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Health management in the private sector in the context of hiv aids 366 ftp
1. Sustainable Development Sust. Dev. 17, 19–29 (2009) Published online 29 October 2008 in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/sd.366 ‘Health Management’ in the Private Sector in the Context of HIV/AIDS: Progress and Challenges Faced by Company Programmes in South Africa Gavin George* and Tim Quinlan Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa ABSTRACT ‘Health management’ of employees is becoming a common imperative for companies that do business in regions where there is an HIV epidemic. Private sector initiatives in South Africa have evolved considerably. However, core components of HIV/AIDS-oriented work- place programmes, voluntary counselling and testing and anti-retroviral treatment, are not as effective as expected, despite considerable investment in them. There is some evidence to suggest gradual improvement in employee participation, yet this is coupled with employ- ees defaulting from treatment programmes. This article explores reasons for these develop- ments, the focus being on the economic and ﬁnancial challenges facing private sector workplace health programmes. Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment. Received 11 February 2008; accepted 18 February 2008 Keywords: treatment; ART; VCT; private sector; HIV/AIDS; adherence Introduction A GAINST THE BACKDROP OF A CALAMITOUS AIDS EPIDEMIC IN SOUTH AFRICA, WHERE BETWEEN 11 AND 20% OF THE adult population suffers HIV infection (Shisana and Simbayi, 2002), voluntary counselling and testing (VCT) is a foundation of prevention and care intervention. By 2002 the Department of Health had estab- lished over 450 VCT centres (Shisana and Simbayi, 2002), and by 2005 VCT had become core compo- nents of workplace health management programmes of the large corporations and parastatals that operated throughout southern Africa (George, 2006). Some of the larger corporations have also invested considerably in workplace treatment facilities, providing anti-retroviral therapy (ART) for HIV infected employees and clinical care for other diseases such as tuberculosis (TB) and sexually transmitted illnesses (STIs). However, there is little evidence to show that these workplace programmes are achieving the desired results (George, 2006). Many companies report low levels of worker participation in their VCT and ART programmes. This inability to ﬁnd out and, thereafter, to maintain the health of employees, notably to identify and treat HIV infection in the pre-symptomatic stage of AIDS, leads to high operational costs for both the programmes and business production. Programmes that have been operating for several years do show increases in VCT ‘uptake * Correspondence to: Gavin George, Senior Researcher, Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu- Natal, South Africa. E-mail: email@example.com Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment
20 G. George and T. Quinlan rates’, but this is not the case with ART. Furthermore, ensuring adherence to treatment amongst those employees who are enrolled in a programme has become a challenge. While most ART programmes show a gradual increase in numbers of employees on treatment, they also reveal an increasing number of defaulters. This article explores reasons for these developments. Workplace Treatment Programmes VCT has become an integral component of HIV prevention programmes in developing countries (Coovadia, 2000; Kalichman and Simbayi, 2003). This is due to demonstration of its efﬁcacy in promoting behaviour change (Vol- untary HIV-1 Counselling and Testing Efﬁcacy Study Group, 2000), in decreasing rates of sexually transmitted infections (Kamb et al., 1998), and as a precursor for treatment of HIV-infected individuals (WHO/UNAIDS, 1998). In sum, VCT is an entry point for a continuum of health care, rather than merely a means of screening for HIV. Anti-retroviral treatment (ART) is also becoming integral to health management strategies where HIV/AIDS is widespread. This is due to ongoing improvements in medicinal therapies (Harrington and Huff, 2005; Jensen- Fagel, 2004), lessons learned in programme design (Mnguni, 2003; Pemba et al., 2003), reduction of treatment costs (Eley et al., 2003; Science in Africa, 2004) and initiatives of the USA and international agencies such as WHO, UN and the Global Fund for AIDS, Tuberculosis and Malaria. VCT and ART are components of a still-evolving framework for health management of employees. For instance, the need to incorporate sound nutrition, to complement treatment (and prevention), is now being addressed.1 In the private sector, especially amongst the larger companies in Southern Africa, there is a discernable shift from orthodox occupational health programmes to designing and implementing ‘employee wellness’ or ‘health manage- ment’ programmes. Put schematically, programmes commonly begin with ‘education and awareness’ campaigns and, thereafter, incorporate VCT services, possibly adding in ART and including provision of food supplements and ART for spouses. Dr McDonald2 (2004) has summarized the factors that contribute to this situation in South Africa. Maturing epidemic. An increasing number of HIV infected employees are falling ill and employers are starting to experience the ﬁnancial effects of the epidemic by way of rising absenteeism and increasing staff turnover rates. Falling costs of treatment. The cost of treating an HIV infected person has dropped considerably. In 1998, the annual cost of treating an HIV infected individual was approximately R48 000 (US$6857)3. In 2005, these treat- ment costs ranged from R20 400 (US$2924) to R10 980 (US$1569).4 Activist pressure. Civil society, trade unions and NGOs have lobbied the government to provide treatment to HIV-infected individuals, which has inﬂuenced companies to act, indeed to take the lead ahead of the public health services. The government anti-retroviral treatment programme. The establishment of the public health service ART pro- gramme during 2003, and its implementation in April 2004, prompted more companies to investigate provision of treatment to employees. Corporate social responsibility. Companies are beginning to acknowledge the need to be accountable not only to shareholders but also to employees and to society at large on issues such as the social and environmental effects of their business and to demonstrate their contribution to the public good. Consequently, companies have begun to factor workplace health programmes into their business plans and budgets. The underlying economic imperative is that provision of ART can enable infected employees to remain produc- tive and, indirectly, contain recruitment, training and absenteeism costs. A study by the Bureau of Economic 1 In 2005, two international conferences signalled this imperative: the International Food Policy Research Institute’s HIV/AIDS and Food and Nutrition Security: from Evidence to Action Conference, and the WHO Consultative Meeting on Nutrition, Health Services and HIV/AIDS, both of which were held in Durban in 2005. 2 Dr McDonald is executive manager of health risk management consultancy, Qualsa; on the board of governors of the SA Business Coalition of HIV/AIDS and on the executive committee of the Southern African HIV Clinicians’ Society. 3 1$ = R7. 4 Anglo American group costs. Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
‘Health Management’ in the Private Sector in the Context of HIV/AIDS 21 Research (2006) indicates the extent to which South African companies have begun to invest in workplace pro- grammes. The study found that 71% of large companies and 38% of medium-size companies were providing some form of care, support and treatment. The study also revealed that 40% of large and 17% of medium-sized compa- nies were providing ART services. The form of these services varies. There are currently four models of workplace treatment programmes in South Africa (Connelly and Rosen, 2004; BER, 2004). • Model 1: employer provider. The employer ﬁnances and delivers treatment for HIV-positive employees using a ‘closed’ health insurance service (i.e. one designed only for employees and their dependents) and company clinic facilities. • Model 2: medical aid scheme. Employers subsidize health insurance premiums for HIV treatment via ‘medical aid schemes’. The insurance companies that provide services under these ‘schemes’ usually contract with a disease management programme (DMP) (see Model 3 below); hence, scheme members typically have to enrol separately with the DMP and there are additional premiums. • Model 3: independent disease management programme (DMP). A specialized HIV/AIDS management company is contracted by an employer to manage the costs and treatment of HIV-positive employees. • Model 4: clinic provider. The employer contracts a medical NGO or general medical practitioner to provide HIV- related services either at the workplace or at an outside clinic.5 Regardless of the options, many large companies report low uptake rates for VCT and ART, despite sophisticated programme designs and substantive ﬁnancial investments. Table 1 shows that the problem is widespread. The problem extends beyond South Africa, as indicated in Table 2. Furthermore, employees who do come forward for treatment commonly do so when they are unable to work (George, 2006). This confounds a fundamental reason for the programmes: to reach workers before they become too sick to work so that cost of treatment is offset by maintaining labour productivity, and to avoid costs such as loss of experience, institutional memory, recruitment and training that are incurred in replacing dying and deceased workers. This ﬁnding afﬁrms those of other studies in and beyond South Africa. The majority of persons who use public health and workplace VCT facilities do so because of illness (Day et al., 2003; Kalichman and Simbayi, 2003). In other words, VCT services are reaching infected and symptomatic persons more than individuals who may be Industry Number of Number of Number of % of Number of % of all companies employees employees in employees employees employees reporting uptake HIV DMP in HIV DMP on ART on ART Retail 3 44 900 70 0.2 52 0.1 Mining 9 275 300 24 066 8.7 2954 1.1 Manufacturing 4 36 700 Insufﬁcient data* n.a. 518 1.4 Financial serv. 4 112 500 910† 0.8 330† 0.3 CSPS 0 n.a. n.a. n.a. n.a. n.a. TSC 3 119 000 824 0.7 6 0.0 Construction 0 n.a. n.a. n.a. n.a. n.a. Agriculture 2 8 475 140 1.7 48 0.6 Total 25 596 875 26 010 4.4 3908 0.7 Table 1. Cross-sectoral rates of employee participation in company treatment programmes (end 2004) * Two of the manufacturing ﬁrms did not provide information about DMPs. One did not have an HIV DMP and the other did not know how many employees were enrolled. † Utilization ﬁgures for the four ﬁnancial companies include dependents. Source: Connelly and Rosen, 2006. 5 There is little information on the effectiveness of the different models with regard to enrolling HIV-positive workers and providing quality care and treatment, as these data are kept out of the public domain (George, 2006). Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
22 G. George and T. Quinlan Case study Treatment Workforce HIV prev. Start of No. on ART programme model (%) ART prog. Approx No. eligiblea at time of study Anglo-American employer provider 121 113 23 2002 3034b employees on treatment as at end 2005 >7000 eligible Goldﬁelds employer provider 50 000 32 2004 No information available at time of study 4000 eligible Namdeb DMP 2500–3000 7 40 (end of 2003) min. 50 eligible Old Mutual medical aid scheme 13 000 5 38 (as of the end of 2002) 160 eligible Debswana DMP 6534 20.1c 2001 280 employees on ART while a further 32.4d 69 were just being monitored (as at 31 October 2003) 474 eligible for ART Tongaat Hulett employer provided 750 10–12 2003 39 20 eligible Zambian Breweries clinic provider ±900 19–20 20 45 eligible Table 2. Summary statistics of ART uptake in seven corporations operating in Southern Africa * Two of the manufacturing ﬁrms did not provide information about DMPs. One did not have an HIV DMP and the other did not know how many employees were enrolled. † Utilization ﬁgures for the four ﬁnancial companies include dependents. a The assumption was that in contexts of advanced HIV epidemics about 25% of HIV positive people need to receive ART. b Anglo Report to Society 2005 – HIV and AIDS. c Permanent workforce. d Contractor workforce. Source: George, 2006. uninfected or infected but asymptomatic. In South Africa, Shisana and Simbayi (2002) revealed that only one in ﬁve individuals who knew about VCT had opted to be tested for HIV. Subsequent studies have revealed that amongst those who use VCT facilities many do not return for their test results and further counselling (Day et al., 2003; Wolff et al., 2005). Barriers to VCT Uptake There are many reasons for the limited use of public health and workplace VCT facilities. These can be summa- rized as the following. • Limitations in the design of VCT services, such as difﬁculty of access, service charges, perceived hostile attitudes of facility staff and violations of conﬁdentiality (Day et al., 2003; Ginwalla et al., 2002; Kalichman and Simbayi, 2003; Lie and Biswalo, 1994; McKenna et al., 1997; Nuhawa et al., 2002). There is conﬂicting evidence on whether provision of ART affects VCT rates. Baggaley et al. (1998), Nuhawa et al. (2002), and Sweat et al. (2000) indicated that lack of ART services was a barrier. Other studies (Ginwalla et al., 2002; Sangiwa et al., 2000) stated that clients saw value in VCT services even if not coupled with access to ART. • Emotional and cognitive barriers, such as little knowledge of VCT, denial of personal risk of HIV infection, percep- tions of little beneﬁt from VCT and fears of testing positive and the implications for future employment (Baggaley et al., 1998; Day et al., 2003; Ginwalla et al., 2002; Kalichman and Simbayi, 2003; Nuhawa et al., 2002; Wolff et al., 2005). Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
‘Health Management’ in the Private Sector in the Context of HIV/AIDS 23 VCT uptake 2004 (%) AngloGold Ashanti 10 Anglo Platinum 15 Anglo Coal 63 Anglo Ferrous Metals & Industries 17 Anglo Base Metals 87 Anglo Paper and Packaging 69 Corporate Centre 70 Weighted Average 21 Table 3. T uptake in Anglo American in 2004 Source: Brink (2005). • Social barriers, such as the inﬂuence of sexual partners in decisions to use the VCT service, stigma and social marginalization if presumed to be HIV positive by attending workplace facilities (Day et al., 2003; Ginwalla et al., 2002; Kalichman and Simbayi, 2003; Nuhawa et al., 2002; Wolff et al., 2005). Dr Brink (2005), the Vice-President of Health at the Anglo American Corporation, has highlighted the critical need to improve use of VCT services because the latter • are an important opportunity for reinforcement of prevention messages through individual counselling; • enable a company to initiate CD4 count monitoring in HIV+ individuals; • are the means to ensure early access to treatment and reduction of the risk of employees suffering AIDS associ- ated illnesses, and hence to ensure the cost effectiveness of ART provision for the company. Furthermore, the common rationale for VCT is that individuals who voluntarily seek and ﬁnd out their HIV status are more likely to change their behaviour accordingly and so contribute to reducing the spread of the virus. Dr Brink voiced his concerns in view of the experience of the Anglo American group of companies, as repre- sented in Table 3. Nonetheless, the weighted average rate was a 100% improvement from 2003, and in 2005 the average VCT uptake rate rose to 31% (Brink, 2005). In 2006, at AngloGold Ashanti, 75% of its South African employees took HIV tests compared with 10% in 2004.6 Sean Jelly, Chief Executive of Lifeworks, a disease management company, stated in a telephonic interview (13 March 2006) that the key factor affecting VCT participation, in his experience, was the extent of in-company support and/or sabotage, be it at management or at shop ﬂoor levels. He did not think that stigma was a major factor on the grounds that Lifeworks had achieved 80–90% participation in VCT campaigns where there was ﬁrm support from the client company. Furthermore, in arguing against the supposed effects of stigma, he noted that the use of incentives (e.g. rafﬂing a weekend family holiday amongst those who attend a VCT exercise) greatly increased uptake rates. In summary, there are indications of improvement in workforce participation in VCT programmes but little substantive evidence on trends and, as importantly, on lessons learned on how to achieve high participation rates.7 Barriers to Accessing ART In South Africa, the number of people who were receiving treatment was below 50 000 in 2005 (Quinlan and Willan, 2004; Sengwana and Veenstra, 2005). This ﬁgure rose to approximately 280 000 in 2006 (Grimwood 6 2006 Annual Report: AngloGold Ashanti. 7 DMP companies are generally unwilling to share ‘trade secrets’ in what is has become a very competitive service industry. Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
24 G. George and T. Quinlan Company Company size by Estimated HIV Target Registered Enrolment employee numbers prevalence (%) patients patients rate (%) A 200–500 18–20 62 47 76 B 500–2000 10–12 97 63 65 C 200–500 27–29 58 25 43 D 2000–3000 10–12 213 107 50 E 3000–5000 10–12 400 258 65 F 3000–5000 4–6 201 86 43 Table 4. ART uptake in 2006 in companies where Lifeworks manages treatment Source: Sean Jelly, Chief Executive, Lifeworks, 2006. 3000 2500 Number of employees 2000 1500 1000 500 0 2002 Feb Feb Feb Jun Aug Apr June Aug Apr April Oct Oct Dec Dec Started on ART Remaining on ART Figure 1. Anti-retroviral therapy coverage in Anglo American (2002–2005) Source: Brink (2005). et al., 2007, p. 83) and 36 000 in 2007 (ITPC, 2007, p. 104). These ﬁgures are still below the estimated number of people needing treatment (600 000 plus in 2006; Grimwood et al., 2007). Stigma and other social factors are frequently cited as barriers (Chesney and Smith, 1999; Moss et al., 1999; Raveis et al., 1998; Valdiserri, 2002; Stall et al., 1996; Government of South Africa, 2000) and, indirectly, to sus- taining patient adherence to treatment regimes (Government of South Africa, 2003, 2004). However, there is little research on actual rates and variations over time and in different settings, or on reasons for success or failure of the programmes. For instance, De Coito (2005) and George (2006) noted that stigma and discrimination were frequently attributed reasons for low uptake of VCT and ART, but no company had conducted research to verify this perception. Furthermore, Lifeworks, the disease management company cited earlier, has reported relatively high ART uptake rates in companies where it works. Due to the sensitive nature of the data, company names cannot be disclosed. An emerging challenge is ﬁnding ways to sustain patient adherence to treatment. Figures supplied by Anglo American are illustrative. By April 2005, the corporation had 2936 employees enrolled on ART, but for various reasons, including non-adherence (45%), 858 (29%) of employees had been lost from the programme. Figure 1 represents the Anglo American experience. Economic Cost of Low Uptake The economic beneﬁt of VCT and ART has been established in South African studies (Gow, 2002; Rosen et al., 2003; SABCOHA, 2003). However, there is little public research on the cost effectiveness of programmes over Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
‘Health Management’ in the Private Sector in the Context of HIV/AIDS 25 time, on means to reduce the opportunity costs, and on how to increase the beneﬁts to companies and workforces. These costs and beneﬁts need to be measured if companies are to grasp what interventions are and are not working. Put differently, from a company management perspective, assessments of the value of VCT and ART should include a ‘bottom line’ in the form of a monetary equivalent measurement of all beneﬁts and direct and indirect costs of a programme. A programme may provide beneﬁts that are not directly expressed in monetary terms, but there is some amount of money the recipients of the beneﬁts would consider just as good as the programme’s beneﬁts. For example, programmes provide infected employees with both free VCT and access to ART; the value of this beneﬁt to an infected employee is the minimum amount of money that the recipient would take instead of the medical care. Similarly, there are costs and beneﬁts to the company of uptake and non-uptake of the services, which can be calculated through cost impact and auditing techniques. However, in the absence (and difﬁculty) of calculating accurately total costs and beneﬁts at any one time and over time, the general yardstick is that low VCT and ART uptake rates mean the programmes are not as cost- effective as they should be. In response, the general trend has been for companies to elaborate their programmes with new interventions in the quest to improve these rates. With regard to cost effectiveness, the history of Aid for AIDS (AfA), the largest disease management programme (DMP) in South Africa, is informative. AfA manages the initiation of therapy, adherence to treatment, laboratory monitoring, clinical response and costs (Martinson et al., 2002). Total beneﬁts per annum per person range from R5000 ($714) to R40 000 ($5714) depending on the health insurance scheme that uses its services. Between AfA’s inception in 1998 and 2003, approximately 27 000 patients had enrolled in its programme, most of whom have been eligible for ART (Cowlin et al., 2003). However, late enrolment of patients (i.e. when the individual is suffering frequent bouts of AIDS-related ill- nesses) proved to be a costly factor. There was a steady monthly increase in uptake between 1998 and 2001. There was concern about a trend of late enrolments, particularly of individuals with CD4 count less than 50 cells/mL (an indicator of advanced AIDS,8 but the expectation was that this would reverse over time due to the following factors (Hislop, 2004): (a) decrease in stigma surrounding HIV infection and treatment; (b) gradual reduction of the size of the ‘late enrolment’ population; (c) greater public awareness of the role of the DMP and the beneﬁts of ART. However, this reversal did not happen, as is represented in Figure 2. Figure 2. Percentage beneﬁciaries from selected open medical schemes registering on Aid for AIDS with a CD4 count < 50 cells/mL Source: Hislop (2004). 8 CD4 refers to the cells in the human immune system that the HI virus penetrates and gradually destroys. CD4 count refers to the number of CD4 cells per microlitre of blood (mL), normally 1200 cells/mL, and measurement of the number is a means to assess a person’s status between being HIV infected and suffering AIDS. A person with a CD4 count of less than 200 cells/mL is regarded as having AIDS (Barnett and Whiteside, 2002, pp. 30–32). Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
26 G. George and T. Quinlan $800 Per patient per month cost $700 CD4>350 $600 CD4<50 $500 $400 $300 $200 $100 $0 0 3 6 9 Months relative to enrolment Figure 3. Cost beneﬁts of early enrolment Source: Adapted from Cowlin et al., 2003. Hislop points out that 44% of AfA’s patients enrolled later than minimum guidelines for commencement of ART, deﬁned as a CD4 count of less than 200 cells/mL. Fifteen percent of patients enrolled with a CD4 count of less than 50 cells/mL. In other words, medical aids schemes contracted to AfA’s programme had to continue to cover hospitalization costs that, in principle, were avoidable if beneﬁciaries had enrolled for treatment in earlier stages of AIDS-related illness. Length of hospital stay was over three times higher for patients with CD4 count < 50 cells/mL than patients with entry CD4 counts between 200 and 350 cells/mL (Hislop, 2004). Figure 3 illustrates the difference of the actual per patient per month costs incurred as a result of early and late enrolment. In contrast, the Anglo American Corporation9 experience shows what can be achieved with effective treatment. In 2003, the corporation calculated that initial costs of providing ART were R29 294 ($4185) per patient per year. This was due to the initial treatment of opportunistic infections together with the added pathology tests and frequent monitoring. These initial costs were similar to those experienced by AfA. However, after the ﬁrst year of treatment, and adherence of patients to therapies, the cost of providing ART decreased on average to R10 620 ($1517) per patient per annum. Key Problems and Issues for Consideration The general expectation of workplace health programmes is that ‘start-up’ costs are very high, but the unit cost of providing prevention, treatment and care services decreases signiﬁcantly over time. Furthermore, setting up and implementing programmes is part of a broader social process to gradually overcome people’s fears and stigma associated with HIV infection and establishing partnerships between management and workers. However, evidence to date reveals • limited use of VCT services by workers; • limited numbers of individuals on ART presenting a very high cost ratio for individual care; • tendency of individuals to seek treatment once they are sick; • high costs in time and resources expended to enrol employees in programmes. These are signiﬁcant problems. They show that South African workplace health programmes have yet to achieve their core purpose: to prevent spread of HIV and to ensure that HIV infected employees obtain treatment before they are too ill to work. Stigma and discrimination are frequently cited by company managers as the causes, but so too are more prosaic reasons by employees. Fear is a common obstacle because to take a test or admit to needing treatment means that 9 Information can be found on www.angloamerican.com Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
‘Health Management’ in the Private Sector in the Context of HIV/AIDS 27 one knows one’s status, and that knowledge entails responsibility to change one’s behaviour. Other reasons include • lack of ‘buy-in’ from management, for example, when line managers and supervisors view interventions such as peer education and ‘know your status’ campaigns (VCT and company-wide sero-prevalence surveys) as factors that disrupt daily production demands and so they reluctantly support employee participation in them, • insufﬁcient training, time or means given to peer educators to interact with employees, • disincentives such as when contract or casual employees see that they are entitled to VCT services but access to treatment is restricted to permanent employees, • workers not seeking treatment if they have not disclosed to their spouses and/or the latter do not have access to treatment and • interventions that ‘do not speak’ to the individual, taking into account factors such as age, gender, social circumstances and culture. Whatever the reason, the fact that workers often seek treatment ‘too late’ suggests lack of integration of VCT and ART in some way with other components of a workplace programme. This lack of integration, we suggest, is the nub of the problem that companies face. ‘Health management’ is not simply a matter of co-ordinating different activities. Companies have adopted an instrumental approach with sound intent but the results have not been as expected. They have had to recognize that promoting ‘behaviour change’ is a complex task. The adaptation evident in companies experimenting, reﬁning and broadening the scope and content of their programmes reﬂects an awareness of the scale of the challenge. However, this approach, in essence adding components, obscures a deeper understanding of what integration means. It means working from a premise of changing the workplace environ- ment and recognizing the need to anticipate the new challenges and demands that arise inevitably. Therefore, co-ordinating activities and adding programme components to change people’s behaviour are actually subordinate to a broader agenda of social engineering. To illustrate, the limitations of current constructions of workplace programmes are expressed in private sector support for conducting workforce sero-prevalence and Knowledge Attitude and Practice (KAP) surveys.10 These surveys are a standard means to measure progress of a programme; initial surveys provide a baseline while sub- sequent surveys, after a programme has been implemented, are a basis for assessing effectiveness of a programme. However, we have noticed that sero-prevalence surveys are frequently implemented without redeﬁnition of purpose and, speciﬁcally, in relation to a company’s experience of, and information derived from running a programme. Likewise, there is widespread interest in the South African private sector in continuous workplace, HIV/AIDS- focused education and training. This is coupled with an emphasis on setting and improving the standard of this education and training (i.e. courses that are accredited with, and meet the standards of, the government national quality assurance legislation). However, sometimes missing from company training agendas is consideration of the need to update the training given to peer educators and lack of attention to revising the selection criteria for these posts (i.e. ensuring that they are representative of the demographic proﬁle of the workforce or include HIV positive workers who have disclosed their status). Conclusion Companies have little reason not to set up workplace health programmes but for the fact that they are costly exer- cises. This article has illustrated some of the challenges and their long term nature. The South African business sector is acquiring experience and hence working knowledge of what works and what does not work. However imperfect this knowledge, it is evident that workplace programmes cannot be static. The demands on programmes have changed and will continue to change; hence the design and operation of these programmes must evolve. In sum, the orthodox notion of occupational health has become outdated and is being redeﬁned substantively with 10 KAP surveys are usually questionnaire based, and probe for self-reported information on knowledge about HIV and AIDS, attitudes with regard to the disease and working and socializing with HIV infected persons, and social and sexual practices. Repeat surveys enable, in prin- ciple, assessment of changes in levels of knowledge, attitudes and practices. Copyright © 2008 John Wiley & Sons, Ltd and ERP Environment Sust. Dev. 17, 19–29 (2009) DOI: 10.1002/sd
28 G. George and T. Quinlan the advent of ‘employee wellness/health management’ programmes. However, evolution of these programmes does not mean simply adding on components. The inclusion of new components presumes that demands have changed, and so a programme as a whole may require recalibration. This is a point that private sector programmes in South Africa have yet to reach. References Almeleh C, Grimwood A, Hausler H, Hassan F. 2006. HIV/AIDS and tuberculosis treatment update. South African Health Review 65– 76. Baggaley R, Kelly M, Wedirrich S, Kayawu I, Phiri G, Mulonoo W, Phiri M. 1998. HIV counselling and testing in Zambia: the Kara counsel- ling experience. SA/AIDS News 6: 2–8. Barnett A, Whiteside A. 2002. AIDS in the Twenty-First Century: Disease and Globalization. Palgrave Macmillian: Pietermaritzburg, South Africa. Brink B. 2005. An interim appraisal of the anglo american aids treatment programme. Presentation at the 2nd SA AIDS Conference, Durban. 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