Review Article
Factors of Succes of the High Coverage of Occupational Health Services
of Employees in Finland
Helimäki-Aro, Ritva
National Institute of Occupational Health, Budapest, Hungary
Corresponding author: Ritva J. Helimäki-Aro
Address: Nagyvárad tér 2, 1096 Budapest
* Present address: Finnish Institute of Occupational Health
Helsinki, Topeliuksenkatu 41aA.
FIN-00250
Abstract
Act on Occupational Health Services came into effect in Finland at the
beginning of 1979. Seventeen years of active OH have been successful in
the prevention of occupational diseases and in health promotion activities.
The coverage of occupational health is now about 90% of all Finnish employees.
This article deals with some of the factors that can explain the success.
Finland has adopted a comprehensive service model with preventive and curative
care. It faces the future with emphasis on maintaining the working capacity
of an aging population.
Key words: Occupational health services, coverage, Finland, maintaining
of working capacity, prevention.
Abbreviations: OH: Occupational Health
OHS: Occupational Health Services
FIOH: Finnish Institute of Occupational Health
History
The first doctor was engaged to protect workers in 1754. For decades hygiene
and infectious diseases were the main tasks of occupational health care.
It was only after the second world war that the occupational health got
new wind under its wings.
The Finnish Institute of Occupational Health (FIOH) was founded 51 years
ago. The occupational health doctors founded their own association 50 years
ago. Until 1970’s FIOH was also a big producer of practical occupational
health services. The early connection between research and doctors working
on the field helped in the creation of a system of occupational health
services (OHS) which is now effective and one of the best in the world.
The law on occupational safety was renewed in 1958. Obligatory health
examinations became more popular and preventive thinking was introduced.
The curative care lost its primary function. New legislation on occupational
safety and health in the 1970's gave the definitive direction to occupational
health care. This legislation was prepared in cooperation among all social
partners. The decision to prepare an act of OHS was signed by workers'
and employers' organizations as part of their collective agreement. This
method has been used also later on when new functions have been added to
the contents of occupational health care. In Finland over 80% of workers
belong to trade unions. This gives a big power to social partners and on
the other hand it makes the implementation of decisions easier.
Act on Occupational Health Services
1 Tasks
The Act on OHS has come into effect gradually since the beginning of 1979.
The act stipulates that all employers have to organize
OHS for all employees. Also self-employed people and farmers can join the
services. The act focuses firstly on prevention. The protection of workers
against hazardous exposures is the preliminary task. The workplace is seen
as sick, and not only the person. The employer is asked to use occupational
specialists to make workplace surveys, to give information, advise and
work-related health education, to follow-up the health of workers by different
kinds of health examinations, and to take care of disabled employees. Also,
the fist-aid readiness is the task of specialized occupational health personnel.
Occupational health care, on its resources, cannot
alone change work-places. The cooperation of safety representatives of
the employees and the management is very important. It is stipulated in
the Act that the employer has to work together with workers' safety representatives
on matters concerning occupational health.
How the workplace survey is done in Finland, is
described in detail by Professor Jorma Rantanen, chief of FIOH in the book:
Health Protection and Health Promotion in Small-scaled Enterprises.
Later, new tasks have been introduced to OHS. Mental
health of workers and workplaces became popular in 1980's, and the latest
add to the preventive functions of OH is the maintaining of working capacity.
2 Curative and/or Preventive Care
When the occupational system was created in Finland, the French model was
also discussed. In this model the occupational health care is only preventive
and all curative work is done by family doctors. In Finland, this model
was rejected. The Act aims primarily on prevention but it gives the possibility
to the employer to offer the workers also curative care. This possibility
is largely used. In the survey made in 1993 (Räsänen et al. 1994)
it was found that 76% of the employees were covered by curative primary
health care, too.
Occupational health personnel get better information
from the workplace; they have better knowledge of the health status of
workers. The workers have more confidence in occupational professionals,
when they can turn to them in personal questions, too. It has been noticed
that especially in small work-places even the preventive work is done better
if curative care is carried out by the same personnel. The new challenge
given to OHS by the task of maintaining the working ability, would be totally
impossible without the knowledge given to the doctor based on his/her curative
care of workers (Tola 1996).
3 Different Service Models
Occupational health care is delivered through different service possibilities
and by different providers. The employer can decide where to buy OHS.
By the Primary Health Care Act in 1972, Finland
was divided into 213 areas served by communal health centers. These centers
take care of all preventive and primary health services of the municipality.
When the act on occupational health was promulgated in 1978, these health
centers were assigned to provide specially educated personnel for occupational
health care. This obligation provides occupational services all over the
country and gives particularly to small enterprises an option for professional
services.
The municipality can adapt the personnel to the
real situation of the community. Where only few enterprises buy OHS from
a health center, one of the primary health care practitioners is a part-time
occupational health doctor, and an OH nurse takes care of the main practical
work. In Finland the professional status of occupational health nurses
is very high, and they are the main contact persons between work-places
and occupational health care.
In bigger health centers the OH division is a multidisciplinary
team taking care of hundreds of enterprises.
Other service model possibilities are: in-plant
services; group services organized by employers, and private health centers.
Until last year, the state had its own OHS. This service has now been privatized.
A first big survey was carried out by FIOH in 1993
(Räsänen et al. 1994). The OHS (92% of 1025 OHS), who responded
to the questionnaire, served a total of 1,6 million employees and 50 000
self-employed persons; out of them 42 000 farmers. The OH of these persons
was served as follows:
43% at a municipal health center
28% at a plant OHS
16% at private health centers
8% at state OHS
6% at group services organized by employers
Introduction of OH to primary health services has been
one of the main factors of the success of OH in Finland.
4 Compensation Policy
The Sickness Insurance of Finland compensates the employer a part of the
costs coming from the organizing of OHS. Now the compensation is 50%. To
have this compensation the employer needs an annual action plan for OH,
and an annual report of activities. The compensation is paid only provided
that the safety delegate of workers has been integrated into the planning,
and he has had the opportunity to voice an opinion of the annual report.
The Sickness Insurance controls also that legal criteria on the content
of services are met.
The significance of a system of incentive and subsidy
is demonstrated by, for example, experience of Sweden and Finland where
the high level of subsidies expanded the coverage of OHS from 50-60% to
80-90% of all workers in the course of the 1980's (Rantanen 1994).
Many small enterprises have been able to join the
services. Still, some of them think that the society ought to take a bigger
part of the costs (Räsänen et al. 1994).
Coverage of OHS
In 1977 it was estimated that 44% of the labour force were without OHS
(Rossi et al. 1988). Mainly bigger enterprises had their own OHS. Since
the Act on OHS in 1978 the coverage has slowly increased. In the study
on Occupational Health in Finland 1992 (Räsänen et al.
1994) three big surveys were made, and the population was asked, how their
OHS was organized. It was found that about 90% of employees were covered
by OH (Table 1)
Table 1. Coverage of Occupational Health Services in Finland
in 1993
The coverage of small enterprises is, however, much
smaller. In the study quoted above also a sample of small enterprises was
interwieved. Out of 22 work-places which employed one person 73% did not
have organized OHS, and 39% of 64 work-places with two to nine employees
did not have OHS. According to Rantanen (1994) the following factors hamper
the organization of services:
-
poor economic status of the undertaking;
-
low-risk activity in which the need of services is not recognized;
-
poor understanding of basic objectives, working methods and benefits of
OHS;
-
short lifespan of high number of small-scaled enterprises;
-
low level of organization of both workers and employers in the small-scale
sector;
-
special problems of the labor market in construction, transportation and
agriculture.
Education and personnel
Occupational health studies are now integrated into basic medical studies,
and this gives the background education to all doctors to work as occupational
health doctors. The FIOH organizes four-week intensive courses as a post
graduate possibility.
Participation in continuous education every fifth
year is obligatory. The specialization in occupational health takes four
years and a subspecialty on work medicine another two years.
The basic education of occupational health nurses
is a public health nurse education. About 250 hours of occupational health
is integrated into the basic studies of a public nurse. This gives every
public health nurse the possibility to work on occupational health care
and all new nurses coming to occupational health care have the basic knowledge.
Many special occupational health modules are possible as postgraduate studies.
FIOH organizes four week courses for nurses, too. The latest innovation
in education is to organize common courses for doctors and nurses. This
makes the teams work better.
Other partners of working life also need education.
FIOH and other work educational institutes organize continuos training
for safety personnel and management. Many actual courses are tailor-made
for specific workplaces.
At the 1992 survey (Räsänen et al. 1994)
there were occupational health posts for 1532 doctors, 1925 nurses, 831
secretaries, 405 physiotherapists and 127 psychologists. Many doctors work
part-time. If the total work is converted to full time work, it will mean:
-
638 doctors;
-
1437 nurses;
-
155 physiotherapists.
Only some hygienists work inside OHS. Often these services
are requested from outside. 78% of full time doctors and 41% of part-time
doctors have participated in the education organized by FIOH. 447 doctor
posts were served by specialized OH doctors. 74% of full time nurses and
41% of part-time nurses have been specially educated. Only properly educated
occupational staff can serve the modern working environment. Continuous
education has been one of the factors of success in Finland.
Results of prevention
After 17 years of effective occupational health care, most of the classic
occupational diseases do not exist any more, the number and the degree
of occupational accidents have decreased, and many dangerous substances
are not used any more. It is true that occupational diseases can be prevented
(Tola 1996). These kinds of results increase the credibility of OH and
help in promoting it to employers. Here are some examples of results of
occupational illnesses and of results of health promotion.
OCCUPATIONAL DISEASES
Noise induced hearing loss
The evolution shows, how the introduction of protective equipment and changes
implemented at work-places in the 70’s and 80’s have changed the incidence
and actual gravity of new cases. In 1984 there were 2164 new cases; five
years later 1668 cases and in 1994 only 1034 new cases - and 50% of them
were so small that no compensation was paid (Kauppinen et al. 1995).
Skin diseases
Although many new chemicals have been introduced in workplaces, the number
of occupational skin diseases has not increased during the last years.
This is mostly due to the better use of adapted gloves, better working
methods, and the use of less allergic products. In 1984 there were 1206
new cases, and ten years later 1203 new occupational skin diseases.
HEALTH PROMOTION
These health promotion programs have been initiated by public health authorities,
and OH has taken its own role in the implementation of these programs.
When health promotion is introduced to workers by their own occupational
specialists, the effect can be multiplied (Rantanen 1994).
Cardiovascular mortality
In the early 1970’s middle aged Finnish men had the highest mortality in
the world, resulting from cardiovascular diseases. Cholesterol was known
to be one of the predisposing factors.
A big program was conducted in North Carelia and
Kuopio during 20 years. The mortality was extremely high in the province
of North Carelia. The aim was to change the habits of the population on
cholesterol intake (milk), smoking, and treatment of hypertension. In the
most recent surveys in 1992 it was shown that cardiovascular mortality
of working-age men had diminished by more than 50%, and that of working-age
women by more than 60% (Vartiainen et al. 1994). The result is good in
North Carelia but also in other parts of the country. The study showed
that the cardiovascular mortality can be defeated by acting on cholesterol
and smoking, and by good treatment of hypertension.
Smoking
Lung cancer has been the most important cause of cancer mortality among
men for many years. Smoking was known to be the most important risk factor.
Anti-tobacco campaigns began in Finland in the 1970’s. In 1976, a new law
was voted, forbidding smoking in public transport vehicles and other public
places. Passive exposure to smoke was still a problem. In 1992, it was
calculated that 800 000 Finns were exposed to involuntary smoking and this
caused 40 new lung cancer cases yearly (Heloma 1995). Continuous anti-tobacco
publicity and preventive work have changed the public opinion so that last
year a new orientation was possible. All non-smokers were promised a shelter.
The employer has to protect all non-smokers against passive smoking. Smoking
at workplaces can be allowed only in specific smoking rooms with effective
ventilation. The smoking is no longer very popular and many men have stopped
smoking. The decrease in smoking has continued since the 1960’s and begins
to be seen in the lung cancer mortality statistics (Puska 1995).
Women have previously smoked very little. Now, in
spite of public opinion, especially young women continue to smoke. At the
North-Carelian study, quoted above, the prevalence of smoking decreased
from 53% to 37% in men but increased from 11% to 20% in women.
The role of occupational health professionals has
been very important and in many services special courses have been organized
on how to stop smoking.
Role of research and information
As a support in successful OH a continuos research activity is needed.
FIOH with its six regional institutes gives advice and backstopping to
OHS who work in the front line. FIOH has produced many practical and useful
handbooks to OHS. Many databases are available on-line and on CD-ROM's.
The medical association of OH doctors aims also to promote the knowledge
of its members (now about 950). Its own journal “Työterveyslääkäri”
(Occupational health doctor) has been published four times a year during
the last ten years.
Feed-back from employers
Employers’ opinions on their OHS were also studied by Räsänen
et al (1994). 92% of employers think that productivity of the work may
increase by means of OH. Half of the employers estimated that productivity
had already increased in their enterprise. The productivity was estimated
to grow more on the work-places where curative services were included in
preventive OH. In 43% of enterprises sick leaves had decreased because
of the actions of OH.
This positive attitude is a result from the work
of many years. It is also a challenge for occupational professionals because
they are now asked to integrate themselves more deeply inside the enterprise,
and at the same time maintain their own independence.
Maintaining of working capacity
The Finnish population is getting older, and big generations born after
the second world war are coming to the age of early retirement. Many attractive
retirement possibilities were created during the good years of employment.
During the last years Finland has been hit by unemployment originated from
the collapse of trade with the former Soviet Union, simultaneously with
the recession in our main markets in western Europe. Nearly 20% of working-age
population have been unemployed. In the coming years a smaller quantity
of working-age people has to take care of retired and unemployed. The programs
for the maintaining the working capacity aim to keep these big generations
active in working life; give them better personal conditions now and lead
them to active and healthier retirement in due course.
The employers' and employees' organizations had
added a recommendation on this subject to their central collective agreement
in 1989. The advisory board of occupational health care of the Ministry
of Social Affairs and Health has defined this program as “all activity,
where the employer and workers and the common bodies at the workplace to
try to promote and support the working ability of every worker during all
periods of his/her working life”. The advisory board has proposed to OHSs
to act at three levels (Table 2).
First level activity meets the whole workplace.
It is preventive and it is thought to be realized mostly by the workplace
itself. It means different kinds of health promotion programs; motion activities;
life style planning.
The second and third levels are mostly activities
where OHS can help. Second level activity meets workers who have menaces
on their working capacity. Here the aim is also to promote the personal
condition, but the most important thing is to adapt work with the capabilities
of the worker. This means deep cooperation between management and personnel
departments. The national Sickness Insurance Fund organizes special courses
on early rehabilitation (ASLAK) for those who have menaces on working capacity.
These courses are organized together with local occupational health care
personnel.
Table 2. Three levels of the program of maintaining working
capacity
| |
Level 1 |
Level 2 |
Level 3 |
| Target group |
Whole
personnel |
Workers threatened
by diminished
working capacity |
Workers with
diminished working
capacity |
| Recognition |
|
Symptoms, poor
health. Own initiative
or others' initiative.
Evaluation by OHS |
Being sick,
diminished
performance at
working tasks.
Follow-up by OHS |
| Measures |
Preventive work,
promotion of healthy living standards,
development of work and working
conditions, promoting of workplace
atmosphere |
Check-up of health
and working status,
adaptation of the
work, transfer to a
new task, personal
promoting of health
condition,
rehabilitation |
Treatment of illnesses,
rehabilitation,
professional
education,
replacement |
Source: Advisory board of OH of Ministry of Social Affairs and
Health, Finland
The third level means work with disabled workers.
They have illnesses or injuries that decrease their capacity to work. Many
persons with work related diseases (hypertension, diabetes, epilepsy and
asthma, for instance) can work if the treatment is good and the work is
well adapted. At this level, effective treatment of illnesses, rehabilitation
and new professional education, or a replacement are the main actions.
Many kinds of programs aiming at promoting the working
ability have been conducted already through many years. In some workplaces
the maintaining of working capacity is already a process inside the enterprise.
Many projects already realized have proved that
they promote the personal well-being of workers; decrease the sick leaves;
promote the workplace atmosphere, and in many ways increase the productivity
of the enterprise (Matikainen 1995).
References
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(Finnish) Työterveiset 4/95: 18–20.
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(Finnish) Kunnallislääkäri 11: 21–23.
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