There are regional variations in terms: in parts of Asia, OHS is more commonly called Occupational Safety and Health (OSH).
The majority of people working in ‘developing countries’ are without formal contracts with employers, and they work in places that are not covered by occupational health and safety (OHS) laws and rules. The minority who are formally employed get some employment security and benefits through their work, for example: overtime pay, paid leave. An important component of the formal workers’ benefits is provision of occupational health and safety: a clean and safe working environment in the interest of prevention of illness and injury, and a system of compensation in place in case accidents, injury and death do happen.
With the massive shift towards informal employment in the last century, majority of workers receive no such guarantees. In India, informal workers constitute more than 90% of those employed, and these include sectors in which women work in large numbers, such as street vendors, waste pickers, domestic workers and homeworkers. India needs a model of OHS in place for all workers, and this article argues that this will not happen without giving more attention to the role of local government, and addressing preventive and promotive health care, rather than the private insurance industry’s profit model .
The majority of informal workers are active in physical spaces that present hazards on a daily basis: street vendors’ exposure to the weather and to petrol fumes each day; tobacco workers’ daily exposure to tobacco in the fields and in sorting sheds; waste pickers who sort through hazardous materials in garbage dumps; domestic workers’ long and variable working hours. These ‘typical’ working places are not covered by OHS regulation, and informal workers do not receive social protections of other kinds related to work. Furthermore, conditions of work in public spaces such as streets, pavements, parks, garbage dumps etc, are largely controlled by local government (Lund and Marriott 2011); local governments can tend to view informal workers as the source of hazard and uncleanliness, rather than as people trying to make a living in hazardous and filthy conditions.
There is a clear relationship between health and income for informal workers. For most poor informal workers, their body is the most important asset. Hard physical labour, or lighter labour done over long hours, depletes that asset. Informal workers, like all citizens, use a variety of formal and informal health providers. Out-of-pocket expenses on health can be catastrophic for low income earners, propelling many into poverty (Berman 2010). When a worker or her child gets ill, she has to spend money to get to a health facility, and moreover she loses income in that time. Her own poor health and loss of income from being away from her work site in turn affects her children’s future chances of escaping poverty.
National governments in a vast majority of developing countries are unlikely, in the short term, to invest much in occupational health and safety for informal workers. Governments have allowed the withering away of formal labour regulatory regimes through labour broking and outsourcing/contractualisation. There is some light on the horizon, however, with the current international drive towards a minimum floor of social protection (sometimes called the Global Social Protection Floor – GSPF), and with an international call, driven by powerful agencies and funders, for ‘universal health coverage’. The GSPF advocates access to basic income support for children, people of working age, and for elderly people and those with disabilities. The principles are built on increasing evidence from schemes all over the world, north and south, that cash transfers can be developmental, and a good investment. It also calls for universal access to health care, which overlaps with the call for universal health coverage. A key policy question is how OHS for informal workers might be improved in the course of these policy reforms.
OHS for formal workers is built on the financial contributions of workers, employers and sometimes national governments as well. The academic discipline and daily practice of OHS has a preventive and promotive component, as well as acurative and rehabilitative response to disease and accidents after they occur. As beneficial as OHS for formal workers has been, longstanding criticisms are that it is better at reacting to accidents, rather than diseases; it looks at the worker in the workplace, in isolation from his or her health conditions outside of the workplace; and, in developing countries, it has been hugely under-budgeted, and often separate from general health provision. Brazil appears to be an exception, with a more integrated approach to workers and citizens’ health. And Homenet Thailand, an organization working to support homeworkers/ industrial outworkers, has embarked on a pilot project with the government, in 9 health facilities in 3 provinces, to integrate occupational health services in primary health care services .
Where will OHS fit in the new campaign for a GSPF? Formal ILO documents on the GSPF stress that countries decide what mix of private and public provision, and what levels and types of benefits, will be set. Work-based safety and health measures do not get mentioned – and this is not surprising given that the overall vision is an inclusive one, focusing on citizens throughout the life cycle, rather than on workers alone. The parallel campaign for universal health coverage promotes a mix of public and private health providers. At its heart, however, is a strong commitment to an active role for the private insurance industry.
Some hard but important lessons about private insurance-based financing of health have been learned, not least through India’s recent roll out of Rashtriya Swasthya Bima Yojana (RSBY).
From the perspective of informal workers, the early evaluation evidence is clear – RSBY has of course enabled poorer people including informal workers to access health care. However it has been grafted on to a poor public health service, and an expensive private health service. Jain’s study synthesizing early evidence of the effectiveness of RSBY from the perspective of informal workers identified specific problems (Jain 2012). First, unlike the case of formal OHS which is both preventive and promotive and reduces costs both for the present cohort of workers now and in the future, RSBY is flawed because the private insurance companies have nothing to gain from doing preventive and educational work. This vital aspect of OHS will disappear unless government health services make new intervention programmes .
Second, RSBY covers the cost only of in-patient care/ hospitalization. However it is the smaller amounts of money paid during frequent visits to outpatient services that constitute the high amounts going on out-of-pocket expenses (Berman et al, 2010). There is also a bias towards unnecessary surgery at the tertiary level, whereas informal workers are more likely to need attention more often to less serious injury.
Third, for informal workers, the time spent on seeking medical help is time spent not potentially earning. Kalpana Jain’s study of evaluations of RSBY and two large state schemes (Yeshasvini in Karnataka, and Rajiv Aarogyasri in Andhra Pradesh) showed how the lack of accurate information about schemes led to an expensive waste of time in identifying the correct health provider, at the right time of the day (Jain, 2012). This issue of the importance of accurate information was found also in studies of informal workers’ access to the new National Health Insurance Scheme in Ghana (Alfers, 2011). Good examples of intensive community- and worker-based involvement in policy design, implementation and monitoring and evaluation, come from Maharashtra in India (Shukla XXX), and from Homenet Thailand.
So, there are positive policy changes in the air, towards more security and protection for all, including informal workers. Regarding OHS for informal workers, however, there is cause for concern. Far from work being the route to security for a workers and her/ his family, the conditions of work are a threat to that security. Private health insurance sets up trends that are not compatible with the broader view of the social determinants of health. Close attention needs to be paid to the effect that private insurance has in determining what package of benefits is provided, the necessity of surgical interventions, and the impact of their lack of attention to information dissemination. There needs to be a greater focus on local government’s role in dealing with the social determinants of health for poorer informal workers – especially in water and sanitation. Informal workers’ realities and interests need to be expressed more clearly, and listened to more intently, in the clamour for ‘global social protection’, and ‘decent work for all’.
Francie Lund is a Senior Research Associate at the School of Development Studies, where she specializes in social policy. She is also involved in WIEGO – Women in Informal Employment: Globalizing and Organizing.
She is engaged locally and globally in research and policy advocacy around informal workers, especially regarding local government intervention, and around the provision of social security. An emerging research interest is in occupational health and safety for informal workers. She is a Research Associate at the Brooks World Poverty Institute, University of Manchester.