Universal health coverage (UHC) has been recognized by the World Health Organization (WHO) as a key element in reducing social inequility and a critical component of sustainable development and poverty reduction (WHO, 2014b). In most of the world UHC is sought through a combination of public- and private-sector health care systems. In most low- and middle-income countries health systems are evolving to increasingly rely on the private sector (e.g., health providers from different parts of the private sector, corporations, social enterprises, and philanthropy) because the public sector lacks the infrastructure and staff to meet all health care needs. With growing individual assets available for private-sector expenditure, patients often seek better access to technology, staff, and medicines. However, in low-income countries nearly 50 percent of health care financing is out of pocket (Mills, 2014). With the expected increase in the overall fraction of care provided through the private sector, these expenditures can be financially catastrophic for individuals in the informal workforce.
Occupational accidents, diseases, and fatalities create significant burdens globally in terms of human suffering and economic costs, which are
1 The planning committee’s role was limited to planning the workshop. The workshop summary has been prepared by the rapporteur as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any group consensus.
estimated to be roughly 4 percent of the global gross national product annually (Takala, 2002). Occupational health and safety services, intially designed during the advent of industrialization, prevent and treat acute and chronic illness as well as injuries among the working population.The field is evolving in reponse to social, political, economic, and technological changes globally, but the services are usually private entities and continue to be primarily financed by the employers. In the global workforce of approximately 3 billion people, only 10 to 15 percent are estimated to have some type of access to occupational health services. The informal workforce is growing worldwide, and the degree to which its occupational health needs are satisfied depends on the capabilities of the general health care system. As noted by workshop speaker Ivan Ivanov from the WHO, general health care practitioners often lack the skills and knowledge to address work-related health needs, which is one of the primary limitations to meeting these needs in most countries, although there are some encouraging examples of capacity enhancement and building. In countries where the enforcement of occupational health and safety rules relies on labor inspection, such enforcement is usually confined to formal workplaces and employment relations. In contrast, there are examples of public health systems in several developing countries in which the enforcement of occupational health and safety is based in public health law that is not conditioned by the nature of employment relations. As was highlighted by several workshop speakers, there is a need to explore the roles, responsbilities, and opportunities of the labor and health minisitries in meeting the occupational health and safety needs of informal sector workers in developing countries. Additionally, the financing of universal quality care and the development of models to best deliver care, including occupational health and safety services, often require innovative solutions for this population, and promising examples and opportunities are worth illuminating.
On July 29–30, 2014, the National Academies of Sciences, Engineering, and Medicine’s Forum on Public–Private Partnerships for Global Health and Safety (PPP Forum) held a workshop on approaches to universal health coverage and occupational health and safety for informal sector workers in developing countries. The PPP Forum was established in late 2013 to illuminate opportunities for strengthening the role of public–private partnerships (PPPs) in meeting the health and safety needs of individuals and communities around the globe. The forum seeks to foster a collaborative community of multisectoral health and safety leaders to leverage the strengths of varying sectors and multiple disciplines to achieve benefits for global health and safety. By regularly gathering and learning from leaders of diverse, exemplary, and innovative entities, the forum focuses on catalyzing more effective global health initiatives that
will capitalize on the complementary assets and motivations of the sectors involved. The membership is committed to engaging the expertise of its members and broader groups of stakeholders, its resources, and its networks to explore opportunities to catalyze partnerships; to elaborate norms that will protect the interests of those partnered and those served; to capture and share best insights, evidence, and practices for decision making and resource allocation for partnerships; and to foster innovations that may increase efficiencies and equitable access to effective care. This workshop was the first public convening of the forum.
The workshop examined the approaches, successes and challenges, and lessons learned in a purposefully selected group of countries in order to explore the topics of universal health coverage and occupational health and safety for the informal workforce in developing countries. Many of the presenters described the roles of the existing PPPs that are engaged in promoting universal health coverage and meeting the occupational health and safety needs for informal workers. The overall workshop objective was to illuminate best practices and lessons learned for the informal workforce in developing countries in the financing of health care with respect to health care delivery models that are especially suitable to meeting a population’s needs for a variety of occupational health issues, including the prevention or mitigation of hazardous risks and the costs of providing medical and rehabilitation services and other benefits to various types of workers within this population. These experiences and lessons learned may be useful for stakeholders in moving the discussions, policies, and mechanisms (including enhanced or new PPPs) forward to increase equitable access to quality health services without financial hardship for the informal workforce, including prevention, curative, and rehabilitation services for injuries and illness due to occupational hazard exposure.
To establish a consistency in the terms used in the workshop presentations and discussions, the planning committee selected operational definitions for universal health coverage, health system, and the informal workforce in the context of the workshop.
Universal Health Coverage
The planning committee chose to use two widely accepted definitions of universal health coverage, one from the WHO and the other from the United Nations General Assembly, as both were highly relevant to the workshop discussion and to the current discussions on UHC at the global and national levels.
The WHO defines universal coverage (UC) or universal health coverage (UHC) as
ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition of UC embodies three related objectives:
- Equity in access to health services—those who need the services should get them, not only those who can pay for them;
- That the quality of health services is good enough to improve the health of those receiving services; and
- Financial-risk protection that ensures the cost of using care does not exposure individuals to risk of financial hardship.
Universal coverage brings the hope of better health and protection from poverty for hundreds of millions of people, especially those in the most vulnerable situations. Universal coverage is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the AlmaAta declaration in 1978. Achieving the health Millennium Development Goals and the next wave of targets looking beyond 2015 will depend largely on how countries succeed in moving towards universal coverage. (WHO, 2015a)
The United Nations General Assembly has defined UHC as a situation in which “all people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative and rehabilitative basic health services and essential, safe, affordable, effective and quality medicines, while ensuring that the use of these services does not expose the users to financial hardship, with a special emphasis on the poor, vulnerable and marginalized segments of the population.”2
The WHO’s Framework for Action defines health system as follows:
A health system consists of all organizations, people, and actions whose primary intent is to promote, restore, or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activities. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It
2 United Nations General Assembly Document A/67/L.36, Global Health and Foreign Policy (accessed May 10, 2015).
includes, for example, a mother caring for a sick child at home; private providers; behavior change programs; vector control campaigns; health insurance organizations; occupational health and safety legislation. It includes inter-sectoral action by health staff, for example, encouraging the ministry of education to promote female education, a well-known determinant of better health. (WHO, 2007, p. 2)
For the purposes of this workshop summary, a health system and its six essential building blocks—medical products, vaccines, and technologies; health financing; leadership and governance (stewardship); health services (delivery); human resources; and health information systems—were considered operationally at a national scale. The system building blocks are linked through the attributes of access, coverage, quality, and safety to a set of overall goals and desired outcomes. These goals and outcomes include improved health (both in terms of level and equity), responsiveness, social and financial risk protection, and improved efficiency.
The Informal Workforce
The concepts of “informal sector” and “informal employment” are relatively new in the field of statistics. The 1993 International Conference of Labour Statisticians (ICLS) adopted an international statistical definition of the informal sector that subsequently was included in the revised international System of National Accounts 1993 (SNA, 1993). In order to fit into the framework of the System of National Accounts and to provide for a separate accounting of gross domestic production in the informal sector, the definition was based on characteristics of production units or enterprises rather than of employment relations (Hussmanns, 1996). The informal sector refers to unincorporated small or unregistered enterprises (e.g., fewer than five employees) in which employment and production take place.
Ten years later in 2003, following from the 2002 International Labour Conference resolution on Decent Work and the Informal Economy, the 17th ICLS defined the concept of “informal employment.”3Informal employment refers to all employment arrangements that leave individuals without social protection through their work, no matter whether the economic units they operate in or work for are formal enterprises, informal enterprises, or households.
Workers who are employed in the informal sector or in informal employment can be further classified according to the categories of the
3 For the full definition of informal employment, see ILO (2003). See also the explanatory notes to the country-specific tables in the annex of this publication. A discussion of the conceptual change and its implications for survey design is given in Hussmanns (2004).
International Classification of Status in Employment (ICSE-93). Based on this classification, the specific groups of workers employed in the informal sector and in informal employment outside the informal sector are as follows:
- Persons employed in the informal sector (including those rare persons who are formally employed in the informal sector):
- Own-account (self-employed) workers in their own informal enterprises;
- Employers in informal enterprises;
- Employees of informal enterprises;
- Contributing family workers working in informal enterprises; and
- Members of informal producers’ cooperatives.
- Persons in informal employment outside the informal sector, specifically
- Employees in formal enterprises not covered by social protection, national labor legislation, or entitlement to certain employment benefits such as paid annual or sick leave;
- Paid domestic workers not covered by social protection, national labor legislation, or entitlement to certain employment benefits such as paid annual or sick leave; and
- Contributing family workers working in formal enterprises.
In summary, there are three related statistical terms and definitions based on ICLS resolutions/guidelines: The “informal sector” refers to unincorporated enterprises that may also be unregistered or small; “informal employment” refers to employment without social protection through work both inside and outside the informal sector; and the “informal economy” refers to all units, activities, and workers so defined and the output from them. Together, workers identified in these categories form the broad base of the workforce and economy, both nationally and globally.
This report provides a summary account of the presentations given at the workshop. Opinions expressed within this summary are not those of the Academies, the PPP Forum, or their agents, but rather of the presenters themselves. Such statements are the views of the speakers and do not reflect conclusions or recommendations of a formally appointed committee. This summary was authored by a designated rapporteur based on the workshop presentations and discussions and does not represent the views of the institution, nor does it constitute a full or exhaustive overview of the field.
During the workshop many of the sessions touched on more than one of the topics within the statement of task (see Box 1-1). Given the overlap in the issues and topics discussed at the workshop, this summary is organized topically rather than chronologically. The agenda from the workshop and a complete listing of the speakers are included in the appendixes.
Chapter 2 includes presentations that provided an overview and orientation to the issues that the workshop addressed. Robert Emrey from the U.S. Agency for International Development presented frameworks for understanding and approaching UHC. Marty Chen from Harvard University and Women in Informal Employment: Globalizing and Organizing (WIEGO) provided an overview of the informal workforce through definitions, data, and illustrative examples. Peter Berman from the Harvard School of Public Health shared a perspective on the evolution of the UHC movement, some of the challenges in its definitions, and issues to consider for the inclusion of the informal workforce in UHC. Ivan Ivanov from the WHO expanded on the challenges of the inclusion of the informal workforce within the objectives of UHC in regard to occupational health risks and exposure. Victor Dzau from the National Academy of Medicine addressed the role of partnerships as a mechanism to accelerate progress in the inclusion of the informal workforce in UHC and occupational health and safety (OHS) protections and services. Mirai Chatterjee from the Self-Employed Women’s Association (India) (SEWA) illuminated the challenges and opportunities for addressing the interrelated issues of UHC, OHS, and the informal workforce from the experience of India.
Chapter 3 includes presentations on mapping solutions to UHC that are inclusive of the informal workforce. Lorna Friedman from Mercer discussed the role of global employers in UHC. Marleece Barber from Lockheed Martin shared her insights on the role of the employer in providing and extending coverage and also addressing occupational health. Orielle Solar from the University of Chile Medical School described efforts to map the informal workforce and health coverage in Latin America.
Chapter 4 includes presentations on institutional efforts to respond to the work-related health needs of the informal workforce. Ivan Ivanov presented an overview and data from the WHO on primary care–based interventions for informal sector workers. Julietta Rodriguez-Guzman of the Pan American Health Organization (PAHO) provided an overview of PAHO’s current and historical efforts to respond to the work-related needs of informal sector workers in Latin America. Yuka Ujita from the International Labour Organization (ILO) presented on the ILO’s approach and good practices for occupational safety and health (OSH) for informal workers. John Howard from the National Institute for Occupational
Safety and Health (NIOSH) provided a brief perspective on OHS for informal sector workers in the United States.
Chapter 5 includes presentations on select country experiences with UHC and OHS for the informal workforce. The presentations are organized alphabetically by the country of focus. In some cases, more than one presentation from a single country is included to provide a deeper and more diverse overall picture of the experience within the country. Vilma Santana from the Federal University of Bahia presented on building the National Occupational Health Services Network in Brazil; Charu Garg from the Institute for Human Development presented on inequities in financing, coverage, and utilization of health care by informal sector workers; Mirai Chatterjee from SEWA presented ideas for action from experiences in India; Hanifa Denny from Diponegoro University presented on the effectiveness of occupational health interventions for the informal sectors and options for delivery in Indonesia; Barry Kistnasamy from the Department of Health in South Africa presented on services to workers in the informal economy in that country; Francie Lund from the University of KwaZulu University presented on OHS and the inclusion of informal workers in South Africa; Laura Alfers from WIEGO presented on linking occupational health and universal health coverage in South Africa and Ghana; Somsak Chunharas from the National Health Foundation in Thailand presented on the UHC system and informal workers in that country; Orrapan Untimanon from the ministry of public health in Thailand presented on OHS delivery for informal workers and financial resources within the country; Poonsap Tulaphan from HomeNet Thailand presented on experiences from a pilot project on OHS promotion for informal workers; and Karen Sichinga from the Churches Health Association of Zambia presented on the country’s experiences with PPPs in health.
Chapter 6 focuses on the way forward and includes comments and suggestions from the workshop speakers and participants on how to make progress in developing countries toward the inclusion of the informal workforce in universal coverage and occupational health and safety. The chapter closes with a perspective from Michael Myers of The Rockefeller Foundation on the foundation’s history and interest in addressing the topic and plans for moving forward.
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