Ill health, social protection, labour relations, and sickness absence

Short abstract

Commentary on the paper by Virtanen et al (Occup Environ Med, March 2006)*

Health and work have a bidirectional relationship. Hazardous work can produce negative effects on health, in terms of injury and disease. It is less evident that ill health, due to the work environment or not, can produce negative effects on work in terms of absenteeism and low productivity. Sickness absence is an expression of this complex relation. In the first place sickness absence is necessary for the recovery of ill workers,¹ as part of the medical treatment, and as such it is certified by a physician. In a second and complementary perspective, sickness absence is a consequence of ill health on work in terms of absence from work. Indeed, it has been considered as an indicator to measure the working population's health status,² and also it may be considered as an indicator to measure the functioning of the companies.³ In other words, sickness absence might be considered as something else beyond simple ill health.⁴

Taking the natural history of diseases as an analogy, a natural history of sickness absence illustrates that ill health (for example, a common cold) could develop into a sickness absence spell or not. There is solid evidence that whether this happens or not, depends on the working conditions of the job (for example, high physical demands), and on personal characteristics of the worker (for example, older age). However, what is very often forgotten is the role played by a third determinant, namely the social protection system, for example, percentage of benefits covered. For instance, a 50 year old manual worker who has a common cold and has social protection benefits that only cover 60% of the salary and do not pay the first three days of sick leave, probably he/she will not take a sickness absence spell. In addition to ill health, and after assessing their working and personal conditions, ill workers will consider what their social benefits are in the case of taking sick leave. It is likely that many workers take all these considerations into account before going to the doctor and asking for a sick leave certificate.

This third determinant (social protection system) is critical to explain the progress from ill health to sickness absence, and is often omitted in our analyses, and interpretations.⁵,⁶ In the current economic period, public policies from governments act essentially on this determinant to try to control the budget of their social protection system, reducing the benefits of workers with sickness absence. At the same time public policies do not take into account the workers who work while ill. This situation, which has been called “presenteeism”,⁷ could increase the risk of more severe diseases.⁸

In the March issue of this journal, Virtanen and colleagues,⁹ from the “Finnish Public Sector Cohort Study”, provide valuable evidence about the complex association between health and work, specifically the role of the labour relations. Among public sector workers, a high rate of sickness absenteeism significantly increases the risk of job termination and unemployment in temporary employment. Conversely, permanent workers with high rates of sickness absence appear to be protected against job termination and unemployment by job security and disability pensions. Ill workers have to introduce a new variable in their algorithm before going to the doctor and asking for a sick leave certificate: sickness absence may affect their employment status. Despite temporary workers having less sickness absence than permanent workers,¹⁰ sickness absence in temporary workers seems to be a predictor of job termination (mainly in women) and unemployment. As Virtanen and colleagues have found, sickness absence may be one of the factors associated with the potential non‐renewal of a temporary job contract, and consequently could be an additional cause of presenteeism. This association is probably worse among private sector workers.

This situation is clearly unjust and can lead to a vicious circle. It has been clearly established that sickness absence is a valid predictor of health.¹¹ A temporary worker with high sickness absence has a high probability of being condemned to a poor career with periods of temporary work and periods of unemployment. This hypothesis is consistent with recent evidence which shows that some forms of temporary contracts are related to some social indicators such as remaining single and having fewer children when married or cohabiting.¹²

In conclusion, in an ever more globalised economy with an increasing number of temporary workers, governments must reinforce their social protection systems instead of reducing them, if one of the aims of our societies is to avoid increasing marginalised people. As Virtanen and colleagues have shown, flexible employment is an obvious public health problem, which should be included in our scientific and professional agendas.