Brewing giant Heineken is grappling with how it can widen its approach to disease in Africa

 

Brewing giant Heineken is grappling with how it can widen its approach to disease in Africa

During the Franco-Prussian war of 1870, Bavarian beer was suddenly in short supply. Consequently sales of Heineken, in the neutral Netherlands, rocketed. The company has not looked back since. And now, the brewer is hoping its investments in Africa may lead to a similar boom in business.

Africa comes with different challenges from 19th century Europe. While politics and the rule of law matter just as much as they did 140 years ago, companies in Africa must also now consider how they tackle the scourge of poor health in the communities where they operate. And Heineken, alongside other large companies, is thinking very hard about what this means in practice.

The giant Dutch brewer has been operating in Africa since 1937, but has massively increased its investments there in the past five years, pumping hundreds of millions of dollars into the sub-Saharan region. Heineken is today one of the continent’s biggest foreign investors. Its African brands include Primus, Gulder and Star. Heineken is also the largest bottler of Coca-Cola products in Africa. In terms of tax payments alone, one thing is clear: the company is a major player in the still-troubled continent.

Around the corner from the company’s modest head offices in Amsterdam sits a smaller, uncluttered building. Inside is the company’s health centre, where employees and managers can be, among other things, tested for HIV/Aids. It seems an appropriate place to meet the company’s non-executive adviser to the board and former head of health affairs, Dr Henk Rijckborst, to discuss the dilemmas facing progressively minded companies in Africa.

Belgian and French colonial law in Africa had dictated that companies cover all healthcare costs for employees and dependents. As a result, historically Heineken had clinics at every brewery. In the mid-1980s it became obvious to company managers such as Rijckborst that the colonial-era hospitals of many states on the continent just could not care properly for Heineken’s people. This coincided with the beginnings of the HIV/Aids epidemic. The board decided to create its own complete medical system, with doctors, nurses, laboratories and imported medicines for its 8,000 employees and their 32,000 dependents in Africa.

Cautious activity

In 1988 the firm began Aids awareness programmes – with a degree of caution about how its activities might be perceived. “Aids and beer was not an ideal combination for marketers,” says Rijckborst.

At the same time, Heineken began working with Belgium’s Antwerp University and the World Health Organisation on a range of health issues.

For employees in Africa, healthcare is often more important even than salaries, says Rijckborst, but in the late 1990s, the cost of treating an employee infected with HIV was prohibitively expensive – as much as $15,000 a year. As of eight years ago, much cheaper drugs began to appear, spurring companies such as Heineken into further action.

In 2000, six big pharmaceutical companies, including Merck, Bristol Myers Squibb and what is now GlaxoSmithKline, started to offer an effective HIV treatment with a 90 per cent price reduction for bulk buyers. After this landmark event, mining and brewing companies in sub-Saharan Africa began to use their existing health infrastructures to offer treatments to employees and dependents. The annual cost of antiretroviral (ARV) treatments has dropped from $10,000 per patient in 2000 to $130 today.

But outside corporate centres, training and laboratories were severely lacking across the continent, a situation that continues to this day.

Access to care

In 2001, Heineken’s board decided to expand its HIV employee programme to include access to care, support and treatment, most notably access to ARVs. Access is available to employees, partners and children. Heineken is currently considering how to ensure continuing access to treatment for chronic conditions once employees’ children turn 18 and therefore cease to qualify for company benefits.

The company works with Pharmaccess, a foundation that organises ARV treatment in Africa, to acquire drugs and advise on structuring care regimes, and it provides training in the Netherlands for Africa-based doctors, nurses and lab staff.

In 2001, Heineken was the only firm in sub-Saharan Africa to offer treatments to more than a dozen people. Today Coca-Cola uses Heineken’s programme, and mining giant Anglo-American has a similar scheme.

Rijckborst stresses that costs for prevention and treatment remain high. Heineken’s African healthcare programmes currently cost €2.5 million a year. Constant training and retraining, monitoring, awareness-raising and discussion of patient care cost far more than simply handing out pills to patients – who may not always take them correctly.

When Heineken began its new treatment programme in September 2001, the company saw a dramatic decline in the number of employee and dependent deaths from Aids, almost to zero. Naturally, says Rijckborst, this had a major effect on employee morale. Heineken has not quantified the effect of its life-saving programmes on employee productivity and absenteeism costs, not to mention worker time off for funerals. Executives hint that applying a business case analysis here might be a little crass.

After 2001 Heineken quickly secured a 90 per cent adherence rate to its HIV/Aids treatment programmes, a figure high in comparison with HIV healthcare programmes in the company’s home city, Amsterdam, where compliance can be as low as 50 per cent.

And other companies are matching Heineken’s record in Africa – Anglo-American has managed to test more than 90 per cent of its South African workforce.

Heineken ensures that discrimination is minimised by restricting information flow so that workers can have confidence in the treatment process. For example, some managers are not told about the HIV status of workers if there is no reason for them to know. Staff get lifelong treatment via external providers or through Heineken’s programmes, even if they leave the company. When Heineken closes a brewery it continues to offer workers HIV/Aids treatment “or else it would represent a death penalty”, says Rijckborst.

Into the public sphere

Rijckborst is frank about the difficulties senior management in Heineken faced when deciding policy on HIV/Aids. What to do, for example, about an employee who is fired after being caught stealing? Any withdrawal of treatment would usually lead to a quicker death, so Heineken’s management felt they should continue to offer treatment at external clinics in all cases. Another tricky issue is the embarrassment factor for government in some of the nations where Heineken operates. Many do not want to be seen as unable to take care of their citizens. To compound matters, some civil servants do not have access to treatments that are available to corporate employees.

In October 2007, Heineken decided it was time for a review of what it has been doing for employee health around the world. The company convened an international conference entitled “What are the responsibilities of the private sector in healthcare?”

One reason for the conference, says Rijckborst, was to discuss the increasing pressures on the private sector to tackle big global health issues – among them HIV/Aids, tuberculosis and malaria.

Heineken’s chief executive, Jean-François van Boxmeer, announced at the conference that his view of Heineken’s responsibilities had changed. Van Boxmeer said the company must explore how it should be “repositioning” itself, Rijckborst says.

“There is a shift now, not only for medical care for our people … We are looking at possibilities of offering bed nets for malaria to communities. We are looking at what we have to do nowadays,” he says.

Heineken is clear about who is eligible for treatment in its programmes, but “we have to have more discussions about what we are accepting outside the Heineken world”, Rijckborst says.

Heineken is working with a health insurance fund established by the Dutch government and private companies to promote heavily subsidised insurance in Africa among the poor. The idea is to promote small savings in healthy times as well as bad, which helps hospitals invest and maintain cash flow. “It’s a start,” Rijckborst says. The World Bank is following the project closely, he says, and may begin its own trial using middle-income families first.

The pilot scheme, Heineken believes, contributes to sustainable healthcare in low income groups.

Low-income groups covered by the pilot scheme include about 5,000 farmers in northern Nigeria and a similar number in Rwanda, with tens of thousands of dependents between them. Non-governmental organisations help improve public clinics as part of the initiative.

Fionnuala Murphy, HIV/Aids campaigns officer at UK NGO ActionAid, says companies engaging in HIV/Aids programmes are doing so for business reasons.

“It’s just pragmatism,” she says. “It’s great that companies are doing this, but it should be the government that is providing treatment and realise people’s right to health.”

Murphy says real systemic solutions are “much more complex than just providing drugs”. She adds: “The problems are more structural. In Mozambique they have something like 40 doctors for the whole country.”

Another challenge for companies in Africa, Murphy says, is that most corporate drug programmes are targeted at men, “but it’s women who are bearing the brunt of HIV”. ActionAid wants to see companies “talking to government on improving the bigger picture rather than just focusing on their staff”.

Further to go

Companies in Africa, Murphy says, could further their aims and play an active role by “looking at ways to provide non-employee health funding, share the expertise that they have gained from running their clinics, and share knowledge of working with communities, talking to government about how they might support their programmes”.

She adds: “Many companies have set these treatment programmes with their own interests in mind. Not all of them are interested in expanding them into the community.”

Joelle Tanguy, vice-president for global partnerships and programmes at the Global Business Coalition on HIV/Aids, TB and Malaria, says: “Effective business action against HIV/Aids starts in the workplace, and Heineken is certainly among the leaders.” But, she says, businesses in Africa can do more to help Africans fight disease. “More companies need to extend their workplace benefits to dependents – not doing this has limited the impact of their investments in the fight against HIV/Aids,” she says.

Tanguy echoes Murphy’s concerns on the gender imbalance, saying: “Young women and girls are the new face of Aids, comprising more than half of the 33 million people living with HIV worldwide. Businesses can protect the lives of young women by providing them with increased economic and educational opportunities, and by improving access to health services and information. But not enough are doing so now.”

While Heineken considers the suggestions of ActionAid and other NGOs, the crucial measure for the company is the number of new sufferers in the company’s workforce, according to Rijckborst. He says: “The number of new patients is going down. That’s the key indicator.”

Heineken’s HIV/Aids programme

Heineken has had an HIV-prevention programme in Africa for over a decade. Main features include:
· awareness materials for employees;
· education of workers by external public health experts;
· increased availability of condoms in the workplace (free or subsidised);
· general protection and preventive measures (blood supplies, better health and safety);
· management of sexually transmitted infections using the company’s own workplace clinics;
· counselling;
· promotion of voluntary counselling and testing at sites where antiretroviral therapy treatment is becoming available; and
· short courses of drugs to prevent transmission from mother to child.

The company’s existing “Health support programme for HIV and Aids patients” is designed to support HIV-positive employees and their immediate families.

Source: Global Business Coalition on HIV/Aids, TB and Malaria

Aids programme gets results
Just short of 10,000 Heineken employees and dependants in developing countries have been voluntarily tested for HIV/Aids, with 365 testing positive. Of these, 230 are receiving HIV therapy, while the remaining 135 are not yet in a phase of the disease during which treatment would improve their well-being.

In total 8,000 employees, 6,000 partners and 21,000 children are benefiting from all Heineken’s sub-Saharan Africa health programmes.

Source: Heineken Sustainability Report 2006

HIV/Aids: the figures

· According to the UN, almost 34 million people live with HIV/Aids worldwide.
· The International Labour Organization says HIV/Aids killed almost 3.5 million people of working age in 2005.
· Each day, more than 6,800 people become infected with HIV and more than 5,700 die from Aids.
· Sub-Saharan Africa remains the most affected region in the global Aids epidemic, with more than two-thirds of all HIV-positive people living there.
· Incidence of HIV/Aids is on the rise in eastern Europe, China, Russia and India.
· India is now facing the biggest HIV/Aids burden of any single country in the world, with 5.7 million people infected.

South Africa’s shocking statistics

· In South Africa alone HIV/Aids prevalence rates have soared over a relatively short period to among the highest in the world: from less than 1 per cent in the early 1990s to 19 per cent of the adult population in 2006.
· Up to 5.5 million people in the country are living with HIV; close to a quarter of a million of these are children under 15.
· Life expectancy has plummeted to 49 years for women and 47 for men.

Source: Business Action for Africa



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