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Discussion paper on an Occupational Health and Safety System for South Africa

For initial discussion at Department of Health Consultative meeting on 3 February 2016

Introduction

The world of work is continually changing both nationally and internationally and presents

opportunities for the implementation of sustainable preventive practices in occupational

health and safety (OHS). The intention to establish NAPHISA, the deliberations around

ODMWA and the MBOD and CCOD, the new funding arrangements for the NIOH,

amendments to the NHLS Act, the reengineering of primary health care, developments

around the NHI, challenges to our financial and economic systems and to several industrial

sectors as well as the growing inequality nationally and globally have all created new

opportunities to inclusively examine aspects of the occupational health and safety system

(OHSS) in South Africa.

In addition, it is of great significance that the new global development agenda (as outlined in

the Sustainable Development Goals) includes decent work, youth employment, sustainable

economies, and health as well as gender equity amongst the all-important 17 goals. This

provides us with a golden opportunity to aspire more specifically and determinedly to reach

the goal of decent work and therefore integrate OHS into our development agenda in a very

practical manner. Climate change and environmental pollution secondary to industrial activity

contributes enormously to the burden of non-communicable diseases in many countries. It

has therefore become more urgent to consider the inclusion of environmental health and

discuss an occupational and environmental health and safety system. This should constitute

an important part of deliberations on OHS. For purposes of this discussion document we will

refer to the Occupational Health and Safety System.

The WHO Global Plan of Action on Workers Health (2008-2017) has significant synergies

with the ILO Convention No.187, the Promotional Framework for Occupational Safety and

Health of 2006. The WHO did a baseline OHS survey in 2008 to 2009 at country level

amongst member states and will do a follow-up survey in 2017. The baseline survey has

very important information which can assist countries to improve their OHS systems, policies

and practice. There is still a year for South Africa to address some of the important questions

the baseline survey looked into and to see how best we can respond in the 2017 follow-up

survey. Increasingly the WHO and the ILO is working together on OHS as demonstrated

during the tragic events on our continent during the 2014-2015 Ebola Outbreak in West

Africa. The sad and tragic loss of 11,301 lives (as of 20 January 2016) included more than

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800 health workers. The WHO and the ILO have been consulting globally to help ensure that

OHS systems are strengthened to help protect the health work-force pro-actively during such

outbreaks.

This document intends to contribute to the examination of an OHSS mainly through a

Concept Document which reviews the character of occupational health and safety systems

(OHSS’s) around the world with a view to appropriately extracting system elements

representing best practice. But the document also considers the role of the National Institute

for Occupational Health (NIOH), because in the poorly resourced area of OHS the institute is

an important component for future development of an effective OHSS. The Department of

Health has an important role to play in the provision of occupational health and safety

services because many workers, current and former and in all sectors of the economy, are

underserved by these services and they will mostly present to public sector health facilities.

Additionally, the Department is responsible for the ODMWA system. Consequently, the last

section of this document is a brief discussion on aspects of occupational health and the

Department of Health.

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Occupational Health and Safety Systems

It is important at this point to look more closely at what constitutes an OHSS. It is complex

and can be depicted in a number of ways; Figure 1 is a simplistic depiction but it has the

advantage of identifying the major components clearly. A limitation is that it suggests there

are distinct compartments to the system. The system is however integrated and all

components interact with and rely on the others to constitute an effective system.

Tripartite

governance

Occupational health

and safety services

Support and

development

services

Compensation

Rehabilitation

Work accommodation

Figure 1: Some components of an occupational health and safety system

Figure 2 provide some examples of activities within components of the system other than

compensation and rehabilitation. It should be borne in mind, though, that modern OHS

services often include individual worker health promotion and primary care, community

enterprise interactions and protection of the environment; Figure 2 is thus illustrative and not

comprehensive.

GOVERNANCE

Usually several

Government

departments:

Department of Health

Department of Labour

Department of Mineral

Resources

SERVICES

Private sector

Public sector

SUPPORT and

DEVELOPMENT

Private sector

Tertiary institutions

Public entities

(institutions)

Government institutions

OCCUPATIONAL

HEALTH and SAFETY

SERVICES

Enterprises OH and S service

providers State dedicated general

TRIPARTITE

GOVERNANCE

Policy Laws/Regulations Standards Enforcement Tripartite

structures National

campaigns

SUPPORT and

DEVELOPMENT

Information Laboratories High level services Investigations Personnel/Training Research Surveillance

Figure 2: Some examples of activities within components of the system other than compensation and rehabilitation.

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CONTENTS

Part 1: The National Institute for Occupational Health (NIOH). This section briefly outlines

the roles of national institutes of occupational health and comments on organizational and

management options under consideration for the NIOH. It provides a context for the aspects

of the Concept Document which cover the NIOH.

Part 2: Summary of the Concept Document.

Part 3: The Concept Document. The Concept Document draft was authored by Prof Jonny

Myers and much of it is the original draft. Parts of it have, however, been slightly changed

based on ongoing developments. A number of important comments on the Concept Paper

are listed in Appendix B page 41. They have not been dealt with in the Concept Paper

pending further discussion.

Part 4: Discussion paper on aspects of occupational health and the Department of Health.

This paper is from the perspective of the NIOH and its intention is to stimulate debate on the

issues.

Figure 3: Examples of activities within components of the OHSS.

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Part 1: The National Institute for Occupational Health (NIOH)

Background to national institutes for occupational health

National institutes for occupational health and safety are common around the world; all

BRICS countries have these institutes in one form or another. They are common because

OHS requires specialised interdisciplinary functions, an institute is a means of bringing the

requisite disciplines together to support and develop the OHSS. Specialized occupational

health and safety practitioners are usually in short supply. A national institute is a

mechanism for establishing capacity in a range of key disciplines and providing and

developing expertise through critical masses of practitioners.

National Institutes for Occupational Health are almost always multi-disciplinary and function

to develop and support the OHSS of a country. The work of these institutes is a mixture of

technical/professional activities and activities to support the development of policy,

legislation and regulation. They rarely enforce legislation or engage in compensation tasks.

Occupational health requires interdisciplinary action; consequently a feature of many of

these institutes is that they cover all the major disciplines of occupational health, and often

safety as well as the environment. Because occupational health and safety laboratory

capacity typically is neglected without special focus, many of these institutes provide

specialized and strategic laboratory analyses.

The provision of occupational health services to individual workers (currently employed and

those who have left work) is only one aspect of the OHSS. Policy development, legislation

and regulation, and enforcement are major components of the OHSS. Specialised functions

are required for the system to work, for example to build a culture of prevention in

communities, to prevent injury and disease, to quantify workers’ exposure, to disseminate

information and to produce practitioners. Research and surveillance as well as teaching and

training are major activities because of the very many workplace hazards in many diverse

industrial sectors.

Because of the complexity of the OHSS, a number of government departments typically

cover OHS in a country. National institutes, therefore, generally support more than one

government department.

A National Institute for Occupational Health (NIOH) for South Africa

South Africa needs a NIOH because the OHSS is underdeveloped and because critical

services, unavailable elsewhere, is unlikely to be provided without a NIOH. At this stage in

the development of OHS in South Africa a national institute is a key element in providing

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essential services and in developing capacity and supporting policy formulation. The

proposed functions of the NIOH as detailed in the Concept Document are described in

Appendix 1

Organizational and management aspects

The management of specialised services and laboratories is highly problematic unless the

environment is designed to meet their particular operational requirements.

Informally a number of proposals for the future of the NIOH have been mentioned to the

NIOH by the Department of Health, but formal communication of the options and their status

has not taken place.

The current arrangement is for the NIOH to remain in the NHLS

This arrangement has been communicated verbally by NHLS management to the NIOH. The

duration of this arrangement is unknown. An advantage of this proposal is that the NIOH

would be supported by NHLS management and administrative resources – finance systems,

human resources, payroll and provisioning among them. The disadvantage is that the NIOH

would be a small, non-core part of the NHLS. Despite this being the de facto situation now, it

is worth listing proposals that were mentioned as these may come under consideration

again, or still be under consideration.

The NIOH to become part of NAPHISA

For unexplained reasons the Department of Health does not appear to favour this option and

the NIOH has not been included in the planning of NAPHISA. Nevertheless, this option is

most desirable as it would create an environment conducive to an effective institute with

understanding of the operational requirements to provide the range of functions, including

the laboratory functions

A proposal considered seriously until recently was to integrate the NIOH, MBOD and CCOD,

largely as a means of dealing with the ODMWA compensation difficulties.

This proposal may no longer be a serious option, but is in any event flawed. It is government

policy to unify the compensation systems under the Department of Labour. When this policy

is implemented, the CCOD and MBOD may no longer be in the Department of Health and

the MBOD’s role will change, possibly to that of only a certification body. Integration of the

CCOD/MBOD and NIOH, or restructuring of the NIOH to have a larger compensation role is

illogical in this context. Additionally, integration will not solve the backlogs in the MBOD and

CCOD, which require administrative solutions and the constitution of more certification

committees, steps that are currently being put in place. A public-private partnership which

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puts resources into addressing the real obstacles to eliminating the bottlenecks and

backlogs would be more effective.

Another proposal is to break up the NIOH with the laboratories being managed by the NHLS

or on their own and occupational medicine and other disciplines going to the Department of

Health.

This proposal intends to provide occupational health capacity for the Department of Health.

This would of course be to the detriment of other government departments that require a

national institute’s expertise and services. This proposal will result in the loss of a national

institute for occupational health for South Africa, the erosion of critical resources and

services with long-term damage to the OHSS. It ignores the role of a national institute in

serving the whole OHSS, a number of government departments and all industrial sectors.

Another proposal is for the NIOH to become a public entity.

The implications of this proposal are unclear, as service delivery is typically prohibited by

these agencies.

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APPENDIX 1: Proposed functions of the National Institute for Occupational Health as

detailed in the concept paper

Evidentiary basis for OHS policy

The NIOH could inform and support oversight of the OHSS as a whole by playing a key role

in marshalling the evidentiary basis for OHS policy development and in monitoring policy

implementation at various levels in the panoply of public and private institutions tasked with

prevention at all levels. The role of the NIOH will be to facilitate a holistic and

comprehensive view of the entire OHSS including all its component parts.

The NIOH could support and inform the drafting of

national policy

model legislation

strategic and operational OHS plans

Specialised services and laboratories

In a context where basic occupational hygiene, occupational medicine, occupational

pathology and laboratory-based services are sorely deficient, the NIOH could continue

providing these while at the same time support the development of such services at more

extensive levels with the public and the private sectors.

Teaching and training

Similarly, while basic teaching and training in OHS components are lacking (e.g.

undergraduate training in OHS by way of a BSc or by inclusion in other undergraduate

programmes like medicine or nursing, the NIOH can play an important support role for the

development and strengthening of these programmes and courses at academic institutions

by collaborating with staff there.

Production of specialists

The NIOH should play a strong role in the national endeavour to produce specialists in all

OHS disciplines, and to diffuse scarce skills, build expertise at high level, and deploy

specialized equipment which is typically lacking at educational institutions. Where desirable

they should hold joint appointments with tertiary academic institutions including university

departments and referral hospitals to the extent possible. They could support and capacitate

occupational health system disciplines at these institutions and at the level of the Provinces.

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Research priorities and research

Expert and specialized OH staff at the NIOH should play important leading and collaborating

roles in determining OH research priorities in OHS, and in undertaking priority research

activities.

Specialist technical and professional expertise

Specialist technical and professional expertise should be available for consultation and

referral of clinical and workplace service problems and issues of national significance and

those arising from the provincial level.

OHS communication

OHS communication including:

guidelines

norms and standards

information dissemination

Design and development of an OHS surveillance system

The NIOH should lead the design and development of an OHS surveillance system per se,

and as a component of a general health surveillance system operating at national and

provincial levels. There should be OH surveillance in both private and public sectors and

inclusive of primary preventive, secondary clinical prevention and tertiary compensation

prevention aspects, including:

routine and custom/research data collection

data analysis

reporting of findings

using findings for evaluation and refinement of policy,

legislation and planning

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Part 2: Summary of a Concept Paper on Occupational Health and Safety (OHS) for

South Africa.

The Concept Paper is Part 3 of this document. It reviews African and other countries’

OHSS’s, extracts international best practice and assesses current SA OHS practice with a

view to proposing recommendations for the role of the National Institute for Occupational

Health and the way forward for the South African OHSS. Occupational health is an

interdisciplinary activity, and beyond the provision of health services involves safety

engineering, occupational hygiene and a number of other important non-health disciplines.

OHSS’s in a wide variety of high, middle and low income countries including selected African

countries, Brazil, India, Turkey, Thailand, Venezuela, Chile, Australia, New Zealand,

Canada, the UK, Germany and Nordic countries fall into four system types. The least

developed have no specific OH component and rely on labour and health departments, basic

generic legislation and regulation, and the common law. Fragmented OHSS’s between

various government departments - health, labour, social security, agriculture etc. followed.

More evolved systems have an independent national government agency responsible for

OHS policy and oversight, reporting to a Minister (usually labour). Labour inspection or

compensation services are excluded. The most evolved OHSS is found in Scandinavia with

an independent national authority in the context of a polity and economy characterized by

high levels of cooperative governance and social consensus with strong OHS practice

deeply embedded across the system. Strong social security mechanisms take care of all

levels of prevention including compensation and rehabilitation.

Many countries have National Institutes of Occupational Health including high income

countries, all the BRICS countries as well as other middle income countries. National

institutes carry out key functions like centralized laboratories for workplace and biological

monitoring for specialized as well as routine testing not available in the private sector. From

this review, a list of ideal attributes of a National Institute, as the most important component

of an OHSS, emerged.

The review of SA OHS practice in the period since the advent of democracy revealed

substantial dysfunctionality with little capacity in safety engineering; underdeveloped

occupational hygiene, medicine and nursing with few high level specialists being produced.

There is inadequate development support by either the public or private sector. The social

security system has insufficient cover to cater either for general or occupational health and

security needs in either formal or informal sectors. The compensation system is in disarray

and the availability of occupational clinical care is limited to parts of the formal sector. The

OHSS is characterized by distortions where prevention suffers because of an undue focus

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on compensation, and where some industrial sectors for historical or political reasons absorb

more than their fair share of resources to the detriment of OHS needs in other larger and

more important sectors. The unabated silicosis epidemic in the gold mining industry is a

case in point, draining scarce public resources for compensation, while failing to institute

primary prevention through dust control. Inter-sectoral coordination is weak, unable to

provide unified oversight of policy and practice. When problems become impossible to

ignore politically due to intermittent crises, initiatives emerge that are half-baked,

insufficiently consultative and too narrowly sectoral, tending to wither on the vine, making no

perceptible impact. Currently there is no integrated OHS policy. Laws (and regulations) are

outdated in respect of both the prevention and compensation OHSS components which are

fragmented and duplicated.

Accordingly, there is currently little integrated Governmental strategic or operational OHS

planning. It is no surprise that management in some economic sectors has been able to get

away with ignoring OHS requirements for many decades continuing up to the present time.

It has been possible to avoid instituting sound primary preventive practice; to dodge

secondary prevention in the form of occupational medical services provision to in-service or

ex employees; deflect the tertiary preventive burden of compensation for silica-related and

other occupational disease onto the public sector and the pockets of injured and diseased

workers and their families.

There is no structure that could enable a comprehensive overview of the SA OHSS, despite

the stated need for this as determined by various government committees and commissions,

and in published articles by OHS specialists over the past two decades. Unity in direction for

supporting and informing policy-making and oversight of implementation of policy is unlikely

to be possible within one government department given the profusion of disciplines,

institutions and interested parties in OHS. Other aspects of unity involve guidance for OHS

services provision, teaching and training, and research prioritization, along with unified

inspection and compensation systems.

The NIOH would be best placed to effectively undertake many necessary functions and play

an optimal role in attaining the twin goals of improving worker health and safety and worker

compensation. The NIOH is one of the few components of the South African OHSS that is

currently functional, and it concentrates some extremely valuable and scarce OHS

resources. Moreover, it has the potential given a changed role to kick-start and help oversee

the construction of a modern competent OHSS with optimally functioning components. It is

important to conserve the current value of the NIOH with a view to its potential role in

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developing the OHSS for the future and to avoid unnecessary squandering of current

resources which would be extremely difficult to recoup or rebuild. The most appropriate

structural location of the NIOH given its interdisciplinary and intersectoral nature is within the

National Public Health Institute of SA (NAPHISA). As indicated in the Strategic Plan of the

NIOH 2013-2017, the NIOH would be well placed for future reconfiguration and development

in the proposed NAPHISA, where it could more easily cross departmental boundaries, levels

of government, and move between different social sectors. There could be significant

synergies in being placed within the same institutional structure as the Communicable and

Diseases and Non-Communicable Disease Institutes, and the National Cancer Registry.

The core functions of the NIOH are to inform and support OHSS oversight (including policy,

legislation, strategic and operational plans) by providing evidence of effectiveness and cost

effectiveness; provide and develop OH service components; develop and strengthen OHS

teaching and training; identify, prioritise and conduct research; provide specialist technical

and professional referral services; disseminate OHS information; and design and evaluate a

national OHS surveillance system to refine policy and practice. This includes characterising

the SA occupational burden of disease (BoD) and the impact of work as a comparative risk

factor to the general South African BoD. This will provide an evidentiary basis for priority

setting, and for the implementation and evaluation of preventive interventions for

effectiveness and cost-effectiveness. Ongoing analysis of the OHS BoD will constitute a

key part of the surveillance system required for evaluating policy and planning going forward.

Building an accurate picture of the existing OHS BoD will allow timely fine tuning to take

place. In these ways the NIOH will be key to the development of an integrated, cross-

sectoral and inter-governmental OHS policy and to guiding future developments in more

effective enforcement and compensation by identifying priority areas for attention.

Really substantial future improvements in OHS await the development of an effective

population-wide National Health Insurance and social insurance system in South Africa.

Only then will it be possible to integrate the occupational medical services component of the

OHSS into public sector health care as in the case of Brazil, for example, or to integrate

workers’ compensation into the general social security system as is the case in many Latin

American and other middle income countries. These two developments, should they come

about, will still leave out other crucial components of the OHSS in SA such as the other

disciplines and functions (Occupational Hygiene, Safety Engineering, OHS communication,

teaching and training OHS technicians and professionals, conducting research based on

surveillance data and important national priorities and problem areas). These latter

dimensions can only be developed and guided by a strong appropriately directed NIOH

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By setting evidence-based priorities, finding the common ground and working in a more

inclusive and interdependent manner there are excellent possibilities for more efficient

functioning of enforcement, of compensation, of much greater prevention and reduction of

the workplace contribution to the national burden of disease and injury.

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Part 3: A Concept Paper on Occupational Health and Safety (OHS) for South Africa.

A request by the Director of the South African National Institute for Occupational Health to

develop a concept paper on the Occupational Health and Safety System (OHSS) for South

Africa resulted in a comparative assessment of the character of OHSS’s in a range of

countries globally with a view to appropriately extracting system elements representing

international best practice. Countries ranged from high income industrialised to middle and

some low income African countries with large agricultural and informal sectors. The

published and grey literature including government documents were reviewed for the South

African OHSS. OHS practice in South Africa was found significantly wanting in many

respects when compared with global best practice. The NIOH is one of the few components

of the South African OHSS that is currently functional, and it concentrates some extremely

valuable and rare OHS resources. Moreover, it has the potential given a changed role to

kick-start and oversee the construction of a modern competent OHSS with optimally

functioning components. Recommendations for realizing this are elaborated.

Background

This concept paper was commissioned by Dr S Kisting, Executive Director of the National

Institute for Occupational Health (NIOH) in response to a discussion with Dr Anban Pillay,

Deputy Director-General for Regulation and Compliance Management, Department of

Health. The process of producing it commenced with a one day brainstorming meeting of

occupational health experts in Johannesburg in April 2015.

The terms of reference for this work are:

1. Do a desktop review of OHS practice in different countries including selected African

countries, Brazil, India, Turkey, Thailand, Venezuela, Chile, Australia, New Zealand,

Canada, the UK, Germany and Nordic countries

2. Extract from the above review what can be considered international best practice in OHS

3. Briefly review previous OHS reports informing OHS practice in South Africa

4. Make an assessment of current OHS practice in South Africa

5. Recommend the potential role of an NIOH in South Africa based on the information above.

6. Provide a report on the above with recommendations for possible ways forward for the

OHSS in South Africa.

Definitions

For the sake of clarity some definitions are in order.

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Occupational health and safety (OHS) is an area concerned with the safety health and

welfare of people engaged in work, or who were engaged in work but have left work, and

with safe and healthy work and related environments.

The Occupational health and safety system (OHSS) encompasses the organization of

people, institutions and resources that promote safe and healthy working lives and prevent

work-related injuries and disease, and which deliver occupational health care and related

services to meet the work-related health needs of the working population. There is clearly a

strong overlap and link with the general health care system.

OHSS components include:

Policy and implementation of policy in laws, regulations, strategic and operational plans

Organizations including government departments, compensation authorities, inspectorates

for enforcement of laws and regulations, and most importantly a national OHS agency

Promotion and intervention programmes and projects

Surveillance, data monitoring and evaluation systems

Occupational health services viz. safety engineering, occupational hygiene, occupational

medicine, nursing, psychology, physiology, occupational therapy in both private and public

sectors

Administrative, informational, advisory and legal resources

Support services such as specialised laboratories to measure

workplace hazards

Teaching and training provision

Research funding and research activities for programmes, projects

and priority needs.

Occupational health policy comprises a deliberate system of principles to guide decisions

and achieve rational outcomes. Policy provides statements of intent which are implemented

through legislation and regulation along with the generation of strategic and operational

plans executed as programmes and projects.

OHS Services within the OHSS are further usefully approached in terms of levels of

prevention of work-related injury and disease. The major emphasis is typically placed on

primary prevention which is the province of safety engineering and occupational hygiene.

Secondary prevention is the realm of clinical occupational medicine involving nurses and

doctors and other allied health professionals such as psychologists, audiologists,

ergonomists, occupational therapists, physiologists and audiologists. There is also a role for

primary prevention by these health professionals working in collaboration with the primary

prevention professionals. Work-related diseases and injuries may result in permanent injury

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or limitation of structure or function impacting on the ability to pursue further work, and this is

the realm of tertiary prevention encompassing rehabilitation services and compensation for

loss. The health professionals are amplified here by legal experts, administrators, insurers,

health economists and actuaries. At all stages it is optimal to have all these different

professionals and modalities of prevention working seamlessly side by side. Interchange

and feedback between these different domains is key to informed prevention of injury and

disease and to the overall promotion of health and welfare. The occupational health

professional spectrum is broad ranging from generalist to specialist depending upon the

level of development and sophistication of the economy.

The working population includes the economically active, the employed, the unemployed

and the self-employed in both their formal and informal manifestations. The formal sector

includes agriculture, mining, manufacturing and services, while the informal sector could be

active in any of these sectors or more amorphously constituted and intangible. The

participation in the working population includes important equity considerations such as

women and the disabled along with other minority groups suffering discrimination including

legal and illegal aliens. Children’s participation is also an important indicator. Retired

workers can constitute a large proportion of individuals needing public sector services.

The character of work is an important consideration regarding its decency, its availability, its

intrinsic hazards, its constant mutability, and the matching of workers to work.

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1. A desktop review of OHS practice in different countries including selected African

countries, Brazil, India, Turkey, Thailand, Venezuela, Chile, Australia, New Zealand,

Canada, the UK, Germany and Nordic countries.

There is a wide variety of documentation available on occupational health systems in many

jurisdictions globally. Recourse was had to general internet searches and to PubMed as

well as ILO and WHO sources, and the personal libraries of various South African

occupational health experts and international colleagues. For the internet search terms

included “occupational health”, “occupational health systems”, “occupational health

services”, “occupational health policy”, Occupational health organisations”. These

searches were restricted mostly, but not always, to the countries listed in the title line above.

Information was obtained verbally in telephone and skype interviews and by email with

various colleagues in Turkey, India, Brazil and Sweden.

Only English language material was examined. There are obvious discrepancies between

countries regarding the quantity and quality of written and published material pertinent to

their OHSSs. South Africa compares quite favourably in this regard in that much high quality

material has been written over a long period of time concerning the local OHSS which is not

particularly well developed.

An especially valuable source of useful information was a Swedish publication on OSH and

Development edited by Elgstrand (Elgstrand 2010) which covers in a systematic and

comparative manner many of the countries listed in the terms of reference for this review, as

well as some additional countries. Information extracted from this document and the other

materials reviewed is organized as general comment first, followed by specific highlights

concerning the OHSS for various countries of note because of special features of their

systems which suggest possibilities also for a future South African OHSS.

The particular utility of the countries selected in the Elgstrand document is that they are

representative of the range of low to middle income countries and therefore likely to have

high relevance for South Africa. Indeed all five of the BRICS countries (Brazil, Russia, India,

China and South Africa) are included amongst those reviewed.

The operational definition used for developing countries was a per capita GDP lower than

US$ 15,000 per year. Of 21 countries reviewed only two, Russia and South Korea, had a

higher per capita GDP and were classified as industrialised countries.

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The other 19 ranged from lower middle-income countries; US$ 976-3,855 per capita per year

(China, Ghana, India, Kenya, Nicaragua, Tanzania, Vietnam);

through upper middle income countries; US$ 3,856-11,905 per capita per year (Brazil,

Colombia, Costa Rica, Ecuador, Egypt, Morocco, South Africa, Thailand, Turkey); to high

income countries; US$ 11,906 and more, per capita per year (Argentina, Chile, Iran, Russia,

South Korea). This range of countries nicely brackets South Africa which is in the middle of

the spectrum as an upper-middle income country.

Agriculture plays an important role in the 19 countries with a substantial proportion of the

working population ranging up to 90% in the case of India. OHSSs have to deal with all

stages of development. Similarly, the informal sector is very substantial ranging up to 90%

again in the case of India. Apart from mining, construction loomed large as a notable

hazardous industry along with transport. High rates of unemployment were reported

throughout.

The usual OHS risks featured in all countries reviewed including occupational injury,

silicosis, asbestosis and other lung disorders, pesticide poisonings, noise-induced hearing

loss, and musculoskeletal disorders. These risks were generally related to work in mining,

agriculture, construction, metalworking and chemical industries. Few countries had discrete

OHS policies while most had some type of OHS legislation, however outdated. There was

notably little in the way of surveillance, enforcement and penalization of employers flouting

regulations. Most workplaces and workers were not covered by the provisions of the formal

OHSSs due to the large informal sector or other sectors not being covered (e.g. agriculture,

domestic work). Occupational fatalities occurred at high rates in the mining and construction

industries and were particularly high in the informal sector. There was very little in the way

of rehabilitation and compensation benefits which mainly apply to the relatively small formal

sector, and even then not particularly efficiently.

Organisational responsibility for OHS was typically divided between the Ministries of Health

and Labour, and beset by coordination difficulties which seem universal.

While tripartite structures operate in many countries, the trade unions have generally been

weakened and this translates to little or at times no attention to OHS issues. Even where

trade unions are strong (e.g. the NUM in South Africa), it is notable that they usually

prioritize employment and wages and often do not show much interest or activity in OHS.

Not all countries have national OHS institutes, but certainly all of the BRICS countries have a

national institute in one form or another. There is the Fundacentro in Brazil, the National

Institute for Occupational Health in India, the Research Institute of Occupational Health in

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Russia and the National Institute of Occupational Health and Poison Control Chinese Center

for Disease Control and Prevention (China CDC). All the countries without a national institute

strongly expressed the need for a central unifying organization to underpin policy, research

and advanced training.

Preventive occupational health services are non-existent at medium and small-sized

enterprise level as well as in the informal economy. While medical services may be provided

for injuries and common diseases (occupational and non-occupational) affecting workers at

enterprises in the formal economy, occupational health problems are mainly and typically

ignored, except for multinational and other large enterprises which provide specific

occupational health services. Surveillance of occupational safety and health is absent or

mostly poor, and enforcement is lacking. Occupational health professionals are few and far

between, and ratios of these professionals to worker numbers are typically low.

All countries were in need of updated OHS legislation and regulations and stronger

inspection and enforcement. Lack of reliable OHS data was a major problem in most of

countries. Compensation systems were generally felt to be unfair. Although tripartite

systems exist in most countries, these do not follow through to lower levels where

relationships between trade unions, workers and employers in particular industries,

enterprises and on the shop floor are typically absent. Participation of women in the labour

force was generally low and there was considerable discrimination against women in most

countries. Since traditional approaches to OHSS’s including prevention and protection have

not affected the increasing gaps in OHS service provision, it was felt that innovative and

unconventional approaches must be explored and seriously considered. Two such

approaches were proposed by countries reviewed. South Korea which is technically no

longer a developing country but an industrialised one, proposed a change for occupational

health and safety practise to a performance based system. To quote:

“The current system has fallen into a set of self-perpetuating examinations and

measurements specified by codes that fail to produce any meaningful outputs. A move to a

performance-based approach would require Korea to shake up the roles of labour,

government and management in tackling health and safety problems at enterprise level. Up

to now, no active roles have been given to these stakeholders, and the content and style of

health and safety management has been solely determined by occupational health and

safety professionals.”

This sounds very familiar to South African occupational health professionals. Other

countries, including Brazil, on the other hand stressed the need for integration of OHS

services with public sector general health services.

20

The editors concluded (Dwyer, Elgstrand, and Petersson 2010) that the industrial OSH

paradigm was fully dominant amongst all these countries. This is based on regulation and

assumes tripartite cooperation. If preventive approaches do not work then rehabilitation and

compensation are provided instead. Serious weaknesses in this paradigm include the

perpetual need to update regulations which happens at snail’s pace Constant supervision

and oversight of workplace controls is necessary in order to bring significant improvements.

Trade union weakness in the context of tripartism, scarce resources for health professional

training, limited coverage of all those who work due to the invisibility of the informal sector

are features of this paradigm. An alternative paradigm which is not based on a history of

industrialization was required. Proposals included a management solution (the performance

based solution proposed by South Korea), and a more radical occupational primary health

care approach (e.g. Brazil) which includes health promotion, life style, mental and

reproductive health, and which integrates OH services into general health care and relevant

surveillance systems. The latter proposal moves away from the traditional approach in

which the OHS service is viewed as a separate activity which covers only the formal sector.

Worker participation was viewed as an important and crucial ingredient for both alternative

proposals. This idea of new paradigms, although very intriguing, if not frankly tantalizing,

was unfortunately not developed much in this document. A problem with this second

alternative is that OH services need to be preventive and not simply focused on workers and

their health status. This makes integration of OHS into the general primary health care

services very problematic. OH services located in the general health services risk an

exclusive focus on health when safety, occupational hygiene, laboratory and information

services are critical requirements for effective OHS prevention at the primary level.

Specific highlights from the different OHSS’s in various countries

Other African countries including Ghana, Egypt, Morocco, Uganda, Tanzania, Nigeria,

Namibia and Benin all have less developed OHSS than South Africa, while Kenya in 2009

adopted a constitution which like the South African constitution provides for the right to OHS

for workers. However, the Kenyan system in other respects is not as developed as South

Africa.

Australia (Safe-Work-Australia 2012a, 2012b, 2012c, 2012d, 2013a, 2013b, 2013c, 2014,

2015a, 2015b) has a near perfect OHS system which includes an independent state agency

at Federal level which reports to the Federal Department of Employment. It works with the

various other jurisdictions (states and territories) which all have similar independent

agencies specifically tasked with OHS. Policy development leads to strategic and

operational plans, based on information about the occupational burden of disease enabling

21

the identification and setting of specific targets and goals, achieving which are then

monitored using indicators. Progress or otherwise feeds back to policy and legislative

refinement.

Argentina has a very basic OHSS but has a comprehensive social insurance system for

worker’s compensation as do many other Latin American countries.

Brazil is a good example of legal and constitutional innovation and comprehensive social

insurance. Prior to constitutional change following the dictatorship in the 1970s, workers’

unions were responsible for general medical care for workers and their families and there

was not much in the way of occupational health services. Since the end of the 1980s, the

public sector has been establishing workers’ health programs (Repullo and da Rocha

Gomes 2005). The trade unions relinquished general medical care to the public sector

services while the public health sector care has increasingly included occupational health

services at all levels of the these services. There is, however, little in the way of any

published material evaluating OH services nested within the public health sector.

Chile (Chile 2011) has recently expressed the need for a national agency for OSH with

equal participation from government ministries, unions and employers’ associations which

could strengthen training and research and define a national policy.

China has a national plan for prevention and control of occupational diseases. There is a

strong emphasis on prevention and a national, provincial and local authority system has

been set up to promote this.

Thailand (Siriruttanapruk and Anantagulnathi 2004) has four government departments

including Labour, Public Health, Industry and Agriculture tasked with OHS.

Canada (Canosh 2015) has an independent structure - a not-for-profit federal corporation –

the Canadian Centre for Occupational Health and Safety (CCOHS) governed by a tripartite

Council - representing government, employers and labour - to ensure a balanced, approach

to workplace health and safety issues. The CCOHS is tasked mainly with provision of OHSS

wide information.

The UK (UK-HSE 2013, 2015a, 2015b, 2015c) has an Health and Safety Executive (HSE)

which deals mainly with enforcement and regulation. It is an executive non-departmental

public body with Crown status, established under the Health and Safety at Work Act 1974. It

is sponsored by the Department for Work and Pensions (DWP). DWP Ministers have

primary responsibility for health and safety policy in government. HSE also reports to other

Ministers on different aspects of health and safety. The Health and Safety Laboratory is a

large and multifunctional organization playing an important role in prevention.

22

Turkey (Turkey_National_OHS_Commission 2002; Turkey 2009, 2015) has the old system

and is one of the least developed of the countries in respect of occupational health. There is

a particularly low labour force participation by women (24%) who constitute 80% of the

agricultural work force. The agriculture sector is excluded from coverage by the OHSS

occupational health. The İSGÜM has housed the national centre of the ILO CIS, the OSH

information centre, since 1987. İSGÜM was founded in 1968 and resorts under the

Directorate General of Occupational Health and Safety in the Ministry of Labour and Social

Security, and is the only public organization undertaking both workplace environmental and

biological sample analysis. It runs a central laboratory in Ankara and five regional

laboratories throughout Turkey. The staff is composed of engineers, physicians, chemists,

biologists, physicists, statisticians, OHS experts, nurses and technicians.

23

2. Extract from the above review of what can be considered international best practice

in OHS

Dwyer, Elgstrand, and Petersson (2010) identify 2 models of OHSS - the traditional model

based on the industrial paradigm which is largely inappropriate but which may be managed

better, and a proposed new paradigm integrated with the general primary health care

approach which they presume to be more suitable for a developing country. This new

paradigm is unfortunately insufficiently elaborated in their review. However, it is extremely

doubtful that this is a paradigm that would work in South Africa given past experience at

provincial level in the Western Cape.

When considered together with all the other information about the OHSS in the list of

countries in the terms of reference for this review, 4 distinct models of OHSS configuration

may be identified. A clear process of evolution is visible historically and currently in OHSSs

across the world.

The oldest style is characterized by several government departments which participate

under the lead (usually) of a Department of Labour which houses specific directorates for

OHS components (inspection, enforcement, legislation, compensation). This system

operates in countries like SA, Turkey, Thailand and many others.

The new style has independent governmental agencies for making OHS policy and drafting

legislation, programmes and plans, and for monitoring their implementation. While these

agencies may report to a minister of employment or labour or of some other department,

they are independent entities. Their functions are at high level and typically exclude

enforcement, services and compensation. Australia is the model here.

The Scandinavian system seems in the case of Sweden to have passed on to an even

more evolved system where much of the action happens cooperatively at the enterprise

level, but where there is still backup from independent agencies and governmental

authorities. For example, Sweden has a network of large public sector occupational

medicine clinics which, despite the name, are multi-disciplinary units which serve as referral

units for practitioners and regional government.

The 4 types are as follows:

1. No specific OHSS at all with full reliance on the labour and health departments and the

basic or generic legislation and regulations that govern them, and the common law. Turkey

and many African countries are examples of this.

24

2. An OHSS exists but is fragmented between various line departments - health, labour,

social security, agriculture etc. with lots of overlap and lack of OHS specificity. Many low,

most middle income, and even some high income countries, including South Africa fit in

here.

3. A further evolved system of which Australia is the best example where there is an

independent government agency at national level which has responsibility for OHS policy

and oversight generally, and which reports to a Minister (usually of employment or labour),

but which is not in a departmental line structure. This agency typically does not include

labour inspection or compensation services, and constitutes an ideal as well as potentially

achievable model for South Africa. This is elaborated in more detail below.

4. As always, the most evolved OHSS is to be found in Scandinavia. This involves a

minimalist national authority which reports to a Government minister but which is not part of

a line structure or function. This type of system has been successful in a polity and

economy characterized by high levels of cooperative governance and social consensus in

embedding good OHS practice deeply within all relevant structures down to the level of the

shop floor. Much of the preventive OHS activity takes place collaboratively at the enterprise

level. Strong social security mechanisms take care of all levels of prevention including

compensation and rehabilitation. Many OHS components are firmly embedded in

appropriate institutions - e.g. universities for research, training and teaching; other

government departments including strong national OH institutes for surveillance. There is

typically cooperative OHS governance at plant, enterprise and higher levels with the state

playing a minimal oversight and enforcement role. The social security system integrates

compensation. While Finland and Norway have large national institutes, the Swedish

National Institute for Working Life was shut down in 2008 by an incoming conservative

government and its remaining assets after a large number of layoffs distributed to various

educational institutions. This development has been widely considered to be a tragedy for

OHS both in Sweden and globally. (Westerholm 2007). The Finnish Institute is large and

central to the OHSS. The Norwegian National Institute of Occupational Health, also known

as Statens arbeidsmiljøinstitutt or STAMI is a government body organised by the Ministry of

Labour and Social Inclusion. The institute deals with a range of occupational health areas,

with staff competent in medicine, physiology, chemistry, biology, psychology, and other

disciplines. The institute deals with all aspects of Norwegian working life, and works in both

environmental and health fields, and often visits workplaces to look into their health

practices. The institute has an occupational health clinic which treats patients with work

related illnesses and which is involved in training health professionals and other students.

25

Countries with constitutions tend to provide some additional OHS protection whatever the

level of development of their OHSS. The Australian OHSS provides an excellent example

for an independent state authority from a policy point of view, which seems to be achievable

partly or wholly by many other countries. This necessarily functions at a high level and does

not include inspectorates or compensation functions. Other jurisdictions have national

agencies that include key national functions such as centralized laboratories which measure

workplace agents (chemicals, asbestos fibre counting, and biological monitoring). Such

routine and specialised specifically OH laboratory services are scarce in most countries and

their work is not always financially viable or affordable. Additionally, a national reference

function is important in disputes, for quality assurance, and support for inspectorates. Many

countries such as the USA, Finland and the United Kingdom have these laboratories

included in their national agencies as there is no financial logic to having these important OH

functions carried out regionally, or in the private sector and additionally covers situations

were tests are not sufficiently lucrative to be offered by the private sector. Unless there is an

agency with a special interest in occupational health such tests cannot be provided.

One of the key focuses of this review is the role of a national agency or organization that

would be capable of achieving oversight of the OHSS as a whole and be able to pull the

disparate parts together, keeping it on the path to improving of prevention at all levels.

Table 1 provides an ideal structure and functions for a South African NIOH

26

Table 1 : Structure and functions of an ideal independent state agency with cross-sectoral

reach and inter-governmental involvement drawn from on Safe Work Australia, and the UK

HSE, USA NIOSH and FIOH models of specialist laboratory and clinical service provision

and OHS teaching and training

Structure

An Independent statutory agency not part of the line function of any particular government

department reporting to a relevant Minister.

Functions

The agency is intended to lead development of national policy to improve work health and

safety and workers’ compensation. The agency has no regulatory or enforcement functions

and does not administer compensation. It has service provision functions at specialist level

or to cover more specific routine OH tests that are not available in the private or public

sectors for reasons of utilization or profitability/affordability. It has a specialist teaching and

training role with respect to design of curricula and internships/registrarships. It is also a

lead national OH research facility supporting research and collaborating with other

institutions and settings. Communication and information dissemination activities are key

activities.

coordinate and develop

o national policy

o national strategies - multi-year strategic & operational plans

o model work health and safety laws

collect, analyse and report and improve data on national work health and safety and

workers’ compensation

review and evaluate implementation of policy by monitoring compliance of both strategic

goals and model legislation

reduce regulatory burden and improve operational efficiency of laws

support ongoing reform to improve safety outcomes

27

undertake research to identify priority issues, emerging issues and specifically the changing

burden of occupational disease and injury and trends in relation to the general burden of

disease

communicate information based on the above including simple, practical guidelines to aid

compliance for small businesses; promote consistent work health and safety and workers’

compensation messaging; and dissemination of research and surveillance results

collaborate to achieve the national vision of healthy, safe and productive working lives with:

o work, health and safety regulators,

o industry groups and

o unions

promote collaboration between different levels of government in achieving these goals.

Improve coherence and efficiency in workers’ compensation arrangements

International liaison in respect of work health and safety and workers’ compensation.

OH laboratory services, either specialised or to fill gaps

Specialist OH clinical, hygiene and related services provision

Training and teaching of specialist OHS practitioners

28

3. Briefly review previous OHS reports informing OHS practice in South Africa

Much has been thought, discussed and written about the OHSS and its components in

South Africa since the 1970s (Abdullah 1996; S Adams and Ehrlich 2010; Shahieda Adams

et al. 2007, 2012; P Benjamin and Greef 1997; Paul Benjamin 2009; Boyko et al. 2015;

Department of Labour Affairs 2003; DOH 1997, 2003, 2011a, 2011b; Ehrlich and Rees 2015;

Ehrlich 2012a, 2012b; Griffith and Strasser 2010; Jeebhay and Jacobs 1999; London 2011;

Maiphetlho and Ehrlich 2010; WAHSA 2004, 2009). Despite a wealth of written material

including published articles in the scientific media, laws, regulations, reviews about many

aspects of the OHSS it cannot be said that there have been any marked improvements in

worker health and safety nor in compensation benefits over the past 3 to 4 decades. In

several respects some OHSS components have retrogressed. The most comprehensive

description of the state of the OHSS in SA as a whole is that by Adams and Ehrlich (S

Adams and Ehrlich 2010).

Given the orientation of this review, however, it is perhaps most important to examine

documents dealing with national OHS policy and its implementation in legislation and

strategic and operational planning.

There have been two attempts at national policy development emanating from two different

national government departments. The first was the Report of the Committee on

Occupational Health (the Abdullah report) of 1996 (Abdullah 1996) commissioned by the

then Minister of Health, and the Draft National Policy on Occupational Safety and Health by

the Department of Labour in 2003 (Department of Labour Affairs 2003).

The Abdullah report proposed an occupational health system that was fully integrated with

the primary health care approach which was the reigning policy of that time within the

Departments of Health at both national and provincial levels. There would be district level

public sector occupational health services, not as a vertical stand-alone programme, but

rather integrated into a package of primary level services. These would serve the informal

sector and small and medium business sectors which do not have access to their own in-

house OH services nor can afford to subscribe to a private service. The model proposed

was firmly intersectoral (including Departments of Labour, Health, Minerals and Energy and

Environmental affairs with an inter-sectoral executive setting standards and drafting

legislation to ensure optimal occupational health services. Tight integration with labour

inspection was envisaged for occupational health services. Regional occupational health

29

units attached to regional hospitals were also proposed for referrals to the next highest level

of the system. These would be staffed by occupational medicine specialists and

occupational hygienists who would similarly work closely in concert to investigate work-

related diseases and ensure their control in the workplace. Units would also offer

rehabilitation services and administrative assistance with compensation along with the

dissemination of occupational health information. The top Provincial Health departmental

level was envisaged as mainly administrative involved with ensuring overall service

provision, staff training, and further development of services, preventive programme

initiation, information management and priority setting for the Province. It would also be

responsible for strategic communication and take part in common activity with the other

cognate government departments. Nationally the then National Centre for Occupational

Health (NCOH) was to be restructured as a centre of reference for all aspects of OH, and

provision of appropriate research and support for provincial OH Services. Provincial funding

would be increased for OH Services, and new legislation would be needed.

Despite the Chair of the Committee that produced this report attaining high office as a

deputy director-general in the Provincial Department of Health, and the advent of the

National Health Act of 2003, which made the Provincial government responsible for OHS

services provision, none of these recommendations came to fruition. The failure of

provision of OHS services at Provincial level casts very serious doubt upon the feasibility of

even more devolution of OHS services to district level.

The second highly significant document was the draft policy on OHS from the Department of

Labour in 2003 (Department of Labour Affairs 2003). This was preceded by the report of the

Commission of Inquiry into a National Health and Safety Council by Benjamin and Greef in

1997 to the then Minister of Labour (P Benjamin and Greef 1997). The draft policy of 2003

describes all the features that were wrong with the current OHSS in great detail, in much the

same way as the earlier Abdullah report. It laments the lack of a national policy and a

national organization that could integrate policy, structures and activities. It proposed

integration and consolidation of all institutions and legislation regulating the prevention of

occupational disease and injury, and compensation under the direction of the Minister of

Labour, thereby creating an integrated national OHSS. It emphasized that the location of

OHSS components in public sector government departments was severely restrictive. It

recognized the international norm of independent state agencies tasked with coordinating

and leading the OHSS. It concurred with an excerpt from the 1997 National White Paper to

transform the health system (DOH 1997) as follows :

30

It saw key functions of a national OHS agency as policy making and dealing with cross-

cutting issues in ways that prevent duplication and facilitate the efficient application of

available expertise. The model proposed was rather cumbersome in its excessive tripartism,

and veered closer to the UK HSE model than to the Australian Work Safe model. This draft

policy never came to fruition and by 2015 there is still no national OHS policy in place.

Furthermore, the Green Paper (DOH 2011b) on National Health Insurance in 2011 contained

no role at all for OH Services. Despite submissions made by occupational health

professionals including those at the UCT School of Public Health (London 2011) motivating

for inclusion of OHS services in the NHI, no response had been received or noted by the

time of writing this review.

On the compensation end of the OHSS there have been literally no developments of note

since the Nieuwenhuisen Commission in the 1970s. The report of the Commission of Inquiry

into a National Health and Safety Council by Benjamin and Greef in 1997(P Benjamin and

Greef 1997) to the then Minister of Labour made similar recommendations for integrating

compensation as well as the OHSS as a whole and presumably led to the Draft National

Policy in 2003. Much has been written on the compensation system and its seeming lack of

constitutionality whereby mineworkers have been systematically disadvantaged over many

decades. An important constitutional court judgment resulted in overturning the bar for

mineworkers suing their direct employers. Various authors (Paul Benjamin 2009; Ehrlich

and Rees 2015; Ehrlich 2012a, 2012b; Maiphetlho and Ehrlich 2010); (Maiphetlho and

Ehrlich 2010); Ehrlich 2012b) have published extensively on the two disjointed and

dysfunctional components of the workers’ compensation systems in South Africa. At the

31

time of writing there is a crisis at the Compensation for Occupational Injuries and Diseases

Act Commissioner in the Department of Labour whereby medical bills are not being paid and

services have been stopped pending a resolution. This has led to a shake up in the

management with likely corruption charges pending. The Compensation Commissioner for

Occupational Diseases under the Occupational Diseases in Mines and Works Act, which

falls under the National Department of Health, has a huge backlog and operates under the

cloud of unfunded liability. It has not reported for many years as statutorily required, and

compensation services especially for black mineworkers have effectively ceased operating

despite the large burden of silica-related lung disease including tuberculosis as a result of

continued unacceptable silica exposures in the gold mines of South Africa. Affected workers

are to be found in labour sending communities in parts of South Africa and other nearby

Southern African states.

32

4. Make an assessment of current OHS practice in South Africa

The specific details have been best described by Adams and Ehrlich (Adams and Ehrlich

2010), where they fairly assess the state of OHS practice which has remained more or less

unchanged over the past 5 years. This is reproduced as Appendix A.

More general observations about the OHSS:

It may be said without fear of exaggeration that South Africa has in many respects a

dysfunctional OHSS. There is some uneven development within the system, but overall the

picture is one of significant dysfunction.

For a country with a relatively high level of industrialization and development there is little

safety engineering capacity. Occupational hygiene is underdeveloped as a discipline

judging by the level of qualification of the overwhelming majority of its practitioners with very

few doctoral graduates being produced. Occupational medicine and nursing are similarly

underdeveloped at both generalist and specialist levels as judged by the levels of training

and expertise. There are few specialist physicians either in practice or in the pipeline. There

appear to be disincentives to occupational nurse practitioners related to certification and

registration difficulties. The social security system does not cater for workers from either the

formal or informal sectors in respect of social insurance and health and welfare support. The

compensation system, whether for the mineworkers or all other workers, is in serious

disarray. There are large backlogs in claims processing and compensation payouts

generally and issues of unfunded liability in respect of mineworker compensation under

ODMWA. These problems with compensation may exert a distorting effect on the resources

available for the OHSS as a whole and ultimately result in fewer effective resources for

prevention at the more important primary and secondary levels.

Following the framework used by Elgstrand (2010), the nature of the deficiencies are clear.

There is no cross-sectoral coordination in the OHSS overall. Due to sectorally based silo

thinking and practice there is no unified oversight of any of the policy and practice issues

and problems. Initiatives emerge from time to time, seemingly in response to problems that

become impossible to ignore politically due to the supervention of a crisis in one sector or

another. Initiatives are half baked, insufficiently consultative, too narrowly sectoral, and they

tend to wither on the vine, making no perceptible impact. South Africa’s political transition

has unfortunately not managed to strengthen and sustainably improve components of the

OHSS like the inspectorates. As in the education sector there has been a massive

haemorrhage of professional and technical skills to the private sector, or simply to waste,

with nothing put in place to build replacement skills compatible with employment equity. This

33

applies to both the preventive end (the inspectorates) and the compensation end where

similar transitional problems have affected the administrative and financial basis of the

compensation authorities within different government departments. The transfer of

professional occupational hygiene skills to the private sector has further undermined

potentially preventive goals of the regulatory authorities. Despite some progress with

master’s level university training in occupational hygiene and occupational medicine at

selected universities there is still no doctoral programme inserted in an engineering

environment that is able to produce high level hygienists, and there is a limited output of

occupational physician specialists. Occupational nurse training and certification is in

disarray. Insufficient health sector specialist training posts are provided by the Provincial

governments who are legally tasked with the provision of occupational health services, and

the Occupational Medicine Clinical Service, Teaching and Training and Research Units

which exist at a few universities lead a tenuous existence.

There is at the current time no integrated OHS policy. Laws (and regulations) are by now

quite outdated in respect of both the prevention and compensation components of the

OHSS. There is considerable fragmentation and duplication at both ends of the preventive

spectrum. There are no integrated strategic or operational plans for OHS in Government at

any level. It is little wonder that management in certain sectors have been able to get away

with ignoring occupational health and safety requirements for many decades continuing up

to the present time. They have been able to avoid instituting sound primary preventive

practice; provide poor secondary prevention through inadequate specifically occupational

medical services provision either in or after service; and be able to deflect the tertiary

preventive burden of compensation for silica-related disease onto the state and public

sector, and the pockets of injured and diseased workers and their families. This has taken

place at the opportunity cost for the remainder of industry in the country.

The gold mining industry is an illustrative example with regard to hazardous silica exposures

and the epidemic of silica-related diseases notably silicosis and tuberculosis that has been

raging unabated for many years. This industry has been able to get away literally with

murder (many fatalities and the creation of a heavy burden of respiratory disease) over many

decades from the end of the 19th century up to the present moment. The most worrying

aspect is that exposure conditions in this industry have been more or less unchanged over

the past century and these conditions are responsible for an uninterrupted high annual

incidence of silica-related diseases. Gold mining companies are consequently currently

facing litigation seeking fair recompense for decades of abuse. While there have been

claims by the industry that exposures to respirable free silica dust in the gold mines has

34

been substantially reduced over the past decade these has not been independently verified

or validated, and are unlikely to be the case. This situation is very likely to continue

unabated into the future. The silica-related burden of disease unfortunately has been wholly

unaffected by the political transition in SA. This can be attributed in large part to the lack of

central, integrated, coordinated thinking, policy-making and preventive action within a

fragmented impotent OHSS. Without leadership from the national level and a cross-sectoral

independent national authority capable of exercising oversight, directing enforcement and

compensation authorities, rationally planning evidence based preventive interventions

indicated by a relevant surveillance system generating independently validated data on both

silica dust exposures and silica-related diseases, the silica-related disease epidemic is

doomed to continue.

This situation has been little impacted by the advent of new post-apartheid legislation

governing health and safety in the mines and the tripartite structures that this legislation has

created. The industry has proved able to dominate these structures and activities to the

detriment of mineworkers’ health and safety. Another key finding of Elgstrand et al. in the

survey of OHSS in 21 countries is insufficient support for OHS by trade unions. The South

African mining sector is no exception to this. Elsewhere in global gold mining jurisdictions

like Canada, the US and Australia there has been a near total disappearance of silicosis in

recent decades due to dust control that is truly effective in bringing exposures below the

internationally accepted occupational exposure limits, incentives for previously exposed

miners to apply for compensation which is delivered through no-fault systems which are a

component part of adequate overall social insurance. In these countries the advent of

disability from silica-related diseases only affects ex-miners in their 70s or 80s, if at all.

South (and Southern) Africa’s ex-gold miners continue to suffer exceptionally high silica-

related disease incidence rates, high morbidity, disability and mortality from these diseases,

and in the context of a high tuberculosis incidence environment aggravated by the HIV

epidemic.

The structure of the OHSS is fragmented in many respects. The range of departments

and departmental subunits involved is considerable. There are problems with integration

across government sectors (e.g. Labour, Health and Mineral Resources) with duplicate

initiatives; across economic sectors like mining and industry; and across levels of

government (national and provincial). In this context of discoordination there are no unified

structures or organisations that could bring everything together under one purview, despite

the stated need for such structures as determined by various government committees and

commissions and in published articles by OHS specialists.

35

This is not to suggest that all functions need to necessarily be integrated into one single

body, but there should be a unified direction insofar as supporting and informing policy-

making and oversight of implementation of policy is concerned. This is very unlikely to be

possible within one government department given the profusion of institutions and interested

parties listed above. A National OHS agency or body, most likely situated in a National

Public Institute would be best placed structurally in order to effectively undertake these

functions.

Unity in the following three dimensions is critical to the attainment of the twin goals of

improving worker health and safety and worker’s compensation:

Unity of direction and leadership in informing and supporting OHS policy including guidance

for OHS services provision, teaching and training, and research prioritization.

Unity of law enforcement and inspection

Unity of the compensation system

36

5. Recommend the potential role of an NIOH in South Africa

It is the opinion of this author that the first of the three dimensions of unity listed above

should be the remit of the NIOH. It must be emphasized that the NIOH is one of the very

few components of the South African national OHSS that is functional. It may be fairly

characterized as the jewel in the crown of an embryonic OHSS since the directorship of

Professor JCA Davies. Apart from its considerable current value, it is even more valuable as

a foundation for further positive developments in the OHSS going forward if the correct

policy direction is taken. Consequently it is critically important to take the utmost care to

conserve what is of core value for a desirable national OHSS reconfiguration. It is also

important to note that current institutional capacity which always takes decades to build

might be rapidly destroyed should an incorrect policy direction be taken with little possibility

of reversal should that policy direction be abandoned.

While the ideal structure and functions of a national OHS agency taken from Table 1 above

are not realizable in the near to mid-term future, it may be useful as a framework for

reflecting upon the current structure (Figure 1) of the NIOH.

37

Figure 1: NIOH Organogram

The NIOH would be well placed for future reconfiguration and development within the

context of a National Public Health Institute, where it could more easily cross departmental

boundaries, levels of government, and move between different social sectors. There could

be significant synergies in being placed within the same institutional structures are Infectious

Disease and Non-communicable disease institutes and the National Cancer Register.

The NIOH could inform and support oversight of the OHSS as a whole by playing a key role

in marshaling the evidentiary basis for OHS policy development and in monitoring policy

implementation at various levels in the panoply of public and private institutions tasked with

38

prevention at all levels. The role of the NIOH will be to facilitate a holistic and

comprehensive view of the entire OHSS including all its component parts.

The NIOH could support and inform the drafting of

o national policy

o model legislation

o strategic and operational OHS plans

In a context where basic occupational hygiene, occupational medicine, occupational

pathology and laboratory-based services are sorely deficient, the NIOH could continue

providing these and support for the development of such services at more extensive levels

with the public and the private sectors.

Similarly, while basic teaching and training in OHS components are lacking (e.g.

undergraduate training in OHS by way of a BSc, BA or by inclusion in other undergraduate

programmes like medicine or nursing), the NIOH can play an important support role for the

development and strengthening of these programmes and courses at academic institutions

by collaborating with staff there.

The NIOH should play a strong role in the national endeavor to produce specialists in all

OHS disciplines, and to diffuse scarce skills, build expertise at high level, and deploy

specialized equipment which is typically lacking at educational institutions. Where desirable

they should hold joint appointments with tertiary academic institutions including university

departments and referral hospitals to the extent possible. They could support and capacitate

occupational health system disciplines at these institutions and at the level of the Provinces.

Expert and specialized OH staff at the NIOH should play important leading and collaborating

roles in determining OH research priorities in OHS, and in undertaking priority research

activities.

Specialist technical and professional expertise should be available for consultation and

referral of clinical and workplace service problems and issues of national significance and

those arising from the provincial level.

OHS communication including:

o guidelines

o norms and standards

o information dissemination

39

The NIOH should lead the design and development of an OHS surveillance system per se,

and as a component of a general health surveillance system operating at national and

provincial levels. There should be OH surveillance in both private and public sectors and

inclusive of primary preventive, secondary clinical prevention and tertiary compensation

prevention aspects, including:

o routine and custom/research data collection

o data analysis

o reporting of findings

o using findings for evaluation and refinement of policy, legislation and planning

The most important outcome of this review is identify ways in which NIOH can promote the

notion of integrating the OHSS and provide support and inform policy makers at national

level for coherent leadership and action in pursuit of the twin goals of improving worker

health and safety, and compensation.

For these to be achieved there must be clear policy development and a clear unified

understanding of the OHS system as a whole, including its requirements and gaps for the

country. It should then be possible to craft appropriate policy, implement this in law and

regulations, as well as in priority programmes and projects in collaboration with other key

players in the OHSS. Setting up a centralized monitoring and evaluation/surveillance

system would lead to continuous refinement of policy and its implementation into the future

on an ongoing basis. More specifically all activity, financial allocations and expenditures

should be evidence-based, and in line with evolving best practice policy globally and in

South Africa.

Are there potentially additional model components for an appropriate OHSS for South

Africa drawn from the operation of other paradigms e.g. South Korea or Brazil?

The Brazilian model appears at first sight attractive as it is based on a comprehensive social

security system combined with a primary health care approach to OH services provision to

individual workers and unserved sectors within the general public health system ranging

from the primary care level to the tertiary specialized level including a fair and efficient

compensation within the public health sector. National aspects such as developing a culture

of prevention, advisory services and training are provided by the national institute. This

system could deal with a large informal sector, but importantly would lack the primary

preventive components of occupational hygiene and safety services. However, there is as

yet no comparable comprehensive social security system in South Africa, nor is this likely to

40

materialize in the near to midterm future. Importantly, the Brazilian system has not been

adequately described or characterized, nor formally evaluated or assessed in the scientific

literature to date. The South African experience with integrating OH healthcare into the

general health services at provincial level over the past two decades has been a

disappointing failure. With respect to the performance management paradigm proposed by

South Korea, the South African health system has additionally been struggling with a very

heavy burden of disease inclusive of the challenges of the HIV and AIDS epidemic.

It is argued that getting the central organization right to set policy and to drive and monitor

its implementation is the key priority in the current situation where there are many demands

in the context of scarce resources.

This also helps to avoid system overload resulting from inappropriate assignment of OHSS

functions to a national entity to the detriment of its essential functions to coordinate the

different parts of the OHSS for maximal efficiency.

41

6. Recommendations for possible ways forward for OHS in SA

The way forward for OHS in SA begins and continues with a reconstituted NIOH along the

lines proposed above as a national institute providing support and evidence based

information to policy makers and housed within a National Institute. The reconstituted NIOH

should be responsive to the OHSS as a whole, rather than to the interests of a single

government department.

Should this come about it will facilitate the necessary oversight of the OHSS system and all

of its many components, and the production of the first fully comprehensive picture of what

exists. This includes establishing the burden of occupational disease (BoD) (Fingerhut and

Driscoll 2005; Leigh et al. 1999) and injury as a contribution to the overall South African

Burden of Disease, the latter being exceptionally well characterized at the present time. It is

an important and urgent need given the parlous state of the OHSS in South Africa that as

well as understanding the magnitude of the OHS BoD, it is also possible to examine the

impact of work as a comparative risk factor for the major contributors to the general South

African BoD. This will provide an evidentiary base for priority setting and for the

implementation and evaluation of preventive interventions for their effectiveness and cost-

effectiveness. Ongoing analysis of the OHS BoD will constitute a key part of the

surveillance system required for evaluating policy and planning going forward. Building an

accurate picture of the OHS BoD will allow timely fine tuning to take place.

With this information in hand, an integrated, cross-sectoral and inter-governmental policy

needs to be put in place in consultation with all interested parties - not just the usual high

level tripartite mechanisms which do not go broadly or deeply enough to fully grasp the

problems and potential solutions. Noting the current OHS struggles of trade unions and their

federations and their apparent lack of meaningful engagement when it comes to OHS, it is

particularly important to have mechanisms that take the temperature of those directly

affected at the level of the enterprise and on the shop floor and to support trade unions in

their OHS challenges. The information will also be key to guiding and building the

enforcement and compensation authorities to play a more effective role in achieving OHSS

goals by smart means such as, for example, random inspections directed at priority risks for

priority occupational diseases and injuries.

Monitoring and evaluating the implementation of a truly integrated policy into legislation and

regulation, strategic and operational plans, and priority programmes will then constitute an

important part of the work of the NIOH in close collaboration with the enforcement and

compensation authorities. Integrated oversight has the best chance of improving worker

42

safety and health along with fair and adequate compensation. These two broad goals

(together with other more specific priority goals that emerge) will be constantly kept in

foreground by measuring progress towards their attainment. The focus here has been mainly

on the NIOH’s role in building the national OHSS from the top down using resources that are

currently in place.

Using Elgstrand’s (Dwyer, Elgstrand, and Petersson 2010) terminology viz. the traditional

industrial paradigm for OHSS, the approach proposed here is compatible with optimizing

system function in the context of a partially industrialised and developed South African

economy and society with a large proportion of the working population still in rural

agriculture, and a large informal sector, with considerable disparities with regard to gender

and disability. The proposals are also compatible with the first alternative model for OHSS

proposed by South Korea viz. tighter performance management. The evidence based

approach outlined above allows for performance management at all levels. The second

alternative model proposed by Brazil may in the future eventually be brought into alignment

with the approach adopted in this review. This will require the provincial governments to

carry out their obligations for OH service provision on the one hand, and a considerable

expansion of the social security system on the other. Sorting out the compensation

challenges remains an urgent and compelling priority. Adequate compensation is one

measure of social justice that workers in South Africa, sick from work, continue to struggle

and endlessly wait for. It is incumbent on us to seek inclusive, practical, transparent,

implementable and sustainable ways forward as a matter of great urgency. We have the

ability, capacity and skills set to do so in our country if we work together for the common

good. If not, history will not absolve us!

43

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46

APPENDIX A: Chapter on South Africa by Shahieda Adams and Rodney Ehrlich in OSH &

Development ed K. Elgstrand, 2010

OSH panorama

The economically active population numbers approximately 13 million. Unemployment is

high at 24%, with 4 million unemployed. There is also a large informal sector accounting for

30% of the economically active population. The past decade has witnessed a contraction of

mining and agriculture, historically major employment sectors, whilst non-manufacturing

sectors have grown. Within the formal sector, the non-industrial sectors of trade, community

and social services and finance now account for 69% of employment. Only 32% of workers

were unionised in 2006, with the highest rate (76%) being in mining and the lowest among

domestic workers (2%) and agricultural and forestry workers (8%). Currently, the largest

three trade union federations in South Africa have a combined membership of just under 3

million. South Africa has separate occupational health and safety (OHS) systems for mining

and non-mining sectors. OHS surveillance relies on statutory reporting of compensation

claims, although it is likely that there is a high degree of underreporting of occupational

disease and injuries. This is less of a problem in the mining sector owing to greater

regulation and the mandatory provision of occupational health services. In the mining sector

an injury rate of 4.1 per million hours worked was reported in 2006 (gold mining accounted

for 56% of all such reported injuries). During the same year a fatality rate of 0.20 per million

hours worked was reported for the mining sector, 202 deaths.

In recognition that safety standards in South African mines are still not in line with

international standards, the Mine Health and Safety Council has set the goal of achieving

international safety benchmarks by 2013 in all underground metalliferous mines. In the non-

mining sector a total of 219,399 occupational injuries were reported in 2006. This represents

a reported injury rate of 42 per 1,000 workers registered with the compensation fund. In the

non-mining sector, occupational diseases account for only one percent of all claims certified.

On average three to five thousand occupational disease claims were reported annually to

the compensation fund between 2001 and 2006. The most common were noise induced

hearing loss, post-traumatic stress disorder, tuberculosis in health care workers,

occupational skin disease and pneumoconiosis. Occupational lung disease and noise-

induced hearing loss account for most occupational diseases reported in the mining sector.

Legislation, policy and organisation

Multiple statutes provide for OHS in the different sectors. Tripartite advisory boards involving

state officials and representatives of business and labour operate under these statutes.

Enforcement is currently the responsibility of two different inspectorates. The Department of

Labour is responsible for OHS enforcement outside the mining sector and the Department of

Minerals and Energy within the mining industry. Resources for enforcement of occupational

47

health legislation are limited and unevenly distributed. As a result little capacity exists for

effective accident investigation, workplace risk assessments and oversight over occupational

health services. This is compounded by the lack of a national consistent reporting system for

accidents and occupational disease. OHS research is concentrated in the parastatal

National Institute for Occupational Health and a number of university departments of public

health. The only sustained source of major research funding is derived from a levy on the

mining industry. This underwrites the tripartite Mine Health and Safety Council which solicits

research into mining safety and health. Information on employer provided workplace based

health services outside the mines is scarce. Previous studies have found such services in

11-18% of workplaces. Employees in sectors such as agriculture and government have little

or no access to occupational health services. The National Health Act refers to the delivery

of occupational health services as a function of the provincial departments of health.

However, this is ill defined. Outside of specialised occupational medicine referral clinics in a

few of the provinces, occupational health is not part of the services provided to users of the

public sector health system, although 80 percent of the population is dependent on this

system for health care. Integration of occupational health and primary care for clients of

public sector health services has been tried in some places, but without success. In the

professional OHS workforce, there are approximately 1,000 occupational health nurses, 470

occupational medicine practitioners and 130 occupational hygienists, almost all in the private

sector. Most occupational medicine services are provided by general practitioners with a

postgraduate diploma. A recent advance has been the establishment of occupational

medicine as a medical specialty in its own right, requiring four years of postgraduate study.

Current and future needs

Overcoming fragmentation in occupational health and safety OHS legislation

A national strategy focusing on strategic targets for prevention of occupational injury and

disease is desperately needed. A National Occupational Health and Safety Bill was

promulgated in 2005 to provide for the establishment of a single National Health and Safety

Authority, with the aim of achieving integration in prevention and compensation activities. If

promulgated, this legislation could have a positive impact via improved enforcement

capacity, uniform standard setting, improved information systems and research capacity,

and an enhanced unified compensation system. However, there has been very little progress

towards promulgation. The South African trade union movement is strong but has not been

effective in these national health and safety endeavours. This is paradoxical as the

Congress of South African Trade Unions, the largest federation, is part of the governing

alliance.

Surveillance and research

South Africa currently does not have a nationally coordinated surveillance system for

48

occupational injuries or diseases. It is therefore impossible to assess the full extent and

impact of occupational injury and disease and the impact of any policy intervention. The

development of a national reporting system that builds on existing databases is therefore a

priority. Further, the lack of a national OHS research strategy and of significant funding for

research outside of the mining industry remains a deficiency.

Achieving equity in workers’ compensation

The government sponsored Commission into a Comprehensive System of Social Security

identified the problem of exclusion of workers in large labour sectors such as domestic

workers, informal sector employees and self-employed persons from the compensation

system. Any new compensation system would need to broaden coverage to include such

workers. Another source of historical inequity is the specialised legislation covering mining

related lung diseases which offers fewer benefits than those given for the same diseases

acquired in non-mining industries.

Rehabilitation of injured and disabled workers

The lack of compulsory rehabilitation or vocational training programmes to assist injured or

disabled workers to return to work results in a huge loss to the economy; there is also a high

probability of unemployment following significant injuries or occupational disease. The

burden of occupational disability is shifted from employers to workers and their families and

onto social security. The no-fault principle on which the compensation system is based

shields employers from the full cost of occupational injuries and diseases and also

proscribes workers’ recourse to civil litigation. An actuarial assessment of the entire

compensation system is required to assess the feasibility of increasing employer premiums,

both to improve employee disability benefits and to allow for the funding of compulsory

occupational rehabilitation programmes.

HIV/AIDS and tuberculosis

The scale of the HIV/AIDS epidemic has led to the development of workplace-based HIV

education and prevention programmes such as voluntary counselling and testing, mainly in

larger companies. Some of these companies finance anti-retroviral treatment or even

provide treatment through their own medical services. However, the stigma attached to

being identified as HIV positive and the fear for job security are likely to remain barriers to

workers’ use of workplace-based health services for HIV/AIDS treatment. The HIV/AIDS

epidemic has also fuelled a secondary tuberculosis (TB) epidemic. One of the consequences

has been a rising risk of tuberculosis among health care workers, including drug resistant

tuberculosis. This had led to renewed interest in screening of health workers for tuberculosis

disease through novel methods and in improving access for TB and HIV care in this high-risk

group. The impact of the dual epidemic has been particularly severe on the gold mining

industry since silica dust, silicosis and migrant labour patterns had already resulted in very

49

high rates of TB. This epidemic has occurred despite the intensive tuberculosis screening

and treatment services provided by mining companies. Improved TB control in the mining

sector thus need stricter dust control in mining operations and extension of TB programmes

to include rural areas where labour is recruited.

Informal and casual labour

Little is known about the OHS needs of the shifting population in the informal sector. A

striking example is informal gold mining where mercury is used for small scale extraction or

where dormant underground shafts are worked. A White Paper on the Transformation of the

Health System proposed that the Department of Health provide occupational health services

to the neglected and/or marginal sectors such as small and medium enterprises, the public

sector, workers in the informal sector and the recently unemployed. However, this has not

happened. The provision of labour to the formal sector through labour brokers has grown

very rapidly, fuelled by efforts by business to achieve labour flexibility and reduce labour

costs. Although covered by OHS legislation, such workers are likely to fall outside the safety

net of such legislation. Currently there are moves to restrict and even ban labour brokerage;

however, pressure to weaken labour regulations is likely to remain. There is a concurrent

initiative to extend medical care access to the whole population via mandatory national

health insurance payments. Paradoxically this may weaken occupational health services as

companies perceive such payments as a way to discharge their responsibility for health

services to their employees, including preventive services.

Basic facts on South Africa

Size of area 1,219,000 sq km

Population 49 million

Main religions Christian: (47%), Pentecostal/Charismatic (8%), Catholic

(7%), Methodist (7%), Dutch Reformed (7%), none (15%)

Literacy 86% of the population age 15 and over can read and write

GDP per capita (PPP) US$ 10,100

Gini index 65

Life expectancy at birth male 52 years, female 55 years

Infant mortality rate 46 deaths before age 1 year/1,000 live births

Malaria, mortality rate less than 1 per 100,000 populations

HIV, prevalence rate 16,293 per 100,000 adult populations

50

APPENDIX B: Comments on the Concept Document by occupational medicine

specialists

A number of important comments were made about the Concept Paper which has not been

incorporated into the document pending discussion. They are:

There are statutory structures which advise government departments and Ministers on OHS.

The role of a national institute with expanded policy functions needs to be clarified in relation

to these structures. (The two most important ones are the Mine Health and Safety Council

and the Advisory Council for Occupational Health and Safety.)

The support that a national institute would provide to government departments other than

those primarily responsible for OHS needs clarification. (These departments might include

Agriculture, Transport, education e.g. a preventive occupational health and safety culture

includes teaching of preventive practice in schools)

The support that a national institute could provide to provincial OHS structures is not clearly

presented in the Concept Document.

More thought is needed about the role of a national institute in supporting underserved

economic sectors e.g. agriculture and the informal economy.

Is the NIOH able to play a greater role in policy development given the nature, qualifications

and experience of its current staff? What additional human resources would the NIOH

require to be able to effectively contribute to policy development?

The roles of academic occupational health and safety entities and a national institute require

clarification.

Should the national institute be involved with cluster investigations and health hazard

evaluations (as NIOSH in the USA is)? If so, should these investigations and evaluations be

done in conjunction with provinces?

The role of a national institute in working with key stakeholders to influence a national OHS

research agenda should be considered.

51

Part 4: Discussion paper on aspects of occupational health and the Department of

Health

Background

The Department of Health’s (DoH) occupational health responsibilities include formulating

policy for the delivery of occupational health services from public sector clinics and hospitals

and other facilities; supporting the development of occupational health services; and the

obligations relating to the Occupational Diseases in Mines and Works Act (ODMWA) with its

systems and the MBOD and the CCOD.

The need for reform of the ODMWA and systems, the changed arrangements for the

financing of the National Institute for Occupational Health (NIOH) and the need for the DoH

to strengthen its occupational health and safety capacity create opportunities to have a fresh

look at the enabling possibilities that OHS provide in support of a realisable focus on greater

prevention through workplaces. Occupational and environmental health and safety is an

integral and important part of Public Health and if optimally utilized can make an immense

contribution to reducing the enormous burden of disease our Department of Health is

currently addressing. The WHO Global Plan of Action on Workers Health (2008-2017) was

deeply influenced by the ILO Convention No.187, the Promotional Framework for

Occupational Safety and Health of 2006. The WHO did a baseline survey in 2008 to 2009 of

OHS at country level and will repeat the survey in 2017. The baseline survey has very

important information which can assist countries to improve their OHS policies and practice.

There is still a year for South Africa to address some of the important questions the baseline

survey looked into and to see how best we can respond in the 2017 follow-up survey.

ODMWA, CCOD and MBOD

ODMWA

The ODMWA is outdated and provides inferior benefits compared to the Department of

Labour’s (DoL) Compensation for Occupational Injuries and Diseases Act (COIDAct).

ODMWA does, however, provide for biennial benefit medical examinations (BMEs) and

autopsy examinations, which COIDact does not. It is government policy to have a single

compensation system. This could be achieved by repealing ODMWA and either amending

the COIDAct or including ODMWA provisions as a regulation of COIDAct. The BMEs and

autopsy benefits for miners should be retained for a prolonged “sunset” period to avoid loss

of long-standing entitlements.

52

CCOD

There appears to be growing consensus that the CCOD, a structure for the payment of

compensation benefits, is inappropriately placed within a national DoH. A recent but undated

paper entitled “National Department of Health and National Treasury Discussion Paper and

Resource Requirements towards a Reform of Mining Compensation Schemes” concluded

that “Running a compensation fund should not be a Health Department function as it

impedes focus on its core functions.” The CCOD would be better placed in entities that

routinely manage compensation payments such as the Department of Labour or one of the

mutual assurance companies operating in terms of the COIDAct. The legislative changes will

take time so an interim arrangement is required for the CCOD.

MBOD

Pending legislative reform, the backlog in certification of cases by the MBOD needs to be

addressed. This could be achieved by ensuring that MBOD posts are filled and that there is

a Director: MBOD, two Deputy Directors and sufficient Certification Committee members to

run two Certification Committees per day. A public private partnership is a mechanism to

obtain resources – money and people - for filling these posts and dealing with the backlog.

There are barriers to the effective functioning of the MBOD and CCOD. These have been

described in a 2015 publication “A rapid process evaluation of the Medical Bureau for

Occupational Diseases and the Compensations Commissioner for Occupational Diseases”

available from the NIOH. The publication has recommendations, many of which are short-

term solutions. Awareness of their entitlements by mine workers and access to ODMWA

system are also important aspects. For the system to improve, active support by the DoH

and the Minister is essential. For example, appointment of Certification Committee members

is a rate limiting step and has to be supported by the Department and Ministry. [It should be

noted that a number of steps have been planned to implement the interventions described

above.]

An active role by the NIOH in the management of the MBOD is unlikely to achieve much.

The problems are structural and systemic and need to be dealt with by having an active

Director and deputy directors supported by the Department. The NIOH would, however, be a

willing partner in establishing the public private partnership, implementing it and in

supporting the new incumbents, for example by clinical training and consultations. The NIOH

already supports the MBOD lung function laboratory and chairs and staffs the Medical

Reviewing Authority, a statutory body in terms of ODMWA to consider objections to the

decisions of the Certification Committee.

53

NIOH

The 2015 paper “A concept paper on occupational health and safety (OHS) for South Africa”

makes a strong case for a multi-disciplinary occupational health institute to support

occupational health and safety in South Africa. The paper - available from the NIOH –

outlines the roles and functions of a modern occupational health institute.

An effective and sustainable NIOH has to have all the major occupational health disciplines

and it requires an appropriate management arrangement that provides support services (IT,

laboratory specimen receiving, provisioning, human resources, financial management, billing

and debtors management, cleaning etc) and which enables service delivery of both

laboratory and non-laboratory services. A viable and long-term solution is NAPHISA. A

government component would be problematic because, as currently constituted, it precludes

service delivery (the core of a national institute); and it would not solve the support services

issue.

Occupational Health Cluster

The MBOD and the NIOH have very different mandates and functions. From afar it would

seem that some sections have many overlapping functions but this is not so. Occupational

medicine makes the point. NIOH Occupational Medicine’s clinical services are only one

aspect of the section’s work which includes multidisciplinary research, advisory services on a

wide range of occupational health matters, teaching and training and clinical services. The

clinical services cover all industrial sectors and all body systems (not just the lungs) and are

provided at a tertiary referral level to deal with complex cases. Investigations of patients and

multiple consultations with them are common. The MBOD covers only mining, only the lungs

and only collects medical information for certification in a rigid format i.e. it is not a referral

level service and does not do special investigations of cases. It does not provide the range

of services either.

It should also be appreciated that the NIOH provides services and support to a number of

government departments including DMR and DoL, but many others besides.

A closely constituted cluster of officials in the DoH, MBOD and the NIOH will not enhance

the management of the entities or service delivery.

Nevertheless over many decades the DoH, NIOH and MBOD have had a close relationship

which continues today. The best option for an Occupational Health Cluster is to constitute a

virtual cluster which would develop annual workplans together and which would meet

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periodically through the year to revise workplans and consult on issues of mutual

importance.

Policy Unit in the Department of Health

The DoH needs a small team to develop occupational health services policy and to support

the development of occupational health services at other levels of government. Since a

number of other government departments are active in occupational health and safety

(OH&S), and are mandated by Cabinet to promulgate occupational health legislation and

enforce it, the team would also be able to work with these government departments to

ensure that there is role clarity and to avoid duplication and conflicting policies among the

departments.

National Institutes for Occupational Health typically do not formulate policy, but they do

provide technical and professional support for policy formulation and the evidentiary basis for

it. (There are exceptions and some institutes in advanced systems do formulate policy.)

For many reasons occupational health policy formulation is done more effectively by officials

within a government department who have insight into general departmental goals and

policies, and policies across a range of other disciplines which impact occupational health,

primary care would be an example. The role of the NIOH should be to provide professional

and technical support for policy formulation and the evidentiary basis for it.