Introduction
Employment and working conditions are major social determinants of health (CSDH 2008). While those in employment are often healthier than the unemployed, they risk being exposed to various health and safety hazards at work. The International Labour Organization (ILO) estimates that each year about 2.3 million men and women worldwide die from work- related accidents and diseases, with close to 360,000 fatal accidents and an estimated 1.95 million fatal work- related diseases (ILO 2009). The 880 million people in the WHO European Region include about 400 million workers. Occupational disease and injury ranks among the top ten risk factors responsible for the total disease burden in the WHO European Region (Concha- Barrientos, Imel Nelson et al.
2004). More than 300,000 lives are lost in Europe each year due to work- related diseases and accidents. Adverse health effects of poor working conditions are resulting in an economic cost of 4–5% of GDP (Takala, Hämäläinen et al. 2009).
Persons with insecure jobs are at an increased risk of poor health (László, Pikhart et al. 2010). The protection of workers from sickness, disease, and injury is not only a fundamental human right, but also one of the main goals of the World Health Organization (WHO) and ILO, as set out in their constitutions.
Although there have been consistent improvements in health and safety at work in the WHO European Region, large disparities remain between and within countries with regard to the health status of workers, their exposure to occupational risks, and access to occupational health services. Workers in vulnerable or underserved groups (such as young or older people, pregnant women, people with disabilities, migrants) and those in high- risk sectors (such as mining, construction, health care, agriculture, small and medium- sized enterprises, informal employment, the self- employed) are more likely to suffer from occupational diseases and injuries (WHO 2007).
Following the example of Germany, where Bismarck introduced an industrial accident insurance system in 1884, most industrialized countries in Europe
established occupational health services and workers’ compensation systems.
In parallel, industrial medicine emerged as a distinct medical specialty, incorporating preventive medicine and public health as well as clinical medicine.
Industrial medicine then evolved into occupational medicine and, by the late twentieth century, occupational medicine and occupational hygiene became the two principal disciplines of modern occupational health. Occupational health and safety programmes have become an important part of modern public health services addressing the wider social and environmental determinants of health.
This chapter explores current challenges and opportunities for occupational health and safety in the WHO European Region. We first provide some terminological clarifications and then review the main international instruments for advancing occupational health and safety in Europe. This is followed by an overview of the situation in different parts of the region and an analysis of the main challenges today. The next section discusses strategic directions for the future. We conclude that modern public health services should include a substantive programme for health and safety at work, particularly targeting vulnerable workers and high- risk sectors.
Terminological clarifications Occupational health
According to the twelfth session of the Joint ILO/WHO Committee on Occupational Health in 1995, “occupational health” concerns (Joint ILO/WHO Committee on Occupational Health 1995):
the promotion and maintenance of the highest degree of physical, mental and social well- being of workers in all occupations; the prevention amongst workers of departures from health caused by their working conditions; the protection of workers in their employment from risk resulting from factors adverse to health; the placing and maintenance of workers in an environment adapted to their physiological and psychological capabilities; and, to summarize, the adaptation of work to workers and of each worker to his or her job.
The main foci of occupational health are maintaining and promoting workers’
health and working ability, ensuring work and the working environment are conducive to safety and health, and developing work organizations and working cultures so that they support health and safety at work.
Occupational safety
Occupational safety focuses primarily on the prevention of occupational accidents and injuries in all types of industries and services. Recognizing that unsafe workplaces and work practices can also cause work- related diseases, the term “occupational safety” is often combined with the term “occupational health”. In certain cases, a broader definition of occupational safety embraces the area of occupational health.
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Occupational health and safety, and occupational safety and health
A healthy workplace should be a safe one, and a safe workplace should be a healthy one. Occupational health, occupational safety, occupational health and safety, and occupational safety and health are thus used interchangeably.
Occupational health, as defined by WHO and ILO (see above), is often referred to as occupational health and safety in the health sector (e.g. by ministries of health, occupational health physicians and nurses, occupational hygienists), whereas it is often referred to as occupational safety and health in the labour sector (e.g. by ministries of labour, labour inspectors, safety engineers).
The expression “occupational health and safety” is favoured by WHO, but
“occupational safety and health” by ILO. Both are also referred to as “Health and Safety at Work” or “Safety and Health at Work” in EU legislation and policy documents (see below).
Occupational health services
The ILO has defined occupational health services as (ILO 1985):
services entrusted with essentially preventive functions and responsible for advising the employer, the workers and their representatives in the undertaking, on the requirements for establishing and maintaining a safe and healthy working environment which will facilitate optimal physical and mental health in relation to work, and the adaptation of work to the capabilities of workers in the light of their state of physical and mental health.
Modern occupational health services include: improvement of work organization; workplace and health surveillance; risk assessment, management, and communication; first aid and accident management; and workplace health promotion.
Basic occupational health services
Universal coverage of all workers in all occupations with occupational health services has been recommended by WHO and ILO. However, workers in small and medium- sized enterprises and informal sectors often receive minimal occupational health services. To make the goal of “Occupational Health for All”
more feasible, the concept of basic occupational health services emerged and was endorsed by the 13th ILO/WHO Joint Committee on Occupational Health in December 2003. Basic occupational health services are an application of the Alma Ata principles on primary health to occupational health. They can be defined as essential services for the protection of people’s health at work, the promotion of health, well- being and work ability, and the prevention of ill- health and accidents, using scientifically sound and socially acceptable occupational health methods, through a primary healthcare approach (Rantanen 2005).
Workplace health promotion
Workplace health promotion has been defined as (ENWHP 2013):
the combined efforts of employers, employees and society to improve the health and wellbeing of people at work. This can be achieved through a combination of: improving the work organization and working environment;
promoting active participation; encouraging personal development.
The workplace is an excellent setting that can promote the physical, mental, economic, and social well- being of workers, and in turn enhance the health of their families, communities, and society at large.
International commitments and instruments
A number of international commitments and instruments have been adopted at the global and European level on health and safety at work.
Resolutions of the World Health Assembly
The World Health Assembly (WHA) is the decision- making body of WHO, and its resolutions constitute “soft law” in international relations (Fidler 2003).
In 1996, it adopted Resolution WHA49.12, endorsing the Global Strategy on Occupational Health for All (WHO 1996). It urged member states to devise national programmes on occupational health for all, with special attention to the underserved working population, including migrant workers, workers in small industries and the informal sector, and other occupational groups at high risk or with special needs, including child workers. In a follow up, the 2007 World Health Assembly adopted Resolution WHA60.26, endorsing the Global Plan of Action on Workers’ Health 2008–2017, with five objectives for actions (see Box 5.1).
Box 5.1 The five objectives of the 2007 WHO Global Plan of Action on Workers’ Health
•
to devise and implement policy instruments on workers’ health;•
to protect and promote health at the workplace;•
to improve the performance of and access to occupational health services;•
to provide and communicate evidence for action and practice;•
to incorporate workers’ health into other policies.Source: WHO (2007)
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ILO conventions
A key function of the ILO is to develop international standards on occupational safety and health. It has so far adopted approximately 70 conventions in this area. ILO conventions are legally binding international law for those countries that have signed and ratified them. The 1981 Occupational Safety and Health Convention (No. 155) and Recommendation No. 164 established the duty of employers to provide safe work conditions, the need for enterprise- based cooperation between workers and employers in occupational safety and health, and the right of workers to be informed about and decline dangerous work. The 1985 Occupational Health Services Convention (No. 161) and Recommendation No. 171 set out principles for the protection of workers against sickness, disease, and injury arising out of work and established the preventive function of occupational health services (Box 5.2). It further clarified that occupational health and safety policies should be adopted at the national level, based on tripartite collaboration between government, employers, and employees.
Box 5.2 Functions of occupational health services according to ILO Convention No. 161
•
Identifying and assessing the risks related to health hazards in the workplace.•
Advising on planning and organization of work and working practices.•
Providing advice, information, training and education on occupational health, safety, and hygiene, and on ergonomics and protective equipment.•
Surveillance of workers’ health in relation to work.•
Contributing to occupational rehabilitation and maintaining people of working age in employment, and assisting in the return to employment of those who are unemployed for reasons of ill health or disability.•
Organizing first aid and emergency treatment.European Social Charter
The European Social Charter, adopted in 1961 by the Council of Europe and revised in 1996, guarantees social and economic human rights, and most of the 47 member states of the Council of Europe have agreed to be bound by it.
Article 2 on “the right to just conditions of work” mandates states parties to eliminate risks in inherently dangerous or unhealthy occupations.
Article 3 on “the right to safe and healthy working conditions” specifies the responsibilities of governments, including the progressive development of occupational health services for all workers with essentially preventive and advisory functions. The potential for recognized entities and non- governmental organizations (NGOs) to take legal action against non- compliant governments
makes the European Social Charter a powerful instrument to promote occupational health and safety in Europe.
EU directives and strategies
EU directives on safety and health at work have their legal foundation in Article 153 of the Treaty on the Functioning of the European Union (Treaty of Rome;
effective since 1958), which gives the EU the authority to adopt directives for improving safety and health at work. The EU Framework Directive on Safety and Health at Work (Directive 89/391/EEC) guarantees minimum safety and health requirements throughout the EU (Council of the European Communities 1989). The framework directive also established general principles, including risk assessment, avoidance, substitution, and prevention. It specifically prioritizes collective protective measures through the participation of health and safety representatives, and obliges employers to take appropriate preventive measures to make working safer and healthier.
The framework directive made widespread changes to occupational safety and health legislation in some EU member states. It also gave rise to “daughter directives”, applying its general principles to specific areas and aspects of health and safety at work (European Agency for Safety and Health at Work 2013). These directives contributed to instilling a culture of prevention throughout the EU, as well as simplifying national legislative systems. However, various flaws were highlighted in the application of the legislation (European Commission 2004).
One major challenge is poor compliance in small and medium- sized enterprises (SMEs), especially as regards risk assessment, workers’ participation and training, and in the traditionally high- risk sectors of agriculture and construction.
Following a first EU Strategy on Health and Safety at Work for 2002–2006, the EU adopted a second strategy for 2007–2012, which aimed to cut by a quarter work- related accidents (European Commission 2007). These strategies were an important policy signal and driver for national action on occupational safety and health and facilitated useful coordination with respect to public health initiatives. A new strategy was recommended for musculoskeletal disorders, stress, and occupational cancer deaths that ought to target in particular the challenges related to the implementation of the legal framework, with an explicit focus on SMEs and micro- enterprises (European Commission 2013).
Situation in the WHO European Region
Legislation on occupational health and safety differs greatly across the WHO European Region, ranging from legal requirements for every enterprise to provide occupational health services, through legal requirements only for large- and medium- sized enterprises, to no legal requirements at all. As a consequence, the coverage of occupational health services varies from less than 10% of the workforce in some countries to more than 90% in others.
Mortality related to work- related accidents is a good indicator of the effectiveness of occupational health and safety systems, because deaths are less likely to be under- reported than injuries and diseases. According to the
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official data reported to WHO’s European Health for All database, mortality rates from work- related accidents have decreased consistently since 1980 (Figure 5.1). However, there are persisting disparities between different parts of the region, with higher death rates in the countries of central and eastern Europe and the former Soviet countries.
Figure 5.2 shows trends in non- fatal injuries due to work- related accidents. In striking contrast to mortality rates, the countries of central and eastern Europe and the former Soviet Union report much lower rates of non- fatal work- related injuries than the EU member states before May 2004. This paradox is likely due to a severe under- detection and under- reporting of non- fatal work- related injuries in these countries.
EU member states
Figures 5.1 and 5.2 illustrate the gap that exists between different parts of Europe in terms of occupational health and safety. The progress in many “old”
EU member states (as well as countries such as Norway or Switzerland) is largely due to continuous dialogue between the social partners, as well as the efforts of trade unions and providers of occupational health services. However, even in some of these countries, such as Greece, occupational health and safety Figure 5.1 Deaths due to work- related accidents per 100,000 population (CIS:
Commonwealth of Independent States) Source: WHO (2013)
is only accorded a low priority and under- reporting of occupational mortality and morbidity is considerable (Rachiotis, Alexopoulos et al. 2010).
The twelve “new” EU member states adopted EU directives on occupational safety and health during their accession period. However, they still lag behind their western neighbours in reducing work- related mortality. Reasons include weak enforcement, a lack of capacity, and insufficient involvement of social partners.
As of 2013, there was no specific EU directive on occupational health services, and quality and coverage differ greatly across and within EU member states. Except in those countries with a legislative requirement for universal or near- universal coverage (e.g. the Netherlands, Belgium, France, Finland, and Luxembourg), occupational health services coverage is well below 60% (WHO 2007). Furthermore, in most EU member states, workers in micro- enterprises and the informal sector often do not have access to occupational health services.
According to the Fifth European Survey of Working Conditions, covering 44,000 workers from 34 European countries in 2010, more than one in three Figure 5.2 Persons injured due to work- related accidents per 100,000 population (CIS: Commonwealth of Independent States)
Source: WHO (2013)
Occupational health and safety 79 manual workers and almost one in five non- manual workers thought that their health or safety was at risk because of their work, and that their work affects their health. Less than half (44%) of the lowest skilled manual workers thought that they would be able to do their current job when they were 60, while more than two- thirds (72%) of the most highly skilled non- manual workers thought so (Eurofound 2012).
South- east European countries
Albania, Turkey, and the countries emerging from the Socialist Federal Republic of Yugoslavia have also harmonized their national laws with the EU acquis communautaire. The Socialist Federal Republic of Yugoslavia had strong occupational health and safety services, but these have been weakened in the years of transition, partly due to the extensive privatization of the public sector and the collapse of the big state- owned industrial combines, as well as the growth in the number of self- employed people and of the informal sector.
Although many national strategies and action plans have been drawn up, their implementation lags behind that in western Europe, due to a lack of capacity and, in some countries, lack of political will. The total number of specialized occupational health physicians in south- east Europe is under 500, whereas more than 2000–2500 are needed. Occupational health surveillance and disease registry systems are also insufficient, leading to serious under- reporting.
Countries of the former Soviet Union
In the Soviet Union, occupational health services were delivered through centrally planned and managed networks of sanitary- epidemiological (san- epid) facilities. The transition period has generally undermined occupational health and safety programmes and structures. The reasons are similar to those in the countries of south- east Europe and include a lack of transparency and accountability, lack of genuine social dialogue, and indiscriminate privatization of public services.
The scale of occupational fatalities and injuries is so extensive that they cost Russian employers on average 10–15% of their payroll (Fudge and Owens 2006).
However, the under- reporting of accidents is huge, especially among SMEs and in the informal economy. The situation is further aggravated in those countries that have retained the outdated system of compensation for work in hazardous working conditions (“hazard pay”), which does not encourage employers to improve working conditions.
There have, however, also been some positive developments. With the support of ILO, most countries in the region have prepared national profiles analysing their national occupational safety and health systems and prepared programmes for improvement.
Kazakhstan has adopted an occupational safety and health programme, while Kyrgyzstan and Tajikistan have signed tripartite general agreements that include consideration of occupational safety and health issues. In Azerbaijan, the
government has pledged to modernize labour inspection and occupational safety and health. Kyrgyzstan has become the lead country in the sub- region introducing ILO’s Work Improvement in Neighbourhood Development (WIND) programme for the improvement of working conditions in farms and rural enterprises.
In Georgia, the situation was very different, as the former government terminated all occupational safety and health- related inspection services and minimum safety requirements. After a number of serious workplace accidents, employers and trade unions voluntarily set up an occupational safety and
In Georgia, the situation was very different, as the former government terminated all occupational safety and health- related inspection services and minimum safety requirements. After a number of serious workplace accidents, employers and trade unions voluntarily set up an occupational safety and