Review Article

Factors of Succes of the High Coverage of Occupational Health Services of Employees in Finland

Helimäki-Aro, Ritva

National Institute of Occupational Health, Budapest, Hungary
Corresponding author: Ritva J. Helimäki-Aro
Address: Nagyvárad tér 2, 1096 Budapest
* Present address: Finnish Institute of Occupational Health
Helsinki, Topeliuksenkatu 41aA.
FIN-00250


Abstract

Act on Occupational Health Services came into effect in Finland at the beginning of 1979. Seventeen years of active OH have been successful in the prevention of occupational diseases and in health promotion activities. The coverage of occupational health is now about 90% of all Finnish employees. This article deals with some of the factors that can explain the success. Finland has adopted a comprehensive service model with preventive and curative care. It faces the future with emphasis on maintaining the working capacity of an aging population.

Key words: Occupational health services, coverage, Finland, maintaining of working capacity, prevention.



Abbreviations: OH: Occupational Health
OHS: Occupational Health Services
FIOH: Finnish Institute of Occupational Health

History

The first doctor was engaged to protect workers in 1754. For decades hygiene and infectious diseases were the main tasks of occupational health care. It was only after the second world war that the occupational health got new wind under its wings.

The Finnish Institute of Occupational Health (FIOH) was founded 51 years ago. The occupational health doctors founded their own association 50 years ago. Until 1970’s FIOH was also a big producer of practical occupational health services. The early connection between research and doctors working on the field helped in the creation of a system of occupational health services (OHS) which is now effective and one of the best in the world.

The law on occupational safety was renewed in 1958. Obligatory health examinations became more popular and preventive thinking was introduced. The curative care lost its primary function. New legislation on occupational safety and health in the 1970's gave the definitive direction to occupational health care. This legislation was prepared in cooperation among all social partners. The decision to prepare an act of OHS was signed by workers' and employers' organizations as part of their collective agreement. This method has been used also later on when new functions have been added to the contents of occupational health care. In Finland over 80% of workers belong to trade unions. This gives a big power to social partners and on the other hand it makes the implementation of decisions easier.

Act on Occupational Health Services

1 Tasks

The Act on OHS has come into effect gradually since the beginning of 1979.
    The act stipulates that all employers have to organize OHS for all employees. Also self-employed people and farmers can join the services. The act focuses firstly on prevention. The protection of workers against hazardous exposures is the preliminary task. The workplace is seen as sick, and not only the person. The employer is asked to use occupational specialists to make workplace surveys, to give information, advise and work-related health education, to follow-up the health of workers by different kinds of health examinations, and to take care of disabled employees. Also, the fist-aid readiness is the task of specialized occupational health personnel.
    Occupational health care, on its resources, cannot alone change work-places. The cooperation of safety representatives of the employees and the management is very important. It is stipulated in the Act that the employer has to work together with workers' safety representatives on matters concerning occupational health.
    How the workplace survey is done in Finland, is described in detail by Professor Jorma Rantanen, chief of FIOH in the book: Health Protection and Health Promotion in Small-scaled Enterprises.
    Later, new tasks have been introduced to OHS. Mental health of workers and workplaces became popular in 1980's, and the latest add to the preventive functions of OH is the maintaining of working capacity.

2 Curative and/or Preventive Care

When the occupational system was created in Finland, the French model was also discussed. In this model the occupational health care is only preventive and all curative work is done by family doctors. In Finland, this model was rejected. The Act aims primarily on prevention but it gives the possibility to the employer to offer the workers also curative care. This possibility is largely used. In the survey made in 1993 (Räsänen et al. 1994) it was found that 76% of the employees were covered by curative primary health care, too.
    Occupational health personnel get better information from the workplace; they have better knowledge of the health status of workers. The workers have more confidence in occupational professionals, when they can turn to them in personal questions, too. It has been noticed that especially in small work-places even the preventive work is done better if curative care is carried out by the same personnel. The new challenge given to OHS by the task of maintaining the working ability, would be totally impossible without the knowledge given to the doctor based on his/her curative care of workers (Tola 1996).

3 Different Service Models

Occupational health care is delivered through different service possibilities and by different providers. The employer can decide where to buy OHS.
    By the Primary Health Care Act in 1972, Finland was divided into 213 areas served by communal health centers. These centers take care of all preventive and primary health services of the municipality. When the act on occupational health was promulgated in 1978, these health centers were assigned to provide specially educated personnel for occupational health care. This obligation provides occupational services all over the country and gives particularly to small enterprises an option for professional services.
    The municipality can adapt the personnel to the real situation of the community. Where only few enterprises buy OHS from a health center, one of the primary health care practitioners is a part-time occupational health doctor, and an OH nurse takes care of the main practical work. In Finland the professional status of occupational health nurses is very high, and they are the main contact persons between work-places and occupational health care.
    In bigger health centers the OH division is a multidisciplinary team taking care of hundreds of enterprises.
    Other service model possibilities are: in-plant services; group services organized by employers, and private health centers. Until last year, the state had its own OHS. This service has now been privatized.
    A first big survey was carried out by FIOH in 1993 (Räsänen et al. 1994). The OHS (92% of 1025 OHS), who responded to the questionnaire, served a total of 1,6 million employees and 50 000 self-employed persons; out of them 42 000 farmers. The OH of these persons was served as follows:     Introduction of OH to primary health services has been one of the main factors of the success of OH in Finland.

4 Compensation Policy

The Sickness Insurance of Finland compensates the employer a part of the costs coming from the organizing of OHS. Now the compensation is 50%. To have this compensation the employer needs an annual action plan for OH, and an annual report of activities. The compensation is paid only provided that the safety delegate of workers has been integrated into the planning, and he has had the opportunity to voice an opinion of the annual report. The Sickness Insurance controls also that legal criteria on the content of services are met.
    The significance of a system of incentive and subsidy is demonstrated by, for example, experience of Sweden and Finland where the high level of subsidies expanded the coverage of OHS from 50-60% to 80-90% of all workers in the course of the 1980's (Rantanen 1994).
    Many small enterprises have been able to join the services. Still, some of them think that the society ought to take a bigger part of the costs (Räsänen et al. 1994).

Coverage of OHS

In 1977 it was estimated that 44% of the labour force were without OHS (Rossi et al. 1988). Mainly bigger enterprises had their own OHS. Since the Act on OHS in 1978 the coverage has slowly increased. In the study on Occupational Health in Finland 1992 (Räsänen et al. 1994) three big surveys were made, and the population was asked, how their OHS was organized. It was found that about 90% of employees were covered by OH (Table 1)
 
Table 1. Coverage of Occupational Health Services in Finland in 1993
 

    The coverage of small enterprises is, however, much smaller. In the study quoted above also a sample of small enterprises was interwieved. Out of 22 work-places which employed one person 73% did not have organized OHS, and 39% of 64 work-places with two to nine employees did not have OHS. According to Rantanen (1994) the following factors hamper the organization of services:

Education and personnel

Occupational health studies are now integrated into basic medical studies, and this gives the background education to all doctors to work as occupational health doctors. The FIOH organizes four-week intensive courses as a post graduate possibility.
    Participation in continuous education every fifth year is obligatory. The specialization in occupational health takes four years and a subspecialty on work medicine another two years.
    The basic education of occupational health nurses is a public health nurse education. About 250 hours of occupational health is integrated into the basic studies of a public nurse. This gives every public health nurse the possibility to work on occupational health care and all new nurses coming to occupational health care have the basic knowledge. Many special occupational health modules are possible as postgraduate studies. FIOH organizes four week courses for nurses, too. The latest innovation in education is to organize common courses for doctors and nurses. This makes the teams work better.
    Other partners of working life also need education. FIOH and other work educational institutes organize continuos training for safety personnel and management. Many actual courses are tailor-made for specific workplaces.
    At the 1992 survey (Räsänen et al. 1994) there were occupational health posts for 1532 doctors, 1925 nurses, 831 secretaries, 405 physiotherapists and 127 psychologists. Many doctors work part-time. If the total work is converted to full time work, it will mean:     Only some hygienists work inside OHS. Often these services are requested from outside. 78% of full time doctors and 41% of part-time doctors have participated in the education organized by FIOH. 447 doctor posts were served by specialized OH doctors. 74% of full time nurses and 41% of part-time nurses have been specially educated. Only properly educated occupational staff can serve the modern working environment. Continuous education has been one of the factors of success in Finland.

Results of prevention

After 17 years of effective occupational health care, most of the classic occupational diseases do not exist any more, the number and the degree of occupational accidents have decreased, and many dangerous substances are not used any more. It is true that occupational diseases can be prevented (Tola 1996). These kinds of results increase the credibility of OH and help in promoting it to employers. Here are some examples of results of occupational illnesses and of results of health promotion.

OCCUPATIONAL DISEASES

Noise induced hearing loss

The evolution shows, how the introduction of protective equipment and changes implemented at work-places in the 70’s and 80’s have changed the incidence and actual gravity of new cases. In 1984 there were 2164 new cases; five years later 1668 cases and in 1994 only 1034 new cases - and 50% of them were so small that no compensation was paid (Kauppinen et al. 1995).

Skin diseases

Although many new chemicals have been introduced in workplaces, the number of occupational skin diseases has not increased during the last years. This is mostly due to the better use of adapted gloves, better working methods, and the use of less allergic products. In 1984 there were 1206 new cases, and ten years later 1203 new occupational skin diseases.

HEALTH PROMOTION

These health promotion programs have been initiated by public health authorities, and OH has taken its own role in the implementation of these programs. When health promotion is introduced to workers by their own occupational specialists, the effect can be multiplied (Rantanen 1994).

Cardiovascular mortality

In the early 1970’s middle aged Finnish men had the highest mortality in the world, resulting from cardiovascular diseases. Cholesterol was known to be one of the predisposing factors.
    A big program was conducted in North Carelia and Kuopio during 20 years. The mortality was extremely high in the province of North Carelia. The aim was to change the habits of the population on cholesterol intake (milk), smoking, and treatment of hypertension. In the most recent surveys in 1992 it was shown that cardiovascular mortality of working-age men had diminished by more than 50%, and that of working-age women by more than 60% (Vartiainen et al. 1994). The result is good in North Carelia but also in other parts of the country. The study showed that the cardiovascular mortality can be defeated by acting on cholesterol and smoking, and by good treatment of hypertension.

Smoking

Lung cancer has been the most important cause of cancer mortality among men for many years. Smoking was known to be the most important risk factor. Anti-tobacco campaigns began in Finland in the 1970’s. In 1976, a new law was voted, forbidding smoking in public transport vehicles and other public places. Passive exposure to smoke was still a problem. In 1992, it was calculated that 800 000 Finns were exposed to involuntary smoking and this caused 40 new lung cancer cases yearly (Heloma 1995). Continuous anti-tobacco publicity and preventive work have changed the public opinion so that last year a new orientation was possible. All non-smokers were promised a shelter. The employer has to protect all non-smokers against passive smoking. Smoking at workplaces can be allowed only in specific smoking rooms with effective ventilation. The smoking is no longer very popular and many men have stopped smoking. The decrease in smoking has continued since the 1960’s and begins to be seen in the lung cancer mortality statistics (Puska 1995).
    Women have previously smoked very little. Now, in spite of public opinion, especially young women continue to smoke. At the North-Carelian study, quoted above, the prevalence of smoking decreased from 53% to 37% in men but increased from 11% to 20% in women.
    The role of occupational health professionals has been very important and in many services special courses have been organized on how to stop smoking.

Role of research and information

As a support in successful OH a continuos research activity is needed. FIOH with its six regional institutes gives advice and backstopping to OHS who work in the front line. FIOH has produced many practical and useful handbooks to OHS. Many databases are available on-line and on CD-ROM's. The medical association of OH doctors aims also to promote the knowledge of its members (now about 950). Its own journal “Työterveyslääkäri” (Occupational health doctor) has been published four times a year during the last ten years.

Feed-back from employers

Employers’ opinions on their OHS were also studied by Räsänen et al (1994). 92% of employers think that productivity of the work may increase by means of OH. Half of the employers estimated that productivity had already increased in their enterprise. The productivity was estimated to grow more on the work-places where curative services were included in preventive OH. In 43% of enterprises sick leaves had decreased because of the actions of OH.
    This positive attitude is a result from the work of many years. It is also a challenge for occupational professionals because they are now asked to integrate themselves more deeply inside the enterprise, and at the same time maintain their own independence.

Maintaining of working capacity

The Finnish population is getting older, and big generations born after the second world war are coming to the age of early retirement. Many attractive retirement possibilities were created during the good years of employment. During the last years Finland has been hit by unemployment originated from the collapse of trade with the former Soviet Union, simultaneously with the recession in our main markets in western Europe. Nearly 20% of working-age population have been unemployed. In the coming years a smaller quantity of working-age people has to take care of retired and unemployed. The programs for the maintaining the working capacity aim to keep these big generations active in working life; give them better personal conditions now and lead them to active and healthier retirement in due course.
    The employers' and employees' organizations had added a recommendation on this subject to their central collective agreement in 1989. The advisory board of occupational health care of the Ministry of Social Affairs and Health has defined this program as “all activity, where the employer and workers and the common bodies at the workplace to try to promote and support the working ability of every worker during all periods of his/her working life”. The advisory board has proposed to OHSs to act at three levels (Table 2).
    First level activity meets the whole workplace. It is preventive and it is thought to be realized mostly by the workplace itself. It means different kinds of health promotion programs; motion activities; life style planning.
    The second and third levels are mostly activities where OHS can help. Second level activity meets workers who have menaces on their working capacity. Here the aim is also to promote the personal condition, but the most important thing is to adapt work with the capabilities of the worker. This means deep cooperation between management and personnel departments. The national Sickness Insurance Fund organizes special courses on early rehabilitation (ASLAK) for those who have menaces on working capacity. These courses are organized together with local occupational health care personnel.
 
Table 2. Three levels of the program of maintaining working capacity

  Level 1 Level 2 Level 3
Target group Whole 
personnel
Workers threatened 
by diminished 
working capacity
Workers with 
diminished working 
capacity
Recognition   Symptoms, poor 
health. Own initiative 
or others' initiative. 
Evaluation by OHS
Being sick, 
diminished 
performance at 
working tasks. 
Follow-up by OHS
Measures Preventive work, 
promotion of healthy living standards, 
development of work and working 
conditions, promoting of workplace 
atmosphere
Check-up of health 
and working status, 
adaptation of the 
work, transfer to a 
new task, personal 
promoting of health 
condition, 
rehabilitation
Treatment of illnesses, 
rehabilitation, 
professional 
education, 
replacement
Source: Advisory board of OH of Ministry of Social Affairs and Health, Finland

    The third level means work with disabled workers. They have illnesses or injuries that decrease their capacity to work. Many persons with work related diseases (hypertension, diabetes, epilepsy and asthma, for instance) can work if the treatment is good and the work is well adapted. At this level, effective treatment of illnesses, rehabilitation and new professional education, or a replacement are the main actions.
    Many kinds of programs aiming at promoting the working ability have been conducted already through many years. In some workplaces the maintaining of working capacity is already a process inside the enterprise.
    Many projects already realized have proved that they promote the personal well-being of workers; decrease the sick leaves; promote the workplace atmosphere, and in many ways increase the productivity of the enterprise (Matikainen 1995).


References

HELOMA, A. (1995). “Justification and Interpretation of the New Act on Smoking.” (Finnish) Kunnallislääkäri 11: 32–35.

MATIKAINEN, E. (1995). “Productivity of the Maintaining of Working Capacity.” (Finnish) Työterveiset 4/95: 18–20.

PUSKA, P. (1995). “More than a hundred years of communal health care.” (Finnish) Kunnallislääkäri 11: 21–23.

RANTANEN, J., LEHTINEN, S., and MIKHEEV, M. (1994). Health Protection and Health Promotion in Small-scale Enterprises. World Health Organization and Finnish Institute of Occupational Health, 1994.

ROSSI, K., and VAARANEN, V. (1988). Occupational Health Services in Finland, Reviews 10, Finnish Institute of Occupational Health, Helsinki.

RÄSÄNEN, K., PEURALA, M., KANKAANPÄÄ, E., NIEMI, J. PIIRAINEN, H. NOTKOLA, V., and HUSMAN, K. (1994). Occupational Health Care in Finland in 1992. Finnish Institute of Occupational Health, Helsinki.

TOIKKANEN, J., KAUPPINEN, T., VAARANEN,V., VASAMA, M., and JOLANKI, R. (1994). Occupational diseases in Finland in 1993. Reviews 21. Finnish Institute of Occupational Health, Helsinki.

TOIKKANEN, J. KAUPPINEN, T., VAARANEN, V., VASAMA, M., and JOLANKI, R. Occupational Diseases, 1994, (Finnish) Katsauksia 132, Terveys 1995: 3, Finnish Institute of Occupational Health, Helsinki.

TOLA, S. “On the Evolution of Occupational Medicine during 50 years.” (Finnish) Työterveysläääkäri 1/96: 10–13.

VARTIAINEN, E., PUSKA, P., PEKKANEN, J., TUOMILEHTO, J., and JOUSILAHTI, P. (1994). “Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland.” British Medical Journal 309: 23–27. 


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