Family Medicine & Community Health 3

Integration of Primary Care & Occupational Health Services

DR. M. F. R. Jr. | 14 September 2019
 Unfortunately, health services for workers do not adapt
I. Key Messages sufficiently quickly to new conditions
II. Introduction  Occupational health services tends to focus on medical check
III. Occupational Health ups, registration, treatment and compensation of occupational
IV. Primary Health Care diseases and injuries
V. Integration  General health services fails to detect and address health
VI. Background of the Integration of Primary Health problems related to employment and working conditions
Care with Occupational Health  The linkages between occupational and general health care
VII. Integrating Primary Health Care with services are often very poor and in some countries the two are
Occupational Health structurally separated.
VIII. Next Steps  The results:
o Insufficient primary and secondary prevention of work-
I. KEY MESSAGES related health problems
o Rising rates of sickness absenteeism
 Workers health is an integral part of general health and daily o An inability to reintegrate sick and injured workers back
life into the workplace
 Health system should facilitate local strategies to meet worker o A lack of continuity of care
health needs And inefficient use of human and financial resources
 In moving towards universal coverage, those at greatest risk of
having greatest needs should be included first III. OCCUPATIONAL HEALTH
 When developing policies about worker health all relevant
stakeholders should be involved  Occupational diseases and injuries, work-related and workplace
 Training in health and work should be part of all healthcare preventable disease and injuries are responsible for:
professional training o Current levels of reduced work capacity
 Empowerment of workers and the encouragement of decision- o Increased temporary and permanent work disability
makers are critical for the promotion of the health and safety of o Shortened life expectancy
workers o And premature retirement or death
 High rate and early onset of chronic diseases contribute
II. INTRODUCTION o High expenditure of national health care systems
o High demands for disability pensions
 The health of the worker is determined by occupational o And compensation from social insurance funds
hazards, individual risk factors and access to health services
 Industrial and other enterprises that lack adequate prevention
 And these are also influenced by social factors, such as and control measures, contribute to environmental pollution
employment status and power relations. and pose health risks to the population
 Work provides income to support human needs.  There are emerging challenges that require policy changes for
 It has a positive impact on the health and well being of health at the workplace. Some of them are:
individual and on social and economic development. o Ageing of working populations- resulting in different
 World’s worker still labor under unhealthy and unsafe working occupational health needs
conditions, resulting in about 2 million of deaths annually from o Changing structure of employment - increase in temporary
disease and injuries. employment
 Occupational risks account for a substantial portion of the o Diversity and dispersal of the traditional work structures
burden of chronic diseases (i.e.: outsourcing)
 Between 3 - 4% of global GDP is being lost to costs associated  There are emerging challenging that require policy changes for
with sickness, absenteeism, diseases and injuries resulting from health at the workplace. Some of them are:
work. o Increased number of interpersonal contacts at work -
 The changing world of work is characterized by: psychosocial problems
o Increasing mobility of the workforce Intensification and repetitive work
o Growing numbers of small- and medium-sized enterprises o Unpredictable working hours
(SMEs) o Violence and harassment at the workplace
o An informal economy  None of these problems can be solved using traditional
o Subcontracting methods focused on reduction of physical, chemical or
o Precarious forms of employment biological hazards at work.
o The rapid spread of new technologies  However, they can be addressed by the holistic approach to
o And transfer to occupational health hazards between and management of health, environment and safety
within countries  Changes in the global economy

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DR. M. F. R. Jr | 14 September 2019
 Continuous restructuring of production and sever
organizations,
 Subsequent changes in working life and in the responsibilities
 All of these have created an urgent need to strengthen
and adapt the tools and methods used to ensure that
health, environment and safety measures are protected,
promoted and properly managed at the enterprise level
 Successful leading multinational enterprises and
integrating health, environment and safety issues into
their overall management systems
 Challenges posed by globalization require enterprises to
adapt holistic and integrated views of health and
environment management to retain competitiveness on
well-regulated markets
 The decisions of enterprise leaders & government and
municipal leaders: Create an obvious impact on their own
health, on their families, neighbors and customers
 Health, Environment, Safety and Social Management in
Enterprises (HESME):
o A multidisciplinary approach to promote health at the
workplace and to minimize its harmful impacts on the
environment
o Also deals with the impact of the workplace on the
neighborhood health, on the health and
environmental impact of products and services and
on the preservation of the general environment
o May be a powerful tool for municipal and other local
authorities willing to promote an effective health
dimension to social, economic, environmental and
development policies
IV. PRIMARY HEALTH CARE
 PHC is a whole-of-society approach to health and well being
centered on the needs and preferences of individualism
families and communities
 It addresses the broader determinants of health and focuses
on the comprehensive and interrelated aspects of physical,
mental and social health and well being
 It provides whole person care for health needs throughout the
lifespan, not just for a set specific diseases
 Primary health care ensures people receive comprehensive
care - ranging from promotion and prevention to treatment,
rehabilitation and palliative care - as close as feasible to
people’s everyday environment
 Rooted in a commitment
o To social justice and equity
o In the recognition of the fundamental right to the highest
attainable standard of the health
 Article 25 of Universal Declaration on Human
Rights: “Everyone has the right to a standard of living
adequate for the health and well-being of himself and of his
family, including food, clothing, housing and medical care and
necessary social services.
 Different concept of PHC:
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o In some contests, it has referred to the provision of
ambulatory or first level of personal health care services
o In other contexts, it has been understood as a set of
priority health interventions for low-income populations
(also called “ selective primary health care)
Others have understood it as an essential component of
human development, focusing on the economic, social and
political aspects
 WHO has developed a cohesive definition based on the three
components:
1. Meeting people’s health needs through comprehensive
promotive, protective, preventive, curative, rehabilitative
and palliative care throughout the life course, strategically
prioritizing key health care services aimed at individuals
and families through primary care and the population
through public health functions as the central elements of
integrated health services;
2. Systematically addressing the broader determinants of
health through evidence-informed public policies and
actions across all sectors, and;
3. Empowering individuals, families and communities to
optimize their health, as advocate for policies that
promote and protect health and well-being, as co-
developers of health and social services, and as self-carers
and care givers to others.
 The Alma-Ata declaration on PHC of 1978 emphasized the
importance of bringing health care as close as possible to
“where people live and work”.
 When PHC was put into [practice, focus was on health services
where people live
 The provision of health care where people work was absent
from the debate, the programmes and the strategies on PHC
 Many countries reforming their health systems based on the
primary health care approach have asked WHO to provide
policy options for the provisions of health care to WORKING
POPULATIONS.
 Concerned about the low level of access of the workers to
health services, the World Health Assembly (WHA) urged
Member States in 2007 “to work towards full coverage of all
workers, including those in the informal economy, small- and
medium-sized enterprises, agriculture and migrant and
contractual workers, with essential interventions and basic
occupational health services for primary prevention of
occupational and work-related diseases and injuries”
(Resolution 60.26, “Workers’ Health: Global Plan of Action”)
 In 2008, the WHO launched a set if reforms to provide PHC to
all citizens
 The 62nd World Health Assembly in 2009 emphasized the need
to strengthen health system based on PHC in keeping with the
values and principles enshrined in the Alma-Ata Declaration
This renewed attention to developing PHC provides plentiful
opportunities to scale up occupational health services based on
the values of equity, solidarity and social justice and the
principles of multisectoral action and community participation
 The process could enable health systems to adequately respond
to the specific health needs of a large groups of workers,
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particularly by providing channels to participation and
intersectoral action, covering working populations in a given
territory and integrating approaches to health at work and in
family life.
V. INTEGRATION
 “A discrete set of techniques and organizational models
designed to create connectivity alignment and collaboration
within and between the cure and care sectors at the funding,
administrative and/or provider levels.” (Kodner & Kyriacou,
2000)
 Result of a workshop on the topic of integrated care held at
the 2006 European Social Network Conference in Edinburgh
suggest that integrated care has different meanings for
various stakeholders, including the user, frontline provider,
manager & policy maker.
 For example, the user might perceive integrated care as care
that is “seamless, smooth, easy to navigate” whereas to the
policy maker, it implies consolidating budgets and conducting
joint policy evaluations (Lloyd & Wait, 2005).
 Not only can integration have different meaning to different
users, it also occurs at different levels of the healthcare
system
 Delnoij et al. (2002) specifies integration at the macro, meso
and micro levels of the healthcare system
 Functional integration occurs at the macro level and involves
the financing and regulation of cure and prevention activities
of both sectors
 At the meso or community level, there are (2) types of
integration: Organizational Integration & Professional
Integration. The former implies a strategic alliance or merger
between public health and primary care. The latter suggests
that such mergers involve healthcare professionals working
together, for example, in group practices.
 Finally, at the micro level, there is clinical integration, in which
it involves continuity, cooperation and coherence of
healthcare delivery to individual patients.
VI. BACKGROUND OF THE INTEGRATION OF PRIMARY HEALTH
CARE WITH OCCUPATIONAL HEALTH
 There have been many calls to renew PHC at international,
regional and national conferences organized by or in
collaboration with WHO, many coinciding with the 30th
anniversary of the Alma-Ata Declaration.
 The basic idea behind health for all through PHC is that taking
into account both priority health needs and fundamental
determinants of health enables people to lead socially and
economically productive lives, which in turn helps to drive
overall development.
The call represent the goal of dealing effectively with current
and future challenges to health, mobilizing health professionals
and lay people, government institutions and civil society in
support of an agenda whose key elements include
transforming health-system inequities, organizing service
delivery, setting public policy and furthering development.
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 Following the World Health Report 2008 (WHR 2008) Primary
Health Care: Now More Than Ever, the 62nd World Health
Assembly (WHA) urged Member States to take a number of
actions to strengthen health systems based on PHC (resolution
WHA 62.12 “Primary Health Care, Including Health Systems
Strengthening”)
The 62nd WHA also discussed the reducing health inequities
through action on social determinants of health
 The WHA resolution emphasizes the need to take health equity
into account in national policies that address such
determinants, including employment, to strengthen
intersectoral collaboration, to involve all partners, and to
empower individuals and groups to improve societal conditions
that affect their health
 Universal PHC would help to achieve these goals
The 60th WHA in 2017 endorsed the WHO Global Plan of Action
(GPA) on Workers’ Health 2008-2017 (resolution WHA 60.12
“Workers’ Health: Global Plan of Action)
This plan deals with all aspects of workers’ health and is
underpinned by certain common principles
All workers should be able to enjoy the highest attainable
standard of physical and mental health and favorable working
conditions
 The workplace should not be detrimental to health and well-
being
Primary prevention of occupational health hazards should be
given priority
 All components of health systems should be involved in an
integrated response to the specific health needs of working
populations
 The workplace cal also serve as a setting for delivery of other
essential public health interventions, and for health promotion
Activities related to workers’ health should be planned,
implemented and evaluated with a view to reducing
inequalities within and between countries
 Workers and employers and their representatives should also
participate in such activities
 One of the objectives of GPA is to improve the performance of
and access to occupational health services
VII. INTEGRATING PRIMARY HEALTH CARE
WITH OCCUPATIONAL HEALTH
 GPA states that coverage and quality of these services should
be improved by:
o Integrating their development into national health
strategies, health-sector reforms and plans for improving
health systems performances;
o Determining standards for their organization and coverage
o Setting targets for increasing the working population
covered
o Creating mechanisms for pooling resources and for
financing the delivery of services
o Ensuring sufficient and competent human resources and
establish quality assurance systems
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o Providing basic occupational health services for all
workers, including those in the informal economy, small
enterprises and agriculture
o Occupational health and primary care share common
values that are important for the health of people and
populations, but health services that adequately addresses
work is not universally available for people
 In particular relevant are:
o The holistic approach, looking at individuals in the context
of their life
o The interest in communities - be it work-communities or
living communities - to secure equity and the involvement
of those with greatest needs
o Focus on improving individuals functioning (in work and
other aspects of life ) and not only on disease outcomes
 Currently, health services based on these values are not as
widely available as is desirable
 Closer collaboration between occupational health and primary
care would enhance the opportunities to contribute to
productivity and to extend working life
 This requires moving from a care oriented on diseases and
health problems to care that emphasizes optimizing functional
capability of individuals
 A more integrated approach to occupational health and primary
health care will yield a bigger impact on the health of people,
than each can achieve on their own, to secure work-focused
health care.
 How that integration works in practice, depends on national
and local circumstances
 Substantial global demographic trends, changing health
problems and the changing nature of work mean that this
integrated approach will become even more important in the
decades to come
 This will require more care to be provided, without the
certainty of any increase the professional manpower
 Important assets in initiating this collaboration are the
experiments that can be found in a number of countries and
settings around the world
 The following principles should guide further development in
pursuing an integrated approach to occupational health and
primary care:
o Workers’ health is part of general health and life
o Health system should facilitate local strengths to meet
workers’ health needs
o In moving towards universal coverage, those at greatest
risk for having greatest needs should be targeted first
 The following principles should guide further development in
pursuing an integrated approach to occupational health and
primary care:
o When developing policies about workers health all
relevant stakeholders should be involved
o Training in health and word should be part of all health
care professional training
o Empowerment of workers and the encouragement of
decision makers are critical for the promotion of the
health and safety of workers
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 The following strategic directions for delivering occupational
health in the context of integrated primary health care were
developed devoted to universal coverage, people-centered
care, participatory leadership. Health in all policies:
All workers should have access to essential interventions and
basic health services for prevention of occupational and work-
related diseases and injuries
 This requires:
o Emphasizing the role of national and local government for
guaranteeing the access of all workers to curative and
preventive health care that allows for full and productive
working life
o Including essential interventions for occupational health
and work ability in the delivery of comprehensive,
integrated primary care, such as
 advice for improving working conditions
 promoting health at work
 early detection of occupational and work-related
diseases
 support for return to work and preservation of
working capacity
 Including the financing of basic occupational health care for
those most in need or at greatest risk, within existing
arrangements for financing of basic primary health care.
 New mechanism may need to be developed where existing
ones are inadequate to meet priority needs. These should, as
far as possible, be integrated into existing national or local
health financing system.
Developing human resources and technological capacities at
the primary care level for the effective delivery of essential
interventions and basic health services for prevention of
occupational and work-related injuries and diseases through
training consultation, information, and supportive tools,
including telecare
 Strengthening and expanding specialized occupational health
services, including the basic occupational health services and
scaling up access to such services and increasing the number of
interventions with priority on primary prevention of
occupational hazard
Evaluating the models for service delivery and financing for
occupational health and primary care and carrying out research
on barriers to access to and coverage with preventive
interventions
 people in their environment, including work, should be in the
center of health care. This requires:
o Strengthening the role and responsibilities of the primary
care providers for all health-related aspects of personal
life, including early recognition of occupational and work-
related ill-health, as well as preserving and resorting
working capacity of individuals
o Building the capacities of primary care centers to respond
effectively to the general and specific health needs and
expectations of working populations in the catchment
area, including training in basic occupational health and
supportive tools for interventions
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o Linking occupational health services and primary care
centers under local primary health care networks,
including joint training, referral systems, information on
occupational hazards and other mechanisms for
collaboration and continuity of care
o Providing clinical guidelines and standards for health care
professionals that take into account the impacts of work
and employment and working capacity
o Empowering and supporting individuals and work
communities to take over the control of their own health,
to protect themselves against occupational hazards and to
promote health at the workplace, for example by training
and developing programs for healthy workplaces,
introducing tools for self-assessment and for work
improvement, supporting workers health and safety
representatives and community health activities
o Carrying out research on the effect of the tools for
empowering workers and work communities for take
control over their health, including the effectiveness of
work improvement techniques and community based
participatory research
 Protecting and promoting health at work requires a new,
participatory health leadership. This should include:
o An integrated response by all building blocks of health
systems to the health needs of workers in the ongoing
healthcare reforms with priority being given to the needs
in the informal sector, migrant and self-employed workers
and small enterprises
o Involving labor stakeholders, such as employers, trade
unions, governments, civil society and the private sector in
the debates about health care reforms and the
development of national and regional (preclinical, district)
health strategies and plans
o Developing and maintaining national profiles for workers’
health including measuring health outcomes and the
performance of health systems regarding the health of
workers, basic information on working conditions,
workers’ lifestyle, education, as well as interventions and
services.
o Strengthening the collaboration between health and labor
sectors for the ratification and implementation of core
international instruments for occupational safety and
health, such as Occupational Safety and Health Convention
155, Occupational Health Services Convention 161 and
Promotional Framework for Occupational Safety and
Health Convention 187, establishing connections between
labor inspections and occupational health and safety and
primary care.
 The health of workers should be taken into account in designing
and implementing policies in all sectors, this includes the
following:
o Identification of workers’ health impacts and co-benefits
of national policies and strategies in the area of labor,
environment, education, agriculture, economic
development, trade etc. as well as capitalization of
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benefits and risks and enabling healthy public policies as a
common ground for dialogue across sectors
o Development of national parts of action on workers health
involving all stakeholders and sectors, creating common
grounds as whole-of-government health initiatives and
identifying the non-health benefits from action on
workers’ health
o Ensuring input from primary care to the development and
implementation of national public programmes for
occupational health and safety, identifying, measuring and
highlighting the benefits of such programmes for the
delivery of integrated, comprehensive primary care
o Addressing the health needs of workers and hazardous
working conditions in the policies dealing with the
informal economy, rural development and labor migration,
including the provision of health services to such
populations
VIII. NEXT STEPS
 WHO and its networks of collaborating centers for occupational
health and primary care will collaborate with ILO, the non-
governmental organizations in official relations with WHO and
with the other international stakeholders, such as the World
Bank and the International Social Security Association on the
following actions:
o Developing policy options, methodologies and case studies
and integrated financing mechanisms, including costing of
the delivery of essential interventions for occupational
health at the primary care level
o Encouraging collaboration between the professional
associations of occupational health and primary care, such
as the International Commission on Occupational Health
(ICOH) and the World Federation of Family Physicians
(Wonca
o Establishing a global repository of training materials and
information for building human resource capacities for
basic occupational health among primary care teams -
doctors, nurses, technicians and community health
worker, for facilitating the inclusion of occupational health
into undergraduate and postgraduate training and
education in medicine, nursing and allied health
o Collecting, evaluating and disseminating case studies and
examples of delivery of essential interventions and basic
services for occupational health in the context of
integrated primary health care and setting up an agenda
for interdisciplinary research on the occupational health
aspects of health systems and health services delivery
o Supporting governments to adapt policies based on the
outcomes of research on occupational hazards, to
promote healthy environment at the workplace and to
minimize the sickness absence, working incapacity and the
related costs.
REFERENCES
1. Dr. M.F.R.J.’s power point lecture
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