Time for a global response to labour rights violations in the manufacture of health-care goods

Bull World Health Organ 2017;95:314–314A | doi: http://dx.doi.org/10.2471/BLT.17.193417 Editorials 314 On 23 March 2017, the British Medi- cal Association, in partnership with the Sustainable Development Unit for the health sector in England, released Ethical procurement for health: work- book 2.0,1 a guide and workbook for protecting labour rights in medical supply chains. This is an update to a document released 6 years earlier in response to evidence of abuse of worker rights at several factories manufacturing health-care products destined for global markets. Poor labour conditions should concern all those in health care. Work is inextricably correlated to physical and mental well-being: unsafe working con- ditions risk bodily injury; inadequate remuneration links to malnutrition, poor housing and lack of opportunity.2 Long or irregular working hours and a lack of respect at work contribute to stress, anxiety and depression.3 Working conditions found in the manufacture of some health-care prod- ucts have been among the worse en- countered anywhere. Most medical gloves are manu- factured in factories in Malaysia or Thailand, where employees are usually immigrant workers.4 Interviews with some of these workers revealed that many had secured employment by pay- ing extortionate fees to international recruitment agencies in exchange for poorly paid jobs.4 Most will work 12–13 hours a day, 7 days a week, and suffer exhaustion.4 Some have been subject to bullying and harassment. In one in- stance, an employee alleged that he was imprisoned in a factory and threatened with physical violence by the employer.4 An estimated two-thirds of the 150 million reusable and disposable surgical instruments in the global market are produced each year in Sialkot in north- ern Pakistan.5 Here, over 50 000 workers do most of the filing, grinding, ham- mering and polishing of instruments by hand.5 They will regularly work over 80 hours a week for an inadequate wage, and frequently suffer musculoskeletal injuries, that are sometimes incapacitat- ing. The surgical instruments’ industry in Pakistan employs hundreds of chil- dren, some aged as young as 7 years. Many children work to pay off debt to their father’s employer. Most work full time and receive no formal education and are thus trapped in poverty. Long working hours and low pay has also been noted in the manufacture of surgical masks in Mexico6 and health- care uniforms in India.7 People working in the manufacture of medical goods, in general, are considered at high risk of labour rights abuse8 because most of the factories are located in countries where such abuse is frequent. The British Medical Association, through its Medical Fair and Ethical Trade Group,9 has coordinated an inter- national response to this issue. Suppliers of goods have been reactive in their need to protect workers. Significant progress has only been made through developing new regional and national procurement policies. Since 2010, health care procure- ment in all 21 regions of Sweden has been bound by a code of conduct,10 requiring suppliers to comply with the International Labour Organization Declaration on fundamental principles and rights at work, as well as with local employment and health and safety legis- lation. For high-risk products, suppliers are also contractually required to allow independent audit of manufacturing sites to identify problems and to oblige remedial action. This requirement has led to demonstrable improvements in working conditions for the people making surgical instruments,11 gloves4 and textiles that supply the Swedish health-care system. Monitoring has led to better remuneration, a reduction in working hours, improved health and safety and elimination of unfair recruit- ment fees in factories in India, Malaysia and Pakistan. A similar approach has been used by South-Eastern Norway Regional Health Authority12 with com- parable outcomes. In England, the single largest procurer of medical goods is the Na- tional Health Service (NHS) Supply Chain. In 2007, the NHS Supply Chain released a supplier code of conduct, and then in 2012 introduced the La- bour Standards Assurance System, a contractual obligation for suppliers of surgical instruments to assess and continually improve working condi- tions.13 This system has now been extended to other high-risk products, including textiles and gloves. This ap- proach has been successful: only one of 29 approved surgical instrument suppliers to the NHS Supply Chain subsequently had their contract ter- minated for failure to demonstrate protection of worker rights. These policies are a step in the right direction, leading to hundreds of mil- lions of United States dollars (US$) of health care purchasing coming under scrutiny for labour rights protection. Yet this still represents only a small propor- tion of the global market for health-care products, which is growing, and esti- mated to soon be worth over US$ 500 billion annually.14 When more health-care providers adopt ethical procurement policies, respect for workers will become a norm in this industry. Ethical procurement for health: workbook 2.0 is a resource that provides governments, institutions and individuals with guidance and a toolkit to help achieve that aim. ■ Time for a global response to labour rights violations in the manufacture of health-care goods Mahmood F Bhuttaa References Available at: http://www.who.int/bulletin/vol- umes/95/5/17-193417 a Medical Fair and Ethical Trade Group, International Department, British Medical Association, BMA House, Tavistock Square, London WC1H 9JP, England. Correspondence to Mahmood F Bhutta (email: m.bhutta@doctors.org.uk). E itorials Editorials 314ABull World Health Organ 2017;95:314–314A | doi: http://dx.doi.org/10.2471/BLT.17.193417 References 1. Ethical procurement for health: workbook. (Version 2.0). London: British Medical Association; 2017. Available from: http://www.sduhealth.org.uk/ areas-of-focus/commissioning-and-procurement/procurement/ethical- procurement-for-health-workbook.aspx [cited 1 Apr 2017]. 2. Marmot M. The influence of income on health: views of an epidemiologist. Health Aff (Millwood). 2002 Mar-Apr;21(2):31–46. doi: http://dx.doi. org/10.1377/hlthaff.21.2.31 PMID: 11900185 3. Harvey SB, Modini M, Joyce S, Milligan-Saville JS, Tan L, Mykletun A, et al. Can work make you mentally ill? A systematic meta-review of work-related risk factors for common mental health problems. Occup Environ Med. 2017 Mar;74(4):301–10. doi: http://dx.doi.org/10.1136/oemed-2016-104015 PMID: 28108676 4. In good hands: Tackling labour rights concerns in the manufacture of medical gloves. London: British Medical Association; 2016. Available from: https://www.bma.org.uk/collective-voice/influence/international-work/ fair-medical-trade/medical-gloves-report [cited 1 Apr 2017]. 5. Bhutta MF. Fair trade for surgical instruments. BMJ. 2006 Aug 5;333(7562):297–9. doi: http://dx.doi.org/10.1136/bmj.38901.619074.55 PMID: 16877453 6. Santhakumar A, Bhutta MF. Labour rights violations in the manufacture of healthcare goods. ENT Audiol News. 2015;24(1):56–7. 7. The dark side of healthcare. Stockholm: Swedwatch; 2007. Available from: http:// www.swedwatch.org/en/reports/dark-side-healthcare-0 [cited 1 Apr 2017]. 8. Framework for an ethical procurement strategy for the healthcare sector. London: Impactt Ltd; 2008. 9. Fair medical trade. London: British Medical Association; 2017. Available from: http://www.bma.org.uk/collective-voice/influence/international- work/fair-medical-trade. [cited 1 Apr 2017]. 10. Code of Conduct for Suppliers. Stockholm: Stockholms läns landsting; 2013. Available from: http://www.sll.se/om-landstinget/socialt-ansvarstagande/ [cited 1 Apr 2017]. 11. Jaekel T, Santhakumar A. Healthier procurement: Improvements to working conditions for surgical instrument manufacture in Pakistan. Stockholm: Swedwatch & British Medical Association; 2015. Available from: http://www. swedwatch.org/en/reports/healthier-procurement [cited 1 Apr 2017]. 12. South-Eastern Norway Regional Health Authority: Ethical guidelines. Hamar: Helse Sør-Øst; 2010. Available from: https://www.helse-sorost.no/south- eastern-norway-regional-health-authority [cited 1 Apr 2017]. 13. NHS Supply chain sustainability corporate statement. Alfreton: NHS Supply Chain; 2016. Available from: https://www.supplychain.nhs.uk/about-us/ sustainability/ [cited 1 Apr 2017]. 14. Global market for medical equipment - Analysis and forecast 2010-2020. May 2016 - Aruvian’s Research - 380 pages. Lyon: ReportLinker; 2017. Available from: http://www.reportlinker.com/p03823889-summary/Global-Market-for- Medical-Equipment-Analysis-and-Forecast.html [cited 1 Apr 2017].