Workers health surveillance: implementation of the Directive 89/391/EEC in Europe

Occupational Medicine 2017;67:574578 Advance Access publication 19 August 2017 doi:10.1093/occmed/kqx113 Workers health surveillance: implementation of the Directive 89/391/EEC in Europe C. Colosio 1, S. Mandic-Rajcevic 1, L. Godderis 2,3, G. van der Laan 1,4,5, C. Hulshof 6 and F. van Dijk 4,5 1 Department of Health Sciences of the University of Milano and International Centre for Rural Health of the San Paolo Hospital, 20142 Milano, Italy, 2 Centre for Environment and Health, Katholieke Universiteit Leuven, Leuven 3000, Belgium, 3 IDEWE, External Service for Prevention and Protection at Work, Heverlee 3000, Belgium, 4 Learning and Developing Occupational Health (LDOH) Foundation, 1213 RH Hilversum, The Netherlands, 5 Department of Public and Occupational Health, EMGO+ Institute for Health and Care Research, VU University Medical Center, 1105 Amsterdam, The Netherlands, 6 Academic Medical Center, Coronel Institute of Occupational Health, 1105 Amsterdam, The Netherlands. Correspondence to: C. Colosio, Department of Health Sciences of the University of Milano and International Centre for Rural Health of the San Paolo Hospital, Via San Vigilio, 43, 20142 Milan, Italy. Tel: +39 028184365; fax: +39 02 89180221; e-mail: claudio.colosio@unimi.it Background European Union (EU) Directive 89/391 addressed occupational health surveillance, which recommends to provide workers with access to health surveillance at regular intervals, aiming to prevent work-related and occupational diseases. Aims Methods Results To investigate how EU countries adopted this Directive. We invited one selected representative per member state to complete a questionnaire. All 28 EU countries implemented the Directive in some form. Workers health surveillance (WHS) is available to all workers in 15 countries, while in 12, only specific subgroups have access. In 21 countries, workers participation is mandatory, and in 22, the employer covers the cost. In 13 countries, access to WHS is not available to all workers but depends on exposure to specific risk factors, size of the enterprise or belonging to vulnerable groups. In 26 countries, the employer appoints and revokes the physician in charge of WHS. Twelve countries have no recent figures, reports or costbenefit analyses of their WHS programmes. In 15 countries where reports exist, they are often in the native language. Conclusions Coverage and quality of occupational health surveillance should be evaluated to facilitate learning from good practice and from scientific studies. We propose a serious debate in the EU with the aim of protecting workers more effectively, including the use of evidence-based WHS programmes. Key words Introduction EU policy; health surveillance; occupational health; occupational health services; occupational health surveillance; prevention; quality of care; workers health surveillance. Workers health surveillance (WHS) is essential for prevention in the workplace, workplace health promotion, detection and reporting of occupational and work-related diseases and controlling the effectiveness of preventive measures [1,2]. To encourage member states to increase WHS coverage, the European Union (EU) launched Council Directive 89/391 on 12 June 1989 on the introduction of measures to encourage improvements in the safety and health of workers at work [3]. WHS was addressed in Article 14 of the Directive, stating To ensure that workers receive health surveillance appropriate to the health and safety risks they incur at work, measures shall be introduced in accordance with national law and/or practices. Measures shall be such that each worker, if he so wishes, may receive health surveillance at regular intervals Health surveillance may be provided as part of a national health system. In this study, we investigated whether and how Article 14 of the Directive has been implemented in all 28 EU countries, and in particular, whether programmes are offered to workers, including information about objectives, provider(s), financing and categories of workers who are invited and may benefit from it. Methods We developed a questionnaire about the implementation of Article 14 of EU Directive 89/391 (Tables 1 The Author 2017. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com

C. COLOSIO ET AL.: WORKERS HEALTH SURVEILLANCE 575 Table 1. Questions and answers regarding the implementation of the Directive, Article 14, coverage by WHS, and employers of occupational health physicians Section Question Answers n (% of 28) Countries Skip to 1 Please choose your country. 28 EU countries 28 (100) All Are you aware about the existence Yes 28 (100) All of the Council Directive (89/391/ EEC) on safety and health at work? No 0 (0) Has Article 14 of the Directive (dealing with surveillance of the health of the workers at regular intervals, appropriate to the risks at work) been implemented in your Country? 2 When has Article 14 been implemented in your country? (year(s) of implementation) How has Article 14 been implemented in your country? 3 Are all workers or defined groups of workers provided with regular health surveillance related to the risks at work in your Country? 4 Specific groups are provided with health surveillance (open) 5 See Table 2 6 Who can be the employer of an occupational health physician in your country? 7 Final comments/contact information, etc. Yes 28 (100) All No 0 (0) Section 3 Year of implementation (19942014) Adopted unchanged as a national law Adopted with some changes as a national law 8 (28) CY, EE, GR, IE, LT, LU, NL, SI 14 (50) AT, BE, HR, DE, HU, IT, MT, PL, PT, RO, SK, ES, SE, UK 3 (11) CZ, DK, LV Proposed as a recommendation Similar provisions 3 (11) BG, FI, FR implemented before the EU Directive was released All workers 15 (54) BG, HR, CZ, EE, FI, DE, HU, LU, NL, PL, RO, SK, SI, ES, UK Section 5 Only some groups 12 (42) AT, BE, CY, FR, GR, IE, IT, Section 4 LV, LT Nobody 1 (4) DK Section 6 Specific risk factors 8 (28) AT, BE, IE, IT, LV, LT, MT, SE Enterprise size 2 (7) MT, GR Job sector 2 (7) CY, PT Vulnerability (pregnancy, 2 (7) BE, CY young age) The company 23 (83) AT, BE, BG, CY, EE, FI, FR, DE, GR, HU, IE, IT, LV, LT, LU, NL, PL, PT, RO, External services provider 23 (83) AT, BE, BG, HR, CZ, EE, FI, FR, DE, GR, HU, IE, IT, LV, LT, NL, PL, PT, RO, Self-employed (no employer) 23 (83) AT, BG, HR, CY, CZ, EE, FI, DE, GR, HU, IE, IT, LV, LT, MT, NL, PL, PT, RO, Health care system 6 (21) HR, CZ, DK, LT, SI, SE Public/private insurance 2 (7) AT, SI Open field AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CY, Cyprus; CZ, Czech Republic; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; GR, Greece; HU, Hungary; IE, Ireland; IT, Italy; LV, Latvia; LT, Lithuania; LU, Luxembourg; MT, Malta; NL, Netherlands; PL, Poland; PT, Portugal; RO, Romania; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom.

576 OCCUPATIONAL MEDICINE Table 2. Questions and answers regarding the participation, financing, providers, objectives and outcomes of WHS Section Question Answers n (% of 28) Countries Skip to 5 Is it obligatory for employers to offer health surveillance programmes to employees? Yes 27 (96) All except DK No 0 (0) Are the workers obliged to participate? Yes 21 (75) AT, BE, HR, CY, CZ, EE, FI, FR, GR, HU, IE, IT, LV, LT, LU, MT, PL, RO, SK, SI, UK Yes (specific risk) 1 (4) ES No 5 (17) BG, DE, NL, PT, SE Who pays for the occupational health surveillance programmes? Who is the provider of health surveillance? Who appoints the provider of health surveillance What is the main objective of health surveillance in your country? How are the above-mentioned objectives of health surveillance defined in your country? Are there recent figures, study reports or scientific articles published about the statistics, costs/benefits, programme-evaluations in the last five years? If YES, please specify. Employer 22 (81) BE, BG, HR, CY, CZ, EE, FI, FR, GR, HU, IE, IT, LU, NL, PL, PT, RO, SK, SI, ES, SE, UK National Health Care 1 (4) MT System Workers and private 1 (4) LV insurance Workers 1 (4) LT Public insurance against occupational accidents and diseases 2 (7) AT, DE Certified occupational 14 (50) AT, BE, EE, FR, DE, HU, IE, physician LV, LU, RO, SK, SI, ES, SE Any occupational 8 (28) HR, CY, FI, GR, LT, MT, NL, physician PL Family physician 2 (7) CZ, MT Authorized physician 1 (4) PT Nurse, doctor, specialist 1 (4) UK Employer 26 (92) AT, BE, BG, HR, CY, CZ, EE, FI, FR, DE, GR, HU, IE, IT, LV, LT, LU, MT, NL, PL, PT, RO, National system 1 (4) SI Reduction of the incidence of occupational diseases and accidents 21 (75) AT, BE, BG, HR, CY, CZ, EE, FR, DE, GR, HU, IE, LV, LT, MT, NL, PL, PT, SK, SE, UK 7 (25) FI, FR, LU, RO, SK, SI, ES Promotion of working capacity Assessment of fitness for 1 (4) IT work Established by law 25 (89) AT, BE, BG, HR, CY, CZ, EE, FI, FR, DE, GR, HU, IE, IT, LV, LT, LU, MT, PL, PT, RO, SK, SI, SE, UK Decided by the employer 1 (4) ES Decided by the workers and employer 1 (4) NL Yes 15 (54) AT, BE, BG, HR, CZ, EE, FI, DE, GR, HU, LV, LT, NL, PL, UK No 12 (42) CY, FR, IE, IT, LU, MT, PT, RO, SK, SI, ES, SE AT, Austria; BE, Belgium; BG, Bulgaria; HR, Croatia; CY, Cyprus; CZ, Czech Republic; DK, Denmark; EE, Estonia; FI, Finland; FR, France; DE, Germany; GR, Greece; HU, Hungary; IE, Ireland; IT, Italy; LV, Latvia; LT, Lithuania; LU, Luxembourg; MT, Malta; NL, Netherlands; PL, Poland; PT, Portugal; RO, Romania; SK, Slovakia; SI, Slovenia; ES, Spain; SE, Sweden; UK, United Kingdom. and 2). Questions addressed status of the Directive s implementation, workers coverage, obligation to participate in WHS programmes, providers and availability of reports on WHS outcomes. In order to harmonize data collection, we based the questionnaire, wherever possible, on closed questions. We tested the questionnaire with a group of occupational health experts from our countries (Italy, Belgium and the Netherlands)

and considered testers responses, doubts and suggestions in the final version, which we distributed online. As our objective was to collect facts, not opinions, we invited only one acknowledged occupational health expert to respond per country. We selected experts from members of the International Commission on Occupational Health and the Modernet network. In case of non-response, we invited a second expert to participate. In the end, we obtained one completed questionnaire from each of the 28 EU member states. No ethical approval was necessary as we only collected publicly available information and practices from experts. Results Occupational health experts from all 28 EU countries were aware of the Council Directive and Article 14, and all 28 EU Countries adopted it in some form between 1994 and 2014. All workers can access WHS in 15 countries, and only some groups in 12 (Table 1, Section 3). Access is based on exposure to specific risk factors in eight countries (Table 1, Section 4), enterprise size (Malta and Greece), industrial sector (Cyprus and Portugal) or vulnerability such as pregnancy or young age (Belgium and Cyprus). Offering WHS is an obligation for employers (Table 2, Section 5). Workers participation is mandatory in 21 countries, while in five countries, including Spain, it is not, or it is only for selected high-risk subgroups. In almost all countries (22), the employer covers WHS expenses, but National Health Care System contributes in Malta, workers and private insurance companies in Latvia, workers in Lithuania and the public system for workers insurance in Austria and Germany. In 14 countries, only a certified occupational physician registered in an official list can undertake WHS, while in Italy, medical doctors specializing in forensics or public hygiene can also enter the official list of authorized physicians, but only after a 9-month occupational health course. WHS can be carried out by any occupational physician in eight countries, by any physician after authorization in Portugal, by family physicians in the Czech Republic and Malta, and in the UK by nurses collaborating with physicians. In 26 EU countries, the employer appoints the physician (Table 2, Section 5), while in Slovenia, the assignment is done by the national health care system. In 23 countries, the occupational physician can be an employee of a company, a private organization or be self-employed (Table 1, Section 6). In six countries, he/ she is employed in the public health care system, and in Austria and Slovenia, they can also be employed in an insurance company. In 21 countries, the main objective of WHS is the reduction of occupational diseases C. COLOSIO ET AL.: WORKERS HEALTH SURVEILLANCE 577 and accidents, and the objective is mostly established by law (Table 2, Section 5). In 12 EU countries, there are no recent figures, study reports or scientific articles on statistics, cost-benefit analyses or programme evaluations showing the numbers and outcomes of WHS. In the 15 countries where figures, reports or articles exist, these are often published only in the national language. Discussion This study found that the concept of health surveillance was not unequivocally defined and implemented in EU countries, since different viewpoints, considerations and practical applications are possible, despite the same EU regulation [4,5]. A limitation of the study is that we collected responses from few field experts. Interpretation of concepts could differ among experts, sometimes with unclear correlation between legal obligations and practical implementation. A larger field of expert responders may have been preferable. However, it is clear that in about half of EU countries, access to WHS is not universal but depends on exposure to specified risk factors, size of the enterprise or belonging to a vulnerable group. This means that most workers in small and medium-sized enterprises, including many in agriculture and construction and many informal workers, have no access, despite relatively high risks of accidents and occupational diseases [5]. In 22 countries, workers participation is mandatory which might raise ethical concerns, especially since in most countries the employer appoints and revokes the physician in charge of WHS. The power to revoke the physician in charge, as well as to influence his/ her employment contract, should be carefully evaluated to ensure professional independence of the physician. There is also a need for harmonized information systems, and in accordance with the Directive, assessment of the practical implementation of WHS every 5 years. Key points The concept of workers health surveillance is not unequivocally defined in the European Union; harmonization is needed. In some countries, workers health surveillance is provided to all workers by law, independently from their exposure to occupational risk factors, gender or vulnerability, while in other countries only selected subgroups of workers have access. Although Article 14 of European Union Directive 89/391 states that workers should receive workers health surveillance if he so wishes, in most countries workers participation is mandatory.

578 OCCUPATIONAL MEDICINE Funding We conducted this study on our institutions budget. No economical support has been provided. Acknowledgements The authors gratefully acknowledge the help of Dr Elsbeth Huber (Austria), Prof. Karolina Liubomirova (Bulgaria), Dr Milena Tabanska-Petkova (Bulgaria), Prof. Nevena Tzacheva (Bulgaria), Dr Hana Brborov (Croatia), Dr Anastassios Yiannaki (Cyprus), Prof. Daniela Pelclová (Czech Republic), Dr Ole Carstensen (Denmark), Dr Mihkel Pindus (Estonia), Dr Riitta Sauni (Finland), Prof. Vincent Bonneterre (France), Dr Sven Timm (Germany), Prof. Athena Linos (Greece), Dr Ferenc Kudász (Hungary), Dr Károly Nagy (Hungary), Dr Imre Nagy (Hungary), Prof. Imre Rurik (Hungary), Dr Peter Noone (Ireland), Prof. Francesco Violante (Italy), Prof. Maija Eglite (Latvia), Dr Gintare Kalinienės (Lithuania), Dr Jelena Stanislavoviene (Lithuania), Dr Nicole Majery (Luxembourg), Dr Mark Rosso (Malta), Dr Piotr Sakowski (Poland), Dr Teresa Mariana Faria Pinto (Portugal), Prof. Elena-Ana Păuncu (Romania), Dr Monika Zámečníková (Slovakia), Dr Alenka Škerjanc (Slovenia), Prof. Begoña Martínez-Jarreta (Spain), Dr Martin Andersson (Sweden), and Dr Dil Sen (UK). Conflicts of interest None declared. References 1. Koh D, Aw TC. Surveillance in occupational health. Occup Environ Med 2003;60:705710. 2. Rantanen J, Lehtinen S, Iavicoli S. Occupational health services in selected International Commission on Occupational Health (ICOH) member countries. Scand J Work Environ Health 2013;39:212216. 3. European Council. Council Directive 89/391/EEC OSH Framework Directive. Off J Eur Commun 1989: No. L 183/18. http://eur-lex.europa.eu/legal-content/en/txt/ PDF/?uri=CELEX:31989L0391&from=EN (18 October 2016, date last accessed). 4. Radon K, Ehrenstein V, Bigaignon-Cantineau J, Vellore AD, Fingerhut M, Nowak D; Occupational Health Crossing Borders Summer School. Occupational health crossing borders part 1: concept, teaching methods, and user evaluation of the first international summer school in Munich, Germany. Am J Ind Med 2009;52:774781. 5. Radon K, Ehrenstein V, Nowak D et al.; Occupational Health Crossing Borders Summer School Team. Occupational health crossing borders part 2: comparison of 18 occupational health systems across the globe. Am J Ind Med 2010;53:5563.