Accessing Occupational Health Services in the Southern African Development Community Region

Only 15% of the global population has access to occupational safety and health services. In Africa, only 5% of employees working from major establishments have access to occupational health services (OHS). Access to primary health care (PHC) services is addressed in many settings and inclusion of OHS in these facilities might increase efficiency in preventing occupational diseases. A cross-sectional study was conducted in four Southern African Development Community (SADC) countries aiming at assessing the availability of OHS at PHC facilities and the organization of OHS. We conducted a literature review to assess the provision and organization of OHS services. In addition to the review, a total of 23 doctors from Zambia were interviewed using questionnaires in order to determine the availability of OHS and training. Consultations with heads of ministries were done in four SADC countries. Results showed that in the SADC region, OHS are fragmented and lack a comprehensive approach. In addition, out of 23 PHC facilities, only two (13%) provided occupational health and PHC. However, OHS provided at PHC facilities were limited to TB screening and audiometric testing. Our study showed a huge inadequacy of trained occupational health practitioners. This study supports the World Health Organization’s advocacy to integrate OHS at the PHC level.


Introduction
Recently, the International labour Organization (ILO) indicated that about 2.8 million men and women die annually due to work related problems [1]. Furthermore, about 86% of the total mortalities are attributed to occupational health related illnesses [2,3]. Over the past two decades, industrial activities have increased leading to the introduction of new hazards and new health outcomes [4]. The consequences of new hazards are likely to be more catastrophic in developing countries due to weaker technological advancement in occupational hygiene monitoring and occupational diseases diagnosis [1,5,6]. This suggests a need to develop mechanisms for practitioners in developing countries to advance their knowledge and understanding on the basic occupational health service package.
In the SADC region, the majority of people are employed in the mining sector [7]. Studies suggest that about half of the world's vanadium, platinum, and diamonds originate in the region, while 36% of gold and 20% of cobalt are produced in this region [8]. Since mining operations have been associated with increased exposure to pollutants leading to several health effects, the SADC region is considered Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 24 July 2020 doi:10.20944/preprints202007.0570.v1 amongst the top high risk countries [9]. Exposure to fine mine dust has increased the risk of illnesses such as silicosis, coal pneumoconiosis, cardiovascular illness and tuberculosis [8,10,11].
Access to occupational health services and primary health care services can be one of the most appropriate ways of reducing associated health effects [7]. Though primary health care services are generally understood as a mandate of government to ensure universal health access mostly for the poor, this understanding needs to change [5,9]. OHS are often funded by industries but regulated by the government [12]. The two understandings on primary and occupational health services suggest that workers are not part of the general public nor are general public member's part of the working population.
In many developing countries there is an increasing challenge on accessing and providing OHS as the demand is on the rise due to employee's awareness programs [6,9]. In the SADC region, the provision of OHS is poorly regulated [10,13]. Furthermore, there is a shortage of trained and knowledgeable occupational health practitioners [14]. Therefore, it is imperative to develop other mechanisms to increase capacity in OHS. Such alternatives might include allocation of resources for training practitioners, establishing or review of legislative frameworks and adding OHS at primary health care centers [1,15].
The connection of labour and health is anticipated as a vehicle to integrate primary health care and OHS [3]. Most current and ex-mine workers are in communities where access to occupational health services is poor but with good access to primary health care services which are widely distributed [8].
This presents a good opportunity of integrating OHS into the primary health care system. Therefore, an introduction of OHS in primary health care is envisaged as a vital tool for accelerating diagnosis and treatment of occupational diseases for those who are affected [3,11].
Resolution WHA 60.26 "Workers' Health: Global Plan of Action", calls for all member states to ensure coverage of all workers in both the formal and informal sectors across all working spaces with essential interventions and basic occupational health services for primary prevention of occupational and workrelated diseases and injuries [16]. It is therefore imperative that occupational health services are provided at primary health care levels.
Our study sought to evaluate the organization of OHS and determine the opportunities for integrating OHS into primary health care centers in four SADC countries: (Zambia, Malawi, Mozambique, and Lesotho). The objective of this study was to determine the need for future integration of OHS into the primary health care institutions in the SADC region. The study hypothesizes that there is limited OHS in primary health care facilities in the SADC region despite high economic growth in the mining sector.

Methods
The study areas consisted of four SADC countries: Lesotho, Malawi, Mozambique and Zambia. The study adopted a mixed methods approach in collecting data whereby a cross sectional study, literature

Sampling population and data collection
The selection of the four countries was influenced by the Southern African TB and Health Systems Strengthening (SATBHSS) project in the four project selected countries supported by the World Bank.

Study limitations
The study sample size for the cross sectional study was from a single country, Zambia, out of the 4 SADC countries, which might not be representative of the entire populations. The study did not account for variability within countries and persons involved which might increase the uncertainty of the results.
The study is only limited to describe access to OHS and does not include the characterization of institutional capacity, gap assessments and barriers in improving access. Furthermore, the study only focused on four SADC countries, but we do acknowledge that there are many countries in SADC. Only medical practitioners and heads of ministries constituted the sample population. This might present a limitation especially since nurses who are often the first contact in health facilities were excluded. The exclusion of the nurses was based on the funding structure which only accommodated medical practitioners.

Results
In this section we have presented the study results in three different parts, the first part provided a review of OHS review in the SADC region. The second part reported the availability of occupational health professionals in four selected project countries, while the third part presented results from a Zambian case study.

Organization of occupational health and safety services in the four countries
In Table 1, several research peer reviewed journal articles and technical reports results were reviewed to assess the status of OHS arrangement and provision in SADC region. Almost all reviewed articles and reports indicated the need to strengthen OHS across the SADC region. Major highlights included increasing institutional capacity in training occupational health professionals, review of legislative framework, OHS financing and

Number of occupational health experts (Zambia, Lesotho, Mozambique and Malawi)
In Table 2, a summary of OHS professionals from various ministries across the four project countries is provided. The results are tabulated based on the record as provided by heads of ministries responsible for occupational health administration in each country. From the results, it is evident that there is an increased shortage of occupational health professionals across the four project countries. Worthy to note that even countries that reported availability the professionals were not trained or accredited. Both Lesotho and Mozambique did not have an occupational hygienist or occupational health nurse. The percentages indicate the compliance status for each occupational health professional. Only Lesotho has managed to have a 100% allocation of OMPs against the national target. Of concern is the understanding of the ratio of occupational health professional vs the target serving populations. Clearly, we have not yet grasped the importance and contribution of OHS in the economy and alleviation of burden of diseases.
Furthermore, the expected number of health professionals at each category suggests that there might be a different understanding regarding the ratio of health professional per population. According to the world health organisation the ratio of 1: 1000 population is recommended as best practice. Looking at the projected figures as in Table 2, it maybe anticipated that the current allocation are not adequate [24].

Occupational health services Provision at primary health level in Zambia
Availability of occupational health services at primary health care level Using data extracted from the Zambian questionnaire respondents, it is evident that occupational health services are currently inadequate in the public health facilities/primary health care level. Table   3, results shows that at the primary health care level, the inception of OHS is limited, with only 11% of the primary health care facilities offering OH services.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 24 July 2020 doi:10.20944/preprints202007.0570.v1 This finding is a cause of concern as a remarkably high proportion of those practicing is not trained.

Health promotion and prevention measures available and practiced
The results in Table 4 show that pre-placement medical examinations were offered by most institutions.
Most of the medical examinations that were done were not risk based. This is evidenced by the low number of available risk assessment services that stood at (48%). Exit medical examinations were only available to a limited extent as only 33% of the respondents indicated the availability of such.

Diagnosis services available
The results in Table 5 show that most institutions in Zambia do not offer comprehensive OHS as evidenced by the low proportions of audiometry (24%) and spirometry (14%) services offered. However, a greater proportion of the respondents, 75%, indicated that vision testing was done in most of the institutions. Blood lead measurements were available in 48% of the institutions

Treatment services and training
The results in Table 6 show that primary health care services are the predominant services offered by health institutions while only 33% offered pneumoconiosis services. TB and HIV services were offered by most health institutions as evidenced by 95% of the respondents who indicated so.

Discussion
From the literature review, only 10 research articles and 2 technical reports were relevant to the study.
This points towards the paucity of published research resources in the field of occupational health in Southern Africa as asserted by Moyo et al. [13]. The literature review findings and results of enquiries with heads of ministries in the four study countries are in concordance with the fact that SADC has gross inadequacies in access to OHS and availability of appropriately qualified occupational health personnel across the medical, nursing, occupational hygiene and safety disciplines. Shortage of trained OHS professionals [10,18,21] and poor OHS legislative frameworks [17,19]   This research reveals the gross inadequacies of OHS provision in the four study countries. It further highlights the lack of integration of OHS into primary health care service centres. Lack of adequate regulatory frameworks in occupational health are major challenges emerging from the findings of our study.

Conclusion
The findings of our study confirm the inadequacies of access to occupational health services in the four SADC countries. It brings to fore the urgent need for the provision of OHS at the primary health care level across the four countries under study. It is key to note that poor and near absent comprehensive occupational health services regulatory frameworks could be one of the chief impediments to the development of occupational health services in the region. The study findings conclude that OHS remain greatly constrained in the four study countries with however a great potential of expanding such services through the transformation of OHS regulatory frameworks and capacity development in the field of occupational health. Since the primary health services offer the first point of access to OHS, it remains a key strategic approach to interface the two services. It is our strong recommendation that building capacity in occupational health and integrating them into primary health services backed by comprehensive OHS legislation, remains the key approach to increased and improved access to OHS across SADC.
Author Contributions: Daniel Masekameni conceptualized and prepared the manuscript. Dingani Moyo worked alongside with Daniel to conceptualise the paper and writing up. Norman developed the methodology for data analysis. He further analyzed the data and assisted in the editing of the manuscript. Chimwewe edited the manuscript and validated the methodology for data collection and analysis.