Occupational Health Barriers in South Africa: A Call for Ubuntu

Challenges Facing a Positive OH Culture

Our focus is on challenges at a facility level, with emphasis on what contributes to the failures to provide effective access, coverage and utilization of OH services to positively impact the health and well-being of HWs.

• Stewardship, arguably the most complex but critical aspect [16], is an ethical value that embodies the strategic guidance and oversight for planning and management of OH resources [18]. This, we observed, is the most important influence on whether HWs have access, coverage, and utilize functional and effective OH services. Top management aligned with trade unions, is responsible for stewardship, which requires political and technical acumen and actions. Top management should seek the participation of provincial political and administrative leadership in OH, as this would increase the financial and human resources for OH as well as be visible and participate actively in OH, so as to lead by example. These leadership and stewardship roles have proven to be lacking based on our observation and where present, OH resources, access, coverage and utilization were notable higher.

  Further, we observed that passive leadership and stewardship on OH services by top management and trade union representatives negatively affect the implementation of OH interventions. Since management is accountable for OH, the continued lack of use of effective intelligence systems for OH decision-making is another challenge [15], which is compounded by the lack of appropriate procedures in OH governance systems.

  Although South Africa is often said to have ‘good laws/and or policies for OH’ [14, 19], these are mostly driven by a top–down approach. During the COVID-19 pandemic, facilities in our research projects received COVID-19 policies and plans prepared by provincial departments of health [14] that were then distributed within each health facility by the OH or IPC coordinators to unit or ward managers along with other documents. These were not always reviewed at the local facility level to ascertain their relevance and to provide education and training for HWs; in a nutshell, the culture of ‘ticking the box’ was fulfilled and the facility leaders and/or stewards did not oversee, monitor or evaluate the implementation of the policies and procedures outlined in the documents.

• Access to OH services is a right recognized by the United Nations, and it is the responsibility of the employer to provide and fund [8, 20]. However, in our setting, there are no clearly ring-fenced budgets for OH, and managers do not budget for OH services [14, 15]. Furthermore, while facilities may have OH professionals rendering services, they are not always present in sufficient numbers or adequately trained. In our setting, even wealthier facilities, OH staffing was often much lower than international norms [21] and nurse-driven. These OH nurses were competent, passionate, and hardworking, but were often overwhelmed and overworked, including having responsibilities for other programmes.

• In South African law, each workplace has to nominate, elect, and appoint health and safety representatives, and where at least two representatives are in place, establish a health and safety committee [22]. The health and safety representatives and committees working with management are to initiate, develop, promote, and review OH measures; where present and effective these committees are associated with fewer health and safety incidents and citations [14]. At the height of the COVID-19 pandemic, we were part of a nationwide drive for the establishment, monitoring, and evaluating the functioning of health facilities’ health and safety committees [14, 23]. While the committees were present, we found them to epitomize the culture of ‘ticking the box’, lacking bipartism (i.e., employer–worker collaboration), with the employer mostly not represented, and the committee members lacking training on their OH duties, even though training has been shown to be beneficial [24]. As an example, a general observation found that hazard identification and risk assessment reports were not conducted in consultation with health and safety representatives and trade unions, not presented at the committee and most committee members had never seen these reports, so were not in a position to implement the recommendations. Further, the trade unions tended to be silent even when present in these committees, suggesting that they may require empowerment in their role.

• Information and information systems on OH are generally poor in the facilities and unable to provide OH intelligence for decision-making [15]. An intervention study examining the installation, establishment, and utilization of an OH and safety information system failed to be implemented during the stipulated study period, further raising the question about the culture of OH [15].

Without rigorous research on the reasons for delayed uptake of the interventions, we can only offer our viewpoint regarding the lack of leadership and stewardship, lack of bipartism on OH, overworked and overwhelmed OH nurses, ineffective health and safety committees, and shortage of resources. We observed that HWs were not holding management accountable for OH, possibly because their trade unions were not active and providing communication to their members, and thus the HWs were not empowered to know their rights.

The Canadian members of our international team note that OH services for HWs are not necessarily strong in their facilities either. However, in the Canadian province where team members are based, there is indeed a functioning OH information system [25], and the much better-resourced public health and infection control infrastructure, combined with a much lower burden of disease, makes the deficiencies somewhat less consequential than is the case for LMICs. Indeed our WHO survey found that OH and IPC mitigating measures during the pandemic were much less acceptable in the African region compared to wealthy countries, especially those with less disparity [26]. As such, the urgency of addressing OH in LMICs needs to be seen as a high priority.