Social care and changes in occupational accidents and diseases - the situation in Eastern Europe in general and for skin diseases in particular

Background As a consequence of the disintegration of the state systems and the expansion of the European Union, there have been marked changes in the political and social affiliations of the countries of Eastern Europe. Of the 22 countries in Northeastern, Centraleastern, Southeastern and Eastern Europe, 12 are now members and 10 are "new" neighbours of the European Union. The accident insurance systems and changes in occupational accidents and occupational diseases in eastern European countries are described. Changes since EU and visible differences from non-EU countries are analysed. Special emphasis is given to occupational skin diseases. Methods The available data from the European Union (MISSOC and MISSCEEC Studies on the Social Protection Systems), the database "Social Security Worldwide" (SSW) of the International Social Security Association (ISSA), the International Labour Office Database (LABORSTA), the World Health Organization (WHO) and the annual statistical reports of the different countries were analysed with respect to changes in occupational accidents and occupational diseases. To find missing data, 128 ministries and authorities in the 22 countries in eastern Europe were researched and 165 persons contacted. Results The social insurance systems were very different in the different countries and some were better established than others. Moreover, not all data were available. For these reasons, detailed comparison was not always possible. The occupational accident rates are decreasing in more than half the countries. In contrast, the fatal accident rates have increased in half the countries. The number of newly registered occupational diseases is decreasing in more than half the countries. The rates for occupational skin diseases in 2006 were particularly high in the Czech Republic, Poland and Slovakia. In half the countries (four out of eight), the number of occupational skin diseases is decreasing. A reliable analysis of any correlation between EU membership and the rates of occupational accidents and occupational diseases was not possible, because of missing current data. Conclusion Comparison of the social insurance systems and changes in occupational accidents and occupational diseases in 22 countries in eastern Europe makes it clear that further effort is needed to develop registration and notification procedures. Only then will it be possible to analyse changes, to map successes and problems and perhaps to initiate necessary improvements. Standardisation of the documents must also be improved, to allow international comparisons between the systems.


Background
As a consequence of the disintegration of the state systems and the expansion of the European Union, there have been marked changes in the political and social affiliations of the countries of Eastern Europe. Of the 22 countries in Northeast, Centraleastern, Southeast and Eastern Europe, 12 are now members and 10 are "new" neighbours of the European Union. There have been extensive social and political reforms in the new members of the Union, as our new neighbours approach European "conditions", and this enhances the interest in a detailed analysis of the situation. For the present study, it was particularly interesting to look at the areas of the social security systems and the occupational safety and health system. The focus was on a comparative consideration of social security and on the changes in the rates of occupational accidents and occupational diseases. It was also investigated whether there had been changes in this context since entry to the EU and whether there are differences compared to non-EU countries. Special emphasis was given to the analysis of occupational skin diseases in eastern European countries.

Methods
Currently available data on the issues at point were collected, in particular, the compilations of the European Union (MISSOC and MISSCEEC Studies on the Social Protection Systems) and the database "Social Security Worldwide" (SSW) of the International Social Security Association (ISSA) on the social insurance systems in eastern European countries. There was little available information for the eastern European countries which are not members of the EU.
Analysis of the changes in occupational accidents and occupational diseases is based on materials from the International Labour Office Database (LABORSTA), the World Health Organisation (WHO) and -particularly for the non-EU member countries -on direct contact with institutions and persons in these countries. For useful literature and internet sites see additional file 1. To provide missing data, a total of 128 ministries, authorities, statistical offices and institutions in the 22 countries of Eastern Europe were researched; 165 possible contacts were localised and sent letters, enquiring about current data and the legal social insurance system for dealing with occupational accidents and occupational diseases. In all, 39 persons responded to this, corresponding to a response rate of about 23% (Table 1).
Changes in occupational accidents and occupational diseases were analysed relative to 2006. If necessary, recourse was made to data for the years 2001-2005.

Comparison of the accident insurance systems
In spite of differences in structure, all social insurance systems in the 22 countries considered here share one feature. They all recognise -if sometimes only theoreticallythe specific insurance cases of "occupational accident" and "occupational disease". On the other hand, there are marked differences in the way in which this risk is covered according to insurance law. In addition, there are differences in the definition of insurance groups, including the level of the insurance premia and who has to pay these, in the guaranteed payments for total and partial invalidity and in additional payments, such as family and care allowances or pensions for dependents ( Table 2 and 3).
In 12 of the 22 countries, insurance against occupational accidents and occupational diseases is an independent component of the compulsory social insurance system. In nine countries -Estonia, Moldavia, Slovenia, Serbia, Macedonia, Turkey and Hungary -, the risks of occupational accident and occupational disease are covered by health insurance in the short term, pension insurance in the long term and also partially by invalidity and dependent insurance. No statements can yet be made about the social insurance system in Montenegro, which is still being developed.
In the six countries of Macedonia, Moldavia, Romania, Slovenia, the Ukraine and Belarus, three different levels of invalidity are distinguished. Two of these are based on 100% inability to work, with or without long-term need for treatment or medical care. The third level defines partial invalidity. However, as far as is known, this is not clearly defined by a percentage specification of the inability to work. In Moldavia, the inability to work is related to the previous profession. Serbia defines eight levels of invalidity. We were unable to establish precisely how these are differentiated.
In the remaining countries, there are very different minimal rates of loss of workability for receiving partial or full invalidity pensions (Table 2 and 3). In addition, some countries differentiate between partial invalidity payments made as an occupational accident pension (mostly when the rate of loss of workability is low) and a pension for loss of workability, as, for example, in Hungary. In addition, if the rate of loss of workability is low (> = 10%), a onetime compensation payment is made in six countries -Albania, Estonia, Latvia, Slovakia, Turkey and Cyprus -, which replaces the corresponding (minimal) partial invalidity pension. Compensation payments are generally excluded in Greece, Lithuania, Poland, Slovenia, the Czech Republic and Hungary.   The countries with the lowest minimum rates of loss of workability for guaranteeing payment of partial invalidity pensions are Hungary (15%), Bosnia-Herzegovina (20%), Cyprus (20%), Serbia (30%) and Albania (33%). The minimum rate is higher in the other countries.
The minimum rate of loss of workability to obtain full invalidity payments is unusually low in the three Baltic countries. In Latvia, full invalidity payments are paid if the minimum loss of workability is only 25%, with 30% in Lithuania and 40% in Estonia and Slovakia. In contrast, this minimum rate has the comparatively high value of 100% loss of workability in Bosnia-Herzegovina, Macedonia, Moldavia, Romania, the Ukraine, Belarus and Cyprus.

Comparison and changes in rates of occupational accidents
For 2006, data could be determined for 18 of the 22 countries in Eastern Europe. Because of the lack of current data, recourse was made to the data from previous years for Belarus, Greece and Macedonia. For Latvia, recourse was made to the data of the State Labour Inspection (SLI). In 2006, the highest rate of occupational accidents was found in Slovenia. High rates were also found in the Czech Republic, Croatia and Macedonia. On the other hand, the rate was strikingly low in Turkey ( Figure 1). The occupational accident rate is not lower in the nine EU countries than in the non-EU countries. It is however striking that the rate of occupational accidents is very low in some of the non-EU countries. As it cannot be assumed that this result can be explained by comprehensive established occupational safety and health guidelines in these countries, it is likely that registration was not performed in a standardised and complete manner. However, the causes could not be conclusively identified.
The change in the accident rate is shown in Table 4. In eleven of the 18 countries for which comparative data were available, the rates of occupational accidents decreased in comparison to the previous year (or the most recent prior year for which data were available):Bulgaria, Greece, Lithuania, Macedonia, Romania, Slovenia, the Czech Republic, the Ukraine, Hungary, Belarus and Cyprus. In contrast, there were increases in Estonia, Latvia, Croatia, Poland, Slovakiaand Turkey. There was little change in Moldavia. The decrease in rate was particularly striking in Bulgaria, Macedonia, Romania, the Czech Republic, Hungary, Belarus, and in the Ukraine (Table 4). There was no evident effect of EU membership on these decreases. Bulgaria and Romania only became EU members in 2007; Belarus and the Ukraine are not EU members. The same applies to the increase in rate, which was found in both EU members and non-EU members.

Fatal occupational accidents
The situation was more heterogenous for fatal occupational accidents in 2006. Relevant data were found for 17 of the 22 countries. The highest rate was in Turkey. The rate for fatal occupational accidents was also high in Lithuania and in the Ukraine. The rates were comparatively low in Hungary, the Czech Republic and Slovenia ( Figure 2). Here too there is no clear effect of EU membership on the rate of accidents, although the lowest rates The information is essentially based on "MISSOC and MISSCEEC Studies on the social protection Systems" of the European Union, the SSW Database (ISSA) (see Appendix) and personal information from the corresponding national authorities. n.s. not specified  The information is essentially based on "MISSOC and MISSCEEC Studies on the social protection systems" of the European Union, the SSW Database (ISSA) (see Additional file 1) and personal information from the corresponding national authorities. n.s. not specified Table 3

: Comparison of the Accident Insurance Systems in the Countries of Northeastern, Central Eastern, Southeastern and Eastern Europe* Non-EU-Members (Continued)
Non-fatal occupational injuries 2006 were in countries which had been EU members since 2004 -i.e. two years before data collection.
In comparison to the previous year, the fatal accident rate increased in nine countries -Estonia, Greece, Croatia, Latvia, Poland, Slovakia, Slovenia, Turkey and Cyprus-, but decreased in 8 countries-Bulgaria, Lithuania, Moldavia, Romania, Czech Rep., the Ukraine, Hungary and Belarus. The rates decreased strikingly in Romania, Moldavia, the Czech Republic and Hungary. On the other hand, the rates in Croatia and Turkey increased strikingly in comparison to the previous year ( Table 4). The accident rates with and without fatality increased or decreased in parallel in almost all countries. The changes in the rates were only different in Greece, Moldavia and Cyprus. An increase was found in 7 EU countries and in 3 non-EU countries, with a decrease in 4 EU countries and 4 non-EU countries. (At the time of data collection (2006), Romania was not a member of the EU and was therefore assessed as a non-member). It therefore appears that, in this context too, there is no clear link between EU membership and a decrease in accident rates. The strikingly low rates in non-EU countries may indicate that the registration system has not yet been comprehensively established.
In addition, the occupational accident rates were to be examined with respect to the different economic sectors. One reason for differences in accident rates may be that employment in different countries is dominated by different sectors, such as mining, agriculture and fishing, which Trend in comparison to preceding year: ▲▲ = strong rise; ▲ = rise; Ýâ = constant; ▼ = regressive; ▼▼ = strong regressive; n.s. = not specified  may be linked to less well established occupational safety and health systems. This theory could not be tested, due to lack of differentiation of the data.

Comparison and changes in occupational diseases
All countries have lists of officially recognised occupational diseases, even though these seem to be purely theoretical in some countries. There is however a great variation of the number and kind of diseases potentially recognized as occupational diseases -regardless of EU membership or non membership. Although the EU Commission has published an EU list of occupational diseases [1], with the recommendation that member states should adopt this, the harmonisation of the lists has not yet been implemented [2].
The Eastern European countries which are not EU members are currently often subject to fundamental reform processes, so that specific information on list systems and the number of occupational diseases are not yet available. Closed lists of occupational diseases exist in Albania, Bosnia-Herzegovina, Cyprus, Greece, Hungary, Poland, Serbia and Slovakia. Mixed systems exist in Bulgaria, the Czech Republic, Estonia, Latvia and Turkey ( It is difficult to analyse changes in registered occupational diseases ( Figure 3). There are evaluable data for 14 of the 22 countries. However, some of this information does not reflect the current situation, as the data are either old or prognostic values. As most of the data are from 2004 or earlier, no conclusion can be drawn on the influence of EU membership on changes in registered occupational diseases.
The number of newly registered occupational diseases is highest in Latvia, Lithuania and Slovakia, followed by the Ukraine and the Czech Republic. The rate is particularly low in Moldavia, Belarus, Croatia, Hungary and Serbia. For 8 of the 22 countries, comparative data could be determined for the prior years. These show an increase in newly registered occupational diseases in Estonia, Slovakia and Belarus, and decreases in Latvia, Croatia, Poland, Romania and the Czech Republic. In 2004, a total of 49 occupational diseases were recorded in Slovenia. As no registration system had been established, the Labour Inspectorate stated that 1000 to 15000 newly registered occupational diseases per year could be assumed. Particularly low rates, such as in Moldavia, Belarus, Croatia or Macedonia -with currently no notified case of occupa-tional disease -support the assumption that the official registration does not reflect the real state of affairs.

Occupational skin diseases
Research into occupational skin diseases turned out to be particularly difficult. The data situation in non-EU states is particularly defective (Figure 4). Even correspondence with the responsible authorities in the corresponding countries (Table 1)  Occupational skin diseases could not be studied separately for the area or type of employment, as almost no differentiation had been made. However, the study performed by the "European Agency for Safety and Work" (2008) concluded for the EU-25 that: "The mining and quarrying sector shows the highest incidence rate of skin diseases (31.5), followed by manufacturing (10.4) and construction (9.1). 34% of all cases of skin diseases were registered in manufacturing, followed by construction (14%) and health and social work (9.5%) [3] (p.19)". "The occupational group of crafts and related trades workers shows the highest prevalence of skin diseases (33.2%). They are followed by the elementary occupations (22.1%), service workers, shop and market sales workers (17.8%) and plant and machine operators and assemblers (14.4%) [3]: (p.20)." It was also impossible to examine any effect of EU membership on changes in occupational skin diseases. Of the countries for which data was available, only Croatia was not a member of the European Union. Moreover, current data could only be determined for Estonia, Latvia and the Czech Republic. All other data were from the years before entry into the EU.

Discussion
The present study is the first comparative compilation of the social insurance systems and an analysis of the changes in occupational accidents and occupational dis- Figure 3 Registered occupational diseases. The data provided represent the number of occupational diseases per 100.000 workers for the different European countries.

Registered occupational diseases
Registered occupational skin diseases Figure 4 Registered occupational skin diseases. The data provided represent the number of registered occupational diseases per 100.000 workers for the different European countries.
eases in 22 countries in Eastern Europe-extending beyond the limits of the EU. It became evident that comparative analysis could only be fragmentary, as a consequence of heterogenous, absent or unstandardised data, as well as the different degrees to which the social security system and the registration procedure had been established.
Other studies have been faced with similar difficulties: "The different occupational health systems and legislations in the countries across Europe make it difficult for one to sketch a detailed picture for the whole continent" [4]. In particular, data were pause in those countries which are not members of the European Union and in which the political and state reforms and the coupled changes in the insurance system were started after the political upheavals, but have not yet been completed.

Comparison of the accident insurance systems
In spite of their different structures, all social insurance systems recognise the special insurance cases of "occupational accident" and "occupational disease" -even though this recognition is sometimes rather theoretical. In 12 of the 22 countries, insurance against occupational accidents and occupational diseases is an independent component of the obligatory social security system. In nine countries, the risks of occupational accident and occupational disease are covered by health insurance in the short term, pension insurance in the long term and also partially by invalidity and dependent insurance. There are differences between EU member countries and non-EU members with respect to the establishment and functional efficiency of their social insurance systems.

Occupational disease lists
All 22 countries in Eastern Europe officially have an occupational disease list. In 7 countries this is closed and in 3 countries this is a mixed system. The list system could not be unambiguously clarified for the remaining 12 countries. For those, it was also impossible to determine the number of occupational diseases included in the lists.

Occupational accidents
The accident rates were decreasing in more than half the countries (11 of 18). On the other hand, fatal accidents increased in 9 of 17 countries. EU membership had no clear effect on the decrease in the accident rates. It is currently not posible to reach any conclusions about differences in specific risks at the workplace or any health and safety measures that may be necessary, as fatal and nonfatal occupational accidents were often not differentiated by area of employment.

Occupational diseases
The number of newly registered occupational diseases was decreasing in more than half of the countries considered (5 of 8). As the data was too old (2004 or older), any pos-sible effect of EU membership on this development could not be established.

Occupational skin diseases
The data on occupational skin diseases was particularly defective. For this reason, it was not possible to consider any effect of EU membership on the development of skin diseases. In comparison to preceding years, the number of occupational skin diseases was decreasing in half the countries (4 of 8). A similar experience was made in another study on occupational skin diseases in the European Union. "The statistical data on skin diseases have to be treated with caution for several reasons. Not all EU countries were included in the data collection and statistical data are only available until 2005. There is no standard definition to approach skin diseases and there are also clear indications that the number of cases and the extent of the diseases are underestimated in the EU" [3] (p. 17).

Conclusion
The results make it clear how important it will be in future -particularly in the eastern European countries which are non-EU members -to carry out continual standardised statistical analysis and to continue with progress in the establishment of their registration and notification procedures. Once transparency has been achieved, it will be possible to analyse future developments, to assess the success of the establishment occupational safety and health regulations, or to initiate timely improvements and ultimately to allow international comparisons between systems.
Finally, it should be said that support from an international exchange of experts can make an important contribution towards the development of social securitiy and workers health protection systems in individual countries -particularly eastern European countries which are not members of the EU. In particular, special attention should be paid to the development and establishment of local accident insurers for health and safety and rehabilitation.