A Toolkit for Strengthening Health Care Policies and Infrastructure of Industries in Developing Countries.

BACKGROUND: The health risks faced by textile workers calls for a workplace health system that is comprehensive and accessible. To enhance the capacity of workplaces to strengthen their health system, a toolkit was developed by the Business for Social Responsibility (BSR), a non-profit global business network and sustainability consultancy.
METHODS: The Health System Strengthening (HSS) toolkit was designed to provide a set of tools, resources, and concrete steps for the factory management and health staff to work toward continuous improvement of their on-site health systems. It was then implemented with academic collaboration simultaneously In three factories/ in three manufacturing units/ in three workplaces in South India over 6 months to find out its usefulness as a self-reference tool for HSS. Monitoring and evaluation tools and indicators were developed based on the logic framework.
RESULTS: The main outcomes of the HSS pilot program include the formation of a health committee which was able to utilize the modules, perform a self-assessment of the health system, and come out with short- and long-term action plans for HSS under expert supervision and guidance.
CONCLUSIONS: Overall, the toolkit was found to be an effective solution for HSS in industries which require expert guidance for implementation. Copyright:

INTRODUCTION

The Indian subcontinent has seen tremendous industrial growth with the textile and garment industries contributing to 13% of the export earnings of the country.[12] This huge contribution from the textile industry has been the outcome of a large number of laborers involved in long hours of repetitive and monotonous work which could put them at risk of general, and occupational health problems unique to this industry.[3]

The health risks faced by the textile workers call for a workplace health system that is comprehensive and accessible. Health services that are currently offered within the workplace are underutilized as they are most often poorly equipped, lack trained staff, and have weak linkages with external healthcare providers. The existing external systems of healthcare in the private sector are either expensive or inaccessible, and on the other hand, the health services offered by the state are poorly utilized due to unfriendly timings, lack of adequate services, and facilities.[34]

The current health systems and services in the industries are modeled and regulated by the Indian Factories Act. The industries restrict themselves to fulfilling the requirements of the act and focus only on the basic parameters.[5] This is also partially fulfilled in most industries due to the lack of trained workforce available for providing occupational health services. Sharma et al.[6] identified a 50% deficiency of trained workforce for providing occupational health services in industries across India.

Saha, in his extensive review of occupational health status in India, has raised an urgent need for the development of institutions and infrastructure of occupational health, need for spreading awareness of occupational health-related issues among all stakeholders, need to increase awareness about the concept of occupational health nursing, and to have in policy for safety, health, and environment in the workplaces.[7] Growing industrialization, changing profile of health needs of workers together with the lack of a system for providing occupational health services, calls for an urgent need to set up comprehensive and sustainable workplace health programs (WHP).[689]

To enhance the capacity of the workplaces to strengthen their health system, a toolkit was developed by the Business for Social Responsibility (BSR), a non-profit global business network and sustainability consultancy. The overall goal of the toolkit is to provide a set of tools, resources, and concrete steps for factory management and health staff to work toward continuous improvement of on-site health services. The toolkit was pilot-tested by a collaborative effort of BSR and its academic partner based in South India. They teamed previously for a health educational interventional program called 'HERproject' targeted to improve the health of female workers in the textile and garment industry.[10]

This paper explains in detail the various phases of the development and implementation of the toolkit, monitoring, and evaluation framework used, the outcomes of the pilot initiative, and the perceptions of the industries about the usefulness and challenges in using the Health System Strengthening (HSS) toolkit.

METHODS

The pilot program was implemented by the academic team simultaneously in three workplaces in South India over 6 months between May and October 2017. A detailed description of the two phases of the study is given below.

Description of the phases of the program

A framework of the various components of the two phases of the study is depicted in Figure 1 followed by a detailed description of the two phases.

Figure 1

Framework of the phases of implementation of the program

Phase. 1a: Development of Health System Strengthening toolkit

The HSS toolkit comprises two main components: (1) Tools for self-assessment; (2) Capacity-building resources.

Tools for self-assessment

The self-assessment component of the toolkit consists of a clinic scorecard [Figure 2] and a mapping tool. The self-assessment tool known as the scorecard was used to benchmark the workplace health system's performance. The scorecard was divided into two sections (a) on-site services and (b) workplace systems and policies.

Figure 2

Outline of the scorecard

Each indicator under these benchmarks was demarcated as basic (B), middle (M), or high (H) based on the priority level. A workplace could self-score its performance by assigning a color code based on the presence and functionality of a particular indicator, and if any improvements are necessary. A mapping tool was developed along with the clinic scorecard to help the management teams map out the external health service provisions, assess existing partnerships, and identify potential partnerships to meet the workers' needs and implementation resources.

Capacity-building resources

The capacity-building component of the toolkit consisted of complementary resources for the workplace team and resources for the academic team. For the workplace team, the resources included self-reference modules and videos; for the academic team, facilitation resources were provided.

Phase 1b: Capacity building of the implementing partners

Phase 1b of the program included capacity building of the implementing (academic) team, selection of the intervention site, and pre-implementation preparations.

Phase 2: Pilot testing of the health system strengthening toolkit

The second phase of the program was initiated with a kick-off meeting with the senior management. This was followed by the baseline assessment of the workplaces using qualitative methods like interviews, focus on group discussions, and observation of clinics to understand the existing health system of the factories. Following baseline assessment, a HSS team was formed at the factories and they were oriented to the modules and scorecard. The HSS team then conducted a self-assessment of the health system. The results of which were calibrated with the findings of the academic team. Short- and long-term action plans were developed by the committee based on the gaps identified. The final and crucial step was the closing meeting was attended by all stakeholders. The HSS team presented their action plans and the way forward.

Monitoring and evaluation framework

The logical model for program planning and evaluation which has been an effective tool for monitoring and evaluation of programs and interventions was used throughout the pilot of the HSS toolkit to monitor progress.[11] The summary of the various phases of the pilot program along with relevant indicators are given in Table 1.

Table 1

Summary of monitoring and evaluation framework of the Health System Strengthening toolkit pilot-based on the logic model

Phases of the model	Activities in the program	Indicators
Input (resources)	Academia team to facilitate the health system strengthening at the factories	Number and composition of members of the academic team
	Toolkit with self-assessment component and capacity-building resources	Availability of the capacity-building resources
	Implementation package	Number and expertise of the members of the health team at the factory
	Health System Strengthening Committee identified and formed at the factory level
Process	Baseline assessment by the academia team at the factory	Report on baseline assessment
	Periodic visits by the academic team for facilitation of the toolkit, building capacity of the factory HSS committee, and overall program monitoring	Number of visits conducted by the academic team
		Strength of members from the health team attending the meetings with the academic team
Output	Utilization of capacity-building resources by the HSS Committee, especially the clinic staff at the factory	Self-assessment results on the clinic scorecard
	Self-assessment of the factory health systems using the clinic scorecard	Presentation of the short- and long-term action plans
	Identification of areas for improvement and develop short-term, medium-, and long-term action plans for the health system strengthening	Approved action plans and completion of the short-term action items before pilot closing
Expected outcome	Implement the health system strengthening measures from the action plan	Periodic self-assessment using the “scorecard’
	Functioning of a comprehensive health system at the workplace	Improved clinic attendance
	Improved access to healthcare products and services	Improved satisfaction of the workers

RESULTS

Section 1: Profile of the factories

A total of three factories (one garment and two spinning mills) were included for the pilot study with a worker strength ranging from 600 to 2000. A majority of the workers in the garment industry were women residing within the factory premises. All the factories have a functioning clinic with a staff nurse. The spinning mill had a full-time physician and nurses working in shifts. From the “mapping exercise,” it was understood that all the factories had established linkages with external service providers, both public and private. Social protection benefits covering health and accident insurance are available through the Employees State Insurance (ESI) for all permanent workers.

Section 2: Outcome of intervention of the program

Table 2 provides a summary of a few areas of improvement identified in different assessment parameters like physical infrastructure and strengthening health committee. The areas of concordance and discrepancy between the factory and academic team can also be observed from the results.

Table 2

Areas for improvement identified by the health team

Assessment parameters	Factory 1		Factory 2		Factory 3
	Factory health team	External evaluation	Factory health team	External evaluation	Factory health team	External evaluation
Physical facilities products equipment materials	Need for the improvement of the clinic facilities, increase the number of health personnel, and to provide patient-waiting area		Nil		Need to strengthen clinic facilities
Facility policies and procedures	Not identified	Need to improve disinfection protocols, develop policies for ensuring confidentiality and safety during patient care	Not identified	Infection prevention protocols not in place	Need for more insurance facilities for workers as private facilities are more utilized.
				Need for the development of policies for regular pre-placement screening for all workers and to develop policies to address grievances of the workers’ concerns for health care
Referral and provision of care	Need to organize non-communicable disease screening program		Nil		Nil
Education and counseling	Not identified	Need for providing health education and counseling in nutrition, hygiene, contraception, and non-communicable disease risk factors, occupational diseases	Not identified	Need for providing health education and counseling in nutrition, hygiene, contraception, and non-communicable disease risk factors and occupational health risks	Increase scope for the nurses to be involved in health management like taking an active role in committees, providing counseling services, etc.
Management system and corporate leadership	Need to initiate and involve health committee in health planning and budgeting		Need for a health committee, written policy on health management: the hiring of workers, appraisals, promotions, etc., and streamlining of health budgeting		Need for strengthening of health committee; their roles and responsibilities, develop written policy on health management-hiring of workers, appraisal, promotions, etc., and streamline health budgeting

*“Nil” denotes that from the assessment no area for improvement identified by the factory and academic team. “Not identified” denotes the academic team has identified gaps but the health team missed the gaps

Then, a concordant list of areas for improvement was developed by the teams in all three factories, which was one of the main expected outcomes of the program. Short-term action plans focused on improving clinic facilities, strengthening biomedical waste management, and ensuring availability and displaying health education materials. Long-term plans focused on improving the physical infrastructure of the clinics, budget reallocation, and strengthening the healthcare team, and bringing policy-level changes.

Section 3: Reaction and perception of the factory team regarding the HSS program

Table 3 is a summary of the perceptions and experiences of the factory team regarding the program in all three factories. The HSS program was a new experience for all three factories.

Table 3

Perceptions and experiences of the program from the pilot industries

Components	Perceptions of team members about the program
Capacity-building resources	“The module on budgeting was a very useful resource for us as we had no idea earlier as to what are the components of a health budget. Now, we are able to do line listing of items.” HR Manager
	“The toolkit will be a good resource to improve our clinics as it gives us a guideline of how a clinic should function, why and how a health budget should be planned.” General manager
Self-assessment using scorecard	“Scorecard was a handy tool for us to self-assess our clinic and come up with short- and long-term plans to strengthen our clinic.” HR manager
	“Rating Methodology-Level (B, M, H) and Red, Yellow, Green very innovative. Just by seeing the color coding, we will be able to have a clear idea of which areas to improve. ” Nurse
	“By using this scorecard-almost everything related to dispensary like what records to maintain, what information to display in the clinic, what cleanliness measures to be followed, was covered.” Nurse
Overall impression of health system strengthening program	“Apart from the module, you have given such valuable health- and hygiene-related guidelines to our staff.” Labour Welfare Officer
	“This strengthening process will be useful for us as we are applying for OSHA certification where health system strengthening is the main component.” Senior Manager
Change in attitude and behavior following the program	“More involvement from the nursing staff into the HR system. She now helps us in budgeting.” HR Manager
	“Increased proactiveness of the nurse.” HR Manager
	“We feel the need to strengthen ourselves in managing communicable diseases, prevent outbreaks.” HR Manager
Outcome of the program	“We have modified the job description of our nurse widening her scope of work.” Senior Manager
	“We have improved the physical infrastructure of our health center.” Nurse
	“We have started making our budget and we already notice that there is a decrease in the cost of medicines as we used to buy unnecessary medicines earlier.” HR manager
	“We have made a policy to send our health staff for continuous professional development programs at least twice a year” HR manager

DISCUSSION

The present study was piloted to develop and implement a HSS package consisting of self-assessment tools to improve the health facility and resources for capacity building of the staff in the factories and to understand the usefulness of the package for the industries. This intervention is very much needed in workplaces as only 5–10% of the industries in the developing countries have employee health services, that too, mostly restricted to the manufacturing industries.[12]

The baseline assessment using a multipronged approach helped to understand the existing health systems at the factory level and the gaps and strengths in running their health systems parallelly with the business operations. All the factories had established a good linkage with the public service providers but utilization was less due to issues in timings and having to wait for long hours. Lack of awareness regarding the benefits of ESI services and low trust levels in the government health institutions were added reasons for poor utilization of the services. Rashidha, in her study in Kerala, observed similar reasons for the average or low utilization of ESI services among the respondents.[13]

The HSS toolkit was designed as a self-reference tool for workplaces. During its pilot run, valuable insights were gained from different stages of its development and piloting. While the toolkit was well-received by all the three pilot factories, it was realized that the toolkit in itself could not be used by the factories without proper orientation and facilitation on the different components and resources through a systematic approach.

The clinic scorecard was well appreciated as an internal audit tool by the factories to track their health systems periodically. The role of the standardized assessment criteria using checklists or any validated tools for the improved quality of healthcare has been emphasized by many authors.[1415] In the first attempt, workplaces tend to score themselves higher on the scorecard, assuming they have all things in place. However, an external non-biased assessment of the workplace health systems using the same scorecard can bring out completely different results. In our pilot study, we found discordance between the factories and external agencies in identifying gaps in counseling and education and policies and procedures. This finding is not surprising considering that workplaces generally look beyond occupational safety as observed by Pescud et al.[16] The WHO has emphasized the role of senior management in establishing workplace health policies and the participation of employees for the proper implementation of such health policies.[17]

An important outcome from the program was a better role clarification of the occupational health nurse, commitment of the management to establish policies for ensuring the continuous professional development of the nurse. The nurses who participated in the program have expressed that the scope of their job has been widened as an outcome of the pilot and they feel that they can play a proactive role in the industry. The multidisciplinary role of the occupational health nurses and the need for strengthening their capacity has been emphasized by the WHO.[17]

Another key outcome from this pilot was the realization that workplaces are primarily preoccupied with business operations, and despite the best intentions, may lack the knowledge and skills required to strengthen healthcare support for their workforce. While the HSS toolkit is well-designed for self-reference use for factories to fill this gap, it is not a complete solution in itself. For best results, it is preferable that an expert agency facilitates this toolkit and builds the capacity of the factory management toward strengthening their health systems.

CONCLUSIONS

Conducting a self-assessment using a validated tool is an effective method for workplaces to identify the gaps in their existing health systems, and further propels them toward their next steps in making action plans for short- and long-term duration. This exercise once facilitated by an expert organization can pave the way toward a self-sustainable practice that the workplaces can periodically continue to review and strengthen their health systems. A tool that was tested in the textile industries can as well be used in any industrial setup with expert guidance.

Ethics approval

The study was cleared by the Institutional Human Ethics committee of PSG Institute of Medical Sciences and Research, Coimbatore, India.

Financial support and sponsorship

The project was implemented through HERproject, Business for Social Responsibility, USA.

Conflicts of interest

There are no conflicts of interest.