asia and the Pacific,with which its Ministry of Labour and Social Welfare has developed a closeworking relationship.

An important channel for the implementation of Thailand’s new policydirection on labour has been its five-year National Economic and Social Devel-opment Plans, formulated by the powerful National Economic and SocialDevelopment Board (NESDB). Since the eighth such plan, spanning 1997–2001,policy guidelines have consistently emphasized reduction of the incidence ofoccupational 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, andrecognition of informal workers’ organizations, thus providing them with greaterprotection and security. NESDB policy has also been aimed at providing infor-mal workers with social security benefits similar to those enjoyed by the formalworkforce (Thailand, 2004).

Since 1997, these issues have been specifically addressed through theNESDB’s Labour Development and Welfare Plans, which also open up avenuesfor collective bargaining on workplace conditions (Ruphan, 1999). These planshave provided for new safety regulations, a national safety culture campaign,better inspection systems, embedded safety management systems, improvedreporting, and participatory training. These measures address both well-knownoccupational hazards and newly recognized biological, psychosocial and muscu-loskeletal risks (Chavalitnitikul, 2005).

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


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

Since 2005, the Ministry of Labour and Social Welfare has openly sup-ported regulation to require organizations employing 50 or more workers todevelop an occupational safety and health management system (Chavalitni-tikul, 2005). The prerequisite reforms and training procedures are still underway; 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 surveil-lance programme. The latter is part of a joint effort to set up a comprehensiveoccupational health and safety surveillance system pooling the resources of theMinistry of Public Health, the Ministry of Labour and Social Welfare and theMinistry of Industry with a view to monitoring the incidence of target diseases(e.g. silicosis), identifying high-risk groups and developing policy interventions(Siriruttanapruk and Anantagulnathi, 2004).

Workplace health and safetyThe Ministries of Health and of Labour and Social Welfare have addressedindustrial health risks such as hazardous chemicals and unsafe manufacturingpractices, but there are new hazards that remain unregulated. Indeed, poorergonomics and workplace design, human resource practices and repetitivework 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 theGovernment’s ability to improve overall standards of occupational health andsafety. In particular, the disease and injury rates reported for informal workersare most probably inaccurate because of under-reporting (Chavalitsakulchaiand Shahnavaz, 1993).

Nevertheless, after peaking in 1990, the numbers of recorded workplaceinjuries and deaths have been falling in recent years, as has the incidence ofoccupational disease. Indeed, statistics from the Office of the Workmen’s Com-pensation Fund reflect a downward trend in death and injury rates since 1994:reported deaths per 100,000 workers fell from 19.2 in 1994 to 17.7 in 1997, 11.6in 2004, and 9.5 in 2006; similar declines were reported in injury rates per 1,000workers: from 43.8 in 1994 to 29.2 in 2004, and 24 in 2007 (see also Chavalitni-tikul, 2005; Wilbulpolprasert, 2008; Seehavong, 2006; Thailand, 2007a).

The role of globalization in Thailand’s transitionAs from 1987 rapid economic expansion was fuelled by massive growth in foreigndirect investment. Concomitantly, the Thai Government’s economic policies


promoted export-oriented development, reduced trade barriers, and privatizedstate enterprises in order to maximize international trade and the country’s com-petitiveness. Thailand’s growing reliance on foreign investment and trade culmi-nated in the Asian financial crisis of 1997, triggered by a massive outflow offoreign capital (Warr, 1993, 1999 and 2005). The country has since tried to strikea better balance in its economic development by reducing its dependence onforeign capital and exports.

This “encounter” with globalization occurred at a time when Thailand hadneither policies nor structures in place to ensure that workplace health andsafety rules were followed by international companies on its soil. Nor did it yethave 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 ofworkplace safety refined over long years of industrial development in moreadvanced countries. In contrast to the deregulation of many developed econo-mies, the Thai bureaucracy is thus demanding increased workplace safety basedon 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 theinfluence of P.A. Payutto. This approach emphasizes well-being, moderationand 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 nationaleconomic development plans (Thailand, UNEP and TEI, 2008). What this actu-ally means for the interaction between work and health in Thailand is unclear.In rural Thailand, at least, there is a movement towards community rights overresources and empowerment, along with emphasis on self-reliance and distrustof financial markets and industrialization (Hewison, 2000; Reynolds, 2001).

Implications for a healthy and productive labour forceThailand is progressing towards a modern, well-regulated labour market asemployment moves steadily from agriculture towards the manufacturing andservice sectors. The labour force is formalizing, workplace health and safety areimproving, and workers enjoy more rights than before. These developmentshave coincided with globalization, which has strengthened external influence onThai policy-making. This is particularly obvious in regard to workplace healthand safety. What is more, growing openness and civil-society participation inpolitics have led to improved legislation, protecting workers and granting themrights in accordance with international standards.

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


the low unionization rates and large informal workforce, occupational diseasesare likely to continue to be a major public health burden. Another unknown isthe way changes in work organization, workloads, autonomy and job insecuritymay affect the mental health of the Thai labour force, both formal and informal.In the developed world, mental health problems such as depression – in whichworking conditions play an important role – are now one of the leading causesof morbidity (Stansfeld and Candy, 2006).

Changes in government policy on workplace health and safety are rela-tively recent, with little research on their benefits to workers’ health. But newacademic journals are being launched and new research alliances are beingformed which may provide the evidence base needed by policy-makers in Thai-land and other transitional economies. Indeed, the bulk of the world’s workingpopulation lives in transitional and developing countries. Hence the need forfurther research on the impact of heavy workloads, work intensification, lowautonomy, job insecurity and low work rewards in these countries. Indeed, inthe context of economic downturns and frequent recourse to offshoring, suchworking conditions may become even more widespread and important for pub-lic health in middle-income countries such as Thailand. Developing this evi-dence base requires large-scale national monitoring arrangements as well asresearch on representative cohorts of workers and their families. Given theimpact of work on health, investment in this research is urgent.

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