Occupational Health Care in Small and Medium Sized Enterprises : How Many Doctors Do We Need and How Do We Ensure Good Care?

Antalya, 04-08. March, 2018 Occupational Health Care in Small and Medium Sized Enterprises : How Many Doctors Do We Need and How Do We Ensure Good Care? Brigitte Froneberg, Germany brigitte.froneberg@gmail.com

Facts about Turkey Area 783,562 km2 Population 79. 815 mio. Median age 30.9 y. Growth rate 0.52 % Urban population 74.4 % Brigitte (Source: Froneberg, ESS: 2nd International Turkey in Occupational Statistics and 2016; Environmental CIA Factbook, Diseases 2016 Congress, / est. Antalya, 2017; 04-08.03.2018 ILO 2012)

Brigitte (Source: Froneberg, ESS: 2nd International Turkey in Occupational Statistics and 2016; Environmental CIA Factbook, Diseases Congress, 2016 / est. Antalya, 2017; 04-08.03.2018 ILO 2012 Facts about Turkey Area Population 783,562 km2 79. 815 mio. Workforce 30. 535 mio. Agriculture 19.5 % Industry 26.8 % Service 53.7 % Unemployment 10,9 % Self-employment 16.7 % Informal employment 30.6 % GDP 5.1 % GDP per capita 26,500 $ (of non-agricultural empl. 2009)

GDP - development and forecast GDP [%] 1960-2018 (Worldbank) Annual Growth Rate [%] Forecast 2009 2019 (OECD)

Newly industrialized countries some characteristics Rapid economic growth; mostly export-oriented industry Migration from countryside to cities Construction work, mining,... with high incidence rates of occupational accidents Considerable underreporting of occupational accidents and diseases Ineffectiveness of OSH system, non-complance with legislation, lack of knowledege, insufficient human resources,

Ratification of ILO Conventions Number Conventions ratified: 59 (ILOLEX -24.02.2018)

Turkey and the EU 1949 Founding member of Council of Europe 1952 Member of Nato 1959 EU membership application 1963 Association Agreement (Ankara) 1987 Application for accession 1996 Customs Union 1999 Cadidate country status 2005 Opening of accession negotiations

Modernization and adaptation of OSH ILO / WHO support EU support (EuropeAid, Twinning, Taiex, Leonardo da Vinci, Erasmus, ) infrastructure and resources Support to the Directorate General for Occupational Health and Safety of the Ministry of Labour (DGOSH) and Social Security and its Occupational Health and Safety Centre (ISGUM) (EuropeAid/114648 /D/SV/TR), 2005 (ISAG Project) EU Twinning Project Improving Labour Inspection System (TR 06/ IB/ SO/ 01). 01/2008 07/2009 (ILIS Project) Improvement of Occupational Health and Safety Conditions at Workplaces in Turkey (EuropeAid/127926/D/SER/TR), 01/2010 02/2012 (ISGIP Project)

ISGIP Health-related activities OHS-MS / 3 sector-specific OHS-MSs OH assessment and counsel of enterprises and occupational health service suppliers Occupational Health Surveillance Guideline Occupational Diseases Diagnosis Guideline Health Surveillance Training Brigitte Froneberg, Closing Conference Ankara 2012-02-14

Health Surveillance Training 1 Ankara I 2 Zonguldak 3 Bursa 4 Afyonkarahɩsar 5 Ankara II 6 Kocaeli 7 İstanbul 8 Denizli 9 Eskişehir Brigitte Froneberg, Closing Conference Ankara 2012-02-14

C161 - Occupational Health Services Convention, 1985 C155 - Occupational Safety and Health Convention, 1981 C187 - Promotional Framework for Occupational Safety and Health Convention, 2006 Council Directive 89/391/EEC on the introduction of measures to encourage improvements in the safety and health of workers at work Labour Law (No. 4857; 2003) Occupational Safety and Health Law (No. 6331; 2012)

Current status of OSH infrastructure National OSH strategy and action plan National Tripartite Council Modern OSH legislation Laboratories, OD hospitals Research and Training Institutions Labor inspectors, Occupational Safety specialists, Occupational physicians, Occupational health nurses,

Development of industry, OSH resources and indicators 2004-2015 Enterprises % SMEs Persons employed % in SMEs Technical Labor Inspectors Occupational safety experts Occupational physicians OH nurses 2004 850 928 98.1 % 6 181 251 58 % 277 1 317 174 141 2015 2 435 774 99.8 % 11 756 955 75.5 % 587 87 207 26 872? (Source: TUIK Turkish Statistical Institute; SSK Social Insurance Institution)

Development of industry, OSH resources and indicators 2004-2015 Enterprises % SMEs Persons employed % in SMEs Technical Labor Inspectors Occupational safety experts Occupational physicians OH nurses Occupational accidents Fatal OA Occupational diseases 2004 850 928 98.1 % 6 181 251 58 % 277 1 317 174 141 83 830 843 384 2015 2 435 774 99.8 % 11 756 955 75.5 % 587 87 207 26 872? 221 366 * 1 626 * 494 * * Data of 2014 Brigitte (Source: Froneberg, 2nd TUIK International Turkish Occupational Statistical and Environmental Institute; SSK Diseases Social Congress, Insurance Antalya, 04-08.03.2018 Institution)

Occupational Health resources (OP) Occupational health resources Few fully trained OPs (mainly at Universities, Public Administration etc.) 26,872 * GPs and other specialists with OSH training Training: Content: Occupational Diseases; Surveillance; Legislation etc. 220 hours * only 48 % working 40 h at work under supervision: 180 h theoretical (50 % long-distance learning possible; examination) Tasks Essentially preventive Counselling and health promotion Participation in risk evaluation Health examinations, notification of ODs Health education, first aid organization, record keeping Collaboration with external stakeholders 5-15 min / worker and month depending on size of enterprise and hazard category

(Source: Brigitte Froneberg, N. Bilir: 2nd Occupational International Occupational safety and Environmental health profile: Diseases Turkey. Congress, ILO Antalya, Ankara, 04-08.03.2018 2016) Human resources in OSH Human resources 1,005 Labur Inspectors 587 technical inspectors 418 social inspectors (labor relations) 26,872 Occupational physicians * 87,207 safety specialists (?N OH nurses) 3 models of OHS In-company services * only 48 % working External OSH services (1995 Joint Safety and Health Units) Community Health Centers (81 in 64 regions) Enterprises (by size, %) 1-9 97.01 20-49 1.98 50-249 0.85 250+ 0.16 Number of persons employed (by size of enterprise) 14% 43% 26% 7% 10% 0-9 10-19 20-49 50-249 250+

Human resources in OSH Human resources 1,005 Labur Inspectors 587 technical inspectors 418 social inspectors (labor relations) 26,872 Occupational physicians * 87,207 safety specialists (?N OH nurses) 3 models of OHS * only 48 % working Laboratory support Institute of Occupational Health and Safety Research and Development Presidency (İSGÜM) Mobile labs Audio-mobile + Radio-mobile (Digital X-ray, ECG, Spirometer) + Bio-mobile (Blood / Urin tests) Hospitals 3 Hospitals for Occupational Diseases > 100 General Hospitals Training institutions Labour and Social Security Training and Research Centre (ÇASGEM) Numerous non-governmental certified training institutions (Source: Brigitte Froneberg, N. Bilir: 2nd Occupational International Occupational safety and Environmental health profile: Diseases Turkey. Congress, ILO Antalya, Ankara, 04-08.03.2018 2016)

Demand for professional competence Need for multidisciplinarity Evolution of Occupational Health Services Stage I Sporadic OHS activity Stage II Unspecific curative - passive - diseaseoriented OHS = GPs curative services Stage III Specific preventive - medical - specialized - active - risk-oriented OHS = preventive services Stage IV Comprehensive developing - specialized - multidisciplinary - active - promotion of work-ability - structural development - developmentoriented OHS = development resource for workers and enterprises 1850 1950 1960 1970 1980 1990 2000 (Source: H. Taskinen, 2001)

Occupational Health Care Task: Maintanance and promotion of workers health and work-ability Should be preventive May also be curative Should cover all Should be effective, efficient and quality-insured (evaluated)

Occupational Health Care Task: Maintanance and promotion of workers health and work-ability Should be preventive May also be curative Should cover all? Does the system do what it is supposed to do? Indicators?

1. How Many Doctors Do We Need? 2. How Do We Ensure Good Care? Indicators Input Process Output Estimated number of OPs necessary to cover all employees in all enterprises y/n Legally prescribed tasks of OPs fullfilled; all stakeholders content y/n No (continuous decrease of) Occupational Diseases

Occupational injuries and diseases Comparisons reported data and ILO estimates = Occ. accidents Turkey, official statistics (2001) ILO estimate Active work force: 22,269,000 (without informal sector of same size) 2,183 >1000 2,881,405 (3 days absence) Occ. accidents (fatal) Work-related diseases (deaths) Total work-related mortality 1,008 3,776 440 28,187 >70 >3 1,448 63,925 >20 Brigitte Froneberg, ILO 11/2005

Development of Occupational Diseases in Turkey compared to ILO estimates Brigitte Froneberg, Closing Conference Ankara 2012-02-14 (Source: SGK, 2009)

[N] 1400 Development of Occupational Diseases in Turkey 1995-2014 1200 1000 800 600 1208 400 200 975 803 519 574 539 429 533 697 395 371 494 0 (Source: SSK Social Security Institute)

Development of Occupational Diseases in [Rates/100 000] Turkey 1995-2014 (Source: Brigitte Froneberg, N. Bilir: 2nd Occupational International Occupational safety and Environmental health profile: Diseases Turkey. Congress, ILO Antalya, Ankara, 04-08.03.2018 2016)

Possible causes of OD underreporting Employer does not report Worker does not report Doctor does not report Specialist Committee is overloaded (backload, bottleneck); Social Security Institution does not recognize Reporting System is under reconstruction

data coming soon

Thanks for Çok teşekkür your ederim attention Danke!

Safety and Health at Work - Germany 2007 Workforce Total 40,217,000 Males 54,7 % Females 45,3 % Enterprises (by size) > 250 10,862 50-249 49,964 10-49 231,975 0-9 3,174,324 3,467,125 Occupational physicians 12,280 = 1 / 3,275 Employees Safety specialists ca. 105,000 = 1 / 383 Employees Labour inspectors (State) ca. 4,000 = 1 / 5,745 Employees ITech. inspectors (Acc. Ins. Funds) ca. 3,000 = 1 / 453 Enterprises Brigitte Froneberg, 5th International OSH Conference, İstanbul 2008-11-03

EU Framework Directive 89/391/EEC - Essentials Employer duty to ensure the safety and health of workers in every aspect related to the work Risk assessment and management (hierarchy of measures; instruction) Designation / contracting of internal or external health and safety specialists (protective and preventive services) (7.7) Member States may define, in the light of the nature of the activities and size of the undertakings, the categories of undertakings in which the employer, provided he is competent, may himself take responsibility for the measures referred to in paragraph 1. Brigitte Froneberg, OHS in Germany, Dortmund 2010-09-20+21

OH care options in Germany Enterprise size Employer model Regular OSH care 10 11... 50 Yes, according to BG regulation Yes, according to BG regulation Yes; but modified: council when needed (else 1-5 y) Yes, as before (according to risk category) > 50 No Yes, as before (according to risk category) Brigitte Froneberg, OHS in Germany, Dortmund 2010-09-20+21

Employer model - Requirements for participation Regular OSH care Employer model Enterprise size Participation in motivation-infomation-training Yes; seminars but modified: in BG training Yes, according center to 10 council (Branch-specific when hazards, BG regulation risk assessment, risk needed management (else 1-5 y) etc.) Yes, as before Yes, according to (according Responsible to risk occupational BG regulation safety and health 11... 50 conduct category) in daily enterprise practice Yes, Utilization as before of OHS as required by performed (according risk analysis to risk and relevant No legislation > 50 (On-demand category) OHS care) Brigitte Froneberg, OHS in Germany, Dortmund 2010-09-20+21