4. Government policies to promote health and well-being at work: An analysis of ten OECD countries

Shunta Takino
Alena Piatrova
Pedro Isaac Vazquez-Venegas
Hyunjin Kang
Marion Devaux
Michele Cecchini

Governments play an important role in steering employers to promote the health and well-being of their employees in the workplace through a mix of regulations, incentives and the dissemination of information. In many circumstances, self-interested employers will see the promotion of health and well-being of their employees as a priority as discussed in Chapter 3, but this may not always be the case. Moreover, the costs of a lack of action to promote health and well-being that falls directly on employers accounts for only a fraction of the total economic cost, which includes reduced employment, pressures on the social security system and increased costs for health systems as discussed in Chapter 2.

The responsibility for employers to protect the health and safety of their employees is well-established both in international and legal policy contexts, but this is often narrow and limited to preventing accidents, injuries and deaths related to work, and misses the opportunities that the workplace presents as an ideal location for intervention and early action to prevent ill-health. This chapter, in line with the report-at-large, looks primarily at how policy levers can encourage employers to use the workplace as an arena for the promotion of healthy lifestyles and practices that are conducive to good health and well-being.

This chapter covers policies in ten countries consisting of the G7 countries and three additional OECD countries in the Asia and Pacific Region (Australia, Canada, France, Germany, Italy, Japan, Korea, New Zealand, the United Kingdom, and the United States). This allows for comparison across countries that have differing legal and policy contexts, but nonetheless share a commitment to promoting health and well-being at the workplace. This review does not aim to be exhaustive, and similar initiatives aimed at promoting health and well-being also exist in many other OECD countries such as the examples described in Box 4.1. This chapter reviews the levers used by the government of the ten countries to support companies to implement health and well-being programme for their employees, beginning by setting out differences in legal and policy contexts (Section 4.2). It then looks at (4.3) regulatory measures related to health and well-being at work, (4.4) paid sick leave and return to work policies, (4.5) financial incentives for employers to implement health and well-being programmes, (4.6) dissemination of information, (4.7) certification and award programmes, and (4.8) the potential of public employment to lead by example.

Standards and legislation relating to health and safety at work have existed for decades at the international, national and sub-national level, which underpin and shape the promotion of health, safety and well-being in workplaces. In many cases, such standards place a focus on traditional occupational safety and health approaches and are thus concerned with the prevention of work-related accidents, injuries and fatalities. At the international level, these include the 1981 Occupational Safety and Health Convention of the International Labour Organization, and the 1989 EU Framework Directive on Safety and Health at Work for three member countries of the EU. Specifically, in the European Union, Occupational Safety and Health (OSH) is regulated by the Framework Directive 89/391/EEC on the introduction of measures to encourage improvements in the safety and health of workers at work, and other related EU OSH directives, which are transposed by the EU Member States into their national laws, regulations and administrative provisions. Member States can adopt more stringent measures, going beyond the minimum requirements provided for in the abovementioned Directives. In countries with decentralised governments, OSH regulation and enforcement may be under the responsibility of sub-national authorities, which is recognised in this chapter. For instance, in Australia, state and territory governments regulate and enforce the work health and safety laws in their jurisdiction. In Canada, each provincial department is responsible for the administration and enforcement of OSH act and regulations.

In all ten countries, employers play a primary role in financing and organising measures relating to health and safety at the workplace, and this is typically enshrined in national legislation. In many countries, such as France, Germany, Italy and Japan, employers are specifically required to provide occupational health services to employees. In Japan, this requirement only applies to employers with more than 50 employees as small and medium-sized enterprises (SMEs) can access regional occupational health centres that are funded by government and can provide advice and guidance for both employers and employees. While such services have traditionally focused on preventing work-related accidents, injuries and fatalities, they have broadened their scope in some cases to also include health promotion.

The shift to focusing on health promotion and well-being and going beyond traditional occupational safety and health is more visible when looking at action plans and programmes that set out priority areas and are shown in more detail in Table 4.1. Workplace health and well-being considerations may be included in occupational health and safety strategies such as in Germany, or within broader health promotion strategies such as in Japan. In Germany, the Occupational Safety and Health Strategy includes traditional issues such as safe handling of carcinogenic materials in its objectives for 2019-24, but also broader issues such as the prevention of psychosocial strain and musculoskeletal disorders. In Japan, while the Occupational Safety and Health Strategy is relatively narrow, the National Health Promotion Movement in the 21st Century action plan includes measures to eliminate passive smoking in the workplace and address long working hours. In Italy, strategies on health at the workplace are included in the broad National Prevention Plan, but there are also three condition-specific national strategies, which are on the prevention of musculoskeletal disorders at work, work-related stress and occupational carcinogens/cancers.

As the range of strategies presented in Table 4.1 shows, the delineation of responsibilities for promoting health and well-being at work varies widely across the ten countries studied. Responsibility for health and well-being at work can fall under the responsibility of either the health agency, the labour agency or a mix of both. In the United States, the National Institute for Occupational Safety and Health (NIOSH) is part of the Centers for Disease Control and Prevention (CDC) within the Department of Health and Human Services. By contrast, in Korea and New Zealand, the Korea Occupational Safety and health Agency (KOSHA) and WorkSafe operate under the direction of the Ministry of Employment and Labour and the Ministry of Business, Innovation and Employment respectively. In many cases, it is unclear where the responsibility for the promotion of health and well-being at work lies, which can result in a lack of co-ordination and attention across government (OECD, 2021[2]). To address this issue, the United Kingdom, for example, launched a Work and Health Unit (WHU) in 2015 as a joint unit of the Department of Work and Pensions and the Department of Health and Social Care, with the aim of promoting cross-sectional collaboration on health and work. The WHU has subsequently led a number of reviews and analyses on the promotion of health and well-being at the workplace to inform policy making.

In addition to governments and policy makers, other stakeholders play an important role in shaping health promotion at work; these includes insurance institutions, employers, employees, trade unions and social partners. For instance, trade unions play an important role in ensuring good working conditions and guaranteeing employee health and safety through promoting collective bargaining. The difference in the proportion of employees who are members of trade unions, despite a crude measure, gives some indication as variability across countries in trade union arrangements. While trade union density lies on average at around 18% among the ten countries studied, it is lowest at 10.3% in France and highest at 32.5% in Italy (OECD and AIAS, 2021[3]).

Collective bargaining plays an important role not only in wage-setting, but also in setting other conditions of employment such as job security, working time and occupational safety and health, all of which are issues that are closely related to health and well-being (OECD, 2019[4]). The role of trade unions in working hour regulation, for example, are described in detail in Section 4.3.1. Trade unions are also involved in international level discussions on workplace health promotion. For instance, the European Trade Union Confederation has contributed to the EU Strategic Framework on Health and Safety at Work 2021-27. Trade unions and their networks may also run their own programmes and research, building on their role of strengthening employee-employer relations. A notable example is the Health Workplaces Project launched in 2013 by the Trades Union Congress, a national trade union centre in England and Wales. The TUC has since increased the involvement of employees in health promotion initiatives working together with the National Health Service and other major employers. As a result of participating in the project, 40% employers reported a fall in sickness absence while more than 70% of employers and 90% of employees reported the workplace was a better place to work (TUC, 2013[5]).

The institutional arrangements of health systems results in significant differences in the role of employers in promoting the health and well-being of employees across the ten countries. For example, workplaces may play a larger role in Korea and Japan where primary care services are less prominent features of the health system as this can result in the decentralisation of the health system (OECD, 2019[6]). In other countries, general practitioners or primary care physicians deliver interventions that might otherwise be well-suited for implementation in workplaces, and typically act as gatekeepers to specialist care. In five of the countries, there are requirements to receive a referral to a specialist (Australia, Canada, Italy, New Zealand and the United Kingdom). In the remaining three countries, there are incentives to register with a primary health care physician (Germany), incentives to receive a referral to a specialist from a primary care physician (the United States) or incentives for both (France) (OECD, 2020[7]).

Health system characteristics also influence the role of the employer in financing health care as shown in Table 4.2. Five of the ten countries operate a national health system that entitle individuals to health care based on residency (Australia, Canada, Italy, New Zealand and the United Kingdom). In these countries, health care services is mostly financed by government schemes and thus employers tend to play a minimal role. Employers may also provide private health insurance as an employee benefit and this is common especially in Canada. By comparison, France, Germany and Japan have multi-payer health insurance systems where employers and employees together pay contributions for health insurance. The United States is an exception as it has no universal health coverage. Despite employers being required to provide health insurance coverage for employees as part of the Affordable Care Act, only around 55% of the US population receive employment-sponsored health insurance. Employers also purchase health care directly for employees, although this accounts for a very small proportion of health care expenditure and no more than 1.2% of expenditure across any of the ten countries studied. The role of accident and workers’ compensation insurance is discussed in Section 4.5.1 on insurance-based incentives, as these all interact directly with employers across the ten countries studied.

Figure 4.1 shows the role that labour and workplace legislation and health systems play in setting the foundation for health and well-being at work and shaping the range of policy levers available to governments to promote health at work. These policy levers, which are described in the rest of this chapter, include (i) regulation, (ii) financial incentives, (iii) dissemination of information, and (iv) certification and award schemes. Figure 4.1 also highlights the role of stakeholders including occupational health professionals – who play an important role to diagnose risks and health problems in companies, identify needs and solutions – governments and policy makers, insurance institutions, employers, employees, trade unions and social partners.

Laws and regulations, when clear and well-designed, play an important role in setting legal standards relating to health in the workplace. General principles around employer responsibilities for employee health have already been discussed within the framework of occupational safety and health laws in Section 4.2, and thus this section looks at more issue-specific regulations that require employers to take actions relating to employee health and well-being in four areas. These are working hours (4.3.1), health check-ups (4.3.2), smoking at work (4.3.3), and alcohol consumption at work (4.3.4). Regulations relating to sick leave, return-to-work and reasonable accommodations for workers with health conditions is covered in Section 4.4.

While regulations can also only play a partial role in promoting health and well-being, it is primarily geared towards preventing accidents and work-related injuries. This is because regulation only sets out a minimum standard that employers are required to meet, which usually relate to workplace hazards, and there is no incentive to take further steps beyond this minimum standard. A combination of the threat of fines and the possibility for labour inspections play an important role in deterring employers from violating these regulations. Many governments also provide information and guidance to employers on how to ensure they are compliant with regulations as discussed in the sections below.

As discussed in Chapter 2, the health risks of excessively long working hours are well-established. A joint WHO/ILO analysis has shown that the disease burden that can be attributed to exposure to long working hours is higher than that of any other occupational risk factors. Most of the ten countries studied therefore have some form of regulation combined with supporting measures to minimise incidence of employees working excessively long working hours as shown in Table 4.3. Most countries set regulation on statutory normal working hours, which is supplemented by a statutory limit on maximum working hours including overtime (OECD, 2021[12]). From a public health perspective, the priority is to prevent excessively long working hours as opposed to reducing median weekly hours, and thus the focus is placed on maximum working hour regulation.

As shown in Table 4.3, the most common limit on maximum weekly working hours is 48 hours (Canada, France, Germany and Italy). This is aligned with the EU’s Working Time Directive, which requires that average weekly working hours must not exceed 48 hours including overtime. The United Kingdom also has a statutory limit of 48 hours per week, but most contracts include provisions where employees opt out of this limit, and hence, it is shown as having no statutory limit. Korea has a slightly higher limits at 52 hours, and the country has implemented reforms to reduce incidence of excessively long working hours in recent years. The impact of Korea’s reform to phase in a reduction in maximum weekly hours from 68 to 52 hours is discussed in more detail in Box 4.2.

It is important to note, however, that while Table 4.3 presents statutory working hours, working time is an area where rules negotiated through collective bargaining are particularly important, as this results in significant variation in practices depending on local and sector-specific needs (OECD, 2019[4]). While the upper limit on maximum hours is bound either by the statutory or collectively agreed level at the central level in Germany and Korea, there is a possibility to exceed the upper limit on maximum hours based on collective agreements at the sub-national level or in individual contracts in the other eight countries (OECD, 2021[12]). For instance, in Germany, collective agreements signed in 2018 pointed to a shift towards unions representing metal workers calling for greater individual choice over working hours rather than a reduction in working hours that apply across all workers in the sector (OECD, 2019[4]).

Despite regulation, excessively long working hours nonetheless remain relatively widespread across the countries studied as shown in Figure 4.2, and is higher among men than women among all countries studied.2 Although in countries with no statutory limits on maximum weekly working hours (Australia, New Zealand, United Kingdom and the United States), the proportion of employees working more than 50 hours per week exceeds 10%, there is still a sizeable proportion of employees reported to be working more than 50 hours in other countries with a 48 hour weekly limit. While there is no comparable data from Japan and Korea, it is well-established in both countries that excessively long working hours is considered an issue with significant health costs that requires policy attention (Hijzen and Thewissen, 2020[14]; OECD, 2018[16]).

Governments face an uphill challenge in enforcing compliance with working time regulations. Employers are typically required to record working hours, and compliance is enforced through a mix of targeted inspections and the threat of potential fines and imprisonment for the individuals responsible. In a recent assessment by the ILO on the implementation of international instruments on working time arrangements, trade unions across many countries reported that the lack of clear delineation of responsibilities hampered inspection efforts, and that in many cases, there has been insufficient resources dedicated to tackle violations of working time regulation (ILO, 2018[17]). Where inspections are held, violations of working hour regulation may still occur regularly. For example, of the 24 042 workplaces that the Labour Standards Inspection Offices in Japan visited in April 2020 to March 2021, more than one in three (37.0% or 8 904 workplaces) were found to have illegal overtime work. Of those found to have illegal overtime work, around one in three (33.5% of those will illegal overtime work or 2 982 workplaces) were found to have employees working in excess of 80 hours of overtime per month (MHLW, 2021[18]).

Governments also provide softer supporting measures to facilitate a reduction in incidence of long working hours. Among the countries studied, Japan and Korea are the only countries that have recently provided grants and subsidies for employers seeking to reduce excessively long working hours. In Japan, there is a subsidy for SMEs to implement work style reforms to reduce overtime work and promote take-up of annual leave. In Korea, as discussed in Box 4.2, the government supported the firms that reduced working hours to 52 hours per week in accordance with the working hour reform. Information is also widely disseminated in some countries to encourage compliance. In Korea, SMEs are able to receive free counselling support from labour experts on how to reform their workplace policies, while in the United States, the Department of Labor has developed a dedicated mobile timesheet app that employers and employees can use to keep track of working hours.

While health check-ups and examinations at the workplace can promote early identification of ill-health and thus facilitate intervention and treatment, this is rarely reflected in national policies. This may reflect drawbacks of health checks, differences in legal and policy contexts and concerns over employee privacy. Among the ten countries studied, while many have sectoral regulation requiring examinations of workers in hazardous circumstances, only three (France, Japan and Korea) require the provision of health check-ups to employees across sectors on a regular basis.

Japan has the strictest requirements, with employers obliged to offer a core health check-up (ippan kenshin) to all employees upon hiring and on an annual basis thereafter. These check-ups must include at least a standardised set of items that cover employee-reported items such as medical history, but also weight, vision, hearing, blood pressure, urinary sugar and uric protein tests (OECD, 2019[6]). All employers with more than 50 employees are required to report this information, and any employer failing to provide a core health check-up to their employees is subject to a fine of up to JPY 500 000 (Japanese Yen) (USD 4 600). SMEs can also apply for subsidies to finance the implementation of the health check-ups. Since 2015, all employers in Japan with more than 50 employees are also required to offer a stress check to their employees. The stress check consists of a questionnaire, which when filled by employees, provides insights for employees themselves, employers and policy makers as shown in the flow chart presented in Box 4.3. Employees receive individual scores, based on which they can alter their behaviours, and employers can make adjustments at both the individual and organisation-level based on the results. Employers then send their anonymised data to the government, which provides evidence on the uptake and usefulness of the stress check.

In France, there is a requirement for a visit for information and prevention of ill-health with an occupational physician within three months of employment, and every five years thereafter. However, there is no obligation to go beyond by asking employees about their health status or by providing them with information and guidance during such visits. While such an arrangement may be non-intrusive and lower cost, this also means that the measures that can be recommended by the occupational physician are almost entirely dependent on the self-reporting of health by employees. In Korea, employers have an obligation to ensure their employees receive a general health check-up at least once every one or two years, although, in practice, employees receive their check-up through the National Health Insurance Service and not at the expense of the employer.3

Health check-ups at the workplace can only be effective if there is a pathway that begins with identifying signs of ill-health and includes follow-up support and interventions. This means that any workplace health check-up scheme needs to be linked to the health system, and account for the potential increase in access to health services that may result from such a measure (WHO Regional Office for Europe, 2020[22]). For example, a standalone workplace health check-up scheme may result in cases where employees identified as at-risk face long waiting lists or have to rely on out-of-pocket payments. In Japan, employees who are identified as being at risk of cardiovascular and cerebrovascular diseases in the core health check-up can request a free secondary-check up and health guidance from a physician on nutrition, physical activity and day-to-day life. As discussed in Box 4.3, follow-up mechanisms similarly exist for individuals identified as having high levels of stress through the annual stress check.

Differences in the role of the primary care sector across the ten countries may partially explain why some countries require workplace health check-ups but others do not. As discussed in Section 4.2, the delivery of public health interventions in the workplace may be more common in Japan and Korea, where primary care does not function as the sole gatekeeper to secondary and specialist care. For instance, in Japan, patients are not required to register with a single general practitioner (GP). This may also partially explain why employers are required to ensure their employees receive a regular health check, whereas conducting such checks in other countries may result in duplication of services offered by primary care physicians. It should be kept in mind when introducing workplace health checks that screening programmes can have both public health benefits as well as potential drawbacks such as over-diagnosis (where a condition or risk factor is identified that would not cause any harm) and overtreatment (where individuals receive more extensive or invasive treatment than is required) (WHO Regional Office for Europe, 2020[22]).

The lack of compulsory workplace health checks is also likely due to concerns over privacy and discrimination based on health or disability status. In many countries, employers are advised to collect the minimum possible data on the health of their employees to conduct their core functions and responsibilities as an employer such as to protect their health and safety. In the United States, employers are only permitted to ask employees to take health examinations and collect information on the findings if this need is directly related to the employee’s responsibilities or the duties of the employer. In the European Union (and hence in France, Germany and Italy), the General Data Protection Regulation recognises data concerning health as a special category of data (European Union, 2016[23]). This places strict limitations on collection of information on employee health by employers, with specific limitations such as cases where collection of health data is necessary for carrying out contractual obligations (e.g. the provision of sick leave) or for public health and safety purposes.

In all the countries studied, there are nonetheless specific regulations requiring the surveillance and monitoring of the health of employees (health monitoring) and exposure to potential health risks (exposure monitoring) in workplaces where toxic or hazardous substances are handled. In Australia, for example, there are specific monitoring requirements if there is a significant risk of exposure to lead, asbestos or any other hazardous chemical. In the United States, most states also participate in a programme operated at the federal level by the CDC through which they provide data on blood lead levels. The data provided from states are then used to determine reporting requirements and regulation on lead exposure.

The issue of what information employers can collect on employee health has also been subject to attention during the COVID-19 crisis, as information not usually collected previously such as previous and current infection status; vaccination status for COVID-19 and temperature checks became valuable for employers seeking to minimise infection risk among their on-site employees. Employers in both the United Kingdom and the United States have been able to ask employees about their COVID-19 vaccination status on the condition that this is to protect the health and safety of other employees (Information Commissioner’s Office, 2022[24]; U.S. Department of Health & Human Services, 2022[25]).

Regulations to prohibit smoking at the workplace can improve public health outcomes, primarily by lowering exposure to second-hand smoke, and to some extent, by creating a supportive environment to reduce or quit smoking for existing users. A meta-analysis of 21 countries has found consistent evidence across countries that general smoking bans improve cardiovascular health outcomes and lower deaths from smoking-related illnesses and health conditions (Frazer et al., 2016[26]). It is important that comprehensive smoking bans are implemented guarantee as evidence show that these are more effective at reducing second-hand smoke exposure than partial bans. For instance, a review of seven European countries finds that PM2.5 levels,4 which are often used as measure of second-hand smoke, reduced more in hospitality workplace settings in countries that introduced comprehensive bans (e.g. Ireland and Scotland) than other countries (Ward et al., 2013[27]). Workplace smoking bans may also incentivise existing smokers to quit or reduce their use as discussed in Chapter 3.

Smoking in enclosed workplaces is regulated in all ten countries, but most do not prohibit smoking entirely as shown in Table 4.4. The most common policy among the ten countries studied is to prohibit smoking in enclosed workplaces except in designated smoking rooms (France, Italy, Japan and Korea). While this is preferable to no limitations on smoking, it can only partially eliminate exposure to second-hand smoke (Cains et al., 2004[28]; Yamato et al., 2000[29]). By comparison, Australia, New Zealand and the United Kingdom are the three countries that prohibit smoking entirely in all enclosed workplaces, while in Canada, comprehensive workplace smoking bans are in place in most jurisdictions that together cover 95% of the population. In the United States, smoking in enclosed workplaces is also prohibited in a majority of states. Germany differs from all other countries in that smoking is not prohibited within enclosed workplaces and there is only a right for non-smokers to be protected from exposure to second-hand smoke.

In countries where workplace smoking is not fully prohibited, employers nonetheless retain the right to prohibit smoking within their own workplaces. This explains the significant variation in the implementation of smoking bans in enclosed workplaces. Data from the International Tobacco Control Policy Evaluation Project (ITC) shows that workplace smoking bans are reported by almost all smokers and ex-smokers in countries with comprehensive bans (Australia, New Zealand, and the United Kingdom) (Figure 4.4). By comparison, there is significant variation in prevalence of reported workplace smoking bans in other countries, ranging from a high of 86.9% in the United States to around 50% or less in Japan and Korea. Both Japan (2020) and Korea (2012) introduced measures to prohibit smoking at the workplace except in designated smoking rooms after the surveys were conducted.

Most countries also put in place supporting measures to ensure compliance, including fines to enforce implementation and requirements to signpost restrictions on smoking. For example, in the United Kingdom, all workplaces must display the “no smoking” sign and employers have a duty to stop people found to be smoking in the workplace. Employers that do not display the sign can be fined up to GBP 1 000 (British pounds) and employers who do not stop people smoking in the workplace can be fined up to GBP 2500. Japan is the only country among those studied that provides subsidies to ensure compliance, in this case specifically for SMEs up to JPY 1 million (USD 9 100) to adapt their practices to meet changes in regulation, including by establishing designated smoking rooms. There are also a wide range of other measures taken by governments to support employers in reducing smoking at work such as financial incentives for smoking cessation programmes and dissemination of best practices. As these measures are not directly related to the implementation of regulations on workplace smoking, they are discussed in further detail in the sections on financial incentives (4.4) and dissemination of guidelines (4.6).

A contentious issue among the ten countries studied is how vaping and the use of e-cigarettes in the workplace should be regulated. The WHO advocates for the strict regulation of e-cigarettes, noting that their use in areas where smoking is otherwise forbidden could contribute to the renormalisation of smoking in public, and that the use of e-cigarettes is increasingly shown to have harmful effects, in particular, for cardiovascular health (2021[32]). France and Korea extend most or all of their regulation on workplace smoking to include vaping, while Australia forbids the sale of e-cigarettes containing nicotine without a prescription. In contrast, Italy, Japan and the United Kingdom have more lenient approaches to workplace vaping to varying extents as shown in Table 4.4. The difference in approaches between smoking and vaping is particularly stark in the United Kingdom, where policy makers have so far decided that e-cigarettes should not be covered by smoke-free legislation. In the United Kingdom, since 2017, Public Health England (PHE) – since replaced by the UK Health Security Agency (UKHSA) – has regularly collected updated evidence on the health effects of e-cigarette consumption. The UKHSA advises that the e-cigarette consumption is not risk free and non-smokers should not start vaping but, if properly regulated, e-cigarettes are far less harmful than smoking (2020[33]). The latest evidence review from the UKHSA also finds that e-cigarettes can be an effective tool to facilitate smoking cessation (McNeill et al., 2021[34]).

The consumption of alcohol is less heavily regulated among the countries studied compared to smoking. This may be as alcohol consumption at work may have less visible harmful impacts on bystanders in most jobs and industries. It may also reflect the tolerance and/or normalisation of consumption of alcohol both at work and work-related events (OECD, 2020[35]), and thus a view that strict regulation would result in excessive intrusion into private lives and lifestyle choices.

In all ten countries studied, consumption of alcohol in the workplace is not explicitly prohibited across all jobs and tasks. As shown in Table 4.5, in most countries, there is only a duty for workers and employers alike to manage health and safety at work, with decision around the provision and consumption of alcohol left to employers or in some cases to collective bargaining agreements. The exceptions are for tasks and jobs where working while under the influence of alcohol entails a high risk of injuries and accidents (e.g. construction workers at risk of falls), and jobs or tasks where impairment due to alcohol consumption can threaten public safety and endanger lives (e.g. bus or train driver).

France and Italy stand in contrast to other countries as they provide more explicit regulation designed to restrict harmful alcohol consumption in the workplace that applies to all jobs and sectors. In France, consumption of all alcoholic beverages other than wine, beer, cider and perry (poiré) is forbidden in the workplace. In Italy, while the law does not explicitly rule out consumption for all jobs and during all tasks, the provision of alcohol in the workplace is limited to the canteen, where only wine and beer may be served.

Alcohol testing at work is not widely implemented across the analysed countries. To some extent, and similarly to other forms of health checks as discussed in Section 4.3.2, concerns over intrusion into employee privacy may be among the reasons underlying a reduced use of alcohol testing at work. The use of alcohol testing – much like requirements to prohibit alcohol – is therefore usually limited to industries where working under the influence of alcohol can pose a threat to public safety. In the United States, for example, while there is no general provision that allows for alcohol testing at work, an estimated 12.1 million transportation employees categorised as performing safety-sensitive functions are subject to some form of alcohol and drug testing (US Department of Transportation, 2022[36]).

Preventing avoidable sickness absence from work due to ill-health is key to promoting health and well-being at the workplace. This applies both to preventing occurrence/recurrence of sickness absence and the promotion of timely return-to-work. While taking sickness absence, where required, should be facilitated, avoidable long-term absence from work due to sickness can have long lasting effects on labour market outcomes. Evidence from a number of OECD countries – including Belgium, the Netherlands, the United Kingdom – shows that return-to-work becomes increasingly difficult as the duration of absence extends and especially so after three months of absence which in turn, increases the likelihood of labour market exit (OECD, 2015[37]). For example, in the United Kingdom, while 5.6% of workers on long-term sickness absence for four weeks leave work, this more than doubles to 12.2% for workers on absence for three to six months (UK Government, 2019[38]). For some workers, such as those with mental health conditions, prolonged absence from work can also be detrimental and contribute to exacerbation of health issues. There are a range of policy levers that can be used to prevent avoidable sickness absence and promote early return-to-work through employer involvement, including the provision of employer-paid sick leave and regulation to facilitate return-to-work.

Paid sick leave – which usually consists of a combination of a period of employer-paid sick leave and thereafter a period of government- or tax-funded sickness benefit as shown in Table 4.6 – can promote better health outcomes at the individual level by allowing sick workers to recover at home and ensuring they can access medical support. In the absence of paid sick leave, workers are often left with a choice of either forgoing income for the benefit of their health, or continuing to receive income yet at the risk of further deterioration of health. In Korea, for example, nine days of unpaid sickness absence can result in income loss equivalent to the monthly rent or mortgage payment (Gould and Schieder, 2017[39]; OECD, forthcoming[40]).

Paid sick leave also has a broader impact on public health beyond the individual as it can mitigate the spread of infectious diseases. Individuals without access to paid sick leave are more likely to continue to attend work while sick (DeRigne, Stoddard-Dare and Quinn, 2016[41]), which in turn, can result in sick workers passing on infectious diseases in the workplace. Estimates during the H1N1 pandemic in 2009-10, there were around 5-7 million additional individuals infected with H1N1 in the United States due to employees who had not fully recovered from influenza-like illness going to work (Kumar et al., 2012[42]). There is also emerging evidence from the COVID-19 pandemic, which shows that access to paid sick leave has played an important role to allow workers who are suspected to – or who have – contracted SARS-CoV-2 to quarantine or self-isolate to minimise infection risk (OECD, 2022[43]).

As shown in Table 4.6, most of the countries studied have a combination of employer-paid sick leave and sickness benefit for workers on sickness absence. The period of employer-paid sick leave is of particular relevance for this chapter, as it creates a financial incentive for employers to promote better health among their employees. This operates through two channels. First, it creates incentives for employers to promote health and well-being at work and prevent sickness absence, regardless of whether this is exacerbated directly by the working environment or not. Second, it can – if the duration is sufficiently long – create incentives for employers to promote the timely return-to-work of employees on sickness absence.

Across the ten countries studied, as shown in Table 4.6, while most countries provide some form of paid sick leave, the maximum entitled employer-paid sick leave at the national level for private sector employees tends to be very short and thus insufficient to create strong financial incentives to reduce or prevent sickness absence. Canada, Korea, Japan and the United States are the only countries with no minimum entitled employer-paid sick leave at the national level, and account for around half of the OECD countries that have no such arrangement (OECD, forthcoming[40]). In Canada and the United States, however, employers must provide paid sick leave in certain regions, provinces and states. In Canada, employer-paid sick leave is available in three provinces and territories (British Columbia, Quebec and Prince Edward Island), while in the United States, 14 states and the District of Columbia have legislation on employer-paid sick leave. It is worth noting that workers in the public sector in Korea are covered by a paid sick leave scheme that provides full salary replacement for up to 60 days of sick leave per year and partial salary replacement for up to two years of sick leave (OECD, forthcoming[40]).

Even in the countries studied where employers have to provide sick pay for a longer duration, the financial incentive mechanism is dampened as employers are only responsible for covering a limited proportion of previous salaries. In the United Kingdom, sick workers are paid for 28 weeks from their employers, although employers are only required to pay the Statutory Sick Pay, as opposed to replacing a proportion of the previous salary. In France, meanwhile, minimum employer contributions depend on employee tenure, but typically continue for around two months, and are provided in combination with contributions from social security. Evidence from Switzerland and the Netherlands, two countries with a long duration of employer-paid sick leave, stronger employer contributions to pay, when implemented with supporting measures, can stimulate engagement from both employers and insurers to prevent ill-health and support rehabilitation and return-to-work. For example, in the Netherlands, since reforms to increase employer obligations to pay at least 2 years of sick leave at 70% of the salary5 in the 1990s, both labour market exit rates and sickness incidence have decreased significantly (Hemmings and Prinz, 2020[44]).

The duration of employer-paid sick leave also differs across occupations and employment status with temporary workers often not covered in such schemes across OECD countries (OECD, forthcoming[40]), whereas many have mandated longer periods of employer-paid sick leave in the public sector. As discussed in further detail in Box 4.4, paid sick leave has played a particularly important role in protecting jobs, incomes and the health of workers who have fallen ill during the COVID-19 pandemic, and this has contributed to long-term policy changes in a few countries.

Regulations can also play a prominent role in promoting rehabilitation of workers absent from work due to ill-health, including by requiring employers to make accommodations for workers with health conditions and implement measures to promote a timely return-to-work. Such measures are particularly important in the ten countries studied, since as shown in Table 4.7, in most of these countries, employer-paid sick leave either does not exist or is very limited in duration, and thus reinforcing measures can help to facilitate timely return-to-work.

Workplace accommodations, which can involve changes in the workplace such as responsibility modifications, working time arrangements or changes to the broader working environment, play an important role in return-to-work and are often requirements placed on employers. As shown in Table 4.7, in all of the ten countries examined, employers are obligated to make adjustments or accommodations to workers with disabilities. However, this does not usually extend to workers with health conditions or workers experiencing sickness, illness or injury in most countries. Expanding eligibility of workplace adjustments to workers with health conditions is important, as many such workers would benefit from targeted support, even if they would not be classified as having a disability. Evidence also suggests that accommodation costs are often minimal, as accommodation typically involves an increase in flexibility provided to employees rather than an increase in expenditure (OECD, 2021[46]).

Gradual return-to-work mechanisms aim to facilitate employees who have been absent from work, often due to ill-health or illness, to return to work through the initial provision of reduced working hours and lighter (or different) working duties, with a view to a phased return to regular duties. For instance, adapting working hours, work tasks, equipment or job roles, that are often low cost measures, was found to help people suffering from chronic conditions, such as musculoskeletal disorders (MSDs), to stay at work (Davis et al., 2020[47]; EU-OSHA, 2021[48]). Many European OECD countries facilitate gradual return-to-work through regulation that ensures workers can continue to receive a proportion of paid sick leave (OECD, forthcoming[40]). Among the ten countries studied, only Germany and the United Kingdom have such regulation. In both countries, employees that return to work with reduced working hours, continue to be eligible for employer-paid sick pay for those hours they are not working as a result of ill-health.

The increased implementation of gradual return-to-work mechanisms reflects the growing evidence that such mechanisms go hand-in-hand with recovery from a range of health conditions, including mental health conditions and musculoskeletal disorders. Evidence from Germany suggests that the use of gradual return-to-work reduces the duration of sickness absence, especially for employees on long-term sickness absence and workers with mental health conditions (Schneider, Linder and Verheyen, 2016[49]). In Norway, where gradual return-to-work is compulsory for employees after eight weeks of sickness absence, these schemes are estimated to reduce lost working hours due to sickness absence by 12% to more than 50% with differences across studies (OECD, forthcoming[40]).

Most of the ten countries studied also place other obligations on employers to take measures to facilitate return-to-work. One common measure across OECD countries is to require the development of return-to-work plans. In Germany, employers are required to invite all employees who have been absent for more than six weeks during a 12-month period to a meeting to discuss and develop return-to-work plans. In Australia, employers are required to implement return-to-work plans in most states and territories, and in South Australia, the employer is required to appoint a Return to Work Co-ordinator if they have more than 30 employees. This does not in practice translate to return-to-work plans being in place for all employees who are absent from work. In the National Return to Work Survey in Australia in 2018, less than two-thirds (65%) reported that they had a return-to-work plan (Social Research Centre, 2018[50]). In France and Japan, meanwhile, employers are required to take measures to make reasonable accommodations based on guidance from an occupational physician.

A few countries also provide financial incentives that reward and incentivise employers specifically to facilitate return-to-work. In the United Kingdom, employers can apply for tax relief for medical treatments up to GBP 500 per employee that are recommended by a health care professional to facilitate return-to-work. To be eligible, the employee must be assessed by a heath professional to be unfit for work for at least four weeks without medical treatment or have already been absent from work due to injury or illness for four weeks. As discussed in Box 4.6, a limited number of subsidies are also available in Tasmania (Australia) for employers specifically seeking to improve return-to-work outcomes. Broader financial incentives discussed in Section 4.4 relating to health and well-being promotion such as in Germany, Japan and Italy could also be used to facilitate return-to-work.

Financial incentives go beyond stipulating the minimum standards for employers and thus can encourage employers to proactively promote health and well-being at work. Such incentives are particularly important for micro, small and medium-sized enterprises. For example, governments may not wish to require employers to put in place accommodations for employees to cycle to work, but they may wish to provide grants, tax breaks or other financial incentives to facilitate cycling to work. When looking at measures that promote health and well-being and go beyond preventing accidents and work-related injuries, financial incentives play a more significant role.

The use of financial incentives remains relatively limited in the studied countries with the notable exception of insurance-based incentives (4.5.1), which is consistent with findings from a prior review by the European Agency on Health and Safety at Work on existing economic incentives to improve occupational health and safety (EU-OSHA, 2010[51]). The other tools available, including tax credits (4.5.2) and subsidies (4.5.3) are then discussed in detail. Financial incentives to facilitate or ensure fulfilment of regulation are not covered in this section but in Section 4.3 on workplace regulations. Incentives relating exclusively to return-to-work, rehabilitation and sick leave are discussed in Section 4.4.

Insurance institutions, typically in the form of workers’ compensation insurance boards and accident insurance systems, play an important role in creating incentives for preventing work-related accidents. The responsibility of such institutions and the rules under which they operate are determined by government legislation, and especially in countries where insurance institutions are public agencies (as shown in Table 4.8). Accident insurance institutions reward companies that have a better record of preventing accidents and ill-health by offering lower insurance premiums. In a number of countries, the responsibility of insurance institutions extends further to facilitating timely return-to-work and workplace health promotion, and boards may even offer subsidies for implementing programmes related to health promotion and the prevention of ill-health.

As shown in Table 4.8 (column 2), all ten countries have schemes to differentiate insurance premiums between employers based on occupational health and safety outcomes, most notably, the frequency of work-related injuries and ill-health. These are often referred to as “experience-rating” approaches as they rely on the performance of employers in previous time periods. Such mechanisms can create financial incentives to promote employee health as employers with stronger outcomes are rewarded with lower insurance premiums, and those with poorer outcomes will face additional costs. For example, in the United States, insurance premiums are calculated at the state level, and are most often based on a combination of occupation and an “experience modification factor” which can increase or decrease the premium based on the history of previous workers’ compensation claims compared to the average in the industry or claims category.

Insurance premiums may also be differentiated based on ongoing initiatives or future performance. In Italy, the National Institute for Insurance against Accidents at Work (INAIL) is running a “Swing for Prevention” (Oscillazione per prevenzione) campaign, under which employers carrying out interventions related to health promotion in the workplace are eligible to receive an insurance premium reduction. These measures can be wide-ranging, ranging from programmes for healthy diets and canteen use to campaigns to prevent smoking and harmful consumption of alcohol and drugs (2022[52]). In Alberta (Canada), SAFE Work certification is available in a number of industries, in which if employers are able to receive a certain standard in ensuring a safe and healthy workplace, they are eligible for a rebate of either 15 percent of the premium paid to the workers’ compensation board or up to CAD 3 000 (Canadian dollars) (USD 2 400) for smaller employers.

Workers’ compensation boards and accident insurance institutions also go beyond insurance premium variation and provide occupational health services or subsidies for employers to prevent work-related injuries. In Italy, in addition to insurance premium variation, from 2010 to 2022, INAIL issued 14 calls to encourage the implementation of interventions in the field of health and safety at work, and allocated over EUR 2.7 billion (euro) (USD 3.2 billion) in funding to such projects over this period, reaching almost 190 000 companies through the scheme. In Germany, prevention of work-related accidents and health hazards is embedded as the key objective of accident insurance institutions by government regulation, and thus these insurance institutions typically offer prizes, awards and recognition of high-performing companies, as well as services – such as counselling and training – and even subsidies for employers implementing prevention measures to fulfil their obligations. In France, the public accident insurance has subsidies for SMEs with less than 50 employees that are investing in equipment or actions to avoid work-related accidents. SMEs with less than 200 employees in France can also apply for a prevention contract, an agreement under which employers are able to receive an advance on expenditure relating to preventing accidents and ill-health, which is then converted into a grant if employers are able to meet the objectives agreed.

Health insurance institutions can also play a sizable role in incentivising employers to promote the health and well-being of employees in countries where health insurance is typically provided by the employer (e.g. Germany, United States) as discussed in Section 4.2. The 2015 Prevention Act in Germany requires health insurance funds have been required to spend EUR 7 (USD 8.28) per insured person on prevention measures, of which at least EUR 2 (USD 2.37) have to be spent on workplace measures. The introduction of this act coincided with a more than three-fold increase in expenditure per insured person on workplace health promotion between 2015 and 2019 by health insurance funds (Gerlinger, 2021[53]). The role of private health insurance companies is also discussed in Chapter 3.

Tax credits, which usually take the form of reductions or exemptions from corporate tax, provide governments with a means to incentivise employers to invest in workplace health and well-being. Compared to subsidies, tax credits are often easier to implement as they can be included within existing mechanisms relating to tax reporting mechanisms. Four of the ten countries studied (France, Germany, Italy and the United Kingdom) provide tax credits at the national level related to health and well-being and such credits are also available at the sub-national level in several states in the United States. In most cases, these measures have been introduced over the past decade (with the exception of Germany), suggesting that there is a growing emphasis on using such measures to incentivise employers to invest in employee health and well-being.

In Germany, a tax exemption introduced in 2008 provides employers with an exemption for health and well-being expenditures up to EUR 600 (USD 710) per employee per year (Federal Ministry of Health, 2022[54]). These measures can be wide-ranging and go beyond the provision of medical treatments, and thus can be used for expenditures related to the implementation of programmes to facilitate physical activity, healthy diets, addiction treatments and stress management. In Italy, a series of laws passed from 2016 onwards have expanded the scope of tax reductions for employers to include issues related to corporate welfare and employee health. In the United Kingdom, a corporate tax exemption of up to GBP 500 per year per employee was introduced in 2015 for medical treatments to support employees return-to-work as discussed in more detail in Section 4.4.

Tax credits have also been increasingly seen as a means to incentivise employers to invest in wellness programmes in the United States among lawmakers, although there has not been agreement to their implementation at the federal level or in most states. In 2009, a bill with bipartisan support called the Healthy Workforce Act was introduced but not passed. It would have provided a tax credit to employers for the costs of implementing workplace wellness programmes across the United States.6 At the state level, a review of legislation found that 34 bills had been introduced for tax credits for employers to implement workplace wellness activities in 2001 to 2006, but that none had been passed (Lankford, Kruger and Bauer, 2009[55]). These examples show that while there is an appetite among some lawmakers for tax credits to employers implementing workplace wellness programmes, barriers remain, most notably in relation to cost. A more recent review of state legislation as of 2014 found that only four states (Georgia, Indiana, Maine and Massachusetts) have tax credits for employers promoting workplace wellness programmes (Pomeranz et al., 2016[56]).

France and the United Kingdom have exemptions designed specifically to facilitate cycling to work at the national level. In France, employers are able to pay employees up to EUR 500 (USD 592) per year for commuting by bicycle or car-sharing schemes as part of the Sustainability Mobility Package (Forfait Mobilité Durable).7 This tax credit was introduced exclusively for commuting by bicycle in 2015 with a limit of EUR 200 (USD 237) per year as a public health measure, but was extended in 2020 to have broader sustainability objectives. An assessment of a trial of the tax exemption found that it resulted in a 125% increase in the share of commuting by bicycle after one year (ADEME - Agence de la Transition Écologique, 2016[57]). Employers providing bicycles to their employees for free are also able to receive a tax exemption for 25% of the cost of purchasing a fleet of bicycles for employees. In the United Kingdom, through the Cycle to Work Scheme, since 1999, employers can hire bicycles and safety equipment on behalf of an employee as a tax-free benefit. If the employer wishes to recoup the costs of hiring a bicycle, deductions can be made from the employee’s gross salary, resulting in an exemption from the employee’s income tax and contributions to National Insurance. Although employers can also apply for a tax exemption for payments to cover employee commutes in Germany and Japan, these are not explicitly or exclusively for commuting by bicycle or other methods that promote physical activity.

While governments provide subsidies and grants to employers in all ten countries, they are typically targeted towards SMEs and often implemented at the sub-national level. As SMEs face barriers to implement workplace health and well-being programmes, dedicated subsidies are one of the facilitators to help them invest in these programmes (Box 4.5). One main point of difference between subsidies and tax credits is that the former is often only available to a limited number of recipients and is thus more exclusive and limited in scope. Of the ten countries studied, only two (Japan and Korea) provide subsidies to employers to promote employee health and well-being at the national level, although many are related to accident injury and prevention and limited in scale. There are also many initiatives at the sub-national level and a select number of initiatives relating to health promotion are discussed below.

In Japan and Korea, subsidies are primarily designed to support implementation of good practices and facilitate compliance with regulation. In Japan, there are at least two subsidies that go beyond accident prevention and seek to facilitate workplace health promotion. SMEs implementing a Mental Health Promotion Plan can apply for a subsidy of up to JPY 100 000 (USD 911), and employers implementing measures to ensure employees with health conditions can balance their work with accessing medical treatments and supports are also eligible for a subsidy of up to JPY 200 000 (USD 1 821) (Japan Organisation of Occupational Health and Safety, 2021[60]). There are also subsidies in Japan to facilitate implementation of the stress check and health check-ups as discussed in 4.3.2, and subsidies for the recruitment of occupational physicians or nurses in the workplaces as required by occupational safety and health regulation. In Korea, there are also a range of subsidies to support good practices, although these are primarily centred on preventing accidents and injuries. For example, the Health Stepping Stone project is primarily for the implementation of exposure screening and health screening, while the Clean Workplace Project provides subsidies to prevent industrial accidents such as deaths and fatal accidents. Korea also provides subsidies for workplaces that are implementing measures to ensure compliance with the working time reform initiated in 2018 (Box 4.2).

Subsidies at the sub-national level that incentivise employers to promote health and well-being also play a role in Australia and the United States. These subsidies are typically not to support employers in meeting their obligations as employers, but rather to implement innovative or new practices to promote health and well-being in the workplace. In Australia, the two grant programmes identified that go beyond accident and hazard prevention focus on mental health, musculoskeletal disorders and return-to-work, which are discussed in more detail in Box 4.6, with a focus on subsidising innovative programmes. In Western Australia, grants are available for employers seeking to address work-related psychological hazards and promote mental well-being in the working environment. In Tasmania, the grant programme is specifically for the prevention of musculoskeletal disorders and the improvement of return-to-work outcomes, with grants capped at AUD 50 000 (Australian dollar) (USD 37 600) per organisation. In Indiana (United States), the local government provides grants of up to USD 10 000 for employer initiatives to promote wellness with a broader focus on initiatives relating to healthy lifestyle choices, increased physical activity, facilitation of breastfeeding and stress reduction.

Subsidies may also be provided to employer organisations, research institutions, and even employees themselves to implement good practices. In the United States, the Susan Harwood Workplace Safety and Health Grants provides annual grants to non-profit organisations that provide training to employers and workers on health at the workplace, with a thematic focus on preventing infectious diseases including COVID-19 for 2022. Successful applicants can receive grants of up to USD 160 000 and the total grants available each year are worth around USD 3 million in total. In Québec (Canada), there are grants available for unions and employer associations seeking to provide training or educational activities relating to workplace health and safety. Organisations that provide research or training are also eligible for the aforementioned grants in Australia for mentally healthy workplaces (Western Australia) and for healthy workplaces (Tasmania) which are discussed in Box 4.6.

A major limitation in existing subsidies and financial incentives directed at employees is that they may only be accessible to individuals with a disability. Broadening eligibility for subsidies to also include individuals with a health condition could be valuable, as many workers with a health condition would benefit from targeted support. This distinction can be seen when comparing Australia and the United Kingdom’s approach to financial supports for employees looking to stay in work. Whereas the Employee Assistance Funds in Australia provides financial support exclusively to workers classified as living with a disability (OECD, 2015[61]), the Access to Work grant in the United Kingdom provides financial assistance both for workers with a health condition and for those living with a disability. The importance of including workers with health conditions in accommodation measures is also discussed in Section 4.4.2.

Governments can also facilitate employers in implementing workplace health and well-being programmes through dissemination of information on the benefits for employers to invest in health of their employees and through providing guidelines and other tools that can support the implementation of good practices by employers. While uptake of guidelines is voluntary, this also allows for the inclusion of measures that promote health and well-being in the workplace and go beyond legal requirements that are usually set out in occupational safety and health regulations. Such guidance and tools may also be used for certification and award programmes as discussed in further detail in Section 4.7.

All ten countries provide information at the national level on health, safety and well-being in the workplace, typically through their agencies dedicated to occupational safety and health, and most provide specific tools such as self-assessment tools and guidelines for employers at either or both the national or sub-national level. Some countries also have dedicated agencies for researching and disseminating information on health in the workplace with an increasing focus on health promotion and early intervention. At the international level, the European Agency for Safety and Health at Work (EU-OSHA), plays a large role in both researching on the effectiveness of interventions to promote health at work and in disseminating this information to relevant stakeholders including employers.

At least four countries (France, Germany, the United Kingdom and the United States) provide tools for employers to assess the extent to which they are promoting health and well-being of employees. In France, the National Research and Safety Institute (IRS), which is responsible for researching on occupational health and safety, has developed a self-assessment questionnaire, which medium- and large-sized enterprises can use to diagnose gaps in workplace health promotion. The questionnaire includes questions for employees relating to self-reported health, work demands and the broader working environment. In the United States, the CDC developed a Worksite Health ScoreCard, which allow employers to assess the extent to which they have implemented evidence-based measures to promote the health and well-being of employees by filling out a questionnaire. The ScoreCard includes questions related to many areas, including weight management, physical activity, high blood pressure, tobacco use, musculoskeletal disorders, stress, sleep and maternal health (Centers for Disease Control and Prevention, 2022[62]). Participating employers in Japan’s Health and Productivity Management programme (see Box 4.9) also receive a scorecard diagnosing areas of improvement based on their responses to a questionnaire.

Guidelines on how employers can promote health and well-being in the workplace are provided by governments at both the national and sub-national level. In Germany, the Businesses do Health (Unternehmen unternehmen Gesundheit) brochure developed by the Federal Ministry of Health outlines the responsibilities of employers, financial supports available to employers, intervention options and examples of good practices in workplaces (Federal Ministry of Health, 2022[63]). In the United Kingdom, beyond guidelines provided by the Health and Safety Executive, there is also a National Institute for Health and Care Excellence (England), a public body dedicated to developing guidelines relating to health and clinical practices. In Australia, at least five states and one territory (Queensland, South Australia, Tasmania, Victoria, Western Australia and the Australian Capital Territory) provide guidelines for employers on how to promote health and well-being in the workplace. In the United States, the National Institute for Occupational Safety and Health (NIOSH) makes available several resources that employers and employees can use to promote a safe and healthy work environment, including Fundamentals of Total Worker Health®, Promising Practices, Let’s Get Started with Total Worker Health® Approaches, and the NIOSH Worker Well-Being Questionnaire (WellBQ).

The involvement of non-governmental actors such as charities, trade unions and business associations in both the development and dissemination of guidelines is common across all countries studied, and is key to ensuring uptake and use of guidelines by employers, given the close associations and connections that these organisations may have with employers. For example, in the United Kingdom, the Prime Minister commissioned a report in 2017 on promoting mental health in the workplace (Thriving at Work), which was conducted by a mental health campaigner and business leader together with the CEO of Mind, the mental health charity (Stevenson and Farmer, 2017[64]). All recommendations were subsequently accepted by the government, and Mind subsequently developed a guide for employers on how to meet and implement the six core standards for mental health in the workplace. Guidelines and tools are also developed independently by non-governmental actors and independently of government. In Australia, the National Workplace Initiative illustrates the collaboration across sectors. The National Workplace Initiative is led by the National Mental Health Commission in collaboration with the Mentally Healthy Workplace Alliance made up of national organisations from business, union, government, workplace health and mental health sectors. The National Workplace Initiative is an AUD 11.5 million investment (USD 8.6 million) by the Australian Government to create a nationally consistent approach to mentally healthy workplaces.

Guidelines and tools are often targeted at specific health issues including MSDs and mental health conditions. As discussed in Chapter 2, MSDs and mental health conditions are among the leading causes of work-related health issues. At the international level, EU-OSHA is running a campaign on MSDs at work called Healthy Workplaces Lighten the Load for 2020-22 and has disseminated information and guidance to employers. At the national level, the Health and Safety Executive in the United Kingdom has developed a digital assessment tool that combines a range of questions to assess the risks for musculoskeletal health of specific tasks. Employers seeking detailed findings can purchase a premium version of the tool. At the sub-national level in Canada, guidance is available in the provinces of British Columbia and Ontario. Guidance in British Columbia released in 2010 by the Workers’ Compensation Board provides information to support employers to identify risk factors, develop appropriate measures to reduce risk, and respond to injuries and symptoms of MSDs among employees. In Ontario, an MSD Prevention Guideline was established in 2007 and has been updated since. An online portal for guidance is now available, which industry- and occupation-specific guidelines and a range of tools available to employers (Centre of Research Expertise for the Prevention of Musculoskeletal Disorders, 2022[65]).

Mental health also features prominently in government guidance on health at work before the COVID-19 pandemic and this trend has continued since. In Germany, as part of the New Quality of Work Initiative (INQA) funded by the Federal Ministry of Labour and Social Affairs, the federal government runs psyGA, a portal targeted to SMEs on measures to promote mental health at the workplace (2022[66]). The tools offered as part of psyGA include a campaign toolbox based on an award-winning initiative at Siemens released in 2022, and a benchmarking tool that allows employers to assess their performance on workplace mental health and identify areas for improvement (Federal Ministry of Labour and Social Affairs, 2022[67]). Meanwhile, Canada’s National Standard for Psychological Health and Safety in the Workplace were the first national guidelines on mental health in the workplace released in 2013, and since being introduced, the government has developed tools to guide implementation such as videos and sharing of promising practices (OECD, 2021[2]). An Ipsos poll in 2017 found that employees working for organisations that implement the Standard are far less likely to say their workplace is psychologically unhealthy or unsafe (5%) compared to organisations not implementing the Standard (13%). The poll also found that implementation of the Standard also results in a decrease in absence from work among employees who report experiencing depression (Ipsos Public Affairs, 2017[68]).

The dissemination of information and guidance has also played an important role in preventing and reducing transmission of the SARS-CoV-2 virus among employees in all ten countries studied. Guidance has typically related to sanitary measures; facilitation of teleworking (Box 4.7); facilitation of sick leave and self-isolation (Box 4.4); encouraging vaccine uptake and air quality and ventilation. While such guidance has typically been designed to slow transmission of SARS-CoV-2, they also apply to other infectious diseases. For example, in the United States, the Clean Air in Buildings Challenge introduced in March 2022 is encouraging employers to follow guiding principles to reduce risk of transmission of viruses and other contaminants indoors through creating an indoor air action plan, ensuring fresh air ventilation, strengthening air filtration and cleaning, and communicating to the broader community. Another example is the Australian National Workplace Initiative that provides organisations with detailed guidance to address emerging issues surrounding COVID-19 and workplace mental health. Examples of topics covered include, among others, setting up sustainable hybrid work environments, and resources for people in high-pressure executive roles, and bespoke guides for SMEs.

An emerging area where governments have been providing guidance to employers in the wake of the COVID-19 crisis is on how to support workers experiencing long-lasting health impacts from SARS-Cov-2 that lasts beyond the period of initial illness. As discussed in Chapter 2, long COVID is estimated to affect around 10% of individuals infected, and in the United Kingdom, is estimated to affect as much as 2% of the general population (Office for National Statistics, 2022[76]). At least three countries (Japan, the United Kingdom, and the United States) and the European Agency for Safety and Health at Work provide guidance to employers on supporting workers experiencing long COVID. Such guidance usually includes a mix of information on long COVID and the wide-ranging potential symptoms; recommendations to conduct an occupational health assessment; and guidance on how to support return-to-work. Paid sick leave systems can also play an important role in ensuring workers are able to work while recovering from long COVID as discussed in Section 4.4. The development of guidelines and reforms to support workers with long COVID could also have spill-over benefits, as this can create an environment where workers with other chronic health conditions can remain in work with the support of their employers.

Awareness-raising tools are useful for certain health issues that are surrounded by stigma in the workplace such as mental health and sexual health. If there is stigma associated with a health condition, employees are less likely to seek the support they need for fear of discrimination and judgment, and managers are less likely to know how to raise the issue with employees if they identify potential symptoms. There is clear evidence from across countries on the stigma surrounding mental health. In a 2019 survey by Ipsos MORI and King’s College London, among the nine of the ten countries studied where data was collected,8 less than two-thirds (62%) of respondents stated that mental illness is an illness like any other (2019[77]). This stigma extends to the workplace. For example, more than a third of respondents to a survey in Australia in 2013 reported that they would never disclose talking about mental health at work, even if it would be appropriate to do so (Mental Health Australia, 2013[78]). Another issue surrounded by stigma is menopause. Reducing stigma and increasing support for women experiencing menopause in the workplace can support workforce participation and have positive impact on women’s overall health and well-being. In Australia, the National Women’s Health Strategy 2020-30 recommends actions to improve awareness and encourage further research and support services for menopause, including examining the overall impact of menopause on work. The example of workplace policies to accommodate the needs of workers who experience menopausal symptoms in the United Kingdom is discussed in more detail in Box 4.8.

It is also important for guidelines and tools to emphasise line management in health promotion. Previous OECD work on mental health has shown line management to be particularly important in promoting employee health as called for in the Recommendation on Integrated Mental Health, Skills and Work Policy (OECD, 2021[2]). Evidence from the Netherlands and the United States also shows that line manager involvement can reduce sickness absence and improve the well-being of employees (Quigley et al., 2022[79]; Hendriksen et al., 2016[80]), while workplace conflicts – often the result of poor management – are a major risk factor for mental ill-health (OECD, 2015[37]). Although senior executives and directors play an important role in creating a culture of health, there is no guarantee that this will trickle down and reach employees if line managers are not adequately aware or lack an understanding of health issues. Line managers need to not only show an understanding of health issues, but also understand their crucial role in designing work in a way that is conducive to good employee health and well-being (OECD, 2021[2]).

Governments can recognise employers that put in place best practices by providing them with certification and award. A variety of schemes are introduced (4.7.1), ranging from large-scale national schemes such as Health and Productivity Management (H&PM) in Japan to smaller schemes such as the Corporate Health Standard in Wales (United Kingdom).

The purpose of certification and award schemes is to create reputational benefits for employers promoting health and well-being in the workplace. There are at least three important criteria to ensure the credibility and usefulness of such schemes. Schemes must be (1) sustainable in the long-run and sufficiently long-lasting; (2) visible and disseminated to relevant stakeholders; and (3) they must be based on sound evidence that can effectively differentiate higher-performing employers implementing good practices compared to employers simply meeting legal obligations. Certification and award schemes are however exclusive as they are mainly accessible to higher-performing employers, and may offer little incentive for health promotion in workplaces where it is not considered a priority. This is especially the case for competition-style awards, whereas certification is usually contingent on meeting a certain standard of health and well-being promotion at work. Award and certification schemes are often classified as non-financial incentives as they incur no direct cost on governments themselves beyond those related to administration, although some may come with small monetary awards.

Japan has the most extensive range of government-led certification and awards including at both the national and sub-national level. The most prominent of these is the Health and Productivity Management programme (H&PM) launched in 2014 by the Ministry of Economy, Trade and Industry (METI), which is the largest-scale award and certification system across the ten countries studied. As discussed in Box 4.9, this programme provides certification for employers meeting a minimum standard in promoting health and well-being at work, and the top 500 SMEs (“Bright 500”) and top 500 large enterprises (“White 500”) are then provided with particular award. Japan also has similar recognition schemes to promote physical activity and bicycle commuting. The Sports Yell Company programme launched in 2017 by the Japan Sports Agency provides certification for employers that promote sports. Measures recognised as good practices in the Japan Sport Agency’s guidelines include the organisation of employee walking campaigns, corporate stretching and yoga programmes and health promotion seminars. The Ministry of Land, Infrastructure, Transport and Tourism (MLIT) also introduced a scheme with a similar recognition mechanism in 2020 to certify employers that support employees to use their bicycles to commute as Bicycle Commuting Promotion Companies. According to METI, there were also close to 100 programmes to reward companies for promoting health in the workplace at the sub-national level of government throughout Japan in 2021.

Recognition schemes in other countries at the national level tend to be much smaller in scale and often take the form of award schemes with a competition-style model in which only a small number of organisations receive recognition. While such schemes may only incentivise a select number of firms already invested in promoting heath at the workplace, they may foster innovative practices. In Germany, the Federal Ministry of Labor and Social Affairs, the State Committee for Occupational Safety and Safety Technology and the German Statutory Accident Insurance have recognised exemplary commitment to health promotion at work through the German Occupational Safety and Health Awards. The competition has been held every two years since 2009, and the focus is aligned with goals agreed to in the national Joint Occupational Health and Safety Strategy, which currently include designing workplaces to reduce musculoskeletal loads, promote mental health and ensuring safe handling of carcinogenic and hazardous substances. New Zealand has also had a Health and Safety Award since 2005, although the award is only available to a small number of organisations each year. In 2022, for example, there are only nine categories of awards for organisations. In the United States, while most schemes are run at the state level or by non-profits, the federal government operates a Safe-in-Sound Excellence in Hearing Loss Prevention Award for employers that have demonstrated significant achievements towards reducing noise exposure and preventing hearing loss among employees.

Certification and award schemes are also provided at the sub-national level in countries including Australia, the United Kingdom and the United States. Two schemes in Wales (United Kingdom) and Canberra (Australia) are worth noting as they follow a certification model and could have a significant impact if scaled up. In Wales (United Kingdom), employers following the Corporate Health Standard can be given five different levels of awards based on their performance. This programme has since been paused, in part due to challenges posed by the COVID-19 crisis, and it is currently under review with a view towards a relaunch. The Healthier Workplace Recognition Scheme in Canberra (Australia) operates similarly with five different levels of recognition, although unlike the Welsh scheme, moving up levels of recognition is reliant on a proven long-term commitment and continued participation in the scheme over consecutive years. Awards are also available in other states and territories of Australia including New South Wales and Victoria, although these take the form of competitive awards that are only available to a small number of organisations.

A wide range of awards and certifications have also been developed by non-governmental stakeholders including private sector actors and non-profit organisations. In France, Harmonie Mututelle, a private insurance firm, holds an annual prize for health-promoting companies. In 2020, 30 initiatives were rewarded with a small monetary prize. In Germany, the Corporate Health Award, which is operated by a private company, has provided awards to companies showcasing excellence in health management in the workplace since 2009. Mind, the UK-based mental health charity, runs a Workplace Well-being Index, which employers can participate in to increase their understanding of employee perceptions of mental health programmes in the workplace, learn from a network of employers, and gain public recognition of commitment to well-being in the workplace. The Workplace Well-being Index showcases the potential for governments to work closely with non-governmental stakeholders. While operated by a charity, its roots lay in a report commissioned in 2017 by the Prime Minister on how to better promote mental health for all in the workplace. The six core standards for employers that were established in the report are the criteria used in the Workplace Well-being Index.

Certification and award schemes also go hand-in-hand with collection of more granular information on health and well-being in the workplace, which can be used to widen the evidence base to inform both policy and employer interventions. This is because recognition schemes are typically based on information shared by employers on the health and well-being outcomes of employees and the specific measures and programmes they implement. The H&PM programme, which is described in detail in Box 4.9, provides a wealth of information relating to employer motivations and the relationship between health interventions at the workplace and health outcomes, given the scale of the programme. Even with smaller scale programmes such as Mind’s Workplace Well-being Awards, there are opportunities to identify good and innovative practices that could be disseminated to other employers seeking inspiration. While ensuring that employee privacy rights are protected may be a challenge, the release of such information may also be able to increase transparency and facilitate investment in health promoting companies as discussed in Chapter 5.

The public sector has an important role to play in promoting health and well-being at work as it accounts for a large proportion of total employment, and as the government – through its greater influence on the public sector – can set a standard for other employers in non-governmental sectors to follow. This section begins by considering the importance of promoting health and well-being in the public sector, and then looks at both strategies and programmes designed to promote health and well-being in the public sector.

Promoting health and well-being among employees in the public sector is necessary because of the large contribution of the public sector to total employment. As shown in Figure 4.6, government employees accounted for around one in seven employees across the ten countries studied, ranging from as high as 21.2% in France to 5.9% in Japan as of 2019 (OECD, 2021[82]). In many of these countries, specific public agencies are also the largest employers, giving them a significant role in promoting health and well-being at work. The Department of the Defense in the United States employs around 3 million people (2021[83]), making it the largest employer in the world. Meanwhile, the National Health Service, which provides universal health care in the United Kingdom, employs around 1.4 million people, making it the largest employer in Europe (2022[84]).

At least two countries (France and Korea) have strategies specific to the promotion of health and well-being among government employees at the national level. In France, the inaugural Occupational Health Plan for the Public Service (Plan Santé au travail dans la Fonction publique) sets out 30 actions to be taken between 2022 and 2026 across five separate areas with a focus on prevention. It integrates lessons learnt from the COVID-19 crisis, and thus includes commitments to strengthen psychosocial risk prevention through the roll-out of mental health first aid, strengthening of data on occupational health, and the development of preventative medicines (Minister of Transformation and Public Service, 2022[85]). In Korea, efforts to promote health in the workplace are based on the Guidelines for Public Officials’ Health Management, a document released in 2009 by the Ministry of Interior and Safety. The guidelines call for the expansion of health care support facilities in public agencies, including fitness centres and gyms, refresh zones and counselling centres, and the organisation of campaigns to improve awareness and understanding of health in the workplace.

Strategies to promote health and well-being in the public sector at the sub-national level also exist in Australia and the United States. The regional Government of Western Australia (Australia) sets out a vision for ensuring public sector health and safety to ensure compliance with the principles set out in the Australian Work Health and Safety Strategy 2012-22. North Carolina (United States) also has a Worksite Wellness framework that introduces measures related to smoking cessation, improving nutrition, encouraging physical activity that state government agencies are expected to consider. There are also leading examples within state agency. For instance, the U.S. CDC/NIOSH provides its own workforce with programmes, practices, and policies that prevent injury and illness while promoting health and well-being, under the Healthiest NIOSH programme (NIOSH, 2022[86]).

Governments – at both the national and sub-national level – play a significant role in facilitating, incentivising and supporting employers to promote the health and well-being of employees, working closely with other stakeholders. At the bare minimum, governments must continue to ensure employers are meeting minimum standards of health and safety regulation and addressing work-related health issues. Yet governments can also go further to support employers to promote the health and well-being of employees. Governments can use a range of reinforcing and complementary measures to support employers. These include regulations relating to working hours and smoking; financial and non-financial incentives to facilitate investment of employers in employee health and well-being; dissemination of information, tools and best practices to guide employers; recognition of high-performing employers; and the reform of sick leave and return-to-work systems. Governments can also showcase good practices in promoting health and well-being of employees in the public sector by acting as an exemplary employer, and set an example for employers in the private sector to follow.


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← 1. Total Worker Health® is a registered trademark of the U.S. Department of Health and Human Services.

← 2. This may mean that men are more at risk of health issues related to excessively long hours of paid work, but women are significantly more likely to work more hours of unpaid work than men in all countries studied. When both paid and unpaid work are accounted for, it is estimated that women work longer each day than men in all of the ten countries studied with the exception of New Zealand.

← 3. In Korea, employers are required to ensure their employees receive a general health check-up once every one or two years, but this may not be at the expense of the employer. While the Occupational Health and Safety Act stipulates that a workers’ general health check-up is compulsory, it also states that it may be substituted by a health check-up offered under the National Health Insurance Service, which is not provided at the expense of the employer.

← 4. PM2.5 refers to particulates, whose diameter is 2.5 μm or smaller. Smoking is a major generator of PM2.5, and PM2.5 levels are therefore used as a reliable measure of the extent of exposure to tobacco smoke.

← 5. In the Netherlands, employers have an obligation to pay at least two years of sick pay at 70% of the previous salary. The duration can be longer and the rate of replacement of previous salary can be higher under certain circumstances.

← 6. Slightly different versions of the bill – but with the core principle of tax credits for workplace wellness programmes – were later introduced, but these were also not passed.

← 7. When first introduced, the ceiling for tax exemption for commuting to work by bicycle was EUR 400 per year. This was subsequently increased to EUR 500 per year in January 2021.

← 8. All of the ten countries other than New Zealand were included as this was a report to inform policy at the G20 level. The average presented is thus of the remaining nine countries.

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