Research and analysis

Summary: International comparison of occupational health systems and provisions

Published 20 July 2021

Dr Juliet Hassard, Dr Aditya Jain and Professor Stavroula Leka

1.1 Overview

This report presents the findings from a comparative review of 12 international case studies exploring their national-level occupational health (OH) systems and provision of services.

1.2 Research context

The Work and Health Unit (WHU) is a UK government unit which brings together officials from the Department for Work and Pensions (DWP) and the Department of Health and Social Care (DHSC) to lead the government’s strategy supporting working age disabled people, and people with long term health conditions to enter, and stay in, employment. To enable this, the government aims for more individuals to have access to appropriate and timely OH advice.

As set out in ‘Health is everybody’s business’, the government recognises that action is required to ensure employers can purchase good quality, cost-effective OH services that meet their needs. In order to gain a greater understanding of the OH landscape internationally, including how systems vary, to inform potential policy approaches on issues like system regulation, the WHU commissioned research that aimed to conduct a comparative review of 12 international case studies detailing national-level OH systems and provisions.

1.3 Methodology

The research was conducted in 3 iterative stages. First, a literature review was conducted and a diverse set of countries selected to examine as case studies: the United Kingdom, Australia, Canada, Germany, the United States of America, the Republic of Ireland, the Netherlands, Finland, France, Poland, Italy, and Japan. Second, a more detailed review of the literature was conducted to draft the series of case studies. Finally, the information collected and presented in each case study was used to conduct a comparative analysis, with the aim to identify variations in the content, systems, structure, coverage, and delivery of reviewed national-level OH systems and provisions.

1.4 Findings

1.4.1 Legal and policy context

At the international level, the International Labour Organisation (ILO) plays a central role in the formulation of global OH policies and international labour standards. The standards can be specified as either legally-binding conventions, or non-binding recommendations.

Within Europe the development of OH services is, in part, informed by the transposition and implementation of the Framework Directive 89/391/European Economic Community on Safety and Health at Work within each reviewed European Member State. This directive highlights employer responsibilities for ensuring the health of employees, and instructs that employers should designate one or more workers to carry out activities related to the protection and prevention of occupational risks. How such principles are transposed and enacted in national law is at the discretion of the countries themselves.

At the national level, this report identifies two key typologies of legislation regulating OH services: Type A and Type B. Type A OH legislation is typically enshrined in a single act with focus on an integrated, multi-disciplinary service, stipulating rights and roles of employers and employees. Type B OH legislation is fragmented across social security, health and safety, and labour laws. Delivery of OH provision is typically (but not always) more open for interpretation in Type B countries. With regards to the case study countries, Type A countries are: France, the Netherlands, Poland, Finland, Japan, Italy and Germany. Type B are: the UK, Canada, Australia, the USA and the Republic of Ireland.

1.4.2 Organising and financing OH services

The organisation and financing of OH services varies between countries based on national tradition, healthcare systems, legal context, social security system, and economic structure. To meet the OH needs of companies a number of different models of OH services are commonly used. These include:

• in-house provision – OH organised and funded by the employer
• private provision – outsourced OH operating externally from the employer
• group service models – OH services shared and jointly funded by multiple companies
• community based healthcare – OH services provided by regional health service units
• workers compensation – state run authorities funded through employer levies
• state provision – OH services provided through state-run programmes

According to the ILO, primary responsibility for financing OH rests with the employer. However, OH services can be financed by the government, organisations, insurance systems, social security funds, or a combination of these. Across many of the reviewed case studies, the funding of OH services is typically arranged by employers and driven by the market. This is particularly true in countries where OH service provision is voluntary in nature.

1.4.3 Level of coverage of OH services

The estimated coverage of OH services varies considerably across the reviewed case studies: from approximately 40% (e.g. Republic of Ireland) to almost 90% (e.g. Finland). Those countries where OH services are legally specified were observed to have higher estimated levels of coverage, such as: Finland, France, Japan, the Netherlands, and Italy.

Within many countries there are segments of the working population that may not have access to OH services, particularly in sectors such as agriculture, the self-employed, small-scale employers, and the informal workforce. Even among countries where coverage rates are estimated to be high, there continue to be observed gaps in coverage across these groups.

In many countries, the healthcare system is central to the delivery of OH care and management services (e.g. Canada, Australia, and the USA). Therefore, variations in eligibility criteria to access health care services within each given national context may impact coverage of OH services across workers within that country.

Additionally, in many national contexts, having private insurance (whether self-funded or given as employment benefit) is an important mechanism to access OH services (e.g. Canada, Australia and the USA). However, the level of coverage of individuals with private insurance varies by sector, size of organisation, and employment contract; which likely influences overall coverage rates.

Those countries that use social security institutions in the provision of OH services will have provided universal coverage to all contracted employees. Such provisions will not extend to the self-employed or contracted workers. In addition, among those that are insured under worker compensation schemes, the health conditions covered (eligible for compensation) vary by jurisdiction. Consequently, not all employees will be covered (will receive compensation for treatment) as it may be dependent on their health condition.

1.4.4 Minimum standards in OH services

Minimum requirements for OH services are declared by the legal context of the given countries. Due to variation in the understanding of the role of OH services, their structure and functions, there exist a variety of different approaches used to achieve minimum standards of quality and care in OH services.

These approaches include:

• supervision and enforcement – the most common method of achieving minimum standards, typically conducted by labour or sanitary inspection
• standards and guidelines – this approach focuses on the development of standards, codes of practice, and guidelines to support OH professionals
• accreditation and certification – these are used as tools to evaluate and quality assure OH services

1.4.5 Staffing OH services

The ILO Convention on OH services emphasises the importance of OH services being fully independent from employers, workers, and their representatives and being provided by a multidisciplinary team. Traditionally however, OH services have been delivered primarily by a small, ‘core’ group of key professionals – typically an Occupational Physician (OP) and a nurse.

In some countries OH service providers have to employ certain professions, and/or specific OH services require specific professions. In countries where OH services are voluntary and market driven however, it is difficult to determine who the key OH professionals involved in the delivery of services are and, in turn, what the key tasks and roles are. In the UK, several voluntary accreditation systems exist for OH services that make recommendations regarding the staffing of OH service providers, and thus gives an insight into the considered minimum requirement of human resources for OH service providers within the UK.

A limited number of the reviewed countries require OH providers to be staffed and delivered by a multidisciplinary team of OH (e.g. the Netherlands and Germany). For the reviewed countries in general however, the use of a multidisciplinary team varies greatly across in-house and external OH services meaning it is challenging to map the use of such teams across reviewed studies.

In terms of the qualification and regulation of OH professionals, competence criteria for OPs and OH nurses tend to be well-established across the reviewed countries, however criteria for other disciplines have not been so well developed. This is identified as a factor hindering the more widespread availability of multi-disciplinary OH services.

1.4.6 Employers’ responsibilities in OH Services

The key motivating factors for employers in providing OH services are:

• legal compliance with health and safety regulations
• the maintenance of organisational reputation
• maintaining and increasing the productivity of the workforce through improved worker health
• minimising the costs associated with sickness absence
• meeting the expectations of employees with regards to OH provision

Employer’s responsibilities for providing OH services can be further divided down into: prevention and management activities, work adaptations, curative and rehabilitative measures, and sick pay.

Prevention and management responsibilities cover the requirements of an employer to prevent health problems at work, unnecessary sickness absence, presenteeism and health related job loss. Good practice in this area requires clear integration of prevention activities into the content and activities of OH services. Global policy development in this area has, more recently, focused on minimising the impact of long hours on workers’ health (e.g. EU Working Time Directive).

Work adaptations cover the requirement of employers to make reasonable adjustments to employees work and workplace based on needs. In all reviewed countries some work place adaptation obligations exist for employers, although variation exists in who this covers. This may apply to ill, injured and disabled employees (e.g. the Netherlands), or only to disabled employees (e.g. the UK). British employers can also receive help through the Access to Work scheme however.

Curative and rehabilitative measures cover the requirements of an employer to support the rehabilitation of illness and injury and reintegration of an employee back into the workplace following absence. Obligations in this area vary with some countries having no requirements and others requiring employers to return an employee to work, if not in the same position, in a different position with different conditions.

Lastly, sick pay covers the requirements of an employer to provide continued, time limited payment of (part of) the worker’s salary during a period of sickness. Employers in most reviewed countries are obliged to pay sick pay for a specified time period, ranging from a few days or weeks (e.g. Australia, Japan, Canada) to longer periods (28 weeks in the UK; 104 weeks in the Netherlands). Sick pay is considered alongside the wider context of sickness benefit within the case study countries. Sickness benefit is provided by the social protection system to individuals who are unable to work due to illness and is paid either as a fixed rate of previous earnings, or as a flat-rate amount.

1.4.7 Short case studies

This section of the report contains case studies for the 12 reviewed countries (United Kingdom, Australia, Canada, Germany, the United States of America, the Republic of Ireland, the Netherlands, Finland, France, Poland, Italy, and Japan). These examine the areas previously discussed in greater depth for each individual country.