Abstract
Background:
Work-related injuries and diseases have a significant impact on workers and their families, society, and the economy. There is a gap in the literature regarding the structures, content, quality, and outcomes of international occupational health systems serving injured and ill workers. This global round table was an attempt to elucidate, evaluate, and identify areas needing improvement.
Methods:
International occupational health professionals were identified via chain/snowball sampling and asked to answer five questions designed to evaluate the structures, processes, and outcomes of the workers’ compensation systems in each country.
Findings:
Areas for improvement identified during this round table included timely access, reducing the impact of liability and eligibility determinations on access to medical care, equitable access to care, and the accuracy of reporting. Canada had successfully utilized a virtual approach to care for the geographically remote worker.
Conclusions:
International workers’ compensation structures are designed to ensure timely access to quality care and services. Financial incentives optimize the safety of the working environment. There remain areas for improvement. Resources are limited, especially within the public health systems, which may delay care and affect quality. Informal and remote workers often do not have the same access to care. Occupational Health Services (OHS) and national reporting databases exist throughout the world but may not accurately capture data on informal, self-employed, small business, migrant, and remote workers.
Keywords
Background
Work-related injuries and diseases have a significant impact on workers and their families, productivity, society, and the economy (Rantanen et al., 2020). It is estimated that 1.9 million workers died due to work-related injuries (19%) and illnesses (81%) in 2016 (World Health Organization & International Labour Organization [ILO], 2021). Approximately 340 million workers suffer from work-related injuries, and 160 million from work-related illnesses every year worldwide (ILO, 2023a). In 2016, work-related injuries (about 30%) and illnesses (about 70%) caused the loss of 90 million disability-adjusted life years (DALYs) internationally (World Health Organization & International Labour Organization, 2021). These numbers are considered underestimates due to significant underreporting of work-related accidents and injuries (Pega et al., 2023).
Many countries have a significant portion of their workforce working informally, without occupational health prevention programs or workers’ compensation systems. In 2019, prior to the onset of the COVID-19 pandemic, informal employment represented approximately 6 out of 10 workers internationally (ILO, 2023b). Occupational risks such as long working hours also contribute to diseases such as depression, stroke, and ischemic heart disease (Pega et al., 2021).
The United Nations General Assembly (UNGA), the International Labour Organization (ILO), the World Health Organization (WHO), the International Commission on Occupational Health (ICOH), and the European Union (EU) have recognized worker injury and illness as a worldwide crisis and have asked countries to establish Occupational Health Services (OHS) for all workers, most recently at the United Nations (UN) Resolution on Sustainable Development Goals in 2016 (Rantanen et al., 2020). A global survey of 49 ICOH National Secretaries from countries representing 70% of the global workforce in 2015 found that most countries have OHS programs, but these programs are still very limited in terms of coverage, services, comprehensiveness, infrastructure, and staffing (Rantanen et al., 2020).
This global round table aims to present the structures, processes, advantages, disadvantages, and data monitoring of work-related injury and disease care around the world to guide evaluation of the current OHS systems and plan for future improvements, help with advocacy efforts, and make work-related injury and disease care more equitable.
Methodology
Five questions regarding workers’ compensation were posed to a global panel of nurses, physicians, academics, and workers’ compensation risk management and administration professionals with significant experience in occupational health in academic, public, and private company settings. Experts selected to participate in this round table provided a rich sampling of global occupational health perspectives. Representatives from the university, research, and healthcare sectors were included. Participants were chosen via a chain/snowball sampling process based on experience and relevant roles ((administrator, direct care provider, consultant, or professor) in the provision of workers’ compensation care. Julie Thurlow and Terrance D’souza provided the workers’ compensation insurance, risk management, and healthcare business analytics perspectives. All other participants are experienced occupational health clinicians in addition to their current roles. Drs. Bagasse De Dhaem, Foster-Chang, and Serra collaborated to develop the round table questions, establish a framework, and solicit participants. Dr. Chandrashekar was instrumental in identifying additional international participants. Dr. Begasse de Dhaem served as the round table moderator.
Findings
How Is Workers’ Compensation Injury and Illness Care Structured in Your Country? Where Does It Reside, How Is It Provided?
All employees in Turkey are required to be affiliated with the Social Security Institution (SGK), which is the governing body of the Turkish social security system. The SGK comprises two elements: healthcare and social security benefits. Once an employee is in the SGK system, they are entitled to health care in Turkey, and most of their health problems, work-related accidents and injuries, early retirement due to occupational injury (pensions) and occupational diseases will be covered.
Like Turkey, in Mexico, workers’ compensation is organized through the public health system, the IMSS (Mexican Social Security Institute). When an employee first seeks care at the IMSS, the doctor determines whether it is a work-related illness or injury, and if so, the employee is referred to an occupational doctor. In the case of an occupational disease, if disability is required, the occupational doctor grants disability according to the evolution of the disease. An official document must be issued for temporary/partial disability or state of invalidity. In the case of an occupational risk, an official document is granted that begins the process to qualify the risk. Disability is granted if required and when the last disability is granted, the process must be closed with the medical discharge form. For general illness, 60% of the base salary is covered from the third day of disability. For work-related illness or work risk, 100% of the base salary is covered.
Workers’ compensation in Japan is also organized at the national level, through the Workers’ Accident Compensation Insurance (WACI) system of the Ministry of Health, Labor, and Welfare (MHLW). This system provides coverage for medical expenses, rehabilitation, leave allowances, disability compensation, compensation for bereaved families, and support for the insured person’s reintegration into society.
In Canada, workers’ compensation is under provincial/territorial jurisdictions rather than at the national level, but it is still in the public domain. Each province/territory has a Board or commission responsible for administrating and managing the workers compensation system. These organizations manage all aspects of the workers’ compensation system, including setting and collecting premiums, adjudicating, and paying benefits and managing return to work and health care.
In the United Kingdom, statutory sick pay (SSP) coverage is provided by employers for a period up to 28 weeks if any kind of illness or injury prevents work. Beyond that duration of disability, incapacity benefits are covered by the U.K. Government Department of Work and Pensions. Workers suffering work-related injury or illness can claim welfare benefits from the state (if they meet objective eligibility criteria), but they can also claim compensatory damages via civil court (tort law) if they can establish employer’s liability. Compulsory Employers’ liability insurance provided by private carriers covers losses arising from bodily injury or disease sustained by employees and arising out of and in the course of their employment.
Unlike the countries previously discussed, there is an option for private workers’ compensation insurance for some employers in India. Workers’ compensation coverage may be either public or private depending on the employer. The Employees’ State Insurance Act of 1948 (ESI Act) mandates any organization with more than 10 employees have workers’ compensation Insurance. The ESI Act ensures that employees and workers receive insurance benefits from their employers. Both the ESI and private insurances taken by the employer (based on the workers’ salary) cover treatment for both work-related and non-work-related illness and injuries of all the workers enrolled and their immediate dependents.
In Egypt, workers’ compensation is provided by the factory’s/employers’ health insurance rather than a public national security system. The factories provide all their workers with health insurance. The factory physician makes the work-related illness and injuries assessment and informs the health insurance committee.
Like in Canada, the workers’ compensation system in the United States is not the same across regions. Every state in the union has their own specific eligibility criteria, forms, required reporting timelines, and mechanisms. Texas is the sole state that allows optional workers’ compensation coverage for employers—unless the private employer contracts with government entities. Workers are strongly encouraged to report occupational injuries and illnesses. In terms of care delivery, there is heterogeneity across states as to whether the employers or employee chose the primary treating providers—and some state’s legislation creates a hybrid construct. Some employers provide care, follow-up, and case management services within the organization (onsite) while others contract with pre-designated Medical Provider Networks. Federal government employees are covered under the Federal Employees Compensation Act (FECA) and have different, but required elements for medical documentation, eligibility criteria, forms, reporting timelines, and mechanisms.
Who Pays for Workers’ Compensation Care for Work-Related Injuries and Illnesses?
All Canadian jurisdictions use a single payer system. The Workplace Safety and Insurance Board (WSIB) pays for compensation care for work-related injuries and illnesses. The system is entirely funded through employer premiums.
Japan uses a single payer system funded through employer premiums like in Canada. Every employer, including those hiring just one employee, as well as dispatched workers and part-timers, is required to pay 100% of the insurance premiums, which fund the system.
In Turkey, a single payer system, the SGK, compensates for treatments due to work-related injuries or occupational diseases initially. Then, depending on the employee’s, employer’s, and third party’s roles and responsibilities involved in the incident, SGK demands reimbursement or payment (recourse) from the employer for treatment, retirement, or death compensation costs due to workplace injuries and diseases.
“Worker care” can involve a mix of state and employer-funded benefits payments, nursing and/or medical health care, and legal remedies in compensatory damages where injury or illness is someone’s fault. The U.K. Government’s Department of Work and Pensions pays disability benefits under the Industrial Injuries Scheme and other schemes in the form of a pension and/or other regular payments initially. Once responsibilities involved in the incident are established, employers’ insurers pay compensatory damages for pain and suffering, medical expenses, and loss of earnings usually as a lump sum, often settling “out of court.”
India doesn’t have a single payer system. There is a mix between ESI and private medical insurances taken by the employers to cover workers’ compensation for illness and injuries. All the organizations covered under the ESI Act and all factories that employ more than 10 employees and pay wages below Indian Rupees (INR) 21,000 per month (INR 25,000 for employees with disability) must register with the Employee State Insurance Commission and contribute towards the ESI. Both employers (3.25% of employee salary) and employees (0.75% of employee salary) contribute to the ESI. For workers whose wages are higher than the limit set by the ESI, employers must provide private medical insurance, which covers both work-related and non-work-related illness and injuries among employees and their immediate dependents.
Contrary to Canada and Japan, all work-related injury and illness care is covered by the company’s health plan and fully paid by the company in Brazil. Employees do not pay for treatment. When employees are unable to work due to a work-related illness or injury, employees are referred to Social Security, which partially pays for the days of absences and asks the company to cover the remaining costs.
Like in Brazil, the employers’ health insurances cover the work-related injuries and illnesses.
Employers pay for workers’ compensation benefits through either a fully insured or self-insured paradigm. In the United States, workers compensation is a no-fault, exclusive remedy. Employers are responsible to pay for “reasonable care,” lost time, and vocational rehabilitation if indicated—and employees largely waive their right to sue the employer—with few exceptions in rare circumstances. Most states allow for the scheduled payment of permanent partial or permanent total disability benefits in cases where there is permanent loss of function. Non-federal injured employees are managed as dictated by state law. The Department of Labor covers workers’ compensation (WC) care, case management and lost work time for federal employees (continuation of pay for 45 days and then two thirds of their estimated wages sans taxes), but costs are “charged back” to the employer. The Federal Employees’ Compensation Act (FECA) provides retraining if a worker cannot return to a prior job. Disabled employees receive additional payments set by the “compensation schedule” (e.g., loss of an arm would result in the employee receiving the equivalent of 312 weeks of “compensation” as a lump sum).
What Are the Advantages of Your Structures for the Provision of Workers’ Compensation Care for Work-Related Injuries and Illnesses?
In Egypt, all factories are mandated by law to provide all their workers with health insurance.
In India, the Workers’ Compensation Insurance Act of 2016 mandates employers to provide compensation to their employees or their dependents for work-related injuries and illnesses that occur during employment.
The Japanese WACI system ensures that injured or ill workers receive necessary and timely medical treatment without incurring personal expenses. It provides compensation for lost wages during the recovery period, protecting employees’ financial well-being.
As a single payer, the Canadian WSIB can leverage the public healthcare system in more flexible and unique ways than that of the province. As the WSIB is smaller than the public health system, the WSIB uses bundled programs and contracted services to directly benefit from timelier access and higher quality of care through a managed care model. The WSIB is also able to leverage its scale to negotiate terms for services (e.g., hearing aids).
Like Japan and Canada, the care provided to employees in Mexico is timely and very well structured. When the employee reports their injury or illness in a timely manner, good accompaniment is provided and a successful return to work can often be achieved.
Another advantage is that the high cost to companies of work-related accidents and occupational diseases serves as an incentive for companies to invest in safety and health and provide quality medical care.
This is the case in the United States too. Companies are motivated by the “General Duty Clause” of the Occupational Safety and Health Act of 1970 and financial considerations to provide a safe working environment. Individuals employed by companies, or the federal government, have rights and responsibilities defined by law.
In the U.K. Industrial Injuries Disablement Benefit (IIDB) Scheme, the employee does not have to prove any negligence on the part of the employer to be eligible for benefit if they worked in a listed occupation for the minimum specified time and developed the relevant disease. Industrial Injuries Disablement Benefit is payable on a “no-fault” basis. Health care is free at the point of access.
What Are the Disadvantages of Your Structures for the Provision of Workers’ Compensation Care for Work-Related Injuries and Illnesses?
In Egypt, the health insurance provided to workers does not cover all diseases. Despite the efforts of the structures in place to provide care, the care may be of lower quality and delayed due to the significant lack of resources.
SGK health insurance in Turkey only covers public hospitals, which delays care and affects the quality of care in comparison with private hospitals.
In India, employers try to remediate this issue by buying private medical and accident insurance which covers disability and death because the low compensation provided by the ESI puts more financial pressure on the employers.
There is a huge burden on the employers in Japan too. They must contribute to the WACI system, potentially impacting business costs. Furthermore, due to increasing employer liability, many companies are providing significant compensation to workers or their families for occupational accidents, in addition to the benefits offered by the WACI. This has led to a growing need for additional private insurance to enhance occupational accident compensation and employers’ liability coverage.
The process of establishing an employer’s liability, fault, or negligence is often a lengthy and expensive legal process in the United Kingdom. Employer liability claims are “fault based,” which requires a claimant to establish legal liability arising from a breach of common law or applicable statutory provisions. Whereas compensatory damages paid by employers found liable for causing injury or illness are designed to cover most losses suffered by the injured person, state benefit levels are calculated at objective levels to provide a basic welfare safety net without reference to the amount of the financial losses incurred by the individual concerned.
Like the United Kingdom, the legal process of determining liability and assessing eligibility for workers’ compensation can be complicated and expensive. Injured workers unable to meet complicated reporting requirements of state and federal laws may have claims denied. Workers’ compensation litigation is common. Employers accept questionable claims due to the high cost of lawsuits. Companies may sue other companies responsible for manufacturing equipment or items contributing to WC claim (subrogation). Private insurance companies refuse to pay for work-related injury or illness care. Care can be delayed while the WC and private insurance carriers determine liability. Strict separation of work-related and personal health care can result in suboptimal management. However, unlike employer-sponsored health insurance that can be accompanied by high employee cost sharing (co-payments, premiums, and deductibles), workers compensation typically provides reasonable medical benefits that are fully paid by the employer.
Is Access to Care an Issue for Certain Groups of Workers in Your Country? If So, Which Ones and Why?
Most of the workforce in Brazil is informal and hence does not have access to health care, legal support, and often not even social security. Only large companies are charged and fined for noncompliance with Health and Safety. Only employees who work in large companies have access to adequate health care.
IIDB in the United Kingdom only covers employed earners; the self-employed are excluded. Agency workers may also not be covered.
In Egypt, too, self-employed personnel and some small-scale industries workshops do not have health insurance.
“Gig workers,” contractors, and employees working in businesses with fewer than 10 employees may not have access to health or WC benefits. Several states have enacted laws requiring WC coverage for such workers. Many jurisdictions now cover migrant workers regardless of immigration status. Access can also be hindered in certain industries or management frameworks where an unprincipled culture discourages the reporting of occupational injuries and/or illnesses.
In Japan, foreign workers may face language and cultural barriers that hinder their access to appropriate healthcare services.
Another disadvantage is that the compensation assessment and calculation may take a long time in Turkey.
In India, access to care is an issue for those working in an unorganized sector such as agriculture, which accounts for a large proportion of the workforce. However, there are safety mechanisms in place. Workers in unorganized sectors are provided with free medical care through Government Primary Care Centers, District Hospitals, and Government Medical College Hospitals, and referral hospitals. In September 2018, the government launched a medical insurance system for those below the poverty line per the government criteria. Many of the workers in unorganized sectors are eligible for this medical insurance system.
Even if the public system can help increase access to care, disparities remain in the quality of care received.
Similar to India, this is an issue in Turkey. Employees who only have SGK health insurance and no private health insurance can only access public hospitals. Because public hospitals are overcrowded due to the discrepancy between the country’s population and the insufficient number of medical professionals (doctors), public health services are of lower quality and delayed. As a result, the treatment and care processes for work-related injuries and accidents may be impaired. Employees with private health insurance can access private health facilities, allowing them to get medical treatment and care quicker.
Access to health care is free to all U.K. nationals working in the United Kingdom through the NHS. Some larger and more extensively resourced employers will have their own supplementary arrangements on a private basis or may fund private health insurance premiums as a component part of an employee’s remuneration package. Although there is reasonable access to care for injured workers, an employee may be unable to work for significantly longer periods than first anticipated due to the increasing backlog of people waiting for treatment on the NHS. With many surgeries being delayed and postponed, there is often no definitive date of when the employee should be able to return. Those who have more funds and receive medical consultations, tests, or treatment on a private basis (not NHS) may be seen quicker. Self-employed workers are excluded from IIDB, or disability pension.
Geographic distance may also be a barrier to care. In Mexico, distance from IMSS clinics or hospitals especially for employees working in remote areas may be a barrier. However, any employee with an active social security number can be treated at any IMSS clinic or hospital.
There used to be barriers to care in remote regions due to differences in access to clinical staff across the province in Canada. Now through bundled models and contractual agreements, WSIB has been able to improve access to care and wait-times across the province. Effective use of virtual care has further improved access to care.
Is There a National Tracking System for Work-Related Injuries and Illnesses in Your Country? How Is Information Gathered?
The Association of Workers Compensation Boards (AWCBC) of Canada manages the National Work Injury Statistics Program (NWISP), which gathers data on work-related, accepted Lost Time Claims, Diseases and Fatalities across 20 major industries and 10 major occupation groups. Provincial and territorial Workers’ Compensation Boards and Commissions amass information submissions by primary sources—workers, employers, and healthcare practitioners—within their jurisdictions. These data are then coded according to several different factors and forwarded to the NWISP, where it is set into the appropriate statistical framework that allows for summaries nation-wide, for individual jurisdictions, and multiple cross-tabulation.
Egypt also has a national tracking system for work-related injuries and illnesses. Each health insurance organization has their own registry and then submits their data to the national registry.
The MHLW collects data from employers, healthcare providers, and labor inspection offices to maintain the Industrial Accident Information System, which is the national database of work-related injuries and illnesses in Japan.
In Mexico, the national tracking system for work-related injuries and illnesses is regulated by the Social Security Law. The information collected is categorized in terms of (a) Disability issued by IMSS.
(b) ST7: format to determine if the injury or illness is related to work
(c) ST4: format for granting invalidity status
(d) ST3: format for issuing temporary or partial disability
(e) ST2: format to grant medical discharge for a work accident
The SGK gathers and publicly publishes all the data obtained from all the employers around Turkey on a yearly basis. Every employer is required to collect, classify, archive, and notify the SGK of all occupational injuries and work-related diseases within their company via the online e-SGK portal. Every new work-related injury or occupational disease must be reported to the SGK within 3 days by the employer. Private and public hospitals are mandated to independently report every employee hospitalized for the treatment or work-related injuries and diseases to the SGK.
All injury or illness claims in the United Kingdom must be registered with the Compensation Recovery Unit within the Department for Work and Pensions. New cases of specified “prescribed diseases” (with an established occupational cause) assessed for compensation under the Industrial Injuries Disablement Benefit scheme are recorded. Certain types of work-related injuries are reportable by employers under Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). Physicians report work-related ill health (respiratory disorders and skin disease) in surveillance schemes run by The Health and Occupation Reporting network (THOR and THOR-GP).
All employers with more than 10 employees are required to report certain work-related injuries and illnesses via the Occupational Safety and Health Administration (OSHA) 300 A annually. Precise definitions exist as to what injuries and illnesses are “reportable.” Information gathered through these required reporting forms is analyzed and published by the National Bureau of Labor Statistics, a division of the Department of Labor.
Although all work-related injuries and illnesses must be reported to the government through Social Security and various indicators are generated, underreporting is very common in Brazil and potentially punished with very high fines.
There is no accurate data on work-related injuries and illnesses in India. The data available are heavily underreported. Only the organized sectors have a system to report work-related injuries and illnesses, but the organized sector only represents about 30% of the total workforce. There is no workers’ compensation system nor reporting of work-related injuries and illness for the workers of the unorganized sectors, which represent more than 70% of the workforce in India. For the organized sector, all ESI organizations are required to report to the Ministry of Labor & Employment. However, the medical staff of the ESI organizations are not trained in Occupational Health, and they seldom check for work history. The ESI system is used more as a general health benefit/insurance plan for both the employee and their dependents rather than as a workers’ compensation. Only work-related fatalities that cannot be hidden easily are reported. Work-related fatalities of contract workers are largely unreported and contract workers are given increasingly more hazardous tasks.
Summary
From a global perspective, workers’ compensation is offered through a national social security system, a national public workers’ compensation system, a combination of a national public system supplemented by private insurances provided by the employers, or solely through private insurances provided by the employers. However, the system may differ within a country by region.
Workers’ compensation is financed through single payer system funded through employer premiums, through a single payer system initially that later asks reimbursement from the employer or is followed by contributions directly from the employer or employer’s insurance depending on the employer’s responsibility, through a combination of the employer’s health insurance for medical costs and the national social security for medical leaves, or solely through the employers’ health insurances (whether public or private insurances). The financial burden for the higher quality of coverage is on the employer.
The structures in place for workers’ compensation for work-related injuries and illnesses are meant to ensure timely access to quality care and services. There are incentives to optimize the safety of the working environment. There remain areas for improvement. Resources can be limited, especially within the public health system, which delays care and affects the quality of care. In addition to issues with the timeliness and quality of care, there may be a long, complicated, and expensive legal process to evaluate liability and eligibility for workers’ compensation.
There are significant disparities in terms of workers’ compensation care and reporting of injuries and illnesses. Informal workers, workers in small companies, and sometimes foreign workers do not have access or the same access to care. Some of the riskiest and lowest paid jobs have the least coverage and lowest number of reported work injuries. The government in India set up a telehealth system to provide care to the many workers in the unorganized sector, but work-related injuries and illnesses in the unorganized sector still go unreported. Geographic distance may also be a barrier to care. Canada is remediating this through the implementation of virtual technologies.
Occupational Health Services and national reporting databases have been set up throughout the world to support and care for workers. Areas for improvement identified during this round table include timely access, reducing the impact of liability and eligibility determination on actual access to medical care, equitable access to care for all workers, and the accuracy of the reporting. Successful practices include the Canadian managed care approach model to provide timelier access and higher quality of care to injured or ill workers even if still through a public system, the use of virtual technologies to reach workers in more remote areas, and national safety nets to support injured or ill workers who do not have access to workers’ compensation. Given the significant socioeconomic burden of work-related injuries and illnesses, a future round table may discuss international practices for workplace safety and disease prevention.
Applications to Professional Practice
Areas for improvement identified during this round table include timely access, reducing the impact of liability and eligibility determination on actual access to medical care, equitable access to care for all workers, and the accuracy of reporting. Successful practices include the Canadian managed care approach model to provide timelier access and higher quality of care to injured or ill workers even if still through a public system, the use of virtual technologies to reach workers in more remote areas, and national safety nets to support injured or ill workers who do not have access to workers’ compensation. Occupational Health Services (OHS) and national reporting databases have been set up throughout the world to support and care for workers. Given the significant socioeconomic burden of work-related injuries and illnesses, a future round table may discuss international practices for workplace safety and disease prevention.
Footnotes
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
