Approximately half of the world's population spends at least one third of its time in the workplace. Fair employment and decent work are important social determinants of health and a healthy workforce is an essential prerequisite for productivity and economic development. However, only a small proportion of the global workforce has access to occupational health services for primary prevention and control of occupational- and work-related diseases and injuries. Furthermore, certain global health problems, such as non-communicable diseases, result in increasing rates of long-term sick leave and challenge the ability of health systems to preserve and restore working capacity.

The 62nd World Health Assembly in 2009 emphasized the need to strengthen health systems based on primary health care (PHC) in keeping with the values and principles enshrined in the Alma-Ata Declaration. Action must be taken to provide universal access to PHC by developing comprehensive health services, introducing national equitable and sustainable financing mechanisms and implementing vertical health programmes, e.g. occupational health, in the context of integrated primary health care. (1)

Currently, a number of countries are reforming their health systems based on the values and principles of PHC[1] to improve service delivery, cost-efficiency and to ensure equity. National debates on health reforms often touch upon insufficient collaboration between health and labour sectors, the organization of preventive and curative health services for working populations, and their relation to primary care[2]. Employers, businesses and the private sector are engaging in providing health services to workers and communities.

In 2007, the 60^thWorld Health Assembly urged Member States to work towards full coverage for all workers with essential interventions and basic occupational health services for primary prevention of occupational- and work-related diseases and injuries. This coverage should be particularly provided to those in the informal economy, small- and medium-sized enterprises, agriculture, and migrant and contractual workers.(2) How can this goal be achieved, bearing in mind that most countries experience a shortage of human resources for health and most people lack access to the most basic elements of social protection in a world of work that is ever more diverse, small scale, precarious and informal?

Occupational health and primary health care

Recent decades have seen significant progress in the development of occupational health services in a number of industrialized countries and economies in transition and rapid economic growth. Compulsory provision of services along with national funds for their financing has led to almost universal coverage in some countries and a significant increase of coverage and quality in others. However, there are some concerns. The coverage remains low and increasingly inequitable and workers with the biggest needs, such as those in agriculture, small enterprises and informal economy, remain without access to the most basic occupational health services. Where occupational health services exist, they often focus on provider-driven menus of few interventions and may not be adequate to meet the health needs and expectations of workers. In addition, there are language, employment status and structural barriers to accessing services which in themselves are becoming more and more profit-oriented. In many countries occupational health is still detached from other parts of the health system, thus resulting in fragmentation of care, difficulties with referral and follow up, and, in general, an inability to handle work-related health problems.

The 1978 International Conference on Primary Health Care called for bringing health care to where people live and work. (3) However, when PHC was put into practice, the focus was mostly on health services where people live. With only a few exceptions, the provision of health care where people work was absent from the debate on programmes and strategies for primary health care. Thirty years after Alma Ata there are even more compelling arguments for using the workplace as a point of entry to the health system. The workplace can be a setting for delivery of essential health interventions and for reaching out to workers’ families and communities.  In some cases, the workplace is the only way of providing health care, e.g. for mining communities and migrant workers. Furthermore, improving workers’ health can help to reduce poverty, and is an essential prerequisite for productivity and economic development. (4)

There have been a number of innovative attempts to extend the coverage of basic occupational health services through integration of occupational health with primary care at the point of delivery. One example consists of training primary care providers, such as general practitioners, nurses, technicians and community health workers to understand work-related health problems and to provide some basic support for small workplace settings to improve working conditions, to train workers on how to work in a healthy and safe way and to provide first aid. This has been undertaken primarily in rural areas and the informal sector. Another example is designating a member of the primary care team to provide occupational health support to workers and workplaces in the catchment area of the primary care centre. Yet, a third example  is when occupational health experts periodically visit the primary care centre to hold an occupational health clinic providing consultations and advice as needed. (5)

Whatever the model, integrated PHC-based services for workers would provide the first point of contact within the health system while emphasizing primary prevention of occupational and work-related diseases and injuries, promotion of health and restoring working capacity. Such services require active mechanisms for workers’ participation in planning, delivery and evaluation, an adequate skill mix of service providers, equitable financing and purchasing mechanisms as well as a sound policy, legal and institutional framework.

Policy directions for reform

In 2008, WHO launched a set of reforms to provide PHC to all citizens focusing on universal coverage, people-centered care, participatory health governance and including health in all policies. (6) Furthermore, a recent WHO international conference[3]considered the opportunities and challenges for occupational health arising from PHC strategies and outlined several strategic directions for delivery of occupational health services in the context of integrated primary health care.

Working towards universal coverage with occupational health services entails certain complex measures, such as reducing the proportion of costs to the individual undertaking the service and/or workers (insurance schemes), adding interventions to the existing package of service provision (primary prevention in addition to curative care), increasing the number of workers covered, and reducing barriers to undertaking services and to individuals accessing health services.

A new health leadership should include a solid regulatory framework to guarantee a basic level of health protection in all workplaces and for all workers, as well as careful planning for the provision of different occupational and primary health care services to under-served working populations. Collaboration between health and labour sectors is essential to ensure comprehensiveness and continuity of care. A new leadership also requires participation of workers, employers and other workplace actors in the debate about health-care reforms in the context of integrated primary health care.

The aim of reforming the delivery of occupational health services should be to strengthen their linkages with primary care centres. Occupational health institutes, laboratories, clinics and information centres should provide expertise, information and laboratory support to occupational health services and to primary care centres. The content of occupational health services needs to be reoriented towards the health needs and expectations of the workers and not geared towards a supply of providers. Particularly in need is provision of workplace initiatives, practical tools and working methods that enable workers, employers and other work actors to undertake the most basic measures for protecting and promoting health at work without unnecessarily relying on health services.

Finally, delivering occupational health to all workers requires public policies that stimulate intersectoral collaboration and coordination, not least involving health, labour, environment, agriculture, industry, energy, transport, construction, finance, trade and education. Social security institutions, employers, trade unions, the private sector and civil society organizations have a particular role to play in shaping public policies for workers’ health.