Basic Occupational Health Services

1 Introduction

Of the total 3 billion workers in the world, more than 80% work and live without having access to occupational health services (OHS). This in spite of the fact that several authoritative bodies, including the International Labour Organization (ILO), the World Health Organization (WHO) and numerous professional organizations and the organizations of workers have, already for several decades, emphasized the need for services. The coverage, i.e. the proportion of workers and workplaces with access to services, is today diminishing rather than expanding. The ILO Convention No. 161 on Occupational Health Services and the WHO Global Strategy on Occupational Health for All call for the organization of services to all working people of the world. We are still far from this goal, and it is not likely that the coverage will essentially expand without concerted efforts. To address the new safety and health needs the WHO has launched a new Global Plan of Action on Workers’ Health and the ILO has produced a Global Strategy on Occupational safety and Health and the ILO Convention No. 187 on Promotional Framework.

The introduction of the concept of Basic Occupational Health Services (BOHS) has its roots in the WHO Alma Ata Declaration from the year 1978, which spells in article VI: “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods……It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work……….”.

As the previous health policies were primarily focused on developing hospital infrastructures, the Alma Ata policy with the WHO Health for All Strategy has shifted the priority to the organization of primary health care services for large populations throughout the world. The health impact of this policy shift cannot be over-estimated. It has made the health services accessible to people in villages and remote areas, and to poor people, i.e. to all those who have been traditionally underserved.

The BOHS are an application of the Alma Ata principles in occupational health. It is an effort to provide access to occupational health services to the so far underserved majority of the workers of the world. The BOHS are simultaneously a way to the development of occupational health services to the level required by the ILO Conventions Nos. 161 and 155.

The globalization changes the economic structures and conditions of work substantially in virtually each workplace of the world. The need for occupational health services increases rather than declines. The needs for the services change also qualitatively, and become more versatile, more difficult to organize and the served groups become more dynamic and mobile, the workplaces more unstable, and the jobs more precarious and temporary.

These trends set special demands to the provision of occupational health services in terms of their structure, contents and methods. Although the ultimate objective is to provide OHS which correspond to the level defined in the ILO Convention No. 161, the underserved sectors need a starting point which opens the way to such development.

This publication is a third edition of the guideline produced with the support of the Finnish Institute of Occupational Health (FIOH), WHO, ILO and International Commission on Occupational Health (ICOH). It is a basic guideline in the series of new tools for the implementation of the decision of the Joint ILO/WHO Committee on Occupational Health to develop Basic Occupational Health Services in collaboration with the International Commission on Occupational Health, ICOH, and as a joint priority during the 5- year period 2004–2008. This guideline has been commented by Dr. Gerry Eijkemans, WHO, Dr. Jukka Takala, Dr. Igor Fedotov and Dr. Shengli Niu, ILO, as well as Dr. Kari Kurppa, FIOH.

The guideline will be followed by a number of short practical guides (toolboxes) for various technical activities of the BOHS (see Figure 4 on page 11).

2 Policy and mission of BOHS

2.1 Strategy background of BOHS

More than half of the world population belong to the global workforce. Health, safety, work ability and well-being of every worker are a key issue for the overall socioeconomic development of each country. Health at work and healthy work environments are among the most valuable assets of individuals, communities and countries. Occupational health is an important strategy not only to ensure the health of workers, but also to contribute positively to the national economies through improved productivity, quality of products, work motivation, job satisfaction, and to contribute also to the overall quality of life of working people and society.

The overall strategic paradigm for BOHS is presented in Figure 1.

Figure 1. The WHO and ILO Global Strategy for Basic Occupational Health Services

Both the WHO Global Strategy on Occupational Health, WHO Global Plan of Action on Workers’ Health, the ILO Global Strategy on Occupational Safety and Health, and the ILO Convention No. 187 on Promotional Framework define as an important objective the strengthening of occupational health services, expanding their coverage, and improving their content and activities. Training of occupational health personnel, organizing support services and providing a research basis and standards for OHS are the most important means to achieve that goal. To meet these objectives for the whole global workforce the BOHS initiative was made.

2.2 Concept and objectives of BOHS

The Basic Occupational Health Services are an essential service for the protection of people’s health at work, for promotion of health, well-being and work ability, as well as for prevention of ill-health and accidents. The BOHS provide services by using scientifically sound and socially acceptable occupational health methods through primary health care approach.

The objective of Basic Occupational Health Services is to ensure the provision of services for all workplaces in the world (in both industrialized and developing countries) which so far have not had such services available or the services have not met their occupational health needs. The BOHS are an effort to provide occupational health services available to each and every working individual in the world irrespective of sector of economy, size of company, geographical area, or nature of employment contract.

The following principles will be applied in the organization of Basic Occupational

Health Services:

Available to all working people
Addressing to local needs
Adapted to local conditions
Organized by the employer for employees
Affordable to providers and clients
Provided by the public sector for the self-employed and the in formal sector
Supported by intermediate level services

3 BOHS system and infrastructures

3.1 Stepwise development of the OHS system

As described above, a majority of the workers in the world live without access to OHS. Many responsible decision makers find a high threshold in starting the establishment of infrastructures for OHS as there may be many other competing priorities. On the other hand, every worker is entitled to a safe and healthy work and work environment. The countries which have developed well-working OHS have found it beneficial, not only from the health point of view, but also for the promotion of work ability, productivity and thereby also the economy of the workers, companies and nations.

In order to gain such benefits from OHS the relevance, competence and quality of services need to be ensured. In other words, the OHS need to respond to the real needs of the workers and enterprises. And the activities need to be adjusted to the national and local circumstances, without compromising the real content of OHS. In the primary health care (PHC) services, the PHC worker needs to know what the communicable disease is he or she is dealing with, and what the methods of choice are to prevent and control the disease. Also the OHS staff need to know the most important occupational health hazards and their origin, nature and means for prevention. This implies that OHS cannot be provided without at least a minimum amount of special training in OHS substance and methods.

To get the OHS developed, a stepwise strategy is recommended. Every country should analyse its prevailing situation in OHS. On the basis of such an analysis, a national strategy and action programme need to be drawn up. Different geographical areas or different sectors of economy may have a very different situation in the OHS development. Well-organized industries may have an excellent service, while the neighbouring informal sector or small enterprises may have no services at all. The actions should be adjusted to these differences without, however, compromising the real content of OHS.

Thus, depending on the situation, the development steps may be started from different levels. The development stages of OHS are divided into four steps, starting from the very initial one and continuing to more developed stages of OHS.

Stage I: Starting level

To the workers and workplaces, which do not have any OHS at all, this is a reasonable starting point. The stage is planned to lower the threshold for initiation as much as possible and still preserve the OHS competence and content. This is the service utilizing field OHS workers (if possible, a nurse and safety agent), who have a short training in OHS and who work for a primary health care unit or a respective grassroots level facility. The content of the service focuses on accident risks, heavy physical work, basic sanitation and hygiene, and on the most hazardous chemical, physical and biological factors (including HIV/AIDS). Advising the clients to seek help from expert services constitutes an important part of the service.

Stage II: Basic Occupational Health Services (BOHS)

This is the infrastructure-based service working as close as possible to the workplaces and communities. The service provision model may vary depending on the local circumstances and needs (see page 17). The personnel, usually a physician and a nurse, have a short training (some 10 weeks) in occupational health. They would benefit from the support of a safety expert who is competent in accident prevention and basic safety. The content of services is described in this leaflet and the associated practical guides (toolboxes).

Stage III: International Standard Service

This level is the minimum objective for each country as stipulated by the ILO Convention No. 161. The service infrastructure has several optional forms and the content is primarily preventive, although also curative services may be appropriately provided. The service staff should be led by a specially trained expert (usually an occupational health physician) and the team should preferably be multidisciplinary or the multidisciplinary content of the service should be ensured with appropriate support services from specialized units (such as an institute of occupational health)

Stage IV: Comprehensive Occupational Health Services (COHS)

This level is usually found in the big companies of industrialized countries or it may be provided by large OHS centres providing services for high numbers of various types of client companies. The staff works as a multidisciplinary team often including several specialists like specialist physician, occupational health nurse, occupational hygienist, ergonomist, psychologist, safety engineer, etc. The content of services is comprehensive covering prevention, curative services, health promotion, promotion of work ability, and development of healthy work organizations.

The Stages I and II are primarily designed for the smallest and micro-enterprises, the self-employed and the informal sector which have no possibilities to start immediately from the International Standard level three. Big industries and well organized SMEs should, however, always start to establish the level three services and that level should be the minimum objective for each country and each workplace in the long term as stipulated by the ILO Conventions Nos. 161 and 155.

3.2 BOHS as a part of an integrated OSH infrastructure

The BOHS are an application of the Primary Health Care policy in the sector of occupational health. A wide and sustainable coverage of services cannot be achieved without BOHS infrastructure. The BOHS are a part of the overall occupational safety and health 10 (OSH) infrastructure. The OSH infrastructure is called the OSH system. The current ILO trend is to promote an integrated OSH system. A model integrated system with numerous possibilities for national and local modifications looks like the following:

The overall national system for health services and for occupational safety and health determines the organizational form of the BOHS infrastructure system. BOHS are a part of that interaction either organizationally or functionally. For example, the role of the health administrator becomes more prominent if the occupational health services belong to the Ministry of Health. The key issue is not the form but the availability and functionality of the system so that the health and safety needs of working people in all sectors and every workplace are adequately addressed.

The infrastructure of BOHS has the following characteristics:

Constitutes a part of integrated infrastructure for health and safety
Can be carried out by several types of service units
Collaborates with and takes support from primary health care
Collaborates with safety services
Specially tuned to serve the small and underserved workplaces

4 Activities and content of BOHS

In several international guidelines it has been emphasized that OHS should be multidisciplinary and address to, not only health, but also safety, ergonomic, psychosocial, organizational and technical aspects of work and working conditions. Qualitatively the scope of activities of BOHS follow this principle, but as the available resources often are a physician and nurse only, the multidisciplinary content needs to be achieved with the help of adequate training of the BOHS personnel and, if possible, with the support services. The model content of BOHS is described in Figure 4.

The BOHS cycle follows the conventional action model: identification of needs ―> assessment of problems ―> management of actions ―> evaluation of effect ―> revision of the programme. The various steps indicated in Figure 4 have a dual target: the work environment-oriented activities (outside the action cycle) or the worker-oriented activities (inside the action cycle), and often both simultaneously. It is important to see BOHS as a functional process instead of a number of separate actions. The key steps in the process are described below and each step will be specifically guided by a guideline.

4.1 Orientation and planning

If occupational health services have not been previously provided or when new occupational health service staff members are recruited, a preliminary orientation to the occupational safety and health situation of the enterprise is needed. This step provides information on what kind of client workplaces (e.g. agricultural, industrial, services) and 12 worker groups (e.g. manual workers, office workers, construction workers) the services are dealing with.

This involves the following steps:

Analysis of the type of production indicating the risks and problems typical of the branch or occupation in concern
Review of problems that have been identified previously in the company
Review of the characteristics of the workforce of the company
Available data on occupational diseases and accidents
Data on working methods, chemical substances, etc.
The knowledge by employers and employees of occupational health problems
Plans for changes in production systems, e.g. installation of new facilities, machinery and equipment

Such orientation helps to decide the types of activities need to be planned in more detail.

4.2 Surveillance of the work environment

The surveillance of the work environment is one of the key activities of BOHS. It is carried out for the identification of hazardous exposures and other conditions of work, identification of exposed workers, and assessment of the levels of exposures for various groups of workers. At best, surveillance is made by regular walk-through surveys by a multidisciplinary occupational health team supplemented by employers’ and workers’ representatives. In smaller companies it may be done by the occupational health personnel alone together with the representatives of workers and the employer.

The survey may contain:

4.2 Surveillance of the work environment

Identification and evaluation of ergonomic factors which may affect the workers’ health
Assessment of conditions of occupational hygiene and factors, such as physical, chemical, and biological exposures which may generate risks to the health of workers
Assessment, where appropriate, of exposure of workers to adverse psychological factors and aspects of work organization
Assessment of risk of occupational accidents and major hazards
Assessment of collective and personal protective equipment
Assessment of control systems designed to eliminate, prevent or reduce exposure
Assessment of general hygiene and sanitary facilities

4.3 Surveillance of workers' health

The surveillance of workers’ health is made through various types of health examinations. The main purpose of health examinations is to assess the suitability of a worker to carry out certain jobs, to assess any health impairment which may be related to the exposure to harmful agents inherent in the work process, and to identify cases of occupational diseases which may have resulted from exposure at work. They are also used to check the ultimate effect of preventive actions and, for example, for assessing work ability of workers. Health examinations may also help in making observations on early effects, which have not yet developed a disease.

Numerous guidelines are available for health examinations, their methodology, conclusions and actions on the basis of results, and communication of information to various parties taking into consideration the confidentiality of personal health data. Health examinations should always be combined with the knowledge of workers’ exposures. If adverse health effects are observed, preventive and control actions should be immediately initiated.

The following types of health examinations are carried out either on the basis of regulations or as a part of good occupational health practice:

Pre-assignment (pre-employment) health examinations
Periodic health examinations
Return to work health examinations
General health examinations
Health examinations at termination or after ending of service

A new type of health examination has recently been introduced for assessment of work ability of ageing workers.

4.4 Assessment of health and safety risks

Information from the surveillance of the work environment is combined with the information from health surveillance, and information from other relevant sources, and all these data are used for risk assessment.

The steps in an occupational health risk assessment include:

Identification of occupational health hazards (as a result of surveillances)
Identification of workers or groups of workers exposed to specific hazards
Analysis of how the hazard may affect the worker (ways of entry and type of exposure, threshold limit values, dosage/ response relationships, adverse health effects it may cause, etc.)
Determination of intensity (level) and magnitude (volume) of risk
Identification of individuals and groups with special vulnerabilities
Evaluation of available hazard prevention and control measures
Making conclusions and recommendations for the management and control of risks
Documenting the findings of the assessment
Periodic review and, if necessary, reassessment of risks
The results of risk assessment must be documented.

4.5 Information and education on risks and advice on the need for preventive and control actions

Surveillance and risk assessment constitute the basis for risk management. Information on identified workplace health hazards and risks must be communicated to the managers responsible for implementing prevention and control measures. Legislation also requires full information to the workers on risks and on methods for protection and on avoidance of risks. The national law and practice may also require appropriate information to the Occupational Safety and Health Committee and, often in case of severe risks, to occupational safety and health authorities. In informing on health conditions of individual workers the regulations on protection of confidential data and on informed consent must be observed.

To ensure proper understanding and use of information concerning special risks the employer is responsible for education of his/her workers on risks and hazards at work and on their avoidance, prevention and protection, as well as on safe work practices.

Such information and education tasks are often delegated to occupational health experts. The information and education include the following aspects:

The employer and the self-employed have an obligation to know the hazards of the workplace and works in concern.
The workers have a right to know and get continuously information on hazards related to their own work and the workplace.
The employer is responsible for training the workers on safe and healthy work practices.
The workers have a duty to follow the safety instructions and safe and healthy work practices.
Confidential health information of an individual worker is subject to special legislation and practices and to informed consent.
The advice provided by OHS personnel must be given in a form which is easily understood by employers and workers.
Information given to various partners should be documented.

Preventive actions for the management and control of health and safety hazards and risks

Occupational health services should propose, initiate and advise on appropriate preventive and control measures for the elimination of hazardous exposures and for protecting workers’ health (risk management actions). Where appropriate, the measures are recommended after consulting the enterprise management, employers, workers or their representatives. Recommendations must be documented.

Control measures should be adequate to prevent unnecessary exposure during normal operating conditions, as well as during possible accidents and emergencies. Planned modifications in the work processes should also be taken into account and recommendations should be adaptable to the future needs. In many countries, the use of best available technology for safety management is required by legislation. The overriding principle of occupational health and safety is the primary prevention of hazards and risks.

Numerous guidelines for occupational health and safety management systems provide a practical approach for such actions. It is important to document the proposed recommendations so that their implementation can be followed up. Such documentation should emphasize the responsibility of the management for preventive and control actions at the enterprise, and collaboration between the employers and workers.

The risk management actions may comprise:

Control of hazards at the source
Ventilation or control technology
Dust control
Ergonomic measures
Use of personal protective equipment
Regulation of thermal conditions, etc.

4.7 Prevention of accidents

Accidental injuries are one of the most common adverse health outcomes at work. BOHS have a role to play in accident prevention in several different ways:

Accident risk is identified and assessed in the surveillance of the work environment
Several factors in the work environment may aggravate accident risk, such as exposure to chemicals, haste and stress, and shift work.
The health aspects of the worker may affect accident risk.

Accident risks are managed according to the same logic as other risks at work: identification of risks, assessment of the magnitude of risk, identification of exposed workers and planning and proposing preventive and control measures. The practical methods for accident risk control or elimination are, for example:

Safe planning of facilities, machinery, etc.
Good housekeeping, order and cleanliness
Making walkways and other structures safe (e.g. scaffolds, fences)
Guarding dangerous machines
Technical aids for moving and lifting heavy loads
Safe tools and safety equipment for workers
Analysis of major hazard risks and provision of “redundant safety”

Dozens of sector- or work-specific checklists and guidelines are available for the identification and management of accident risks in various works. These guidelines also include methods for risk elimination, prevention or reduction, and methods for the analysis and control of major hazards.

4.8 Maintaining preparedness to first aid and participation in emergency preparedness

Capacity and readiness to first aid is a legislation-based activity of OHS in most countries. The BOHS personnel need to be able to provide first aid and train the workplace personnel in first aid activities. The BOHS should also periodically control the availability and condition of first aid facilities and equipment at the workplace.

Although the BOHS are not primarily responsible for major hazard preparedness, the occupational health experts need to participate in the building up of emergency preparedness, to ensure appropriate planning, training, equipment, first aid and other emergency resources and contacts with the emergency polyclinics and hospitals, as well as with the rescue teams.

The role of BOHS in first aid and emergency preparedness is:

Providing first aid services at the workplace when appropriate
Introducing and training first aid practices to workers and supervisors
Maintaining and periodically inspecting the first aid readiness and facilities
Participating from the health point of view in emergency planning and organizing the health elements in emergency response

4.9 Diagnosis of occupational and work-related diseases

Occupational diseases are diseases caused by work (physical, chemical, biological, ergonomic and other factors). In many countries there are official lists of occupational diseases, including lists of factors which may cause such diseases. ILO guides the coun- 17 tries by the Recommendation No. 194: List of Occupational Diseases Recommendation, 2002.

Occupational diseases may be detected in connection of health examinations, in diagnosis and treatment of general diseases or on symptoms presented by the worker him/herself. Many occupational diseases can be diagnosed in the BOHS service but many of them need to be referred to specialized occupational medicine clinics. In both instances, the diagnostics follows a special scheme:

Identification of exposure which may cause the disease
Examination of clinical findings which are known to be associated with the specific exposure (lists of occupational diseases)
Exclusion of non-occupational factors as a possible cause of disease
Conclusion on existence or non-existence of occupational disease (diagnosis)
Statement on occupational disease for workmen’s compensation
Proposals for preventive actions to the workplace of the worker in concern
Notification of occupational diseases to authorities

The concept of Work-related disease (WHO 1985) is wider than that of an occupational disease. It includes:

Diseases in which the work or working conditions constitute the principal causal factor
Diseases for which the occupational factor may be one of several causal agents, or the occupational factor may trigger, aggravate or worsen the disease
Diseases for which the risk may be increased by work or work-determined lifestyles.

The diagnosis of work-related diseases does not have a definitive legal status in terms of compensation, but it may have an important impact on preventive and control measures. The prevention of work-related diseases often comprises actions towards work, work environment and individual health characteristics of the worker.

4.10 General health care, curative and rehabilitation services

BOHS personnel may provide general preventive health services by providing immunizations and by guiding preventive and health promotion activities to introduce healthy lifestyles.

Besides the diagnosis of diseases, BOHS services may be involved in the treatment and rehabilitation of occupational and work-related injuries and diseases. The knowledge of occupational diseases and injuries coupled with the knowledge of the job demands, hazards of the work environment and occupational exposures present in the workplace enable the occupational health professionals to play a key role in the management of work-related health problems and in rehabilitation. Ageing workers, pregnant women, 18 adolescents and other vulnerable groups have special needs for the adjustment of work and the workplace to the worker. A special activity is focused on the workers returning to work after an injury or a long sick leave.

In some countries, occupational health services provide ambulatory general health services (usually at general practitioner (GP) level) during working hours. Certain benefits from such services are found in providing quick service to workers and thus saving working time and also in combining the information on occupational health, working conditions and general health of workers. This is necessary, for example, in the promotion and maintenance of work ability of ageing workers. This activity may be fully integrated with BOHS if the occupational health services are provided by primary health care units.

Where appropriate, the BOHS may include:

Immunizations and other preventive measures
Participation in public health actions and programmes
GP-level general health services
Inspection and advice on canteens, sanitary facilities
Advice and education in general personal and community hygiene
Actions for rehabilitation and adjustment of work for workers after injuries, diseases, reduced work ability and on return to work from long sick leaves
General health promotion and introduction of healthy lifestyles

4.11 Record keeping by BOHS

As a health service BOHS have a general obligation to keep record on health services provided to the workers, on exposures detected or measured, and on all events dealing with the health of individual workers, or health and safety aspects of the workplace.

In occupational health there are several record-keeping obligations, such as:

General health record, if the workers are treated as patients or health service clients
Data on surveyed, detected and measured occupational exposures and risk assessments made
Statistics on occupational diseases and injuries
Data on health examinations
Documents on proposals for preventive and control measures

In many countries special legal provisions are given for recording, organizing, maintaining and protecting confidential personal health data.

4.12 Evaluation

To learn from the experience and to undertake measures which may be needed for the improvement of services the BOHS should periodically make a self-evaluation on its own activities and their effectiveness in the prevention of health and safety hazards and in the provision of services to working people. The recorded data, collected in BOHS activities, should be used for such an evaluation. The evaluation result should be documented and presented to the employers’ and workers’ representatives.

The following items are considered in evaluation:

Evaluation is carried out as an inbuilt part of BOHS activity, at least annually
Evaluation is made when the working methods, production structures or other aspects at work are substantially changed
Evaluation is made if the methods or conditions of operation of services are substantially changed
The following questions are answered through evaluation:
- Do the services respond to the needs of the workplace?
- Are the activities directed to priority problems?
- Is good occupational health practice followed?
- Are the resources, human and technical, sufficient?
- Are the services effective in elimination of health problems?
- What can be improved?

The evaluation should support continuous improvement of BOHS activities and give input to re-planning and, if needed, re-orientation of services.

5 Provision of BOHS

In general, numerous models for the provision of occupational health services are available:

Primary health services model
Big company model with in-company services
Group services organized jointly, e.g. by several SMEs
Social security institution as a service provider
Private physician who has special competence in occupational health
Private health centre either providing occupational health services only or occupational health as a part of its services
Local or regional outpatient clinic of hospitals

The clients for BOHS are mainly the SMEs and the self-employed, as well as farmers and the workers in the informal sector. This excludes the use of some models either for 20 structural (scattered distribution) or economic (affordability) reasons. The widest coverage of services is possible to achieve through primary health services unit model. In the countries where the public primary health care units provide BOHS for SMEs and the self-employed, they may cover a substantial proportion of the total occupational health service provision in the country. Often they are in practice the only option to cover the informal sector. The social security institutions organize occupational health services in some countries. The coverage is there defined by the coverage of insurance and the noninsured are not covered. In some countries, the hospital outpatient clinics provide publicly funded occupational health services for the SMEs and other underserved groups. In some countries trade unions have organized OHS for their members.

As the competence of the frontline BOHS is not sufficient to ensure solution of all the problems of practical occupational health and safety, the governments should consider organizing the necessary secondary level support services which provide specialized analytical, measurement and consultation services to BOHS providers, including clinical services in occupational medicine, psychological services etc. and training in occupational hygiene for the BOHS personnel, and for employers and workers.

6 Human resources for BOHS

In the optimal case, the occupational health services will be provided by a multidisciplinary team (comprising a physician, nurse, occupational hygienist, ergonomist and psychologist). Such a resource is not possible to organize for most of the small service provision units and particularly for the SMEs, rural agricultural and informal sectors. The service provision needs to be trusted to a physician and a nurse who may not always have specialty in occupational health.

In many industrialized countries, the basic training curricula for physicians and nurses contain a short introductory course in occupational health. Such an element should be included in curricula in all countries. While larger units may have a possibility to hire occupational health specialists, most of the BOHS will be provided by non-specialists, primary health care personnel, or general practitioners. It is, however, not possible to provide competent occupational health services without special training in occupational health. Therefore, it is vitally important that even the non-specialists have a certain minimum training in occupational health services. In some countries, a well-designed post-graduate course of 10 weeks supplemented with a certain amount of self-studies is considered as a reasonable minimum. Periodic complementary education is also needed.

The quantitative need for OHS personnel in BOHS is not easy to estimate as the structures of constituents and their needs may vary widely. An experience-based estimate speaks for a minimum need of one physician and two nurses per 5000 workers with a great variation depending on the branch of industry and size of workplaces, as well as on their geographical distribution. The public authorities are responsible for ensuring that such a resource is available and its competence is regularly updated in every country.

As indicated in Figure 2, the starting level should have a minimum of a field nurse with short training in OHS and preferably a safety agent who knows the basic elements of safety. The BOHS level should have a physician and a nurse, who work for either a 21 PHC unit or for other facility (infrastructure) and have a short special course in OHS. The levels III and IV are run by experts with specialist training.

7 Financing

According to the ILO Convention No. 161 on Occupational Health Services, the financial responsibility for the provision of occupational health services rests on the employer. As the ability of the SMEs and the self-employed, and particularly the informal sector enterprises and workers, to buy external services is poor or non-existent, often the only possibility to provide services is the provision of BOHS by the public sector, i.e. the primary health care units, public polyclinics or by social security organizations. In some countries, special external OHS are well developed and the OHS units can provide services through the market mechanism to all enterprises and workplaces that wish to get them. Even in such a model the ability of the underserved sector to buy services needs to be ensured through some kind of financial support. Irrespective of the service provision model it is realistic to assume that the need for subsidizing of services for SMEs and the self-employed, agricultural and informal sectors is substantial, amounting to 50–100%. Innovative models for combining public, community and workplace resources have been experimented and the lessons should be distributed to the countries. Occupational health is not only a financial burden for enterprises; there is evidence speaking for the positive economic impact of well-organized occupational health services.

Where accident insurance is available, the premium policy should be used as an incentive for the organization of occupational health and safety services.

8 Actors in the organization and development of BOHS

The overall responsibility to ensure occupational health services for all working people belongs to the Government. In well-organized sectors the employer is responsible for the organization and financing of services. The Government’s competent authority controls the compliance of employers according to national law and practice.

The clients of BOHS are often heterogeneous, scattered, poorly organized and poor in resources. A major part of them do not have an employer-employee relationship as they are self-employees. The only party with an overall view is the public sector, government’s occupational health and safety, health or social security authority (often Ministry of Labour or Ministry of Health).

In the absence of an employer, the responsibility for the organization of services rests on the Government or other bodies of the public sector. The organization of services requires several other actors, who vary according to the sector and the target group. In addition to the government’s competent authority, the following partners can contribute to and should be involved in the activity, when appropriate:

Government’s special agencies in occupational safety and health and in the health sector
Provincial and local municipal authorities
Social partners, employers’ organizations and trade unions
Branch organizations and chambers of commerce
Associations of agricultural producers and small enterprises
Associations of occupational health professionals
Safety representatives of local workplaces and communities
Ministry of Agriculture and Ministry of Industry
Universities and other training institutions for training support

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www.icohweb.org
www.ilo.org/safework
www.who.int/oeh

Name :	Dr. Narendra K. Rojha
Qualifications’ :	MBBS,MD,DCCP, DHM,AFIH. Certified Lead Auditor OHSAS: 18001
Current Designation :	Consultant: Occupational, Industrial, Environmental Medicine & Hospital Administration

Experience :	Hospital Administration; government, charitable &multi-super-specialty hospitals’ Advisor & Consultant; Occupational &Industrial Health, ‘EHS’ Auditor to a wide spectrum of industrial organizations, Medical & Biosafety Advisor – past & present to pharmaceutical & biotech companies including MNCs of Canada & Switzerland Visiting faculty to Regional Labour Institutes (RLI) – Faridabad, COEH- MAMC, New Delhi & NIHFW, New Delhi Chief Medical Advisor; KRDWG, an Indo- French NGO. Technical specialist to Bureau Veritas & TUV-NORD for IMS & QMS auditing
Expertise :	Hospital Administration &Management, Medical Sleuthing in Environment, Safety, Industrial &Occupational Health.Auditing – NABH, IMS & QMS, Teaching &Training
Memberships’ :	NSC, IAOH, MFS&SEOH& IAOH
Achievements’ :	Commended as The ‘Turn Around Man’ for reviving a moribund hospital, successful NABH conclusion (His First & Hospital’s Fourth Attempt) of another hospital, and received plaudits by W.H.O. Audit Team for unearthing the cryptic source of Fungal Contamination in a Vaccine Manufacturing & R&D facility

Experience :	Total Years of Professional Experience: – More than 37 years Senior Residency, SJH Delhi – 3 years. ( 1983-86) Pool Officer, LHMC, Delhi – 3 years ( 1986-89) Experience in ESIC Hospitals: Specialist Medicine, ESI Hospital, Jhilmil, Delhi – 4 years. (1989-93) Specialist (Sr. Scale), ESI Hospital, Jhilmil Delhi – 4 years. (1993-97) Senior Specialist, ESI Hospital, Jhilmil Delhi & ESI Model Hospital, Noida – 11 years. (1997-2008) Senior Specialist (SAG) ESI Model Hospital, Noida – 10 years ( 2008-2020)
Publications :	More than 6 publications in different national and international indexed journals.
Awards and Orations :	L & T Award: by Indian Association of Occupational Health (India) in 2012. Distinguished Service awards from Indian Medical Association, New Delhi Branch, Delhi Medical Association, Integrated Diabetes Wellness Society, Medical Fitness Society, Lions Clubs International 321-A1from time to time.
Expertise :	Occupational Health, Preventive &Public Health, Clinical& Critical Care Medicine. Workplace Ergonomics &Musculo-Skeletal disorders Nanotechnology Education and Training in Occupational Health.
Memberships :	IMA, DMA, MFS, IDWS, IOAH, AEOH, SEOH, AIESDA, DDF, Lions Club International, API, ICOH, etc.
Achievements :	Founder President of Society of Environment and Occupational Health (India) 2017-19. Organizing Secretary and Chairpersons of fourteen international and National Conferences Health Camps in different parts of Society: Involved in organizing in Health camp with Honourable Minister of Labour, Shri Ashok Pradhan in planning and organizing the Health Camp for three days wherein 60, 000 people came in the camp. Is organizing Health camps since 1994 at different forums of Indian Medical Association, Medical Fitness Society, Indian Association of Occupational Health, And others in slum areas, places of worship, etc. School and College program: Organized educative health awareness, environmental, healthy lifestyle programs in schools and colleges since 1998. Has been involved in Identifications, planning, implementing, and monitoring health needs in terms of medical services; health audits (risk assessments, audits, and inspections); liaison with local and regional hospitals of ESI, Governmental health authorities, and international medical service providers; and organized National and International conferences in India for National and International Bodies and chaired and presented papers… I have organized Health camps in Delhi and other parts of India. Also organized many health awareness campaigns in Schools and Colleges in India.

Experience :	Sep’2016- till date: Sincere & Dedicated over 3 years of Clinical Craftmenship Experience and Working in Dermatology Department at ESIC Model Hospital, Noida. Accountabilities Focussed Treatment on Dermatology with more than>100 patients per day Precise Diagnosis and effective Treatment with clinical skills and knowledge Meeting all Government Norms and Protocols of MCI for adhering to compliance of Medical Practice
Expertise :	A dynamic dermatologist and effective clinician with 5+ years of Clinical experience in Dermatology with a major focus on Diagnostics, Treatment planning and results orientation with patient satisfaction. Currently Working at ESIC Model Hospital, Noida as an eminent Dermatologist. Accountable for achieving patient satisfaction with an increase in patients inflow. Ability in cementing healthy relationships with the patients for generating growth. Possess excellent interpersonal, communication, and analytical skills.
Memberships :	SEOH
Achievements :	Actively participated in more than 13 International and National Conferences

Name :	Dr. Dharmendra Kumar Gupta
Qualification :	MD, MBBS – GOLD MEDALLIST
Current Designation :	Chairman and Managing Director Felix Healthcare Pvt. Ltd.

Experience :	Medical Officer: Municipal Corporation, East Delhi, 2007-2015 Managed maternity hospital Treated Patients in OPD & IPD Established NICU Level II Master Trainer for Delhi state for RBSK Resident Doctor Dr. Ram Manohar Lohia Hospital, New Delhi (Department of Paediatrics), 03-02-2004 to 30-04-2004) Resident Doctor RNT Hospital, Udaipur, Rajasthan (Department of Surgery), 02-05-2004 to 20-06-2004
Publications :	Many publications are in different national and international indexed journals.
Awards and Orations :	• Awarded as “Entrepreneur of the year” in a service business (Healthcare) for Established Entrepreneur of 2017 (7th Edition) in partnership with ET NOW News Channel. Guest speaker at the BW Healthcare Summit and BW Diagnostic Summit in the year 2019. Chief speaker in Patient Experience Conclave and Awards 2019 on “Improving Healthcare Services through technology” Honoured as chief guest for Women Empowerment Awards in JANSHARAM (women and child development NGO) Honoured as a panelist speaker in India Healthcare Leadership Forum (IHLF) to discuss growth opportunities in the healthcare sector in India. Participated as a chief speaker in Patient Experience Conclave and Awards 2019 on “Improving Healthcare Services through technology”. Honoured as a speaker in ‘Annual Healthcare Innovation Summit’ organized by EletsTechnomedia.
Expertise :	Healthcare entrepreneur and Healthcare Management Expert Panelist member and eminent speaker at prestigious healthcare platforms Adept medical doctor with thirteen years of practice experience. Dedicated to exemplary patient outcomes and following all necessary medical procedures with the use of the latest industry equipment and technology. Strong focus on listening to and addressing patient concerns and answering all questions in terms patients can easily understand. Willingness to work with all members of the medical team and listen to their suggestions and input to improve results and maximize patient satisfaction.
Memberships :	CII, FICCI, ASSOCHAM, IMA, IAP, SEOH
Achievements :	Panelist member of Policymaking Delegation of Healthcare Providers, PWC & Niti Aayog. Constructive discussions on best practices and ways forward for building hospitals were held with Health and Nutrition Advisor MrAlok Kumar (IAS). Received First Gold Quality Certificate in UP by Hon’ble Health Minister Dr. Harsh Vardhan in the presence of Dr. J L Meena GM Ayushman at Delhi “INTEGRATED DIABETES WELLNESS SOCIETY” 7th national annual conference of IDWS on World Diabetes Day. Represented healthcare sector in ASSOCHAM business delegation accompanying Hon’ble President of India to Manila, Philippines from 18th – 19th October 2019.

Experience :	Corporate Occupational Health Consultant Physician for various MNCs for 27 years in Mumbai including HPCL, Bharat Shell Ltd, Shell India Ltd., SAP India Ltd, De Gussa HULS India Ltd, Da Cunha Communications, Hindustan Unilever Ltd, Jacobs Engineering Ltd., to name a few. Assistant Professor – MGIMS, Sevagram Wardha & Epidemiologist for MGM Medical College, Kamothe, Navi Mumbai
Publications : Original Research Paper & Workshop Presentations :	More than 20 publications in different national and international indexed journals. More than 80 scientific papers were presented as well as 70 training workshops conducted at state, regional, National and International meetings, symposia and conferences
Awards and Orations :	Lenke-Peschke Gold Medal in Office Ergonomics – Sri Ramachandra University (SRMC- Harvard Institute, Porur, Chennai) Gogate Symposium Resource Person Award from IAOH Reliance Industries Award from IAOH Bombay Port Trust Award from IAOH Britannia Award from IAOH BEL Industrial Medicine Award from IAOH Larsen & Toubro Oration from IAOH IAOH Pune Branch Oration OHSF-IAOH Mumbai Branch Oration Mathuradas Parikh Oration from IMA Greater Mumbai Honorary Fellowship of the IMA College of General Practitioners The Menda Salaskar Oration from IMA Greater Mumbai Honorary Fellowship from The Bangla Desh Academy of Family Physicians 2018 IAPSM Award for Best Research Paper- Gauhati National Conference Best Research Paper on Ergonomics at International 7^th Regional Occupational Health Conference, Kuala Lumpur Malaysia 2018
Expertise :	Occupational Health, Preventive & Public Health, Clinical, Critical Care &Emergency Medicine. Workplace Ergonomics&Musculo-Skeletal disorders Nanotechnology Education and Training in Occupational Health.
Memberships :	IOAH, ICOH, IMA, IPHA, IAPSM, WONCA, AFPI, SEOH
Achievements :	He has been invited to the Global Expert Panel of ICOH [International Commission on Occupational Health] for defining the criteria for the diagnosis of musculoskeletal disorders (MSDs) in 2019. He was on the Executive Committee of IAPSM from -2008 to 2017. He has recently (2019) been elected as President of AFPI [Academy of Family Physicians] for Maharashtra Chapter. He is the AFPI representative to the WONCA World Council. [WONCA -World Organization of Family Doctors]. He is Chairperson of SIG (Special Interest Group) on Workers Health for WONCA South Asia Region- since 2018. Has been invited at Health, Safety & Environment Conclaves of The Confederation of Indian Industries (CII), BCCI, National Safety Council and Ministry of Defense, Government of India (invited as expert faculty on Nanotechnology) at the National Level. At the International level, he was awarded a grant as well as invited by the American College of Occupational & Environmental Medicine to speak on the current status of Environment & Occupational Health in India in May 2020 (event rescheduled to be held at Austin, Texas from 3 to 6 May 2021).

Experience:	Associated in different health awareness, research, data analysis., organizing seminar, and other activities for the past 20 years. Also worked and assisted in the projects/programs of the following reputed agencies who are very popular in the field of public health: 1. Centre for Global Health Research (CGHR), 2. India CLEN, 3. WHO, 4. UNICEF, 5. UNDP, 6. UNFPA, 7. Govt. of West Bengal, 8. NRHM, 9. WBSAPCS, 10. APSACS, 11. ICMR etc.
Publications:	12 publications in different national and international indexed journals.
Awards, Speaker Invitations and Orations:	Participated as a speaker in the CME organized by All India General Practitioners’ Association and Indian Academy of General Practice at NRS Medical College & Hospital on 23rd May 2015. Participated as speaker in the seminar on the theme “Depression: Let’s Talk” on the occasion of World Health Day organized by South Dumdum Municipality and IPHA South Dumdum Paikpara Branch on 7th April 2017. Participated as speaker in the awareness program on “Prevention and Control of Dengue” in Bangur, Kolkata organized by South Dumdum Municipality and IPHA South Dumdum Municipality on 30th April 2017. Competitive Examination Teacher in South Dumdum Municipality, Kolkata.
Expertise:	Data entry, data analysis, SPSS in quantitative research and management Video and photo Editing Composing MSc & Ph.D. Reports, Supervised Field Training Programs, etc. Knowledge of SPSS in quantitative research.
Memberships:	IPHA, ISPSW, APCRI, Rotary Club of East Calcutta, SEOH
Achievements:	Attended and presented many papers in more than 34 national and international conferences, seminars, CMEs, etc. Central Council Member (HQ) of Indian Public Health Association – Term 2016-2018 Joint Editor of Rotary International Club of East Calcutta, Dist. 3291 Treasurer, IPHA SDPP Branch Executive Secretary – Rotary Club of East Calcutta

Experience :	Total Years of Professional Experience: – More than 25 years Consultant Physician Rheumatologist at PUSHPANJALI CROSSLEY Hospital, Vaishali, Ghaziabad, UP. Associate Consultant at NOIDA MEDICAL CENTRE, Noida from July 2005 to January 2006. Senior Registrar, Department of Internal Medicine, SIR GANGA RAM Hospital, New Delhi December 2001 – January 2005. Postgraduate student, Department of Internal Medicine. SIR GANGA RAM Hospital, New Delhi September 1997 – August 2000.
Awards and Orations :	Dr. P S Gupta Award for Best Resident. Thesis on “Incidence and pattern of lung involvement in Malignancy- Primary and Secondary”. Scientific papers on Myelitis in case of Chikungunya Viral Fever and Very high levels of CA 125 in tubercular ascites. Fulminant Vasculitis – A Wild Fire (Paper Presentation) Chaired many sessions in IRACON, UPAPICON, and Fitness Society of India.
Expertise :	A trusted patient focus and experienced doctor with a reputation for serving patients through Diagnosis, Treatment, Counselling, and Rehabilitation. Rich hands-on experience of 14 years (post senior residency). Ability to diagnose various complex conditions including auto-immune diseases. Proficient in procedures like Immunotherapy with various biologics for RA, SLE Ankylosing Spondylitis, and Vasculitis. Intra-Articular joint injections for both small and large joints. Viscosupplementation. Bone Marrow aspiration & Biopsy, Pleural Tapping, Lumbar Puncture, etc. Independent Management of Rheumatology Clinic and IPD since 2005.
Memberships :	NAMS, API, IRA, DDA, ACR & SEOH
Achievements :	Independent Management of Rheumatology Clinic and IPD since 2005. Competency in Media briefs and Media addresses, Health Talks, and other promotional activities. Experienced in carrying out Corporate and Out-station OPDs. Involved in various Health Check-up Camps under the social responsibility of the Hospital. Single-handedly managed around 100 patients per day with OPD during the Chikungunya epidemic in 2016.