Вы находитесь на странице: 1из 6

DELIVERY OF OCCUPATIONAL HEALTH SERVICES, THE FINNISH MODEL Jorma Rantanen, MD, PhD, Professor, Finnish Institute of Occupational Health (FIOH)

Abstract

The history of Finnish occupational health services (OHS) traces back to early industrial revolution. The service system has been developed according to the needs of the working life starting from occupational primary health care services for workers and their families in the 19th century and continuing as a development of comprehensive, multidisciplinary development-oriented service toward the third millennium.

At present the services cover virtually 100% of large and medium-sized companies while the micro enterprises and self-employed are covered only for about 50%. The average coverage of the employees is some 90%. Development of such high coverage has been supported by the following factors:

 wide societal consensus on importance of OHS  stipulation of specific legislation on OHS  strong expert community for OHS  long-term research activity for the development of services  demonstration of economic efficiency of OHS.

The recent and future development of Finnish OHS include further expansion of coverage, strengthening of evidence base for OHS, promotion of work ability of workers and development of workplace, work organization and enterprise conducive to health. This calls for new strategies, new methods, and new competence of OHS.

DELIVERY OF OCCUPATIONAL HEALTH SERVICES, THE FINNISH MODEL Jorma Rantanen, MD, PhD, Professor, Finnish Institute of Occupational Health (FIOH)

Introduction

The social dimension has traditionally been an important aspect of Finnish work life from the early days of industrialization, i.e. from the beginning of the 19th century, and long before, already in the ancient society. The first legislation passed in the second half of the 19th century established the basic principles of the employer's liability for occupational accidents, the regulation of unreasonable working hours, the work of women and of minors, the establishment of labour inspection and control, and compulsory accident insurance. This first set of laws was renewed 40 and 50 years later in the 1920s and 1930s, when two new important aspects were added, workmen’s compensation of occupational diseases, and a universal old age pension system (flat-rate pension system for all citizens).

The occupational health of early industries in the 19th century was mainly curative primary health care services. Systematic prevention in occupational safety and health was started sporadically in some big industries already in the 1930s, but universally much later along with the third stage of legal reform in the 1950s. In the 1960s universal sickness insurance for all citizens was established. As a part of that development the employers were allocated funds from sickness insurance for curative health services at the workplace. The 1970s witnessed the reform of occupational safety and health legislation and administration and labour inspection in connection with the "Nordic work environment movement". New provisions for labour inspection were given and the legal status of occupational safety and health committees at the company level as well as of safety representatives of employers were stipulated. Also the legislation on universal primary health care providing primary health care services free of charge for all inhabitants was passed. A special Act on Occupational Health Services was also produced providing preventive occupational health services for all who take part in working life. The next major step was taken in the first half of the 1990s when the EU Directives were transposed into the Finnish occupational safety and health legislation. Though the main content of transposition was only formal, some important details, such as systematic risk assessment and the obligations for the employer to prepare an occupational safety and health policy for the enterprise were seen as positive stimuli for Finnish occupational safety and health. On the other hand, the Finnish occupational health service system clearly exceeded the requirements of the Framework Directive 89/391 EC, which stipulate on preventive services and on health examinations.

Early developments of occupational health and safety

Occupational health services were first developed for workers in industry, the defence forces, railways, and some other trades from the times of the industrial revolution in the second half of the 19th century. The big manufacturing industries, i.e. metallurgy, metal product industry, textile industry, pulp and paper production, etc. organized general-

practitioner-level (GP) health services for their workers and family members as soon as the factories were established. Such services were in fact conventional primary health care services provided by employers for their employees and their family members. On the other hand, the 1879 Ordinance on Trades obligated municipal councils to supervise both the public health in the community and the conditions of health in industry. These were the early provisions for the improvement of hygiene at work and for undertaking preventive actions. Although early provisions for compensation of occupational accidents and diseases can be traced back to the first half of the 18th century, the first focused provision on protection of workers' health at work was the Ordinance on Protection of Workers from the year 1889.

In the years after the World War II, the workforce was sparse and the work load of the nation was enormous due to the pressures from reconstruction and payment of the war penalties. It was generally understood by the Government, employers and trade unions that any loss of work capacity due to occupational accidents and diseases was to be avoided, and this triggered actions for the further development of accident prevention and preventive occupational health and safety. Systematic development of occupational health services to preventive direction was also started. The consensus on importance and benefits for all partners from occupational health has prevailed since the 1940s and still continuous in the 1990s.

In 1969 the rules of sickness insurance compensation for the costs of occupational health services were amended to favour more preventive activities, and in 1971 the central organizations of employers and trade unions agreed upon the organization of occupational health services for all employees. The coverage of services expanded steadily in well organized industries and other big organizations, while the small enterprises, the self-employed, farmers and service enterprises seemed not to be able to develop services for their workers. To improve the coverage further, to ensure the preventive content, to equalize economic sustainability of OHS, and to provide well-trained expert personnel for OHS, an Act on Occupational Health Services was passed in 1978. The main features of the OHS Act are given in Table 1.

Table 1. Main features of the Finnish Occupational Health Service Act of 1978

Obligations

 

Organizer: the employer Financing: the employer/subsidized Coverage: all employees Use of competent health personnel Voluntary for the self-employed

Contents

 

Essentially preventive Curative services allowed Risk-oriented Only the core activities stipulated by law Subsidies conditioned by content Company-level action programme requested

Organization

Flexible, several alternatives for service provision Full coverage (100%) as objective Municipal health centres always responsible for service provision Collaboration and participation OH&S Committee evaluates the programme and report Subsidies conditioned by the OH&S Committee’s statement OHS personnel Special training requested Complementary training requested Only health personnel stipulated law Multidisciplinary team permitted but not requested De facto need of multidisciplinary approach

The development since the enforcement of the Occupational Health Services Act has been highly positive as regards the coverage of services (Figure 1) and the flow chart of services is presented in Figure 2. At present some 90% of engaged employees are covered by services and more than 4,000 persons work in the Finnish OHS system, of whom 1,300 full- or part-time physicians and almost 2,000 nurses. The OHS system has survived surprisingly well the deep economic recession and massive unemployment in the 1990s and, in fact, some new developments have taken place.

Figure 1. Employees covered by occupational health services (%)

Figure 2. Present flow-chart of OHS functions according to Good Occupational Health Practice

Some 10 years after the first enforcement of the OHS Act, new developments were again initiated by the Government. The new trend was started by the commitment of the government and social partners to develop OHS according to the lines of the ILO Convention No. 161 and Recommendation No. 171 on Occupational Health Services which Finland ratified in 1986. A national programme for the development of OHS according to the lines of the ILO Convention was presented in 1989 by the Government to the Parliament in the National Programme for the Development of Occupa-

tional Health Services. The Programme included 18 national development objectives for further strengthening of the OHS system. The implementation of the Programme was evaluated in 1997, and most of the objectives plus a number of new developments were achieved. The present objectives for the development of the content of Finnish OHS are covering four main substantive approaches:

a) Prevention of health and safety hazards by focusing on the hazards at work and work environment and also on risk factors in the workers' working practices.

b) Curative services to look at work-related and other morbidity, provide GP-level ambulatory health care, referral to specialized health care and follow-up at work of workers with chronic diseases.

c) Promotion of work ability of workers by utilizing the preventive and curative actions as described in a) and b) plus by instituting actions towards workers' health, work environment and work organization for maintenance and improvement of work ability and by improving health and professional capacities of the employers.

d) Development of work organizations, management and other working cultures and collaboration and participation so that motivation, job satisfaction, self-steering and productivity will be improved and continuously developed.

The substantive content of Finnish OHS as stipulated by the OHS Act is presented in Table 2.

Table 2. Core activities stipulated by the Finnish OHS Act

1. Surveillance of the work environment

2. Initiatives and advice on the control of hazards at work

3. Surveillance of the health of employees

4. Follow-up of the health of vulnerable groups

5. Adaptation of work and the work environment to the worker

6. Organization of first aid and emergency response

7. Promotion of health, work ability and health education

8. Collection of information on workers’ health

9. Provision of curative services for occupational diseases

10. Provision of general health care services

Some advanced big industries have made fascinating programmes for the development of comprehensive occupational health services while, particularly the small-scale enterprises (SSEs) still struggle with the basic issues of safety and health. It is also likely that the SSEs and self-employed never can meet the objectives of the Act without external professional support. Since no market systems works in the field of SSEs and self-employed, the public sector interventions and service provision are of crucial importance. Along with the implementation of the National Programme, the Finnish OHS has moved to a new stage of evolution (Figure 3).

Figure 3. Evolution of Finnish occupational health services

Service provision options in Finnish OHS

The early development of service provision was dependent on the voluntary choice of big industries which usually led to recruitment of occupational health physician and nurse to the company OHS units. The Act on Occupational Health Services changed substantially the situation when all employers were obligated to organize services for their workers. Small enterprises were not expected to organize their own OHS units and therefore more options for service provision were needed. The OHS Act allows flexible choice of the service provision model, was it in-plant or service provided by municipal health centre, external group services or private physicians' service. The two former options provide occupational health services at present for about 70% of employees while the two latter services cover about one third of work force (Figure 4). The services provided by municipal health centres which are publicly funded primary health care units are of crucial importance since they are the only systems which can take responsibility on services for small- scale enterprises, farmers and self-employed in such a large country with remote sparsely populated areas as Finland.

Stipulating obligations for all employers to organize the services for all working people regardless of the size of company, nature of employment, sector of economy or geographic location of the workplace together with options for practical service provision has expanded the coverage of OHS to 90% of workers and about 95% of enterprises (including the whole public sector, state and municipalities) (Figure 4).

Figure 4. Organizational models for occupational health services in Finland in 1995

New strategies for the Finnish OHS in the 1990s

Surviving recession. When the economic recession and massive unemployment suddenly hit the country at the beginning of the 1990s, the OHS system was already well stabilized, comprising both preventive and GP-level curative services for more than 85% of the workforce, and including 50% of the self-employed. The Social Insurance Institution reimbursed 50% of the costs of OHS to the employer, which constituted a substantial incentive for enterprises to initiate and continue the provision of services. Contrary to the fears of many, this high level of organization and reimbursement has survived the years of recession well. The reasons for such survival have been the wide and strong consensus on the importance of OHS, demonstration of economic efficiency of OHS and need to take care of the work ability of aging work force.

Promotion and maintenance of work ability. At the beginning of the 1990s some interesting new developments have taken place. The Finnish workforce is aging rapidly, work ability problems are paramount, and high demands and pressures for high productivity and quality are set by the modern competitive work life. Systematic research on aging workers and work ability was started by the FIOH already at the beginning of the 1980s, and in 1990 the social partners agreed, in connection with the collective agreement, on the development of measures for the maintenance of work ability (MWA). In 1991 the government, through amendment of the Act on Occupational Health Services, included the MWA activity as a legitimate element in occupational health services. Simultaneously, the Finnish Institute of Occupational Health, the Ministry of Social Affairs and Health and other actors designed a MWA paradigm and practices for MWA at the workplace. The core of the new paradigm is the so-called "triangle strategy" according to which the health of the worker, the safety and general health of the work environment, and the work organizations are developed simultaneously (Figure 5). At the moment dozens of MWA projects are going on. In 1997 over 75% of all occupational health staff members were given training by FIOH in MWA principles and practices. The FIOH established a MWA Centre in 1995 and research in the area was strengthened. A nation-wide Action Programme for Aging Workers was launched by the government in June 1997 which will further strengthen the MWA movement. The impact of such reform remains to be evaluated, but some of the evaluations of individual MWA projects show clearly positive health and economic effects.

Figure 5. The new OHS paradigm

Quality management. The ISO quality standards are widely applied in the Finnish industries as elsewhere in Europe. Also the health care sector has started to apply QM systems to ensure quality and improve the effectiveness of services. It was found necessary to develop quality systems also for occupational health services. A joint proposition was made by the Ministry of Social Affairs and Health and the FIOH to produce quality guidelines in collaboration with the OHS practitioners. The guidebook, called "Good Occupational Health Practice", was completed in 1997. It has been distributed to all over 1000 OHS units in the country, and is being boosted with an effective training programme by FIOH. It is intended that each OHS staff member will be trained for GOPH within the next 1–2 years. The guideline is supplemented with a high number (40–50) of specific guides providing instructions for dealing with special issues and problems at work, such as chemicals, heavy physical work, occupational stress, measurement of work ability, biological factors, crisis management, workplace surveys, ergonomic planning, risk assessment, etc.

Small enterprises. Small enterprises have always been an underserved target group for OHS in all countries. Though the Finnish OHS Act clearly stipulates that all employers, irrespective of company size, are obligated to organize OHS for their employees, the practical implementation of such provision has been difficult, so that only about 50% of micro- enterprises of 1–10 workers, in particular, have been covered. To provide a response to the problems of SSEs the FIOH launched in 1995 an Action Programme for Small Enterprises. The main objectives of the Programme were to survey the OHS needs to expand the coverage of OHS, to improve the ability of OHS units to deal effectively with the problems of occupational health and safety, to introduce methods for MWA, to provide tools for risk assessment, and to improve the capacity to control the adverse environmental impact of the SSE on the neighbourhood of the company.

The programme has covered 319 SSEs, altogether 10,000 workers and 10 sectors of the economy. The number of participating OHS units is 116. The programme and a number of other projects developing OHS for SSEs will provide valuable new knowledge on OHS needs, methods for service provision and the impact of OHS on health, safety, work ability and economy of SSEs.

Future challenges for OHS

The globalization of world economies, growing competition, aging of the workforce, rapid changes in the work life, growing demands of work ability and competence, and the introduction of new technologies constitute a battery of challenges which also OHS is expected to respond effectively. About 50% of the workforce of the 30 major Finnish international companies work already outside Finland. More than 60% of the Finnish employees use communication and information technologies at work. The proportion of aging workers is steadily increasing, while a relative shortage of highly trained young workers is already visible. New substances, new technologies and new work organizations are introduced, and new flexible work time schedules are implemented. Problems of light work ergonomics, psychological stress and information work load burden a growing number of workers. New biological hazards and organic materials are derived from growing mobility and from new biotechnology products. At the national level the enterprises are fragmented, work contracts are shortened, and the continuity of care from the single workplace may disappear. Surveillance of the work environment and workers' health, assessment of their exposures and risks become more complicated and cumbersome. More and more people are self-employed and working at home. Such challenges differ substantially from those of the traditional manufacturing industries for which OHS was originally designed. The problems and challenges mentioned above call for further development of OHS their service provision and substantive content. More comprehensive approach, more multidisciplinarity, more outcome-oriented direction, effectiveness and impact-orientation instead of input and pro??cess-orientation is needed. As well the OHS cannot work in isolation, they need to strengthen their collaboration with both the company core activities and the services and activities outside the company.

Keeping abreast with the developments of new working life and providing competent and effective services in such new situations will be a major challenge to OHS. Many of the solutions needed have not yet been generated.

The Finnish OHS model which is based on wide societal consensus, special legislation, a well-established service infrastructure which to some extent is also a part of the municipal primary health care service infrastructure, has good possibilities to adapt to the new conditions. Particularly, the optimal service provision models and primary responsibility of municipal health centres to provide services always if the employer or self-employed needs them provide realistic possibilities to cope with the new trends in the working life.

But much still remains to be done to meet both the traditional and new problems of OHS. The substantive content and the methods as well as the competence of the OHS staff need to be continuously evaluated and renewed.

At the turn of the millennium we will be in the next step of evolution of OHS, which is characterized by the following key elements:

comprehensive service covering physical, medical, psychological and social aspects of work

multidisciplinarity

prevention and promotion

quality-oriented and evidence-based

integrated with other activities of the company

collaborating with other services of the enterprise and those outside the company

based on the principle of participation of workers and employers  contributing positively to the work ability of the workers and to overall development of the enterprise.

References

FIOH. Hyvä työterveyshuoltokäytäntö. Opas toiminnan suunnitteluun ja seurantaan. (Good Occupational Health Practice). Antti-Poika M, Taskinen H (toim.). Sosiaali- ja terveysministeriö. Työterveyslaitos, Helsinki 1997.

ILO Convention No. 161 on Occupational Health Services. ILO, Geneva 1985.

ILO Recommendation No. 171 on Occupational Health Services. ILO, Geneva 1985.

Ministry of Social Affairs and Health. National Programme for Development of Occupational Health Services, 1989.

Noro L. Työterveyslaitos, tausta ja kehitys (Institute of Occupational Health, background and development), Kerava, 1979.

Rantanen J. Occupational health in Finland 1945–1995; TTL–FIOH–50 years. In: From Research to Prevention. Rantanen J, Lehtinen S, Hernberg S, et al. (eds.). Finnish Institute of Occupational Health, Helsinki 1995:17–31.

Rantanen J. Vision on the development of working life in the next decade. Government Report to the Parliament, part II. Helsinki 1997:85–132.

Räsänen K, Mäkelä P, Kankaanpää E, Peurala M, Husman K. Työterveyshuolto Suomessa vuonna 1995. (Occupational health services in Finland in 1995). Työterveyslaitos. Sosiaali- ja terveysministeriö, Helsinki 1997. (in Finnish with English summary)