Friday, 11 February 2011 20:11

Occupational Health Services in Small-Scale Enterprises

Written by
Rate this item
(0 votes)

The coverage of workers in small-scale enterprises (SSEs) is perhaps the most daunting challenge to systems for delivering occupational health services. In most countries, SSEs comprise the vast majority of the business and industrial undertakings—reaching as high as 90% in some of the developing and newly industrialized countries—and they are found in every sector of the economy. They employ on average nearly 40% of the workforce in the industrialized countries belonging to the Organization for Economic Cooperation and Development and up to 60% of the workforce in developing and newly industrialized countries. Although their workers are exposed to perhaps an even greater range of hazards than their counterparts in large enterprises (Reverente 1992; Hasle et al. 1986), they usually have little if any access to modern occupational health and safety services.

Defining Small-Scale Enterprises

Enterprises are categorized as small-scale on the basis of such characteristics as the size of their capital investment, the amount of their annual revenues or the number of their employees. Depending on the context, the number for the last category has ranged from one to 500 employees. In this article, the term SSE will be applied to enterprises having 50 or fewer employees, the most widely accepted definition (ILO 1986).

SSEs are gaining importance in national economies. They are employment-intensive, flexible in adapting to rapidly changing market situations, and provide job opportunities for many who would otherwise be unemployed. Their capital requirements are often low and they can produce goods and services near the consumer or client.

They also present disadvantages. Their lifetime is often brief, making their activities difficult to monitor and, frequently, their small margins of profits are achieved only at the expense of their workers (who are often also their owners) in terms of hours and intensity of workloads and exposure to occupational health risks.

The Workforce of SSEs

The workforce of SSEs is characterized by its diversity. In many instances, it comprises the manager as well as members of his or her family. SSEs provide entry to the world of work for young people and meaningful activities to elderly and redundant workers who have been separated from larger enterprises. As a result, they often expose such vulnerable groups as children, pregnant women and the elderly to occupational health risks. Further, since many SSEs are carried out in or near the home, they often expose family members and neighbours to the physical and chemical hazards of their workplaces and present public health problems through contamination of air or water or of food grown near the premises.

The educational level and socio-economic status of SSE workers vary widely but are often lower than the averages for the entire workforce. Of particular relevance is the fact that their owners/managers may have had little training in operation and management and even less in the recognition, prevention and control of occupational health risks. Even where appropriate educational resources are made available, they often lack the time, energy and financial resources to make use of them.

Occupational Hazards in SSEs and the Health Statusof their Workers

Like all other aspects of SSEs, their working conditions vary widely depending on the general nature of the enterprise, the type of production, the ownership and location. In general, the occupational health and safety hazards are much the same as those encountered in larger enterprises, but as noted above, the exposures to them are often substantially higher than in large enterprises. Occasionally, however, the working conditions in SSEs may be much better than those in larger enterprises with a similar type of production (Paoli 1992).

Although very few studies have been reported, it is not surprising that surveys of the health of workers in SSEs in such industrialized countries as Finland (Huuskonen and Rantala 1985) and Germany (Hauss 1992) have disclosed a relatively high incidence of health problems, many of which were associated with lowered capacity for work and/or were work-related in origin. In SSEs in developing countries an even higher prevalence of occupational diseases and work-related health problems has been reported (Reverente 1992).

Barriers to Occupational Health Services for SSEs

There are formidable structural, economic and psychological barriers to the provision of occupational health services to SSEs. They include the following:

  1. Traditionally, occupational safety and health legislation in most countries has exempted SSEs and is generally applicable only to manufacturing industries. The “informal sector” (this would include, say, the self-employed) and agriculture were not covered. Even where the legislation had wider coverage, it was not applicable to enterprises with small numbers of employees—500 employees was the usual lower limit. Re-cently, some countries (e.g., France, Belgium and the Nordic countries) have enacted legislation requiring the provision of occupational health service for all enterprises regardless of size or sector of the economy (Rantanen 1990).
  2. SSEs, as defined for this article, are too small to justify an in-plant occupational health service. Their wide diversity with respect to type of industry and methods of production as well as style of organization and operation, along with the fact that they are spread over wide geographic areas, makes it difficult to organize occupational health services that will meet all their needs.
  3. Economic barriers are substantial. Many SSEs hover on the edge of survival and just cannot afford any additions to their operating costs even though they may promise significant savings in the future. Further, they may not be able to afford education and training in hazard recognition, prevention and control for their owners/managers, much less their employees. Some countries have addressed the economic problem by providing subsidies either from governmental agencies or social security institutions (Rantanen 1994), or have included occupational health services in programmes promoting the general economic and social development of SSEs (Kogi, Phoon and Thurman 1988).
  4. Even when financial constraints are not inhibiting, there is often a disinclination among the owners/managers of SSEs to devote the time and energy needed to acquire the necessary basic understanding of the relationships between work and health. Once acquired, however, SSEs may be very successful in applying the information and abilities in their workplaces (Niemi and Notkola 1991; Niemi et al. 1991).
  5. Enterprises in the informal sector and small farming are seldom registered, and their formal links with official agencies may be weak or non-existent. Activities carried out as a business may be difficult to distinguish from those involving the private household and family. As a result, there may be concerns about privacy and resistance to interventions by “outsiders”. SSEs often resist becoming involved in trade associations and community organizations, and in perhaps the majority of instances their employees are not members of unions. To overcome such barriers, some countries have used extension organizations for the distribution of information, the creation of special training opportunities for the SSEs by official occupational safety and health agencies, and the adoption of the primary care model for the provision of occupational health services (Jeyaratnam 1992).
  6. Many SSEs are located in communities providing ready access to emergency and primary care services. However, the physicians’ and nurses’ lack of knowledge and experience with respect to occupational hazards and their effects often results in failure to recognize occupational diseases and, probably more important, loss of opportunities to install the necessary prevention and control measures.


International Instruments Covering OccupationalSafety and Health Services

In some countries, occupational safety and health activities are in the jurisdiction of labour ministries and are regulated by a special occupational safety and health authority; in others, this responsibility is shared by their ministries of labour, health and/or social affairs. In some countries, such as Italy, regulations covering occupational health services are embodied in health legislation or, as in Finland, in a special act. In the United States and in England, provision of occupational health services rests on a voluntary basis, while in Sweden, among others, it was once regulated by collective agreement.

The ILO Occupational Safety and Health Convention (No. 155) (ILO 1981a) requires governments to organize a policy for occupational safety and health to be applicable to all enterprises in all sectors of the economy that is to be implemented by a competent authority. This Convention stipulates the responsibilities of the authorities, employers and workers and, supplemented by the concomitant Recommendation No. 164, defines the key occupational safety and health activities of all relevant actors at both national and local levels.

The ILO supplemented these in 1985 by the International Convention No. 161 and Recommendation No. 171 on Occupational Health Services. These contain provisions on policy design, administration, inspection and collaboration of occupational health services, activities by occupational safety and health teams, conditions of operation, and responsibilities of employers and workers, and they furthermore offer guidelines for organizing occupational health services at the level of the enterprise. While they do not specify SSEs, they were developed with these in mind since no size limits were set for occupational health services and the necessary flexibility in their organization was emphasized.

Unfortunately, ratification of these ILO instruments has been limited, particularly in developing countries. On the basis of experience from the industrialized countries, it is likely that without special actions and support by government authorities, the implementation of the ILO principles will not take place in SSEs.

The WHO has been active in promoting the development of occupational health services. Examination of the legal requirements was carried out in a consultation in 1989 (WHO 1989a), and a series of about 20 technical documents on various aspects of occupational health services has been published by WHO headquarters. In 1985 and again in 1992, the WHO Regional Office in Europe carried out and reported surveys of occupational health services in Europe, while the Pan American Health Organization designated 1992 as a special year for occupational health by promoting occupational health activities in general and conducting a special programme in Central and South America.

The European Union has issued 16 directives concerning occupational safety and health, the most important of which is Directive 391/1989, which has been called the “Framework Directive” (CEC 1989). These contain provisions for specific measures such as requiring employers to organize health risk assessments of different technical facilities or to provide health examinations of workers exposed to special hazards. They also cover the protection of workers against physical, chemical and biological hazards including the handling of heavy loads and working at video display units.

While all of these international instruments and efforts were developed with SSEs in mind, the fact is that most of their provisions are practical only for larger enterprises. Effective models for organizing a similar level of occupational health services for SSEs remain to be developed.

Organizing Occupational Health Services for SSEs

As noted above, their small size, geographic dispersion and wide variation in types and conditions of work, coupled with great limitations in economic and human resources, make it difficult to efficiently organize occupational health services for SSEs. Only a few of the various models for delivering occupational health services described in detail in this chapter are adaptable to SSEs.

Perhaps the only exceptions are SSEs that are dispersed operating units of large enterprises. These usually are governed by policies established for the entire organization, participate in company-wide educational and training activities, and have access to a multidisciplinary team of specialists in occupational health located in a central occupational health service that is usually based at the headquarters of the enterprise. A major factor in the success of this model is having all of the costs of occupational safety and health activities covered by the central occupational health unit or the general corporate budget. When, as is increasingly common, the costs are allocated to the operating budget of the SSE, there may be difficulty in enlisting the full cooperation of its local manager, whose performance may be judged on the basis of the profitability of that particular enterprise.

Group services organized jointly by several small or medium-sized enterprises have been successfully implemented in several European countries—Finland, Sweden, Norway, Denmark, the Netherlands and France. In some other countries they have been experimented with, with the help of government subsidies or private foundations, but they have not survived after termination of subsidies.

An interesting modification of the group service model is the branch-oriented service, which provides services for a high number of enterprises operating all in the same type of industry, such as construction, forestry, agriculture, food industry and so on. The model enables the service units to specialize in the problems typical for the branch and thus accumulate high competence in the sector that they serve. A famous example of such a model is the Swedish Bygghälsan, which provides services for construction industries.

A notable exception is the arrangement organized by a trade union whose members are employed in widely scattered SSEs in a single industry (e.g., health care workers, meat cutters, office workers and garment workers). Usually organized under a collective agreement, they are financed by employers’ contributions but are usually governed by a board comprising representatives of both employers and workers. Some operate local health centres providing a broad range of primary and specialist clinical services not only for workers but often for their dependants as well.

In some instances, occupational health services are being provided by hospital outpatient clinics, private health centres and community primary care centres. They tend to focus on the treatment of acute work-related injuries and illnesses and, except perhaps for routine medical examinations, provide little in the way of preventive services. Their staffs often have a low level of sophistication in occupational safety and health, and the fact that they are usually paid on a fee-for-service basis provides no great incentive for their involvement in the surveillance, prevention and control of workplace hazards.

A particular disadvantage of these “external services” arrangements is that the customer or client relationship with those using them generally precludes the participation and collaboration of employers and workers in the planning and monitoring of these services that are stipulated in the ILO Conventions and the other international instruments created to guide occupational safety and health services.

Another variant is the “social security model”, in which occupational health services are provided by the same organization that is responsible for the cost of compensation for occupational diseases and injuries. This facilitates the availability of resources to finance the services in which, although curative and rehabilitative services are featured, preventive services are often prioritized.

An extensive study carried out in Finland (Kalimo et al. 1989), one of the very few attempts to evaluate occupational health services, showed that municipal health centres and private health centres were the dominant providers of occupational health services to SSEs, followed by the group or shared centres. The smaller the enterprise, the more likely it was to use the municipal health centre; up to 70% of SSEs with one to five workers were served by municipal health centres. Significant findings of the study included verification of the value of workplace visits by the personnel of the centres serving the SSEs to gain knowledge (1) of the working conditions and the particular occupational health problems of the client enterprises, and (2) of the need to provide them with special training in occupational safety and health before they undertake the provision of the services.

Types of Activities for Occupational Health Services for SSEs

The occupational health services designed for SSEs vary widely according to national laws and practices, the types of work and work environments involved, the characteristics and health status of the workers and the availability of resources (both in terms of the ability of the SSEs to afford the occupational health services and the availability of health care facilities and personnel in the locality). Based on the international instruments cited above and regional seminars and consultations, a list of activities for comprehensive occupational health services has been developed (Rantanen 1989; WHO 1989a, 1989b). A number of key activities that should always be found in an occupational health services programme, and that are relevant for SSEs, can be picked up from those reports. They include for example:

Assessment of occupational health needs of the enterprise

  • preliminary analysis of the activities of the enterprise and identification of the health and safety hazards common to such workplaces
  • inspection and surveillance of the workplace to identify and quantify the hazards actually present in the particular enterprise
  • assessment of the extent of the risks they present and ranking them in order of their urgency and priority
  • repeating the hazard assessment whenever there are changes in production methods, equipment and materials.


Prevention and control activities in the workplace

  • communication of the results of the assessment to the owners/managers and the workers’ representatives
  • identification of the prevention and control measures that are needed and available, assigning relative priority to them in terms of urgency and feasibility
  • overseeing their installation and implementation
  • monitoring their continuing effectiveness.


Preventive activities oriented to workers

  • assessment and surveillance of workers’ health status by pre-placement, screening and periodic examinations which may be general as well as focused on the biological effects of particular hazards to which the workers may have been exposed
  • adaptation of the job, the work station and the workplace environment to promote workers’ ongoing health and safety with special attention to such vulnerable groups as the very young, the elderly and those with acquired diseases and disabilities
  • providing workers with health education and training in proper work practices
  • providing education and training for owners/managers and supervisors that will inculcate awareness of the health needs of workers and motivation to initiate appropriate prevention and control measures.


Curative activities

  • provide or arrange the delivery of the appropriate diagnostic, therapeutic and rehabilitative services for occupational injuries and diseases
  • provide or arrange for early rehabilitation to obviate avoidable disability and encourage and oversee adjustments in the job that will permit early return to work
  • provide education and training (and periodic retraining) in first aid and emergency procedures
  • establish procedures and conduct training drills for coping with major emergencies such as spills, fires, explosions and so on
  • provide or arrange for workers’ involvement in programmes that promote general health and well-being.


Record keeping and evaluation

  • make and retain appropriate records on occupational accidents, injuries and diseases and if possible on exposure; evaluate the overall health and safety status of the enterprise on the basis of such data
  • monitor the effectiveness of hazard prevention and control measures.


Implicit in the above list of core activities is the appropriate availability of advice and consultations in such occupational safety and health specialities as occupational hygiene, ergonomics, work physiology, safety engineering, occupational psychiatry and psychology and so on. Such specialists are not likely to be represented in the personnel of the facilities providing occupational health services to SSEs but, when needed, they can usually be provided by governmental agencies, universities and private consulting resources.

Because of their lack of sophistication and time, owners/managers of SSEs are forced to rely more heavily on the purveyors of safety equipment for the effectiveness and reliability of their products, and on the suppliers of chemicals and other production materials for complete and clear information (e.g., data sheets) about the hazards they may present and how these may be prevented or controlled. It is important, therefore, that there be national laws and regulations covering proper labelling, product quality and reliability, and the provision of easily understood information (in the local language) about equipment use and maintenance as well as product use and storage. As a backup, the trade and community organizations of which SSEs are often members should feature information about the prevention and control of potentially hazardous exposures in their newsletters and other communications.


In spite of their importance for the national economy and their role as employer of a majority of the nation’s workforce, SSEs, the self-employed and agriculture are sectors that are typically underserved by occupational health services. ILO Convention No. 161 and Recommendation No. 171 provide relevant guidelines for the development of such services for SSEs and should be ratified and implemented by all countries. National governments should develop the requisite legal, administrative and financial mechanisms to provide all workplaces with occupational safety and health services that will effectively identify, prevent and control exposures to potential hazards and promote the enhancement and maintenance of optimal levels of health status, well-being and productive capacity of all workers. Collaboration at international, regional and subregional levels, such as that provided by the ILO and the WHO, should be encouraged to foster the exchange of information and experience, the development of appropriate standards and guidelines and the undertaking of relevant training and research programmes.

SSEs may in many instances be reluctant to seek actively the services of occupational health units even though they might be the best beneficiaries of such services. Considering this, some governments and institutions, particularly in Nordic countries, have adopted a new strategy by starting wide-scale interventions for establishment or development of services. For instance the Finnish Institute of Occupational Health currently implements an Action Programme, for 600 SSEs employing 16,000 workers, aimed at the development of occupational health services, maintenance of work ability, prevention of environmental hazards in the neighbourhood and improving the competence of SSEs in occupational health and safety.



Additional Info

Read 6154 times Last modified on Thursday, 16 June 2011 13:00

" DISCLAIMER: The ILO does not take responsibility for content presented on this web portal that is presented in any language other than English, which is the language used for the initial production and peer-review of original content. Certain statistics have not been updated since the production of the 4th edition of the Encyclopaedia (1998)."


Part I. The Body
Part II. Health Care
First Aid & Emergency Medical Services
Health Protection & Promotion
Occupational Health Services
Part III. Management & Policy
Part IV. Tools and Approaches
Part V. Psychosocial and Organizational Factors
Part VI. General Hazards
Part VII. The Environment
Part VIII. Accidents and Safety Management
Part IX. Chemicals
Part X. Industries Based on Biological Resources
Part XI. Industries Based on Natural Resources
Part XII. Chemical Industries
Part XIII. Manufacturing Industries
Part XIV. Textile and Apparel Industries
Part XV. Transport Industries
Part XVI. Construction
Part XVII. Services and Trade
Part XVIII. Guides

Occupational Health Services References

Association of Occupational and Environmental Clinics (AOEC). 1995. Membership Directory. Washington, DC: AOEC.

Basic law on labour protection. 1993. Rossijskaja Gazeta (Moscow), 1 September.

Bencko, V and G Ungváry. 1994. Risk assessment and environmental concerns of industrialization: A central European experience. In Occupational Health and National Development, edited by J Jeyaratnam and KS Chia. Singapore: World Science.

Bird, FE and GL Germain. 1990. Practical Loss Control Leadership. Georgia: Institute Publishing Division of the International Loss Control Institute.

Bunn, WB. 1985. Industrial Medical Surveillance Programmes. Atlanta: Centers for Disease Control (CDC).

—. 1995. The scope of international occupational medical practice. Occup Med . In press.

Bureau of National Affairs (BNA). 1991. Workers’ Compensation Report. Vol. 2. Washington, DC: BNA.

—. 1994. Workers’ Compensation Report. Vol. 5. Washington, DC: BNA.
China Daily. 1994a. New sectors opened to lure foreign investment. 18 May.

—. 1994b. Foreign investors reap advantages of policy changes. 18 May.

Council of the European Communities (CEC). 1989. Council Directive On the Introduction of Measures to Encourage Improvements in the Safety and Health of Workers At Work. Brussels: CEC.

Constitution of the Russian Federation. 1993. Izvestija (Moscow), No. 215, 10 November.

Czech and Slovak Federal Republic. 1991a. The health sector: Issues and priorities. Human Resources Operations Division, Central and Eastern European Department. Europe, Middle East and North Africa Region, World Bank.

—. 1991b. Joint environmental study.

Equal Employment Opportunity Commission (EEOC) and Department of Justice. 1991. Americans with Disabilities Act Handbook. EEOC-BK-19, P.1. 1, 2, October.

European Commission (EC). 1994. Europe for Safety and Health At Work. Luxembourg: EC.

Felton, JS. 1976. 200 years of occupational medicine in the US. J Occup Med 18:800.

Goelzer, B. 1993. Guidelines on control of chemical and physical hazards in small industries. Working document for the Inter-Regional Task Group on health protection and health promotion of workers in small-scale enterprises, 1-3 November, Bangkok, Thailand. Bangkok: ILO.

Hasle, P, S Samathakorn, C Veeradejkriengkrai, C Chavalitnitikul, and J Takala. 1986. Survey of working conditions and environment in small-scale enterprises in Thailand, NICE project. Technical Report, No. 12. Bangkok: NICE/UNDP/ILO.

Hauss, F. 1992. Health promotion for the crafts. Dortmund: Forschung FB 656.

He, JS. 1993. Working report on national occupational health. Speech on the National Occupational Health Conference. Beijing, China: Ministry of Public Health (MOPH).

Health Standards Office.1993. Proceedings of National Diagnostic Criteria and Principles of Management of Occupational Diseases. Beijing, China: Chinese Standardization Press.

Huuskonen, M and K Rantala. 1985. Work Environment in Small Enterprises in 1981. Helsinki: Kansaneläkelaitos.

Improving working conditions and environment: An International Programme (PIACT). The evaluation of the International Programme for the Improvement of Working Conditions and Environment (PIACT). 1984. Report to the 70th session of the International Labour Conference. Geneva: ILO.

Institute of Medicine (IOM). 1993. Environmental Medicine and the Medical School Curriculum. Washington, DC: National Academy Press.

Institute of Occupational Health (IOH). 1979. Translation of the Occupational Health Care Act and the Council of the State Decree No. 1009, Finland. Finland: IOH.

Institute of Occupational Medicine.1987. Methods for Monitoring and Analysis of Chemical Hazards in Air of Workplace. Beijing, China: People’s Health Press.

International Commission on Occupational Health (ICOH). 1992. International Code of Ethics for Occupational Health Professionals. Geneva: ICOH.

International Labour Organization (ILO). 1959. Occupational Health Services Recommendation, 1959 (No. 112). Geneva: ILO.

—. 1964. Employment Injury Benefits Convention, 1964 (No.121). Geneva: ILO.

—. 1981a. Occupational Safety and Health Convention, 1981 (No. 155). Geneva: ILO.

—. 1981b. Occupational Safety and Health Recommendation, 1981 (No. 164). Geneva: ILO.

—. 1984. Resolution Concerning Improvement of Working Conditions and Environment. Geneva: ILO.

—. 1985a. Occupational Health Services Convention, 1985 (No. 161). Geneva: ILO

—. 1985b. Occupational Health Services Recommendation, 1985 (No. 171). Geneva: ILO.

—. 1986. The Promotion of Small and Medium-Sized Enterprises. International Labour Conference, 72nd session. Report VI. Geneva: ILO.

International Social Security Association (ISSA). 1995. Prevention Concept “Safety Worldwide”. Geneva: ILO.

Jeyaratnam, J. 1992. Occupational health services and developing nations. In Occupational Health in Developing Countries, edited by J Jeyaratnam. Oxford: OUP.

—. and KS Chia (eds.). 1994. Occupational Health and National Development. Singapore: World Science.

Joint ILO/WHO Committee on Occupational Health. 1950. Report of the First Meeting, 28 August-2 September 1950. Geneva: ILO.

—. 1992. Eleventh Session, Document No. GB.254/11/11. Geneva: ILO.

—. 1995a. Definition of Occupational Health. Geneva: ILO.

—. 1995b. Twelfth Session, Document No. GB.264/STM/11. Geneva: ILO.

Kalimo, E, A Karisto, T Klaukkla, R Lehtonen, K Nyman, and R Raitasalo. 1989. Occupational Health Services in Finland in the Mid-1980s. Helsinki: Kansaneläkelaitos.

Kogi, K, WO Phoon, and JE Thurman. 1988. Low Cost Ways of Improving Working Conditions: 100 Examples from Asia. Geneva: ILO.

Kroon, PJ and MA Overeynder. 1991. Occupational Health Services in Six Member States of the EC. Amsterdam: Studiecentrum Arbeid & Gezonheid, Univ. of Amsterdam.

Labour Code of the Russian Federation. 1993. Zakon, Suppl. to Izvestija (Moscow), June: 5-41.

McCunney, RJ. 1994. Occupational medical services. In A Practical Guide to Occupational and Environmental Medicine, edited by RJ McCunney. Boston: Little, Brown & Co.

—. 1995. A Manager’s Guide to Occupational Health Services. Boston: OEM Press and American College of Occupational and Environmental Medicine.

Ministry of Health of the Czech Republic. 1992. The National Programme of Health Restoration and Promotion in the Czech Republic. Prague: National Centre for Health Promotion.

Ministry of Public Health (MOPH). 1957. Recommendation on Establishing and Staffing Medical and Health Institutions in Industrial Enterprises. Beijing, China: MOPH.

—. 1979. State Committee of Construction, State Planning Committee, State Economic Committee, Ministry of Labour: The Hygienic Standards for Design of Industrial Premises. Beijing, China: MOPH.

—. 1984. Administrative Rule of Occupational Disease Diagnosis. Document No. 16. Beijing, China: MOPH.

—. 1985. Methods of Airborne Dust Measurement in Workplace. Document No. GB5748-85. Beijing, China: MOPH.

—. 1987. Ministry of Public Health, Ministry of Labour, Ministry of Finance, All-China Federation of Trade Union: Administrative Rule of Occupational Disease List and Care of the Sufferers. Document No. l60. Beijing, China: MOPH.

—. 1991a. Administrative Rule of Health Inspection Statistics. Document No. 25. Beijing, China: MOPH.

—. 1991b. Guideline of Occupational Health Service and Inspection. Beijing, China: MOPH.

—. 1992. Proceedings of National Survey on Pneumoconioses. Beijing, China: Beijing Medical Univ Press.

—. 1994 Annual Statistic Reports of Health Inspection in 1988-1994. Beijing, China: Department of Health Inspection, MOPH.

Ministry of Social Affairs and Employment. 1994. Measures to Reduce Sick Leave and Improve Labour Conditions. Den Haag, The Netherlands: Ministry of Social Affairs and Employment.

National Centre of Occupational Health Reporting (NCOHR). 1994. Annual Reports of Occupational Health Situation in 1987-1994. Beijing, China: NCOHR.

National Health Systems. 1992. Market and Feasibility Study. Oak Brook, Ill: National Health Systems.

National Statistics Bureau. 1993. National Statistics Yearbook of the People’s Republic of China. Beijing, China: National Statistic Bureau.

Neal, AC and FB Wright. 1992. The European Communities’ Health and Safety Legislation. London: Chapman & Hall.

Newkirk, WL. 1993. Occupational Health Services. Chicago: American Hospital Publishing.

Niemi, J and V Notkola. 1991. Occupational health and safety in small enterprises: Attitudes, knowledge and behaviour of the entrepreneurs. Työ ja ihminen 5:345-360.

Niemi, J, J Heikkonen, V Notkola, and K Husman. 1991. An intervention programme to promote improvements of the work environment in small enterprises: Functional adequacy and effectiveness of the intervention model. Työ ja ihminen 5:361-379.

Paoli, P. First European Survey On the Work Environment, 1991-1992. Dublin: European Foundation for the Improvement of Living and Working Conditions.

Pelclová, D, CH Weinstein, and J Vejlupková. 1994. Occupational Health in the Czech Republic: Old and New Solutions.

Pokrovsky, VI. 1993. The environment, occupational conditions and their effect on the health of the population of Russia. Presented at International Conference Human Health and the Environment in Eastern and Central Europe, April 1993, Prague.

Rantanen, J. 1989. Guidelines on organization and operation of occupation health services. Paper presented at ILO Asian subregional seminar on the Organization of Occupational Health Services, 2-5 May, Manila.

—. 1990. Occupational Health Services. European Series, No. 26. Copenhagen: WHO Regional Publications

—. 1991. Guidelines on the organization and operation of occupational health services in the light of the ILO Occupational Health Services Convention No. 161 and Recommendation No. 171. Paper presented at the African sub-regional workshop on occupational health services, 23-26 April, Mombasa.

—. 1992. How to organize plant-level collaboration for workplace actions. Afr Newslttr Occup Health Safety 2 Suppl. 2:80-87.

—. 1994. Health Protection and Health Promotion in Small-Scale Enterprises. Helsinki: Finnish Institute of Occupational Health.

—, S Lehtinen, and M Mikheev. 1994. Health Promotion and Health Protection in Small-Scale Enterprises. Geneva: WHO.

—,—, R Kalimo, H Nordman, E Vainio, and Viikari-Juntura. 1994. New epidemics in occupational health. People and Work. Research reports No. l. Helsinki: Finnish Institute of Occupational Health.

Resnick, R. 1992. Managed care comes to Workers’ Compensation. Bus Health (September):34.

Reverente, BR. 1992. Occupational health services for small-scale industries. In Occupational Health in Developing Countries, edited by J Jeyaratnam. Oxford: OUP.

Rosenstock, L, W Daniell, and S Barnhart. 1992. The 10-year experience of an academically affiliated occupational and environmental medicine clinic. Western J Med 157:425-429.

—. and N Heyer. 1982. Emergence of occupational medical services outside the workplace. Am J Ind Med 3:217-223.

Statistical Abstract of the United States. 1994. 114th edition:438.

Tweed, V. 1994. Moving toward 24-hour care. Bus Health (September):55.

United Nations Conference on Environment and Development (UNCED). 1992. Rio De Janeiro.

Urban, P, L Hamsová, and R. Nemecek. 1993. Overview of Occupational Diseases Acknowledged in the Czech Republic in the Year 1992. Prague: National Institute of Public Health.

US Department of Labor. 1995. Employment and Earnings. 42(1):214.

World Health Organization (WHO). 1981. Global Strategy for Health for All by Year 2000.
Health for All, No. 3. Geneva: WHO.

—. 1982. Evaluation of Occupational Health and Industrial Hygiene Services. Report of the Working Group. EURO Reports and Studies No. 56. Copenhagen: WHO Regional Office for Europe.

—. 1987. Eighth General Programme of Work Covering the Period 1990-1995. Health for All, No.10. Geneva: WHO.

—. 1989a. Consultation On Occupational Health Services, Helsinki, 22-24 May 1989. Geneva: WHO.

—. 1989b. Final Report of Consultation On Occupational Health Services, Helsinki 22-24 May 1989. Publication No. ICP/OCH 134. Copenhagen: WHO Regional Office for Europe.

—. 1989c. Report of the WHO Planning Meeting On the Development of Supporting Model Legislation for Primary Health Care in the Workplace. 7 October 1989, Helsinki, Finland. Geneva: WHO.

—. 1990. Occupational Health Services. Country reports. EUR/HFA target 25. Copenhagen: WHO Regional Office for Europe.

—. 1992. Our Planet: Our Health. Geneva: WHO.

—. 1993. WHO Global Strategy for Health and Environment. Geneva: WHO.

—. 1995a. Concern for Europe’s tomorrow. Chap. 15 in Occupational Health. Copenhagen: WHO Regional Office for Europe.

—. 1995b. Global Strategy On Occupational Health for All. The Way to Health At Work: Recommendation of the Second Meeting of the WHO Collaborating Centres in Occupational Health, 11-14 October 1994 Beijing, China. Geneva: WHO.

—. 1995c. Reviewing the Health-For-All Strategy. Geneva: WHO.

World Summit for Social Development. 1995. Declaration and Programme of Action. Copenhagen: World Summit for Social Development.

Zaldman, B. 1990. Industrial strength medicine. J Worker Comp :21.
Zhu, G. 1990. Historical Experiences of Preventive Medical Practice in New China. Beijing, China: People’s Health Press.