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2 Universal Health Coverage and Occupational Health and Safety Issues for the Informal Workforce
Pages 11-42

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From page 11...
... The WIEGO network consists of m ­ embership-based organizations of informal workers, researchers and statisticians, and practitioners from development agencies who seek to increase the voice, visibility, and validity of the working poor, especially women, in the informal economy and thereby enable them to demand an enabling policy environment.
From page 12...
... and adopted by the ICLS in 2003, refers to both self-employment and wage employment without social protection through work, both inside and outside the informal sector. Chen said that the fastest-growing segment of informal employment in many countries is informal wage employment for formal enterprises.
From page 13...
... Informal Workers, Universal Health Coverage, and Occupational Health Basing her comments on WIEGO's research, Chen described some of the risks that informal workers face relative to formal workers. Informal workers have greater exposure to health risks due to their living and working environments, less protection against loss of income associated with health risks, and less protection against the costs of health risks because of the lack of employer contributions to health insurance and a limited access to universal coverage.
From page 14...
... 14 UHC AND OHS FOR INFORMAL WORKFORCE TABLE 2-2  Informal Workers' Occupational Health Risks and Barriers to Health Care Occupation Risks Barriers Home-based workers • Musculoskeletal stress • Isolation • Exposure to toxic • Lack of knowledge substances about preventive health • Psychological stress measures from irregular work and • Lack of bargaining power earnings • Limited ability to • Place of work is small, negotiate bureaucracy cramped with poor • Lack of integration in ventilation health insurance and services Street vendors • Musculoskeletal stress • Lack of knowledge from transporting goods about preventive health • Physical abuse by police measures and health • Psychological stress entitlements from fear of evictions, • Lack of bargaining power confiscation of goods, • Limited ability to irregular work and negotiate bureaucracy earnings • Lack of integration in • Exposure to the health insurance and elements and pollution services • Lack of water and sanitation Waste pickers • Musculoskeletal stress • Lack of knowledge from transporting goods about preventive health • Exposure to hazardous measures and health materials entitlements • Psychological stress • Lack of bargaining power from harassment by • Limited ability to authorities and public, negotiate bureaucracy irregular work and and markets earnings • Lack of integration in • Exposure to elements health insurance and and pollution services • Lack of water and sanitation • Risk of accidents SOURCE: Marty Chen presentation to workshop, July 29, 2014.
From page 15...
... To demonstrate the linkages between the interconnected health system components and universal health coverage, Emrey presented a vision for an action framework that included the health system components from Figure 2-1 as inputs, processes, and outputs, and the objectives of universal health coverage (UHC) as outcomes (see Figure 2-2)
From page 16...
... FIGURE 2-2  Vision for action: core functions, outcomes, and impact. NOTE: AFG = AIDS-free generation; EPCMD = ending preventable child and maternal deaths; HSS = health systems strengthening; PCID = protecting communities against infectious diseases; UHC = universal health coverage.
From page 17...
... This process has created systems where coverage is spread into categories that were politically acceptable at the time they were created, and in many cases the financing arrangements have stayed in place for the long term. For example, a health financing arrangement before a national approach to universal coverage is implemented might include within the formal sector a mix of coverage FIGURE 2-3 Dimensions of universal health coverage.
From page 18...
... provided by employers, social security, and through private commercial insurance; and within the informal sector a mix of coverage through user fees, fee exemptions, vouchers, and community-based health insurance or mutual health organizations (Wang et al., 2012)
From page 19...
... Financing Emrey listed three objectives of financing and insurance arrangement: (1) to create health insurance systems that will efficiently pool the losses associated with health risks so that in return for a premium (or tax)
From page 20...
... SOURCE: Presented by Robert Emrey on July 29, 2014. tial barriers to the inclusion of the informal workforce in the financing arrangements are not being organized or recognized as a population able to participate in a scheme and having poor -- or nonexistent -- data on the informal workforce for use in informing financing decisions.
From page 21...
... To ensure the inclusion of informal workers in the insurance system, Emrey suggested that the benefits package design should consider how to increase the utilization of services among the poor and how to achieve the widespread use of benefits for essential life-saving health interventions. Provider Engagement Provider engagement focuses on creating a payment system with incentives for providers and patients to improve quality and equity and to align health insurance policy goals with the choices of providers and with payment methods.
From page 22...
... Several core components of the organizational structure include governance and management, provider services, consumer services, actuarial and risk management, clinical standards and quality assurance, and financial management. In terms of barriers for the inclusion of informal workers, Emrey said that governance arrangements and staffing may not be aware of the needs of the informal sector workers and that there are not many options for involving the informal workforce in policy development and management arrangement.
From page 23...
... UNIVERSAL HEALTH COVERAGE AND THE INFORMAL WORKFORCE Peter Berman, Harvard School of Public Health Peter Berman from Harvard University provided an overview of the evolving definition of UHC since it has entered into the global political discourse, the challenges with how it is defined, and implications for including informal sector workers. Berman said that the initial discussions about UHC were broad and aspirational.
From page 24...
... UHC has been defined in a complete sense, but how does one characterize or compare different positions on the road to UHC in terms of the coverage of some services but not others, the coverage of some population groups but not others, or the different degrees of financial protection? In grappling with some of these issues that emerge within the definition, Berman recommended several areas to consider within each country context when addressing the inclusion of informal workers: • What kind of "coverage" (e.g., services, financial protection)
From page 25...
... UNIVERSAL HEALTH COVERAGE, INFORMALITY, AND WORKERS' HEALTH Ivan Ivanov, World Health Organization Ivan Ivanov from the WHO expanded on some challenges in the inclusion of the informal workforce within the objectives of UHC and on specific OHS needs for the population. While the primary objectives of UHC are to reduce the gap between the need for and the use of services, to ensure that the quality of health services is such that they improve the health of those receiving the services, and to provide financial risk protection, Ivanov emphasized that UHC is also about prevention and about the poor and vulnerable populations.
From page 26...
... In including informal sector workers as a recognized population with unique needs and services, it will be important to understand the burden of occupational health risks. Ivanov suggested that occupational risks are Dietary risks High blood pressure Smoking Household air polluƟon Alcohol use High body-mass index High fasƟng plasma glucose Childhood underweight Ambient PM polluƟon Physical inacƟvity OccupaƟonal risks Iron deficiency SubopƟmal breasƞeeding High total cholesterol Drug use InƟmate partner violence SanitaƟon Lead Vitamin A deficiency Zinc deficiency Childhood sexual abuse Unimproved water Low bone mineral density Ozone Radon FIGURE 2-5  Burden of occupational risks.
From page 27...
... In discussing the burden of occupational risks and how to better understand occupational health needs for specific populations, such as informal sector workers, Ivanov shared a figure that listed the factors that determine the health of workers, such as their working environment, health behavior, social factors, and access to health services (see Box 2-2)
From page 28...
... PARTNERSHIPS AS A MECHANISM FOR PROGRESS Victor Dzau, National Academy of Medicine One of the focuses of the workshop was exploring opportunities for public–private partnerships (PPPs) to advance the inclusion of informal sector workers in universal health coverage and occupational health and safety in developing countries.
From page 29...
... As with many complex global problems, Dzau said, when it comes to addressing the challenge of universal health coverage and OHS for the informal workforce in developing countries, there are two ingredients necessary for success: innovation and implementation. In under-resourced countries and communities, innovation provides opportunities to change the way that things have traditionally been done to solve complex issues.
From page 30...
... . UNIVERSAL HEALTH COVERAGE AND OCCUPATIONAL HEALTH AND SAFETY FOR INFORMAL WORKERS: A VIEW FROM INDIA Mirai Chatterjee, SEWA Social Security To provide an example of the problem that is being addressed by the workshop, including its challenges and the opportunities for addressing it, Mirai Chatterjee, director of the Self Employed Women's Association (SEWA)
From page 31...
... Universal Health Coverage in India According to Chatterjee, the provision of UHC in India is a major anti-poverty measure that is firmly on the national agenda. However, actually reaching all Indians is a huge challenge, given the large and diverse population.
From page 32...
... . What is envisioned by the planning commission are partnerships between government, private health care providers, the insurance industry, civil society, including workers' organizations like SEWA, and citizens themselves.
From page 33...
... Also, with a large population of informal workers who have no easily identifiable employer -- or no employer at all -- the costs of collecting premium or contributions would be high, and the mechanisms would be difficult to set up. Currently, some state governments and the national government are running health insurance programs, with mixed results.
From page 34...
... Community Engagement The fifth recommendation from the planning commission is to engage communities and citizens in their own health and well-being. Given the diversity of the population in India, Chatterjee said, communities need to be equipped to assess their own needs and then to act to improve their own health, with the government and the private sector supporting and enabling the process.
From page 35...
... Urban Health Another recommendation from the planning commission is that there should be a focus on the health of urban India. Nearly one-third of all Indians live in urban areas, where there is a lack of appropriate health infrastructure, especially of primary health care centers.
From page 36...
... Occupational Health and Safety for Informal Sector Workers in India Chatterjee said that SEWA's 40-plus years of organizing women for work security and basic social security, including health care, supports the approach chosen by India for UHC. She suggested, however, that there are some gaps that will require special attention.
From page 37...
... While there are significant gaps in data, she said, there are enough data to get started, and the data need to be put together and shared widely. The third recommendation Chatterjee noted was that OHS services should be integrated with primary health care and UHC, so that primary health care workers recognize possible work-related diseases and that workers are screened and referred in a timely manner to higher levels of care.
From page 38...
... A strong base of workers' and people's organizations can help ensure that the recommendations from the UHC commission reach the most vulnerable in society, including informal workers. Chatterjee suggested that the political economies of villages and urban settlements, the exploitative nature of work arrangements, the lack of essential services and basic social security, and other factors lead to the perpetuation of sickness, deprivation, and poverty.
From page 39...
... Martha Chen from Harvard University commented on the burden of disease from the perspective of informal workers. Chen said that there is a need to better understand the burden of chronic disease on these workers, whose only asset is their labor, and how that burden affects their earning opportunities.
From page 40...
... For example, some states have written details about services in the local language on the walls of the primary health center so that people know what services and medicines they are entitled to and which are free of charge. Another example is instituting certain community processes into the government public health system, including a social audit, which involves periodically sending a joint team of ­ ublic–private p community organizers into communities and holding large public meetings.
From page 41...
... Charu Garg from the Institute for Human Development in India brought up the example of another subpopulation that adds complexity to the discussion -- informal sector workers who have stopped working because of age or illnesses. If individuals in this subpopulation develop diseases or conditions based on their previous exposure to occupational hazards, Garg asked, then how are those conditions to be defined and treated?


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