Asian-Pacific Newsletter 3/2014, OHS and primary health care

Asian-Pacific Newsletter O N O C C U PAT I O N A L H E A LT H A N D S A F E T Y Volume 21, number 3, December 2014

Occupational health services and primary health care

Asian-Pacific Newsletter on Occupational Health and Safety Volume 21, number 3, December 2014 Occupational health services and primary health care

Published by Finnish Institute of Occupational Health Topeliuksenkatu 41 a A FI-00250 Helsinki, Finland

Editor-in-Chief Suvi Lehtinen

Editor Inkeri Haataja

Linguistic Editing Alice Lehtinen

Layout Kirjapaino Uusimaa, Studio Printing SLY-Lehtipainot Oy /Kirjapaino Uusimaa

The Editorial Board is listed (as of 1 September 2014) on the back page.

This publication enjoys copyright under Protocol 2 of the Universal Copyright Convention. Nevertheless, short excerpts of the articles may be reproduced without authorization, on condition that the source is indicated. For rights of reproduction or translation, application should be made to the Finnish Institute of Occupational Health, International Affairs, Topeliuksenkatu 41 a A, FI-00250 Helsinki, Finland.

The electronic version of the Asian-Pacific Newsletter on Occupational Health and Safety on the Internet can be accessed at the following address: http://www.ttl.fi/Asian-PacificNewsletter

The issue 1/2015 of the Asian-Pacific Newsletter deals with networking.

Contents 43 Editorial Occupational health services and primary health care Somkiat Siriruttanapruk, Thailand 44 Challenges and opportunities in occupational

health services in India – A perceptional study from

southern India S Jeremiah Chinnadurai, Vidhya Venugopal, P Kumaravel, K Paari, Krishnendu Mukhopadhyay, India 48 Occupational health services and primary health care in Sri Lanka Rohini de Alwis Seneviratne, Sri Lanka 50 Delivery of basic occupational health services in Thai PCUs Orrapan Untimanon, Somkiat Siriruttanapruk, Thailand 53 Healthy workplace intervention: Scope of basic occupational health services (BOHS) in informal occupations in India J Majumder, RR Tiwari, SM Kotadiya, India 56 Occupational health services and primary health care in Indonesia Hanifa M. Denny, Indonesia 58 Safely navigating your perfect OSH information world Sheila Pantry, UK

Photograph on the cover page: © ILO, Perera Y.R. Printed publication: ISSN 1237-0843 On-line publication: ISSN 1458-5944

© Finnish Institute of Occupational Health, 2014

The responsibility for opinions expressed in signed articles, studies and other contributions rests solely with their authors, and publication does not constitute an endorsement by the International Labour Office, the World Health Organization or the Finnish Institute of Occupational Health of the opinions expressed in them.

Occupational health services and primary health care

W

orkers’ health is one of the most important public health issues. It can lead not only to workers’ well-being, but also to increasing productivity and expanding the economy. Occupational health services (OHS) are essential for improving workers’ health. According to ILO Convention 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 personnel, 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 “putting 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, sanitation, 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 recommended 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 reforms, and leadership reforms.

To enhance the access of workers to OHS, the 13th Session of the Joint ILO/WHO Committee on Occupational 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 International 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 assurance. 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 primary 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 Siriruttanapruk Senior Expert in Preventive Medicine (Occupational and Environmental Health) Department of Disease Control, Ministry of Public Health Tivanont Road, Nonthaburi 11000, Thailand Email: somkiatk@health.moph.go.th

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

Challenges and opportunities in occupational health services in India

– A perceptional study from southern India Introduction Rapid industrialization and new technological development 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 disease burden in India. Occupational health in India is a complex issue due to child labour, poor labour legislation, lack of control over the vast informal sector, insufficient 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 Occupational Health (NIOH) on the prevalence of occupational 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. Morbidity 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

people migrated for employment. This accounts for about 40.8% of the total migrant workers (4) who find employment in jobs that involve very heavy physical work and high exposure to environmental and occupational stressors. The work is on a temporary basis and makes the workers’ 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 hygiene, occupational health surveys and questionnaire administration conducted by authors in various industries

44

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The study aimed to understand occupational 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 system. An insight into the challenges faced by current OHS professionals in formal sectors would help modify the way OHS services are provided, rather than providing more of the same, which in turn might not help to meet the growing OHS requirements of a workforce that is as diverse and large as that in India.

Methodology From 2011 to 2014, the authors conducted the Industrial Hygiene survey in 89 industries which were formally registered under the Factories Act. Some of these had occupational health centres manned by qualified OH (Occupational Health) practitioners and personnel trained to handle occupational health issues. A questionnaire was developed on the basis of the limited available literature in order to conduct a perceptional survey among the qualified OH practitioners and occupational nurses in the selected industries (45). It included questions on their perceptions of the status of OHS in India, policies, infrastructure, trained personnel, functionality, and challenges and opportunities 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 India Figure 1 depicts the strategy of WHO (World Health Organization) for providing basic health services (5). Statistics indicate 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 components mentioned above are highly inadequate 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 discussion According to the 2011 Indian census,

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

12.4%

Availability of OH centre

14.6%

Availability of doctors

10.1%

Doctors specialized in OHS

15.7%

Availability of nurses

14.6%

Availability of ambulances

0

4

8

12

16

20

Figure 2. OHS statistics in 45 industries in Southern India

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 inspectors are responsible for checking the industrial hygiene and safety of about 56 334 960 workers, which is grossly inadequate (8). The status of OHS in the 45 industries surveyed by the authors is depicted in Figure 2.

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

ees State Insurance or Health services. Although the Factories Act has a Permissible Limit of Exposures (PLEs) to chemicals, heat stress and ventilation, in practice, this is rarely followed, and more chemicals are handled in the industries than the 117 listed under the second schedule of the Factories Act. This needs updating by dedicated organizations. The Director 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 responsible 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 handled by the government health care system, 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

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45

46

81

78

86

66

66 47

Needs exclusive budget for OHS

Needs empowerment to improve OHS

Equipped with community occupational health centre

Medical facilities are mandatory for hazardous and accident prone industries

Needs improved OHS status in India

20 Awareness of occupational exposure

21 Knowledge about OSHAS 18001

100 90 80 70 60 50 40 30 20 10 0

Lack of clear legislations

% of respondents

legislation and guidance on many occupational health issues. A total of 59% of the doctors who are in charge of OHS reported difficulties in obtaining clear information regarding how to deal with and document occupational diseases other than the notifiable diseases listed in the Factories 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 awareness among both employers and employees. 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 management; 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 industries. Only 4 out of the 39 medical officers who responded were OHSAS trained and 23 medical officers felt that safety officers and industrial hygienists are better suited for roles in OHSAS than occupational health physicians.

Industrial hygiene (IH) is still in its infancy 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 difficulties in convincing management to invest in hygiene services in their industries due to various limiting factors. Lack of

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

policies and legislations for mandatory IH services in industries was cited as a challenge (44%) and about 66% of the participants were partially aware of the importance of applying a “Hierarchy of controls” to protect workers from ensuing occupational hazards. As much as 47% felt that a strong safety culture in conjunction with IH was a major opportunity for improving the status of OHS in India.

Infrastructure Almost 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 injuries were difficult to manage due to the lack of trained personnel and equipment.

The industries have agreements with near-

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by hospitals for handling complicated issues such as fatal injuries. A total of 78% responded (Figure 3) that having lifesaving medical facilities is mandatory for hazardous and accident-prone industries, 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 centre in an industrial cluster, supported by the industries, could be a viable solution for effective OHS.

Human resources DGFASLI 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 India (6). To meet the regulations, many in-

dustries appoint medical officers who are regular physicians, lack knowledge of occupational health diseases, and are unaware of the occupational exposures causing them. These physicians visit the industry’s OH centres twice a week for compliance purposes, which is inadequate, and does not help in cases of emergencies. Musculoskeletal disorders (MSD) were a major concern in the industries, and one of the issues that ranked highest among workers frequenting the OH Centre. Longer consultation times and waits for dealing with MSDs when referred to external consultants was reported by 76% of the participants as another major concern, and lack of an onsite physiotherapist and ergonomist for dealing with MSDs was quoted as a cause of employee dissatisfaction 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 limits 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 employees. 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 efforts arising from global markets advocating 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 efforts by the government and private institutions 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 respirators more than occupational exposures and ways in which to eliminate them. In the absence of engineering and administrative controls, the employers must provide 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 workers’ health. Many epidemiological studies have reported excess deaths from different types of cancers, attributed to exposures to a mixture of chemicals with no occupational standards (12). Twenty per cent of the respondents thought that the medical officer and safety officer/industrial hygienist should be empowered by the authorities to order biological monitoring for assessing chronic exposure and health effects, the results of which would give them the evidence to convince management to implement specific administrative 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 industries that responded had a trained industrial hygienist; the rest hired IH consultants periodically, an option preferred by management.

Conclusion The statistics undoubtedly show that India 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 providing 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 unregistered industries and those in the informal sectors, especially in rural regions, cause a dark cloud to loom over the OHS framework of India. Research efforts in OHS and industry-specific epidemiological studies are desperately needed for driving 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 occupational 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 Department of Environmental Health Engineering Sri Ramachandra University Chennai, India Email: vvidhya@ehe.org.in * Corresponding author

References 1. Agnihotram RV. An overview of occupational health research in India. Indian J Occup Environ Med 2005; 9:10–4.

2. Khan FJ Okla. Take home lead exposure in children of oil field workers. State Med Assoc 2011 Jun;104(6):252–3.

3. Saiyed. Occupational Health Research in India. Industrial Health 2004; 141–2.

4. Pingle S. Occupational Safety and Health in India: Now and the Future. Industrial Health 2012;50:167– 71.

5. Rantanen J. Basic occupational health services – their structure, content and objectives. SJWEH Suppl 2005;no 1:5–15.

6. Safety Statistics, http://www.dgfasli.nic.in/info1.htm 7. Census of India 2001, http://www.censusindia.net/.

8. Parekh R. Future occupational health prospection. Indian J Occup Environ Med 2004;8:5–6.

9. Saiyed HN, Tiwari RR. Occupational Health Research in India. Industrial Health 2004;42:141–8.

10. OSHA. Personal Protective Equipment booklet. OSHA 2003;3151–12R. 11. Health and Safety Executive. Personal protective equipment (PPE) at work, A brief guide, 2013.

12. Abbate C, Polito I, Puglisi A, Brecciaroli R, Tanzariello A, German¢ D. Dermatosis from resorcinal in tyre makers. Br J Ind Med 1989;46:212–4.

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Rohini de Alwis Seneviratne, Sri Lanka

Occupational health services and primary health care in Sri Lanka 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 unemployed around the world, reflecting an insufficient expansion 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 regions; the two regions that have the bulk of the increase in global unemployment. Vulnerable employment, that is, either self-employment or work by contributing family workers, accounts for almost 48% of total employment, and more than half of the developing world’s workers account for about 1.5 billion workers (2). Informal employment is common in most developing countries, with regional variations. In Eastern Europe, CIS countries, and a few advanced economies, informal employment still accounts for over 20% of total employment. In Latin America, 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 approaches, such as workplace insurance, social protection through public taxation and in-house OHS. Well-established largescale industries have been able to provide on-site OHS to 48

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Primary health care centre

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

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 urgent consideration. In this context, the primary health care (PHC) approach emerges as a feasible and sustainable option. 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, universality, accessibility, essentiality, social acceptability, equity, affordability, autonomy, and community participation.

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

through referrals to correct this. Effeced or reorganized to include OSH clinics tive and practical approaches for indusand to accommodate workers in lifestyle trial waste disposal, such as reduction, reclinics. The health system will need to inusing and recycling should be advocated. crease staff and other clinical resources as Health promotion to address risk well asinformation facilities flow to cater for the increase factors of non-communicable diseases, in the numbers of clients. a major global public health issue, is also Unavoidably, this approach has certain shortcomings. Without legal provia practical option. Approaches to implementing health promotion, such as adsion, it is not possible to gain access to information flow vocating healthy canteen policies and a work settings, to encourage employers to non-smoking work environment, and emallow workers to attend clinics or to recpowering workers to select healthy optify problems in the work environment. tions in day-to-day life issues have been It is therefore necessary that policy directives, instruments, and a suitable leimplemented. PHC clinics provide simPatient consent ple screening facilities for common nongal framework be identified, and that emObtain patient consent for collection of flow are encouraged to build a good asbestos exposure information communicable diseases.

In addition,information ployers workers can be referred to lifestyle clinrelationship with the local PHC manageics for pre-employment screening and pement. The workers themselves also need riodic screening. The screening offered to to understand that safeguarding their own those over 35 years of age for hypertenhealth by utilizing services is for their own Asbestos information flow sion, diabetes mellitus, cervical and breast benefit. exposure cancer can beinformation easily offered to all workcollection ers at pre-determined intervals through the programme already on offer by the Professor Rohini de Alwis Seneviratne Director, WHO Collaborating Centre for non-communicable diseases control proTraining and Research in Occupational gramme of the Ministry of Health.

Health Workers can be referred through exSenior Professor in Community Medicine isting referral practices to primary care Faculty of Medicine clinics for simple health problems and inUniversity of Colombo jury management. Through this system, Kynsey Road even tertiary referral care can be obtained Colombo 08 when necessary for occupational health Sri Lanka problems and injuries.

Email: srdeas@med.cmb.ac.lk However, a few factors must be considered for the effective utilization of PHC approaches in the provision of OHS services, A policy directive and policy instruments regarding the provision of OHS services would greatly facilitate efforts References towards using the PHC approach. In Sri Lanka, the recently formulated National 1. Global Employment Trends 2014: Risk of Occupational Safety and Health Policy Jobless Recovery. Geneva: International (2014) states that, ‘initiatives are needed Labour Office, 2014.

2. World of Work Report 2014: Developing to strengthen the linkage between the priwith Jobs. Geneva: International Labour mary health care system and OHS, and Office, 2014. the Ministry of Health is encouraged to 3. Global strategy on occupational health for set up a national body and to strengthen all: The way to health at work. Recommenit to oversee this’. Appropriate regulations dation of the second meeting of the WHO Collaborating Centres in Occupational and standards need to be drawn up and Health, 11–14 October 1994, Beijing, China. approval obtained to support the success4. Primary Health Care. Alma Ata World ful implementation of OHS programmes.

Health Organization and United Nations PHC workers who are designated to Children’s Fund, 1979. carry out OHS activities need training in 5. World Health Organization. Connecting Health and Labour: Bringing Together OHS issues, which include practical exOccupational Health and Primary Care to posure. Including OHS modules in their improve the health of workers. Geneva: basic curriculum would greatly facilitate WHO, 2012. this. PHC clinics also need to be expandinformation flow

efits of the PHC system for providing basic 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 geographically-defined areas known as health units cover the entire island of Sri Lanka, ensuring coverage and accessibility through PHC. Coverage is well over 95% for established 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 clinics 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 message 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 occupational and environmental health.

This provides them with the opportunity to visit work settings. Walk-through surveys, identifying problems in the work environment, and providing simple advice 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 advice where necessary. Employees also represent a captive audience for workplace health education and health promotion interventions. Health and safety education is more meaningful when provided at the workplace itself.

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

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Photos by Orrapan Untimanon

Primary Care Unit building

Orrapan Untimanon, Somkiat Siriruttanapruk, Thailand

Delivery of basic occupational health services in Thai PCUs 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 outstanding 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 supported by the Contracting Unit for primary care. Community hospitals are part of a network of PCUs. The Bureau of Occupational and Environmental Diseases (BOED), Department of Disease Control, is a national 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 oc50

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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 nutrition 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 diseases. 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 hazards. Moreover, the health welfare of this group is not covered 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 persons or 61.4%) followed by 29.7% in the trade and service sector and 8.9% in the manufacturing sector (1).

Chronological project implementation In 2008, a pilot project aimed to develop OHS in 16 PCUs was established. Capacity building, training and supervision were the main activities for strengthening the health team and network. After the project ended, the PCUs were able to provide OHS for informal workers. Passive OHS, such as screening of occupational diseases, health examinations, and the treatment of diseases and injuries continued. Pro-active OHS, including walkthrough surveys at workplaces using an observation checklist, and risk assessment using a structured-questionnaire were also performed.

In 2010, the development of OHS in PCUs was extended and 300 PCUs participated 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 delivery in PCUs for farmers. Three departments, including the Department of Disease Control, the Department of Mental Health and the Department of Development 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) participated in this project. As a result, 716 571 farmers underwent risk assessment and 533 524 were entitled to blood tests for cholinesterase screening. Pesticide poisoning 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 provinces, Uthaithani, Supanburi and Burirum, to increase the screening and diagnosis of occupational diseases, and to provide holistic health care for farmers.

Farmer clinics had to: (3) 1) Regularly deliver services, for ex ample, once a week or twice a month, and maintain public rela tions to also target the rest of the population.

Table 1. Farmer clinic/community worker clinic criteria

NO.

Interventions

Yes

1

Farmer clinic open one day/week

2

Database of occupations of population in community

3

Risk assessment

4

Screening of other diseases e.g. diabetes or hypertension

5

Reporting to other related agencies

6

Provision of preventive OHS in at least one intervention

7

Occupational diseases diagnosis

8

Training of occupational health volunteer

9

Occupational health information to the community

10

Occupational health knowledge to strengthen the community

11

OHS delivery plan documented together with the Subdistrict Administrative Organization/ municipality

12

Obtaining funds for OHS delivery from Sub-district health funds

13

Implementation of risk management project

2) Assess farmers’ health problems resulting either from work or un derlying diseases. Carry out two questionnaires, including a muscu loskeletal 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 experience 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 participating in the project. Most of PCUs could provide OHS following such criteria. However, there were few farmers who went to the clinic on the day that PCU was open on OHS issues (once a week); therefore, the OHS for farmers or other infor-

No

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 diagnosis of occupational diseases is still limited, 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) ergonomic problems still need to be evaluated 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: • Starting level (6 of 13 interventions conducted) • Good (7−9 interventions conducted) • Very good (≥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

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Farmer clinic

Occupational diseases prevention board

not only interventions for other community workers, but also for health workers (PCUs staff).

Conclusions The BOED has continuously developed the project on OHS delivery in PCUs for over 10 years. However, although the project 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 competency for effective OHS delivery, 3) improvement of data systems for recording and reporting occupational disease cases or other OHS interventions, 4) collabo-

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) specification of OHS interventions in local health funds and a benefit package for the universal coverage scheme.

Orrapan Untimanon Somkiat Siriruttanapruk Bureau of Occupational and Environmental Diseases Department of Disease Control Ministry of Public Health Nonthaburi 11000, Thailand Email: untimanon@gmail.com

Asian-Pacific Newsletter themes in 2015 The themes of the Newsletters to be published in 2015 are: 1/2015 Networking Manuscripts by 1 March 2015 2/2015 Emerging infectious diseases Manuscripts by 15 June 2015 3/2015 Textile sector Manuscripts by 1 October 2015

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 Safety Finnish Institute of Occupational Health Topeliuksenkatu 41 a A FI-00250 Helsinki, Finland Email: inkeri.haataja@ttl.fi www.ttl.fi/Asian-PacificNewsletter See “Instructions for contributors”

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• Asian-Pacific Newslett on Occup Health and Safety 2014;21:50–52

References 1. National Statistical Office. The informal employment survey 2013.

Statistical Forecasting Bureau, 2014.

2. Chancharoen S, Siriruttanapruk S, Untimanon O. Basic Occupational Health Services and the National Programme for farmers. OH&S Forum 2011 Proceedings, Espoo, Finland, 2011:136–9.

3. Bureau of Occupational and Environmental Diseases. Guideline of OHS delivery in PCUs. (Thai version), 2012.

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J Majumder, RR Tiwari, SM Kotadiya, India

Healthy workplace intervention: Scope of basic occupational health services (BOHS) in informal occupations in India Background

The literature reports ILO data of indecent working conditions and work-related exposures in informal sectors, with about 270 million non-fatal accidents, 2.2 million fatalities and 160 million work-related diseases in the world (6). Due to occupational exposure, unintentional injuries at the workplace, exposures to carcinogens, airborne 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 potential risk posed by the informal sectors of occupation to safety, health and the economy.

Indecent work, an unhygienic work environment, exposure 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.

Photo by J Majumder

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 informal 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 organized, 60% self-employed and 30% do not have regular jobs (3, 4).

In India, the informal sector is broadly characterized 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 quarries, ceramics, glass works, block printing, etc. However, householdbased sub-sector activities (e.g., the production of incense and matchsticks, and handloom and tobacco products) as well as the independent service sector (domestic helpers, street vendors, transportation, construction, forestry, fishing, agriculture 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 product comes from the informal economy. However, this sector of employment is not organized systematically and is devoid of mandatory registration or licenses and thus the legislation to cover it.

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Photo by J Majumder Photo by RR Tiwari

Slate pencil cutting – chiseling plates from slate stone.

ination, prevention, and control of factors hazardous to health in the work environment, 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 location of workplace (16).

Fish sellers – injury prone informal work among fisher women.

employed workers and those in decentralized and rural industries is at a higher risk (9). Working in occupations such as mining, construction, transportation, agriculture, forestry and fishing increases the risk to health and safety (10). Occupational stressors are aggravated by labourintensive practices, poor knowledge regarding hazards, extreme tropical climate, less sophisticated machinery, and extensive 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 distributed in the informal workforce (8).

In spite of the dangers associated with these occupations, poor social dynamics such as poverty and low literacy levels force workers to hold on to their jobs (11, 12). Communicable diseases, malnutrition, poor sanitation, environmental concerns, and inadequate medical care are sustained health issues in India (13). Absence of occupational training and safety training and exposure to hazardous sub54

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

Improving these workplaces requires evolving and implementing management frameworks for the development and delivery 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 services (OHS) (15). This is mainly due to the increased labour force and demand of services. The World Health Organization, the International Labour Office and the International Commission on Occupational Health developed the concept of Basic Occupational Health Services (BOHS) in 2003, to provide essential services for the health of workers in small and medium-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-

• Asian-Pacific Newslett on Occup Health and Safety 2014;21:53–55

Approach to addressing the problem Ample studies have been carried out on OSH in the organized sector. India has also 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 Standard on OHS management systems – IS 18001:2000 – Occupational Health and Safety Management Systems – Specification with Guidance for use. Because this standard was formulated on the basis of demand from the industry for a comprehensive framework of OHS, the coverage of the workers in the unorganized sector still remained an issue. However, the priorities and circumstances of OSH programmes 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

of workers in the informal sector are the Minimum Wages Act, 1948 and Payment of Wages Act, 1936, which help fix minimum wages and protect workers from illegal wage deductions or unjustified delays in the payment of wages. The Unorganized Sector Workers (Conditions of Work and Livelihood Promotion) Bill, 2005 assures basic minimum standards on working 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 informal economy.

Further, the development of an OSH programme or the execution of the basic occupational health services in the informal sector remains a complex activity, requiring organizational structure, functional inter-agency communication, and large technical, personnel and financial input. A serious research approach is required for micro-level factors such as measuring work processes and hazards, workgroup cohesiveness and co-operation, and the approach of the employer and employees towards OSH management, as well as macro-level variables that measure local government commitment to occupational safety and socioeconomic support mechanisms. The objective of an OSH programme is to develop a planned, verifiable process for managing the hazards and risks of health and safety at workplaces, by reducing the direct 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 informal sector. The informal sector is devoid of a management system and is thereby deprived of the conventional assessment of an OSH programme. The non-existence of a health care delivery management system in the unorganized sector does not implicate the non-feasibility of developing a safety, health and environment programme in this sector, but rather that developing a BOHS model for this group will be challenging.

This suggests that diverse work-related 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

References 1. Census of India 2011. Office of the Registrar General & Census Commissioner, India, 2011.

2. Ministry of Labour and Employment. Report of the Working group on Social Security for Twelfth Five Year Plan 2012–17. Ministry of Labour and Employment, Govt of India, 2012.

3. Pingle S. Occupational Safety and Health in India: Now and the Future. Ind Health, 2012;50:167–71.

4. Pingle S. Basic occupational health services. Indian J Occup Environ Med 2009;13(1):1–2.

5. Mitra A. In Focus Programme on Skills, Knowledge and Employability Informal Economy Training and Skill Formation for Decent Work in the Informal Sector: Case Studies from South India, ILO Working paper. International Labour Organization, Geneva, 2002.

6. Takala J. Global estimates of traditional occupational risks. Scand J Work Env Health, 2005;1:62–7.

7. Concha-Barrientos M, Nelson D, Driscoll T, Steenland N, Punnett L, Fingerhut M, et al. Selected occupational risk factors. In: Ezzati M, Lopez A, Rodgers A, Murray C, editors. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors Geneva: World Health Organization, 2004;1651–802.

8. Nag A. Identifying Programme Elements for OSH Development in Selected informal Occupation in Rural India. National Institute of Occupational Health, Ahmedabad, 2009.

9. Loomis D, Richardson D, Wolf S, Runyan J. Fatal Occupational Injuries in a Southern State. Am J Epidemiol, 1997;145:1089–99.

10. Villanueva V, Garcia AM. Individual and occupational factors related to fatal occupational injuries: A case-control study. Accident Annal Prev 2011;43(1):123–7.

11. Dash SK, Kjellstrom T. Workplace heat stress in the context of rising temperature in India. Curr Sci India 2011;101(4):496–502.

12. Ahasan M. Work-related problems in metal handling tasks in Bangladesh: Obstacles to the development of safety. Ergonomics, 1999;42:385–96.

13. Saiyed H, Tiwari R. Occupational Health Research in India. Ind Health 2004;44:218–24.

14. International Labour Organization. Safety in numbers: Pointers for global safety culture at work. International Labour Organization, Geneva, 2003.

15. Chen Y, Chen J, Sun Y, Liu Y, Wu L, Wang Y, Yu S. Basic Occupational Health Services in Baoan, China.

J Occup Health 2010;52:82–8.

16. Rantanen J. Basic occupational health services – their structure, content and objectives. Scand J Work Environ Health Suppl 2005;1:5–15.

17. Nag A, Nag P. Do the work stress factors of women telephone operators change with the shift schedules? Int J Ind Ergonom 2004;33:449–61.

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

Practicalities The 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 applying BOHS to the informal workforce, (b) carrying out surveys in rural and semiurban areas using the surveillance system, (c) examining the basic structure of existing systems and exploring the prospect of applying BOHS as a universal OSH programme for the informal occupation, with due component analysis of the work processes with the retrieved analysed OSH data and possible interaction with human systems.

An initiative has been taken by the National Institute of Occupational Health in the state of Gujarat to analyse the possibility 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 Kotadiya National Institute of Occupational Health (Indian Council of Medical Research) Meghani Nagar Ahmedabad 380016, India Email: majumderj@icmr.org.in, rajtiwari2810@yahoo.co.in, sanjaykotadiya@gmail.com

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Hanifa M. Denny, Indonesia

Occupational health services and primary health care in Indonesia

An overview of Indonesia Indonesia, 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 Indonesia There 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 willingness to adopt and engage workers through volunteerism.

This includes workers in informal sectors, home industries 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)

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• Asian-Pacific Newslett on Occup Health and Safety 2014;21:56–58

Photo by Ms Kadek, courtesy of PUSKESMAS Gianyar

Indonesia is considered one of countries with the biggest universal health coverage. The health services are well structured through community health centres (PUSKESMAS), 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 workers’ 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.

Policies (3) 1. Decree of the Minister of Health of the Republic of Indonesia number: 758/MENKES/SK/XII/2003 con cerning 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 operat ing health service infrastructures within fishing com munities, to facilitate health service access for fisher men and their families, and to help with health insur ance claims.

• The Ministry of State Employees Empowerment and 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 operational BKKMs. Occupational Health Risk Mapping procedures were implemented and performed by the Directorate of Occupational Health (Dit.OH) together with some Provincial Health Offices at selected provinces and workplaces, including those in the informal sectors, home industries 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 Offices 2. Occupational health training for PUSKESMAS’ staff, covering 3000 PUSKESMASes in Indonesia.

3. Training and technical assistance on occupational health for tradition al 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 infor mal sectors, for example, farmers, tra ditional 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 peo ple, it will be the highest coverage in the world.

Financing and collaboration (4, 5) The annual budget for the Occupational Health Program administered by the Directorate of Occupational Health and Sports (MOH, RI) has increased threefold 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 sectors. In addition to direct spending by

the central government, a discretionary spending budget was made available to Provincial Health Offices; so called Deconcentration Budgeting. Local government’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 enterprises. 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 example, is involved in selected projects in partnership 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 pesticide handlers. The Ministry of Industries has participated and collaborated with the Ministry of Health for an Occupational Health and Safety Program at some smallscale batik industries.

Financing is and remains the main issue in delivering OHS to informal sectors.

Some examples of other factors potentially hindering progress are the maintenance of the programme and the partnership.

Firstly, if the PUSKESMAS does not continue its supervisory role, informal sectors have difficulties in sustaining occupational health promotion when the assigned Technical Assistant (TA) has left. Secondly, partnership with local large-scale companies as regards OHS for the informal sectors’ workers has not been promoted widely. Thirdly, as no occupational health programme has been included in the National Minimum Standard of Health Services Delivery in PUSKESMAS, its sustainability depends on the funding assistance, willingness and awareness of the PUSKESMAS’ manager.

Success stories The 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 activities among the different interdependent tiers. The ability and empowerment of PUSKESMASes to provide assistance to POS UKKs has improved the workers’ skills in identifying workplace hazards and their respective solutions. For example, 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 colouring products).

Other occupational health promotion activities through PUSKESMAS and POS UKK have directly contributed to a positive behavioural change amongst informal sector workers and in their workplace hygiene and PPE practices. Credit must be given to the notable effort to make home industry owners believe that they themselves and their workers will work better because they are healthier due to provision of occupational health services.

Current barriers Although progress and success are the norm, difficulties in cross-sector collaboration, 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 barriers. Other obstructions also persist, such as informal sector workers’ non-permanent status and difficulty in tracking them.

Last but not least, sustainability efforts for maintaining the Occupational Health programme when funding ends are lacking.

Current limitations Despite the overall vision and will for improvements in the health of Indonesia’s population, major influencing limitations such as the lack of human resources to deliver OHS, and difficulties gaining access to certain villages due to geographical barriers, remain an issue. The time constraints of workers and difficulties in mapping the type of production necessary to establish a POS UKK also play a significant role and are currently limiting progress.

A solution to the limited funding for covering all underserved working populations in Indonesia has yet to be found.

Future plans for the expansion of universal coverage beyond health care coverage

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

Strengths A common strength is that community participation and engagement in social activities is a strongly ingrained part of Indonesian culture. Furthermore, all stakeholders and beneficiaries remain deeply engaged and vested, as the roadmap to national success is now supported and enforced 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 delivery of OHS programmes, better-quality, continuous improvement policies in OHS, and a vision supported by a plan for universal health coverage that has been well structured and implemented.

Hanifa M. Denny, Ph.D. Associate Professor (Lektor Kepala) Department of Occupational Safety and Health College of Public Health Diponegoro University Jl. Prof. Sudharto, SH, Kampus Undip Tembalang Semarang 50239, Indonesia Email: hanifadenny@mail.usf.edu

References 1. Statistics Indonesia, available at: 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/Pub licPrivatePartnershipsForum/2014-JUL-29/ Day%202/Panel%206/35-Denny-Video. aspx 3. Denny H. Impact of Occupational Health Interventions in Indonesia. UMI 3549179, ProQuest LLC, USA 2013). Available at: http://pqdtopen.proquest.com/pqdtopen/ doc/1283390488.html?FMT=AI 4. Wagner N, Denny H. Consultation for the Directorate of Occupational Health, Ministry of Health, Republic of Indonesia, funded

by GTZ-PAF, 2006.

5. Annual Report of Occupational Health Program of the Directorate of Occupational Health and Sports in 2010–2013, Unpublished.

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Sheila Pantry, UK

Safely navigating your perfect OSH information world Ever wondered if your usual occupational safety and health (OSH) sources are validated, 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 believe 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, accurate content.

Questions about OSH information First, 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 knowl edge up to date and comprehen sive? d) An organization that you are a member of, that will obtain an swers 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 usage costs.

• Asian-Pacific Newslett on Occup Health and Safety 2014;21:58–59

Do you need worldwide information?

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

Another question is how much would you pay for authoritative and validated information?

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

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 searching for information on occupational, safety, 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.

• When searching, think of: related terms (both broader and narrower) • synonyms • other chemical names plus unique chemical number • legislation • differences in British and American terminology, for example, fume cup boards and fume hoods

3. Search tips Using what is known as Boolean operators – 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 sophisticated 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 looking 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 different spellings found in American and British 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 retrieve 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 retrieve 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 specialize 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, CDROMs, either full text or bibliographical information

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

10. Search strategy Work out a search strategy before starting your search. Many search engines offer ways of refining your search and this will save time and money in the long run, for example, decide: • how far back in time do you need to go? You will save time by limiting your search.

• on which authoritative sites you wish to search • on language; for example English only, which again will save time and money • on the words and phrases to be used.

Remember to use both English and the language of the site • whether or not to refine your search.

Most search engines offer two types of search - “basic”, and “advanced” or “refined”. In the “basic” search, just en ter 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.

• whether or not to automatically ex clude common words. Most search en gines ignore common words and characters such as “where” and “how”, as well as certain single digits and sin gle 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.

• whether a common word is essential 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 com mon that it is not considered in search es.

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. “airline” and “airlines”. Read the “hints and tips” information for each of the different 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 removed completely, or changed its name, or be temporarily unavailable. Try the following: • Make sure you have typed in the home page correctly: you may have made a spelling mistake • If some specific page is suddenly not available, open the main home page and then look for the link: it may have been re-linked • If the above actions fail, go into one of the search engines, for example, www.google.com and look for the in formation again.

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

• Adobe Acrobat PDF (.pdf) • Adobe Postscript (.ps) • Microsoft Word (.doc) • Microsoft Excel (.xls) • Microsoft Powerpoint (.ppt) • Rich Text Format (.rtf)

Sheila Pantry, OBE BA FCLIP Sheila Pantry Associates Ltd 85 The Meadows, Todwick, Sheffield S26 1JG, UK Email: sp@sheilapantry.com www.sheilapantry.com

Asian-Pacific Newslett on Occup Health and Safety 2014;21:58–59 •

59

Editorial Board

as of 1 September 2014

Chimi Dorji Licencing/Monitoring Industries Division Ministry of Trade and Industry Thimphu BHUTAN N.B.P. Balalla Head Occupational Health Division Block 2 G5-03 Jalan Ong Sum Ping Bandar Seri Begawan BA 1311 BSB BRUNEI DARUSSALAM Yang Nailian National ILO/CIS Centre for China China Academy of Safety Sciences and Technology 17 Huixin Xijie Chaoyang District Beijing 100029 PEOPLE’S REPUBLIC OF CHINA Ho Ho-leung Deputy Chief Occupational Safety Officer Development Unit Occupational Safety and Health Branch Labour Department 14/F, Harbour Building 38 Pier Road, Centrum Hong Kong, CHINA

K. Chandramouli Joint Secretary Ministry of Labour Room No. 115 Shram Shakti Bhawan Rafi Marg New Delhi-110001 INDIA Lee Hock Siang Director OSH Specialist Department Occupational Safety and Health Division #04-02, Ministry of Manpower Services Centre 1500 Bendemeer Road Singapore 339946 SINGAPORE John Foteliwale Deputy Commissioner of Labour (Ag) Labour Division P.O. Box G26 Honiara SOLOMON ISLANDS Le Van Trinh Director National Institute of Labour Protection 99 Tran Quoc Toan Str. Hoankiem, Hanoi VIETNAM

Nancy Leppink Chief of LABADMIN/OSH International Labour Office 4, route des Morillons CH-1211 Geneva 22 SWITZERLAND Evelyn Kortum Technical Officer, Occupational Health Interventions for Healthy Environments Department of Public Health and Environment World Health Organization 20, avenue Appia CH-1211 Geneva 27 SWITZERLAND Jorma Rantanen ICOH, Past President FINLAND Harri Vainio Director General Finnish Institute of Occupational Health Topeliuksenkatu 41 a A FI-00250 Helsinki FINLAND