The workshop closed with a discussion among the individual workshop speakers and participants, facilitated by workshop chair Clarion Johnson and planning committee member Kathy Taylor, on suggestions for how to make progress on achieving universal health coverage and occupational health and safety for informal sector workers in developing countries. To open the discussion on the way forward, Johnson offered a cautionary note: Do not over-rely on the private sector. As is apparent in the mix of members that make up the National Academies of Sciences, Engineering, and Medicine’s Forum on Public–Private Partnerships for Global Health and Safety, there are many different actors and stakeholders from the public and private sectors who can play a role. Throughout the workshop, many speakers and forum members stressed addressing the issue from the perspective of grassroots, small-scale, innovative approaches rather than looking only at large, top-down initiatives. Johnson suggested that within this framework, another aspect to consider is the sharing of resources, such as mentorship, technical assistance, and business plan development. In turning to the speakers to provide their remarks, Johnson asked each of them to focus on what he or she thought could be delivered and reproduced to lead to progress moving forward (see Box 6-1).
Yuka Ujita from the International Labour Organization (ILO) said that ILO has eight critical areas of focus for 2015, and one of them is the formalization of the informal economy. There are two dimensions to this focus area: the formalization of the current informal economy, and the
prevention of current formal economic workers moving to the informal economy. ILO has prioritized this issue not only because it is concerned with the safety and health of informal sector workers but also because it wishes to address the indecent working and employment conditions that these workers often experience.
Ujita also commented that through the workshop she had been inspired by the role that public–private partnerships (PPPs) can serve, and she offered a specific proposal for how PPPs could contribute to occupational safety and health services. The health and safety capacity in such places as Southeast Asia and the Caribbean is quite low, she noted. To build this capacity, she suggested partnerships to provide safety and the health services, including training for workers and employers in risk assessment and health hazard assessment, which could enhance the capacity of the government itself.
Robert Emrey from the U.S. Agency for International Development (USAID) said that while USAID has a major focus on addressing universal health care (UHC), informal sector workers are rarely part of the discussion. He suggested some promising areas where there could be opportunities to address these workers’ needs in terms of UHC. Recent technology-based solutions for coverage, such as those that use mobile
technology, are promising for reaching informal sector workers, he said. Access to data through mobile technology can provide information and health education. Mobile technology also has the opportunity to address accountability and transparency in financing. Concerning metrics, Emrey said that USAID and its partners have a long legacy of investments related to measurement. He suggested that there is now opportunity to focus on developing metrics that better capture informal sector workers. Concerning service delivery, Emrey said that he had been impressed throughout the workshop with the community-level activities that were described and that he was interested in learning more about how these activities could address community and municipal leadership. Progress has been made in a number of countries where the challenges are huge, and the way in which that work has moved forward is a grassroots activity.
Mirai Chatterjee from the Self Employed Women’s Association (SEWA) in India said that throughout the workshop one thing that struck her is that in country after country the world of work has changed dramatically. It is a wakeup call for those in the health sector to reorient their lenses, strategies, and services to fit the world of work where the working poor struggle every day. She also noted that many countries, particularly developing countries, have done substantial work on universal health coverage and occupational health and safety but that there is much to learn. These efforts have not necessarily been high tech or very resource intensive. It does not always require huge investments to make a huge difference to working people. She also said that she was very interested to hear during the workshop about the willingness of industry to engage in going beyond covering its own employees and contributing to the well-being of countries across borders. She pointed out there are corporations that are already doing this by focusing on their supply chain, and these examples should be highlighted.
Concerning partnerships, Chatterjee suggested several potential opportunities: support for low-cost or no-cost tools and processes, mobile clinics and diagnostic camps for early detection and screening, and research and metrics development for occupational health and safety (OHS). She also suggested adding a fourth P to PPPs—for peoples’ organizations.
To continue to move forward and accelerate progress, Chatterjee suggested convening similar workshops in different regions and countries to further the dialogue and sharing among stakeholders. Marty Chen endorsed this idea and added that two different types of meetings could be useful: smaller, more technical meetings centered on occupational health and safety, and workshops like this one in each developing region, with the same mix of participants across disciplines, sectors, and countries.
Lorna Friedman from Mercer picked up on Chatterjee’s reference to the changing world of work. Global employers have an obligation to ensure the safety of the workplace, she said, and there has been much success in their efforts to do so. However, as the workplace changes, as an outsourcer becomes an informal worker, where is that border, and what is the accountability? She said that there needs to be a major dialogue within the global employer community to address this issue. She added that the opportunities for entrepreneurial ideas to address this issue through innovative, low-cost solutions and tools are inspiring. There is a model that employers and investors use in the United States to take people with innovative ideas and link them with mentors and capital. It has been a successful model and is an opportunity for accelerating progress. On metrics, Friedman stressed the importance of including business metrics in any conversation on UHC and OHS so that the value to the economy of productivity and health can become part of the dialogue.
Julietta Rodriguez-Guzman from the Pan American Health Organization pointed out the number of incredible experiences, practices, and interventions that are going on throughout the world, several of which were highlighted at the workshop. They illustrate the importance of working at the local level and are a call to build metrics focused on the local level. She also said that networking has shown to be an effective tool for the sharing, exchanging, and transferring of not only knowledge but also technology and practices. To make progress in the future, she stressed, it will be important to strengthen the field of occupational health within medicine and across the health disciplines.
Somsak Chunharas said that in the area of UHC and OHS for informal workers, there are two important issues related to health system development: ensuring that countries with UHC include OHS as an integral part of their benefit package, and the role of the health sector, regardless of whether there is UHC, in raising awareness among multiple actors, including the ministry of labor and the private sector, about the need for OHS aiming at protecting the health of informal workers.
Kathy Taylor from the University of Notre Dame pointed out that within the current draft of the Sustainable Development Goals (SDGs) 2015, there is no goal that includes health system strengthening of UHC as one of the pillars. As the shift is made from the Millennium Development Goals toward the SDGs to provide a roadmap for the global community, national governments, and funding agencies, she suggested that it will be important to recognize the role of health system strengthening. The draft SDGs include specific conditions such as maternal health, HIV/AIDS, and noncommunicable diseases. She expressed her concern that focusing on condition-specific goals rather than on the system may hinder progress in global health.
In picking up on the suggestion by several speakers to focus on metrics, Taylor stressed the role that universities can play in developing metrics, conducting research, and sharing data to contribute to an iterative process from data to analysis to implementation. Johnson added that within the safety group there exists a standard taxonomy and database of resources that could serve as a starting point for developing a parallel system for the occupational health community. Chen suggested that there may be an opportunity for SEWA to convene exposure dialogues concerning occupational health and safety. In an exposure dialogue, a select group of people spend 2 or 3 days and nights with a working poor person in the informal economy, living with and working alongside him or her. The individuals apply theoretic frameworks, systems, models, and assumptions from their field of practice to the reality of their experience. SEWA has already convened such dialogues for economists and human rights professionals, and there could be an opportunity to do the same for the OHS community.
Chen also suggested that one opportunity for moving the dialogue forward on global employers and their supply chains could lie with engaging with the Ethical Trade Initiative in England. The initiative brings together worker groups, corporations, and government for dialogue and currently has a work group on home-based workers in supply chains.
Simon Bland from UNAIDS provided some comments on the draft SDGs. Over the past 18 months, he said, the world has come together to debate the 17 goals that are included. Within them there are 169 targets, and there will be 2,000 indicators. More could probably be added, but it is already a long list, and all of what is included is highly important. The challenge will be translating it into priorities. Concerning the point of moving from single issues to addressing the entire system, he said there is clearly a need for integrated service delivery and taking issues out of isolation, but it will be challenging. Figuring out how to create institutional change and reform will also be challenging. Concerning UHC, he said, covering the remaining sector of the population is hard for a reason. Geographic remoteness and political isolation both play a role. Leapfrogging legacy technologies could offer an opportunity to lower costs and expand coverage. There should be a focus on partnerships that reduce the costs of interventions, create better point-of-care diagnostics, and are market shaping for lower-cost therapies. Bland said that the challenge that he was taking from the workshop was how to find innovations using both the public and private sector to drive costs down in order to expand coverage and packages of benefits. There are thousands of innovations out there, he said, and he has not figured out how to sift through them, but the ideas from the workshop are really inspiring and exciting.
Ambassador John Lange from the United Nations Foundation com-
mented that many stakeholders in the SDGs dialogue were at the workshop and now that they have participated in the meeting and learned so much about the informal sector workforce, it is incumbent on them to introduce the needs of the informal workforce into the SDGs discussions.
Michael Myers, The Rockefeller Foundation
Michael Myers from The Rockefeller Foundation described how the foundation came to have an interest in the health, safety, and coverage of informal workers in developing countries. When The Rockefeller Foundation was founded in 1913, the first issue it explored was health, and health issues have continued to be at the core of the foundation’s work. The foundation participated in the growth of the field of public health, including the establishment of the Johns Hopkins Bloomberg School of Public Health and other public health schools around the world. The foundation has been engaged in the science of health. Between the foundation and its grantees, more than 200 Nobel Prizes have been achieved. In addition to the sciences, the foundation has been involved in tackling specific diseases around the world, from yellow fever to HIV/AIDS. In the past couple of decades, the foundation has also focused on health systems. Through this work, the foundation has been involved in a joint learning network that is now in nine countries and that facilitates peer-to-peer learning and sharing on issues such as costing manuals and financing schemes.
One of the issues that has been raised within the context of health systems is equity and universal health coverage. UHC is inclusive of all, including informal populations. While the inclusion of informal populations is often thought of as a “last mile” question within UHC, this is not the case when the informal sector makes up the majority of a country, as it often does in developing countries. The foundation is seeking to figure out how to connect people in informal sectors with the formal health system and ensuring that it meets their needs.
The foundation first started thinking about informal workers in the context of what their needs are as workers; however, its approach has evolved to consider a fuller range of what their needs are as individuals within society and not just as workers. There is recognition that these are people who have aspirations and families, who are highly networked, who are entrepreneurial, and who have places where they congregate and enjoy each other’s company. With that perspective, the foundation is addressing how to meet these people’s health needs beyond the context of the workplace or a clinic. For example, what can be done for people in the marketplace in Durban, South Africa? As people—largely informal
workers and their families—are criss-crossing in the market, are there possibilities to address and advance the health of this population?
Myers said that this thinking led to an approach that The Rockefeller Foundation is considering which has been reinforced by the discussions at the workshop. Throughout the workshop, ongoing solutions were discussed that involved community groups, women’s groups, technology, or ministries of health. Perhaps there are creative ways of stitching these initiatives together in new ways to achieve even greater benefits for informal workers and informal communities. Myers suggested that rethinking how to organize these initiatives and stakeholders is a type of recombinant innovation, taking existing elements and combining them into new and more effective ways that give greater power and greater results to what we are doing. The Rockefeller Foundation is exploring opportunities for recombinant innovation for meeting the health needs of informal workers.
Myers illustrated this approach with an example. Imagine a market in Durban, South Africa, where there is a trusted local organization working with informal workers in the market. Imagine that the organization is trained to convey health information that is of value to the population and that the people themselves view their own health as an asset. Without good health, they do not have a livelihood. Imagine that there is a cell phone company looking for business within the informal community that might be willing to add some element to its mobile platform that helps stitch together that community. Imagine using the persuasive powers of the stakeholders who have been a part of this workshop to get the health ministry to locate a clinic near that marketplace which brings the needed services to the workers where they are. Imagine a recombination of existing elements in these creative ways to be a possible model, if it works, to try to replicate in different parts of the world to help solve this last-mile question for universal health coverage. Myers stressed that this vision is what he has found so encouraging about the workshop discussions. The foundation is moving forward to explore this particular model, and much of what was shared during the workshop will inform those actions and the steps.
In closing, Myers stressed the importance of discussions like those at the workshop for linking individuals who are working to create solutions at the local level with each other and connecting the discussions to policy questions at the same time. When examining local approaches, the foundation is also committed to looking at the big policy issues and reforms that are necessary to make such approaches effective and sustainable going forward.
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