Work is the means through which most people provide for their daily sustenance. People work in or out of their homes, with or without labour contracts, and in either safe or hazardous working conditions. Factors related to working conditions have received a great deal of attention and are recognised as a key social determinant of health and health inequalities, but this has not often been the case for employment conditions. Some of the reasons for this neglect are found in the confusion between the concepts of work and employment, and the lack of clarity and development of indicators and data related with employment. Yet, labour markets and social policies determine employment conditions such as precarious or informal jobs, child labour or slavery, or problems such as having high insecurity, low paid jobs, or working in hazardous conditions, all of which heavily influence health inequalities. In sum, these types of employment and working conditions have different implications for the health of populations and the social inequalities in health among social classes, genders or ethnic minorities. To reveal the different ways that employment relations, employment conditions, and working conditions affect the health of populations we need to define what those concepts mean. Then, we must use these concepts and meanings to understand both how society structures labour relations, labour/capital agreements, labour or employment contracts, and what the social processes of production are that affect the health of workers.

To begin with, employment relations, employment conditions and working conditions are different yet interrelated concepts. The first term, employment relations, constitutes the relations between buyers (employers who hire workers who perform labour to sell a profitable good or service) and sellers of labour (employees who contribute with labour to the enterprise, usually in return for payment of wages), as well as the practices, outcomes and institutions that emanate from or affect the employment relationship. Two important components of employment relations are the power relations between employers and employees and the level of social protection that employees can count on. In wealthy countries, employment relations are often subject to the provisions of the law or a hiring contract. In these societies, the government is often the largest single employer although most of the work force is employed in small and medium businesses in the private sector. In middle income and poor countries however, most employment agreements are not explicitly subject to any formal contract, and a high proportion of total employment is in the informal economy.

Given this vast spectrum across which types of employment relations can range, both within and between countries, we concern ourselves with six specific kinds of employment relations, which we call employment conditions. This term refers to the conditions or circumstances in which a person carries out their job or occupation.  It frequently presupposes the existence of an agreement or relationship between an owner who hires workers and an employee who sells his or her labour (see Glossary in section 1 of the Appendices).  These conditions, with a global scope, include full-time permanent or standard employment, unemployment, precarious employment, informal employment and informal jobs, child labour, and slavery/bonded labour.

Focusing more directly upon the workers themselves, working conditions involve exposures in the workplace and the way work is organised. Working conditions can be divided into physical, chemical, biological and social exposures. Simply put, material working conditions involve the physical, chemical, biological, and ergonomic work environments, while the organisation of work involves psychosocial environment, management and control, the tasks performed by workers, and the technology being used. Working conditions also include workplace hierarchy and power relations, worker participation in decision-making, and social and occupational discrimination.

To distinguish between these concepts, it is necessary to point out that two people can perform the same job in the same enterprise, sharing the same working conditions, yet nevertheless be labouring under different employment conditions.

The first worker may be a permanent and direct employee of the enterprise, while the second is a temporary worker contracted by an external employer. In this case, there are three potential differences in employment conditions. First, the first worker has a permanent contract while the second has either a short-term contract or none at all. Second, the first worker may be covered by the social security system while the second receives partial or zero coverage. Finally, the first worker may be part of a trade union while the second is not eligible.

The ways in which any society approaches inequalities in health is a political issue. On the one hand the inequalities may be accepted as the inevitable result of individual differences in genetic determinants, individual behaviours, or the market. On the other hand, they can be seen as a social product that needs to be remedied. Underpinning these different approaches to health inequalities are not only divergent views of what is scientifically or economically possible but also differing political and ideological beliefs about what is desirable (Bambra, Fox, & Scott-Samuel, 2005).

Thus, the reduction of health inequalities, especially attempts carried out at the level of social policy, will largely depend on the distribution of power among key political actors and the role of the state. While political and social scientists debate the structure, function and power of the state, this discussion has yet to penetrate the public health arena despite the state's crucial influence on all health activities. We follow here a theory of power resources that identifies labour organisations and political parties as the key determinants of differences in the impact of the welfare state across countries and over time (Korpi & Palme, 2003).

In spite of growing scientific evidence regarding the effects of employment conditions on health, almost no conceptual models have been proposed to explain these effects. In general, there is a great lack of research concerning the impact, pathways and mechanisms that connect employment conditions with health inequalities. There is abundant literature, however, about the effect of employment conditions on health, yet it rarely focuses directly on the important role they play as a social determinant in shaping health inequalities.

The social determinants of health and employment relations and conditions have been particularly neglected for a number of reasons. First, there is a lack of public health research in poor countries, the places where precisely the most worrisome employment conditions such as slavery or child labour are found. A second reason is the scarcity of data in many countries, especially in low-income countries. A third factor is the lack of sociological training of many epidemiologists and public health researchers, which would help them understand how employment relations and conditions can lead to health inequalities. Fourth, researchers interested in controversial topics such as health inequalities, the politics of health care, or other class-based approaches, may have more difficulty obtaining research funds compared with other mainstream biomedical or clinical approaches. Finally, there is a notable lack of attention paid to theories of development in the disciplines of epidemiology and public health research.

The scarcity of research and data coming from middle income and poor countries creates a real challenge in terms of avoiding taking only the perspective of wealthy countries concerning labour markets and employment conditions. This is a critical trap to avoid because the historical legacy of production, employment, and work varies considerably across different parts of the world. For example, the labour reforms implemented in Europe during the nineteenth and twentieth centuries concerning minimum wages and hours of work did not migrate to former colonies in Asia, Africa, and Latin America.

Bearing these different paths in mind, this book strikes a balance that captures global reality, actively seeking out examples and lessons from the South. In order to deal effectively with such a diverse context, we identify common features and trends among countries while avoiding "one size fits all" descriptions or recommendations.

Origins, aims and organization of this book

In May 2004, the World Health Organization (WHO) created the Commission on Social Determinants of Health (CSDH) with the goal of strengthening states' comprehensive approaches to health inequities. Some specific aims of the Commission included the collection of evidence on the linkages between social determinants and health inequalities, the compilation of successful interventions and policies to address key social determinants, and advocacy for the implementation of policies that address social determinants of health. To that end, the CSDH created nine Knowledge Networks on globalisation, early child development, health systems, urban settings, measurement and evidence, women and gender equity, social exclusion, priority public health conditions, and employment conditions.

This book is based on the Report prepared in August 2007 by the Employment Conditions Network (EMCONET) as part of the work developed for the CSDH. While the structure and contents of this book are similar to the previous EMCONET report, its content has been greatly expanded to include extensive information on case studies, the impact of employment-related conditions on health inequalities, and its policy conclusions and recommendations, among other issues.

This book offers an in-depth investigation of how employment relations affect workers' health in different ways, and from many countries. Armed with this knowledge, we identify and suggest institutional changes and effective policies capable of reducing health inequalities. The specific aims of this book are the following:

1.         To provide a comprehensive description of key employment conditions. We aim to classify the types of employment conditions as they exist across countries, regions, and geographic areas. We categorise them along our six dimensions of full-time standard employment, unemployment, precarious employment, informal employment, child labour, and slavery and bonded labour. In addition, it is important to consider that while this grouping provides a convenient way to organise a complicated issue, we must also consider cross-cutting issues, or "axes," such as social class, gender, age, ethnicity and migrant status.

2.         To understand the main links between employment and health inequalities. This book explores the paths through which employment conditions and health inequalities interact. In other words, we identify not only how employment conditions affect health inequalities, but also how strong this impact really is.

3.         To gather evidence of employment-related policies that effectively reduce health inequalities. With a global categorisation of employment conditions and a thorough understanding of the health-related effects of employment policy, we then take stock of those policies around the world that actually diminish health inequalities. We focus strongly on those programmes designed according to the principles of democratic participation.

4.         To translate this knowledge into health policy recommendations. We will furthermore disseminate the results and collaborate in the implementation of these recommendations. This requires, of course, that this issue first be introduced into the political agendas of the relevant social actors.

This book is intended for three audiences at once. The first audience includes general readers who have no previous specialist knowledge. A second audience consists of those specialists in public health, health inequalities, social or political sciences, and labour studies, who want a deeper understanding of the situation, causes and policies linking employment, work, and health inequalities. Finally, this text is also written for activists and members of unions and social movements who are interested in a global and technical understanding of this topic. This book is organised into eleven main chapters, references, and appendices.

In this Chapter 1 we have described the contexts and concepts underlying this study, setting forth the main objectives of the study. Chapter 2 presents the concept of fair employment, the main employment conditions, and the cross-cutting axes used in this book. Chapter 3 identifies the methods, strategies, and the main sources of information that have been used. Chapter 4 presents a theoretical model with two frameworks that integrate the factors linking employment conditions and health inequalities, at the macro and micro levels respectively. Chapter 5 presents a historical and political review that provides the social context for the whole book. Chapter 6 discusses labour markets and welfare states from a country-level perspective, including selected country case studies. Chapter 7 contains a descriptive perspective on key employment relations, including information on power relations, labour regulations and industrial relations, and a more detailed account of employment conditions and working conditions in a global context. Chapter 8 presents an analytical view of the pathways and mechanisms that drive the links between employment dimensions and health inequalities. Chapter 9 shows main findings concerning policies, including a brief description of four key policy entry points for implementing policy changes to reduce health inequalities. When EMCONET presented its Final Report to the CSDH in 2007 the first inklings of a major economic upheaval were barely apparent. In Chapter 10 we present the relevance of the global economic crisis for this book, and the need to implement a new policy agenda. Chapter 11 summarises the main conclusions and recommendations of the book. Finally, we include the references used in each chapter and several appendices with other related information of interest.