Brian Brink, who serves as an independent non-executive director at Discovery Limited and is the former chief medical officer for the mining company Anglo American plc in South Africa, gave the second presentation of the workshop. It began by addressing the lack of industry involvement in global health. It then outlined strategies for business engagement and noted that these begin with businesses improving the health of their own employees. It provided an example of this type of employee-focused care from the mining industry, which successfully attenuated HIV/AIDS in the industry’s employee population. The session then switched to a focus on shared value and on models of industry and cross-sector engagement in Africa. Finally, it defined approaches to address barriers around private-sector engagement. This chapter summarizes Brink’s presentation and the subsequent audience discussion.
Although there are many conversations about business involvement in environmental issues and sustainability, and much social investment in education exists, there is less focus in the private sector on addressing health issues, noted Brink. Furthermore, the small amount of corporate social investment that currently exists for health is not transformative or far-reaching enough. The focus on global health in the private sector could be broadened because large burdens of disease limit society’s progress, economic growth, and social coherence. Corporations need to consider how they can parlay their business skills toward the goal of improving global health. Within the private sector, companies involved in the business of health differ from those that have other involvements. Health-related businesses, noted Brink, include health insurance, health provision, health commodities, medicines, diagnostics, health technologies, and health information systems. Businesses outside of the health industry include extractive industries such as mining, oil, and gas; heavy industries such as construction, transport, power, engineering, forestry, pulp, and paper; and white collar businesses such as technology and banking. Because each company is unique, each needs to consider how it could most effectively engage in public health.
Strategies Toward Business Engagement in Global Health
Any business that wants to engage in health, Brink suggested, could start internally by examining the ways it could improve the health of its
employees. If this practice were universally adopted by business, it would make a significant difference in global health and in achieving SDG 3.1
Beyond being motivated to comply with health and safety regulations, businesses could prioritize occupational health and safety because it is good for business, employees, and society. Each business could start addressing health within its organization by conducting its own health risk assessment and by defining which health issues confront its employees and stakeholders in relation to the business. Building on that knowledge, the business could then further define approaches to correct identified issues. Preventing problems, Brink suggested, is ultimately easier and less costly than mitigating unforeseen health challenges in the future. Ensuring that all employees and their families have access to quality health care is another step businesses could take. Brink believed that businesses could also work to understand the major health issues within their communities and to determine if they play a role in either exacerbating or reducing the associated health risks.
Mining Industry Involvements in Global Health
According to Brink, the mining industry will address safety issues, but it is less focused on the health outcomes of its employees. Although safety failures are immediate and quickly become crises, adverse health outcomes develop over many years—often after employees have already left the company.
The two main disease categories significant in the mining sector are occupational lung disease from dust exposure and noise-induced hearing loss. When someone develops disability due to one of these, the sector commonly considers compensating them for their condition to be an adequate response. For Brink, this is “a very poor substitute for having stopped it in the first place.”
The gold mining industry in South Africa recently settled a class action case related to occupational lung disease that was filed on behalf of ex-mine workers. The industry will pay out nearly 6 billion Rand for something that Brink believes could have been prevented. The negative health effects produced under these conditions are not limited to one disease; those produced by the triad of silicosis caused by silica-containing dust, tuberculosis (TB), and HIV—another disease common to the mining industry—are disastrous.
Brink concluded that mining companies could take steps to prevent silicosis and noise-induced hearing loss so that these issues do not become societal problems when the business externalizes the cost consequences of its initial lack of focus on health concerns.
HIV/AIDS in the Mining Industry
According to Brink, the mining companies initially punted the growing problem of HIV among miners to the government. However, by the early 2000s, up to 25 percent of the mining workforce had acquired HIV, and the industry had realized that HIV threatened its business and that the government was not doing enough to solve the problem. Anglo American, Brink’s former employer, took “a complete leap of faith” and announced it would provide free HIV treatment to all employees. While the company did not know the cost or the impact of this intervention, the decision was driven by information, knowledge, and science from civil society, academia, and the pharmaceutical industry. In particular, assistance from the pharmaceutical industry facilitated the initiative and enabled its progress.
The benefits of this intervention, according to Brink, have been profound; providing earlier treatment reduces the considerable cost of sick leave due to HIV/AIDS, pensions and death benefits for employees who get sick and die, and recruitment of new employees. Such improvements are evident in an October 2018 study, which demonstrated that a favorable outcome for a company increases the earlier HIV treatment starts (French et al., 2019). The study compared treatments that start below a CD4 count of 200 and those that start above a CD4 count of 350. The researchers found a 37 percent reduced risk of separation from the company and a 20 percent reduced risk of absence due to illness when HIV treatment was initiated substantially earlier in the disease course (French et al., 2019). The study also found that access to earlier treatment reduced sick-leave days prior to treatment by 8 percent (French et al., 2019).
Brink projected several graphs that demonstrated the effects of starting treatment at different CD4 counts (below 100 and above 350). The first graph (see Figure 3-1) showed that regardless of CD4 levels prior to treatment, the CD4 count decreased in all cases prior to treatment and then increased after treatment commenced. However, the later the treatment was initiated, the less effect it had on increasing CD4 levels. The sooner the treatment commenced, the better the long-term outcomes were. Figure 3-2 models the predicted sick days if treatment was or was not initiated. The graph shows that just after treatment commenced, sick days returned to normal levels. However, across 3 years without treatment, the disease progressed, and the predicted sick leave increased to 20 days per month. Figure 3-3 demonstrates that the modeled cumulative difference in sick days between treated and untreated employees across 3 years was 200–250 days, which posed significant economic costs to the company. Figure 3-4 illustrates that a lower incidence of TB is associated with higher CD4 counts. As Brink noted, the by-product of the HIV treatment was that it also lowered the incidence of TB among miners. During HIV treatment initiation between 2009 and 2016, TB incidence declined.
Shared value, Brink explained, is a socially progressive core purpose promoted within companies that defines their production model around how their products may benefit society. Many companies lack a focus on shared value; they can detail what they are working on and how, but often, they are unable to explain why they initially chose to work on those products.
Discovery Insure, Brink noted, is a positive example of a company driven by shared value. What Discovery does is health insurance, life insurance, long-term savings, and short-term insurance. How it does it is through incentivizing behavior change toward healthy behaviors—a model they call “vitality.” Why does Discovery do this? The company operates from a premise that if people can adopt healthy or safe behaviors, those adaptations will benefit the insurer because they will create a healthier membership base. This, in turn, will contribute to creating a healthy society. As Brink noted, Discovery’s business model is driven by its core purpose, which is to make people healthier and enhance and protect their lives—this motivation, and the products it generates, represents the shared value of the business.
Models of Industry and Multi-Sector Engagement in Global Health
Discovery has addressed many health behaviors to promote its shared-value model. According to Brink, the company found that there are four lifestyle behaviors that lead to four chronic conditions that are the root cause of 60 percent of disease fatalities. There are also, for example, five driving behaviors that lead to three driving conditions that cause 60 percent of all fatal accidents. Addressing those five driving behaviors could change these outcomes.
Similarly, in finance, there are behaviors and conditions that could be controlled to lead people to save more money, which could lead to higher levels of retirement savings. Businesses can encourage people to adopt these behaviors by ensuring that people are educated about them and are rewarded for healthy financial behavior.
Road Safety Models in South Africa
Discovery Insure works with the motor vehicle insurance business to integrate technology into vehicles that monitor and measure driver behaviors such as breaking, accelerating, and swerving. Brink explained that companies then reward customers for adopting good driving behaviors. Company data have shown that customers engaged in this initiative
are less likely to have accidents. Discovery Insure uses this same technology to assess road traffic accidents in South Africa, where, Brink noted, the accident rate of 31.9 deaths per 100,000 population is one of the highest in the world—2.5 times the rate in the United States. The burden of these accidents cost South Africa an estimated 10 percent of the country’s gross domestic product (see Figure 3-5).
Discovery Insure found that good and excellent drivers have fewer serious accidents and cost the company almost 50 percent less than poor or average drivers. The company is working to address the leading causes of traffic accidents related to drinking alcohol, using cell phones, and driving behavior exhibited in the 15 minutes prior to a crash (see Figure 3-6). Brink noted the company believes that discounts on ride-sharing services, such as Uber, on weekend nights when accident rates are high could incentivize individuals to use such services rather than to drive. Such actions could thereby reduce the number of alcohol-related fatalities. Discovery Insure has also used its technology in a pilot study with more than 700 school transport vehicle drivers. The company had telematics technology installed in these drivers’ vehicles and then gave drivers an incentive framework to encourage them to drive safely. To date, nearly 500 million kilometers have been driven as part of this study, and the data have shown that participating drivers have 87 percent fewer harsh accelerations, 92 percent less harsh cornering, 25 percent less braking, and 25 percent less speeding when compared
with average drivers in Cape Town. Most importantly, Brink noted, not one serious accident has occurred since the project’s inception (see Figure 3-7).
This successful program has not been scaled throughout the country. Brink explained that Discovery Insure was invited to a meeting of local government, provincial government officials, and national government officials who were promoting a new road safety concept with smart-phones. Through this example Brink illustrated the point that it can be difficult for strong interventions to be taken up by the people and institutions that need to be involved for them to be scaled.
Malaria Control in Mozambique
The MOSASWA Cross-Border Initiative is a malaria-control program in Mozambique, South Africa, and eSwatini.2 Brink explained that the initiative was started by Robbie Brozin, co-founder of the restaurant chain Nando’s. Nando’s contributed $4 million to supplement a $6 million grant, distributed over a 3-year cycle, from The Global Fund to Fight AIDS, Tuberculosis and Malaria. In the first cycle, the Goodbye Malaria program was initiated through MOSASWA to address malaria on the ground. Goodbye Malaria now has 1,441 workers, 36 vehicles, and 779 spray pumps in the Maputo Province in southern Mozambique. It has successfully sprayed 95 percent of the dwellings in targeted districts—213,630 houses to protect 701,111 lives. Both the prevalence and the incidence of malaria have been reduced by more than 50 percent as a result of the initiative, which continues to show improved results.
Brink explained that that Gates Foundation has invested $20 million through the Global Fund over a 3-year period to extend Goodbye Malaria into additional provinces. The now $30 million initiative is effective primarily because of its public–private partnership (PPP) model—and the leadership of Goodbye Malaria has acknowledged that this initiative was only scalable through the aid of such partnerships. Additionally, Nando’s business methodology and marketing and Brozin’s expertise in building and scaling business were parlayed to the initiative, which contributed to its success. Applying such private-sector knowledge to the public sector is one of the biggest contributions that business can make, Brink suggested.
Opportunities and Challenges
Strong partnerships, Brink emphasized, require mutual trust, respect, and a shared vision—and the combined effort needs to be greater than what each party could accomplish independently. Additionally, significant opportunities exist to leverage business expertise—particularly in management, finance, and information systems—to assist in health systems strengthening. Brink noted that the effective management of health systems in developing countries represented the single weakest link in health care provision. There is also a need to increase access to new health products and services for low-income populations, and such access could be aided by the intelligent and sustainable use of in-kind donations. In this vein, Brink noted that demonization of business in general, and the pharmaceutical industry in particular, is counterproductive. Pointing to “double standards” for industry involvement, Brink cited an example
2 Formerly Swaziland.
where a nongovernmental organization (NGO), on principle, refused medicine donations from a pharmaceutical company but received funding from equally debatable sources. Brink emphasized that opportunities to engage exist even within the tobacco industry, and working with such companies could enable solutions that would be more difficult to implement without the industry’s involvement. Furthermore, private-sector engagement frameworks, while intended to enable better engagement and cooperation, often produce barriers. Brink argued that WHO’s engagement framework presents a dividing line between the private sector and the government that is difficult to cross.
Regarding conflicts of interest, Brink noted that what many people call “conflicts” are instead interests that can be managed. Conversations around conflicts could be reframed to focus on declared interests. This reframing could provide partners with the transparency they need to engage in the partnership. In closing, Brink noted that partners cannot be self-serving—operating with ethics and integrity is integral to dissolving problems and creating successful partnerships.
Brenda Colatrella, associate vice president of corporate responsibility and president of the Merck Foundation at Merck & Co., Inc., asked Brink what advice he would give to businesses that are not engaged in public health but want to become engaged and that are concerned about slowly changing double standards and about the “rush to judgment that the private sector often feels when engaging in public health.” Brink suggested that the business could find a business coalition or like-minded people concerned with the same issues with whom it could work to develop a path forward. He noted that companies are often so busy with their core business that when they consider expanding and then receive pushback, they respond by returning to their core business and deciding to get involved in other ways instead. Brink stated that by deterring business in this way, “we are shooting ourselves in the foot,” and more routes need to be developed that allow businesses to engage in health.
John Monahan noted that when they served on the Global Fund Board with Brink, one of the challenges they faced was trying to convince companies to increase their support, financial and otherwise, for the entity. Given this experience, the participant was surprised to hear Brink say that some companies understood the health needs of their employees, families, and communities. Brink was asked how many companies he thinks have this type of health data and the ability to work with other partners to help the company understand their health-related interests and to gen-
erate more engagement. Brink responded by suggesting that the health field could learn from the environmental field, which has successfully engaged the private sector by helping it understand that it needs to start within its own companies and then look beyond its businesses. Groups such as the Global Fund could start by working with businesses to help them set health targets and performance measures. Brink has found that once businesses are educated about the benefits of engagement, they typically support it, but this often takes a long time. For example, in southern Mozambique, Nando’s has encouraged other businesses to get involved in the malaria initiative. Several other companies, including the cell phone operator Vodacom, have either already invested funds or are considering doing so. Coca-Cola, for example, has a huge canning factory in southern Mozambique and may consider joining the partnership because of the consequences of malaria burden on its business. Additionally, banks might consider supporting the partnership because removing the burden of malaria would foster better relations within their customer base.
Next, Ratzan mentioned that Brink highlighted how ideology contributed to preventing the scaling up of road safety work in South Africa. He asked how those barriers could best be overcome and what level of engagement would be necessary for scaling. Cara Bradley, chief corporate engagement officer at PATH, then asked Brink how Discovery Insure had tried to approach the government and noted that she would have expected a “win-win” situation and was surprised that the government resisted taking Discovery’s work to scale.
Brink explained that he lacked easy answers to Ratzan’s and Bradley’s questions, but “the benefits and the opportunities are there, and somehow we need to find a way that is going to get the interest of business.” He suggested going straight to chief executive officers (CEOs) to promote engagement rather than to corporate social investment teams because CEOs focus on long-term, big-picture issues. He noted that approach was taken in his HIV example. Brink concluded by offering advice: start slowly, find businesses that are interested, explain to them what needs to happen and why the initiative is important to their businesses, and then identify ways to start working together.