Diagnostic Challenges – a perspective from South Africa

1. Diagnostic Challenges – a perspective from South Africa

2. Overview • Context • Policy, legislation & services • A systems approach • Prevention to compensation • Some lessons • Conclusion

3. The World…Village (n=100) • 57 Asians • 21 Europeans • 14 Americans • 8 Africans • 52 women & 48 men • 80 persons living in poverty • 70 illiterate • 50 suffering from hunger & malnutrition • 1 person with a university degree • 1 person with a computer Lueddeke GR. 2012

4. Resized World Maps (Lancet. 2011)

5. More Illness and Fewer Health Workers in Africa WHO: Human Resources for Health, 2006

6. Worker Health in South Africa / Sub-Saharan Africa • 53m South Africans (STATSSA 2013) • 17m work (13m formal & 4m informal) • 3 workers die every day from accidents • 875m in Sub-Saharan Africa • 258 000 die from work accidents • 98.9/100 000 (73.3 – world) – Fatal Injuries STATSSA; ILO; WHO

7. Occupational Health in Africa fragmentation of policy and legislative framework (Health, Labour, Mining) inadequate occupational health system deficient occupational health services lack of human resources for occupational health little access, coverage & equity in compensation systems vulnerable workers (migrant, mobile, youth, informal (60% – 78%) no surveillance system for injuries and diseases

8. The Labour Market in Africa • Dualistic • Formal / Informal • Urban / Rural • Modern / Traditional • Organised / Unorganised • Gender differentiation ILO, 2011

9. Africa’s Growth

10. A=Fuelling Africa’s Growth

11. The Mining Economy • 1.8 Trillion USD sector (net asset value) • 7.7% of annual GDP DMR 2010

12. The Informal Sector

13. Workers per Employment Sector (‘000) Labour Force Survey. Statistics South Africa, 2008

14. Gender Distribution of Workers (2007) Labour Force Survey. Statistics South Africa, 2008

15. Migrant Mine Workers in South Africa * Data from TEBA

16. Surveillance “data for action” (Giesecke, 1999) “ongoing, systematic collection, analysis & interpretation of data for planning, implementation & evaluation” (CDC, 1988)

17. Occupational Ill-health hard to find data; if found, difficult to interpret

18. Occupational Injuries • Abrupt break in … AGENT – HOST – ENVIRONMENT balance • Cause established

19. Occupational Diseases • Not diagnosed / mis-diagnosed • Lack of knowledge • Masked by other diseases • Long lag time • Need special investigations • Difficult to find cause

21. NIOH: Pathaut, 2010

22. Nelson et al. Three decades of silicosis: disease trends at autopsy in South African gold miners. Environ Health Perspect. 2010

23. Gold Price (2000 – current)

24. Occupational Exposure Limits for Silica (2008) *Advisory organisation Source: Maciejeska A. 2008. Int J of Occ Med & Env Health 21 (1): 1-23

25. Wilson K. NIOH. 2011

26. Safe Work, Australia. 2010

28. ILO / WHO / UNEP A seat at the table… • Policy deliberations • ILO Decent Work, Safe Work • Seoul Declaration • ILO Plan of Action (2010 – 2016) • WHO Global Plan of Action (2012 – 2017) • Occupational Exposure Levels • HIV / AIDS • Gender • Environment

29. Policy & Legislation • Policy • Safety, Health & Environment / Occupational Health • HIV/TB • MDGs, African Union • Legislation • Conventions, codes, guidelines (ILO & WHO) • Legislation – Departments of Labour, Mineral Resources, Health, others

30. Governance & Management • Governance • Government, Trade Unions, Employers, NGOs, Professional bodies • Management • Development & maintenance of the system • Delivery of services

31. Occupational Health Services: Core Functions • Preventive • Risk identification, assessment & management • Recognise high risk groups & priorities • Health Promotion • Optimal physical & mental health • Healthy lifestyles • Curative services • General practice level • Referral to specialists • First aid • Rehabilitation & Compensation

32. Conceptual Model – Delivery of Services

33. OH Service Model PHC Nurse / CHW SUPPORT REFERRAL Family Medicine / OHN / OccHyg Occ Med Spec + Academic / Reference Units

35. One – Stop Service Framework • Health Services • Benefit medical examinations • Rehabilitation assessment & services • Health Promotion • Primary Health Care support • Social Services • Social Development • Counselling • Financial Services • Compensation • UIF, pension & provident funds

36. Service Delivery Challenges • Human resources (occ. health practitioners; nurses; occ hygiene, etc) • Curative focus (non-renewable human capital) • Fragmented service delivery • Little or no quality assurance (radiology, audiology, spirometry, occ hygiene, laboratory) • Dumping syndrome / Referral system

37. Occupational Health Human Resources • 4.1 / 100 000 doctors (712) – 4300* • 0.77 / 100 000 hygienists (100 or 450) - 1340* • 15.4 / 100 000 nurses (2000) – 8670* • 0.6 / 100 000 ergonomists (80) • Safety practitioners, ventilation etc • ? Education and training inputs * need (Rees, NIOH)

38. Labor market for health professionals Provision of education Demand for education Educational needs Health needs Worker Population A Systems Approach Health System Education System Supply of health workforce Demand for health workforce Provision of health care Demand for health care

39. Emerging Challenges to the Occupational Health System Epidemiological and demographic transitions Occupational Health System Professional differentiation Technological innovation Worker / Community demands

40. Systemic Failures • Mismatch of competencies to need • Weak teamwork • Gender stratification • Curative over prevention & primary care • Labour market imbalances • Weak leadership

41. Promoting Occupational Health Public Health Approach • Action beyond workplace • All health determinants • All workers (contract) • All stakeholders • Overall policy / legal framework Traditional Occ Health • Only at workplace • Only work-related • Permanent employees • Employer’s responsibility • Workers & employers

42. Natural History of Disease • Susceptibility phase - Risk factors • Pre-clinical phase - Biological process has begun • Clinical phase - Signs and symptoms • Recovery - Chronic disease, disability, death

43. Weiner JP. 2003

44. Levels of Prevention • Primordial – building healthy environments • Primary – preventing the emergence of risk factors • Secondary – treating the risk factors • Tertiary – minimising risk in those with established disease

45. National Institute for Occupational Health Government & Public Entities Trade Unions, NGOs & Employers Services Research Education / Training Back Office Local & International Partnerships Universities and other Institutions

46. Services (referred persons, workplace & laboratory assessments) • Public & private sectors (incl NGO & Trade Union sectors) • Pathology services (deceased ex-miners) • Occupational Medicine • Clinical specialist referral service • Surveillance • Ergonomic assessments • Immunology & microbiology

47. Services (referred persons, site & laboratory assessments) • Occupational hygiene (risk assessments & hazard management) • Analytic services & Toxicology • Information services • Query handling • Resource centre • Electronic journals • eLearning platform (in development)

48. Research • Epidemiology • Special emphasis on mining sector, construction, informal sector, health & public sector • Nanotoxicology • Scientific (peer reviewed) • Translation of science for popular use • Scientific endeavour for policy change & service improvement • Support for legal challenges

49. Health Technology Assessment Lifecycle analysis of technology Multidisciplinary team Standard setting & guidelines ‘fitness testing’ ‘gloves’

50. N95 masks