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Private Sector Engagement for HIV Outcomes
Policy Options for Mozambique to Expand Public-Private Partnerships
POLICY Brief March 2021
Background Although Mozambique’s gross domestic product
(GDP) is still chiefly generated by smallholder
Mozambique is reported to have the sixth highest farming, the country’s economic growth has
prevalence of HIV of all countries in the world, been diversifying, particularly through mining,
with approximately 12.4 percent of the population manufacturing, electricity generation, water
living with HIV (Statista, 2021). The estimated resources, and construction (Cruz et al., 2016). In
number of new HIV infections per year decreased particular, the extractive sector (minerals mining,
from 160,000 in 2010, to about 130,000 by 2019, petroleum, and natural gas) contributed 7.4 percent
with 60 percent of people living with HIV accessing of GDP in 2018 (EITI, 2020). Although currently a
antiretroviral therapy (ART) (UNAIDS, 2021a). small share, this contribution has been increasing
However, the country has continued to have poor and may offer opportunities for increased private
retention in care, resulting in mortality rates higher sector engagement in the health sector.
than would be expected for the size of the epidemic
An exploration of options to engage the private
(U.S. Department of State, 2019).
sector to support HIV services in the country may
Mozambique is experiencing programmatic help address the reliance on external funders. By
challenges in its HIV response and, in addition, investing in employee health schemes, companies
remains dependent on development partners. Most can also reduce the direct burden on the public
funds for the HIV response in 2019 came from sector. The Health Policy Plus (HP+) project, funded
external funders (96 percent), with an estimated 4 by the U.S. Agency for International Development
percent of the funds coming from domestic public (USAID), conducted an assessment of private
expenditures and 0.1 percent coming from domestic sector companies located in high-HIV burden
private expenditures (UNAIDS, 2021b). The areas in Mozambique to identify opportunities and
Government of Mozambique has evaluated several challenges to private sector engagement in the HIV
financing options, including a cell phone tax, a “sin” response. This brief summarizes current corporate
tax on tobacco and alcohol consumed in night clubs social responsibility (CSR) trends in Mozambique
or bars, and a mandate for formal sector employers and highlights the individual contributions and
to pay for HIV treatment for employees, but none of perspectives of nine companies. HP+ provides
these are currently being implemented. In addition, here various policy options and recommendations
the government’s recent fiscal crisis limits its that may enable Mozambique to increase private
budgetary space for HIV response funding. Urgent sector engagement and investment for HIV. These
action is needed to identify alternative and feasible recommendations are informed by interviews
financing solutions to increase internal resource with the companies and a review of the global
mobilization and thus help Mozambique achieve its CSR landscape.
95-95-95 goals by 2030.1
1
95-95-95 refers to the Joint United Nations Programme on HIV/AIDS (UNAIDS)’s target for countries to reach by 2030: 95 percent of people
living with HIV know their HIV status, 95 percent of people who know their status are on treatment, and 95 percent of people on treatment have
suppressed viral loads.2 Role of Corporate Social select companies. Prior to the interviews,
HP+ reviewed industry lists and selected
Responsibility in Private a short list of companies to engage. These
Sector Contribution companies were selected based on evidence of
sustained health interventions for employees,
Some companies across sub-Saharan Africa CSR programs, or community engagement;
are investing in HIV services for their and on an estimation of their capacity for
workforce, thereby providing valuable services involvement in HIV programs, based on
to a number of formal workers (Deane et size (revenue and number of employees) and
al., 2018). The broad motivation for firms strategic alignment of company missions and
to invest in health and social programs values. The proposed short list was shared
includes innovation, cost savings, bottom- with the Conselho Nacional de Combate ao
line sustainability, customer and/or employee HIV e SIDA (CNCS). HP+ and CNCS jointly
engagement, and brand differentiation agreed on a final set of 15 companies. Among
(ASH, 2014). CSR is an expression of a the 15, 47 percent were from the extractive
company’s desire to create value by investing sector, 27 percent from the agriculture sector,
in its workforce, their families, and the and 26 percent from the industrial and
communities where it operates. In 2014, the beverage sectors. In November and December
government of Mozambique mandated (by of 2020, HP+ conducted nine semi-structured
law) CSR in the mining sector (Kaufmann and key informant interviews with human
Simons-Kaufmann, 2016). However, beyond resources and CSR professionals within the
the stipulation that revenue will be allocated companies. Topics covered included workplace
to local communities, there is no national health and CSR programs, associated
strategy to steward and engage the private benefits and challenges, and the companies’
sector to fully leverage their support above experiences and interest in partnering with
and beyond compliance to this law (Kaufmann the government in the future. Because of
and Simons-Kaufmann, 2016; ThinkWell, challenges due to COVID-19-related lockdown
2019).
policies, 6 of the 15 selected companies were
Aside from the law, many companies in not available for interviews.
Mozambique are motivated to invest in HIV
services because HIV poses health and Results
socioeconomic risks to their workforce and
their host communities. Workers living with Summary of Health-Related
HIV may face stigma and discrimination Corporate Social Responsibility
in their communities, which can affect
morale and productivity. HIV can have
Programs and Workplace Health
broader effects on the sustainability and Activities
resilience of private sector workforces and Among the nine companies assessed, CSR
production overall. While CSR can open the programs focused on 16 topics, including
door to improved workplace health, efforts health. The three types of health-related CSR
in Mozambique so far have been limited in programs most often described during the
scale. As the government considers various interviews were: (1) disease-specific programs
public-private engagement options for the for HIV, malaria, and tuberculosis; (2)
health sector, assessment of the sustainability infrastructure support, e.g., funding directed
of potential options for the HIV program and at labs and hospitals; and (3) donations of
the magnitude of impact possible through medical equipment and personal protective
partnerships will be necessary. equipment related to the COVID-19 pandemic.
With respect to companies’ workplace health
Method for Company Selection programs, HIV was a frequently cited focus
area. Of the key HIV services across the
HP+ assessed the landscape of private sector care continuum, prevention, testing, and
CSR through a combination of mapping, treatment were covered by most companies,
desk review of literature, and interviews with and counseling was covered by some.Table 1. Company Characteristics and HIV Activities 3
Total # of
Company Revenue
Company Employees HIV Activities
Type (Mozambique)*
(Mozambique)
HIV prevention and awareness,
US$146.4 million testing, and treatment.
Coca-Cola Multinational 1,100
(2014) Treatment covered for
employees and their families.
Companhia
HIV prevention and awareness
Moçambicana US$88.4 million
Mozambican 25 campaigns. Treatment covered
de Hidrocar- (2020)
for employees and families.
bonetos (CMH)
€3.4 billion (Africa,
Middle East, and
HIV prevention and treatment
Eastern Europe,
Heineken Multinational 200 to employees and direct
2019; Mozambique
family members.
revenue is not
disaggregated)
883 permanent Induction programs (including
Mozambican
workers (3,484 broader health education);
subsidiary of US$44 million
Maragra Açúcar seasonal agri- HIV testing, counseling, and
Illovo Sugar (2017)
cultural workers treatment; and food baskets to
Africa
at peak periods) people living with HIV.
Mozambican;
HIV education, counseling,
owned by
and community engagement.
South32, an US$508 million
Mozal 1,250 HIV prevention and treatment
Australian (2020)
to employees and direct
mining and
family members.
metals company
Mozambican 1,600 HIV treatment, condom distri-
Mozambique
subsidiary US$273.2 million permanent bution, voluntary counseling
Leaf Tobacco
of Universal (2014) workers and testing, peer educator pro-
(MLT)
Corporation (7,100 seasonal) gram, and HIV drama group.
HIV prevention and treatment
US$307.5 million
Sasol Multinational 73 to employees and direct
(2014)
family members.
HIV community awareness,
US$214.6 million counseling, and testing. HIV
Total Multinational 78
(2014) prevention activities among
sex workers and their clients.
HIV prevention and treatment
US$25.95 million
Vale Multinational 200 to employees and direct
(2019)
family members.
* Revenue is based on the most recent data available. If not available through interviews, public sources were used.
Most companies also covered dependents’ they value giving back to the community
treatment but rarely were any of these and take pride in enabling the community
benefits offered to local communities. A to implement locally developed solutions.
summary of HIV activities and other company These activities, in turn, result in community
characteristics can be found in Table 1. acceptance of the company, which was
also mentioned as a benefit for companies.
Benefits and Challenges Workplace health activities differed in their
When asked about the benefits of CSR and value to companies; they were explained to
workplace programs, companies said that have a more direct benefit to the bottom line.4 Companies generally cited the importance with their current implementing partners
of workplace health activities for boosting (chiefly with NGOs) that are engaged in
productivity and increasing morale—good for similar activities. Government has an
employees and for the business. opportunity to play a role in helping partners
avoid duplication of efforts and in identifying
However, there were significant challenges
coverage gaps for communities.
for CSR and workplace programs. Budget
constraints and dependence on donations Limitations of the Research
from company headquarters often
threatened sustainability of the interventions This research had several limitations.
implemented. For example, several companies First, data collection during the COVID-19
mentioned the difficulty of sustaining pandemic was a challenge. Because most
previous infrastructure investments, such company representatives were working
as sponsorship of health facilities or medical remotely, there was limited ability for
equipment. For workplace programs, financial in-person visits and contact information for
constraints were cited as well. Companies individuals working remotely was not easily
providing direct healthcare to workers also obtained. In addition, some companies judged
highlighted the instability of supply chains the information requested to be sensitive,
(e.g., difficulty accessing medications) and non-public information that could not be
limited access to specialty care (e.g., high-level shared. Some interviewees did not want to
care needs often required medical evacuation misrepresent company priorities, especially if
to Maputo or outside Mozambique). Overall, representing a large multinational company.
companies faced challenges in scaling Several of these factors may have influenced
support to meet high demand in many an individual’s ability and willingness to
places, with programs and services only engage.
available for individuals in areas where the
company operates.
Policy Options and
Private Sector Experiences Recommendations
Working with the Government and
Implications for Partnerships Mozambican firms across industries can
and do address the health concerns of their
Companies cited largely positive experiences
employees and families to mitigate social
working with the government, although
risks and maintain productivity. However,
their engagement was primarily at the local
the interviews conducted made apparent that
level. Several companies worked with district
health and HIV efforts are typically small
and provincial governments when building
in scale and that a path to working with
local infrastructure, such as schools and
the national government to bolster these
hospitals. Most companies’ interactions
with government, however, were indirect. efforts has yet to be defined. Additionally,
Companies mostly worked directly with only companies offering the most active CSR
nongovernmental organizations (NGOs) and programs were selected and interviewed for
multilateral or international organizations. this effort. Many medium-sized companies
Although most companies did not work with have yet to devise a strategy to contribute to
the national government, they expressed the HIV response. To evaluate the potential to
openness and interest in engaging at the standardize any national strategy for engaging
national level around health programming. the private sector, it would be beneficial to
However, company representatives frequently look at engagement models among a wider
expressed that such engagements were ecosystem of private sector efforts. In this
likely to be more fruitful if the government section, HP+ highlights various approaches
approached them with specific, concrete and case studies for a private sector response
proposals for partnership. Companies also to HIV that may provide insight into what
cited difficulties in coordinating initiatives may be possible in Mozambique.or intermediary, such as an NGO, join the
Option 1. Corporate Fundraising for 5
partnership or receive and manage the funds.
Philanthropy Implementing a more complex mechanism,
Corporate fundraising for philanthropic such as establishing an AIDS trust fund,
purposes largely consists of fundraising would require a broad level of government
among employees, corporate matching of support. Given that companies may require
employee donations, and annual corporate a tangible recipient for fundraising, the
donations. Fundraising may be done annually Ministry of Health should identify where the
as part of an ongoing agreement/partnership funds will be targeted and earmark those
or as a one-off donation. Donations are often funds accordingly. Continuing to engage and
earmarked to a specific recipient or to a motivate the company’s senior management to
broader cause (e.g., children’s health). fund the donation over time will be important
to the sustainability of this approach.
Example: The Brazilian mining company,
Vale, has contributed funds to improve health
indicators for malaria and HIV in Moatize, Recommendations to move
Mozambique. The company donated US$3 forward
million to the Global Fund to Fight AIDS, To encourage private sector donations to
Tuberculosis and Malaria, demonstrating support HIV services, the government can
a willingness to use its private financial identify ways to directly channel corporate
resources to improve the lives of communities donations for such services. For instance,
(Vale, n.d.). the government can identify a number of
public health outposts that provide HIV
Opportunities and challenges for services to communities in high-burden
implementation: Corporate fundraising areas near corporate operations and
offers the Ministry of Health an opportunity propose them for corporate sponsorship.
to increase revenue provided to public The government can stimulate a sense of
HIV services. However, it is not customary long-term “ownership” over these clinics
for companies to donate directly to the through co-branding.
government. Straightforward solutions
involve having a third-party stakeholder
Diagram of Option 1. Corporate Fundraising
Company
Company contributes funds in line with
its corporate values to the government
or an intermediary, such as an NGO.
Government OR Intermediary
Government or NGOs determine
how the funds are to be used and
implement programs accordingly.92 percent of those identified as positive were
6 Option 2. Direct Service Provision for
receiving ART. This program has been studied
Workers and Communities and has demonstrated a positive impact on
Direct service provision to employees is the health and well-being of employees and
a common model in which companies, on business performance (Anglo American,
either through on-site clinics or medical aid 2020, 2021).
packages, finance healthcare for employees
and sometimes for their families. Significant Opportunities and challenges for
health and productivity results can be implementation: Generally, companies can
achieved for companies with large workforces act on their own terms to operationalize this
who receive prevention, testing, counseling, model and set their own workplace policies
and/or treatment for HIV. and investment levels in the workplace
program. This requires less balancing of
Example: In southern Africa, including priorities and coordination than a multi-
in Mozambique, several multinational partner arrangement, but also puts the
companies are supporting and operating HIV onus on the individual company to define
services for their workforces. Anglo American its priority interventions and develop and
is a British mining company operating in operationalize its own program. Although
15 countries (not including Mozambique), minimal coordination is needed with external
employing around 90,000 people worldwide. stakeholders, there is also a downside to
Within its safety and health program, Anglo working alone. Typically, a finite number of
American operates a long-established HIV staff and families are reached year after year,
program and is recognized as a leader in HIV and it can be difficult to scale up. Companies
management. It launched its HIV program will vary in terms of the investments they
in 2002 when it became one of the first can make up front. However, the national
companies in southern Africa to offer free impact would be significant if HIV prevention
antiretrovirals to its employees. This benefit services were offered by most mid-to-large
was later expanded to include employees’ sized companies across Mozambique.
dependents. In 2011, more than 110,000
Anglo American employees and contractors Companies that want to invest to achieve
in southern Africa (90 percent) received HIV larger impacts in their communities could
testing. Anglo American additionally offers a leverage their corporate workforces to scale
wellness program for employees living with prevention activities to nearby communities
HIV, plus education and awareness programs, through outreach programs, campaigns, or
condom distribution, and early diagnosis and peer educator programs or they could invest
treatment of sexually transmitted infections. in more comprehensive testing and treatment
The company stated in 2019 that 94 percent programs, such as Anglo American’s. Rather
of its employees knew their HIV status and than viewing these programs as donations or
Diagram of Option 2. Direct Service Provision for Workers and Communities
Company obtains government
support informally to provide
HIV services for its employees.
Company Government
Company finances the intervention (e.g.,
prevention, testing, and/or treatment). Individual
company efforts boost private sector contributions
to the HIV response but may be limited in scale.CSR initiatives, companies could consider this in the workplace can multiply their impact 7
an investment in their core business. While through co-financing initiatives—for example,
calculating return on investment can take extra experienced companies with high-quality
time and resources, sharing the social and programs might find donors to co-finance
financial benefits to employees, community activities so they can expand their reach more
members, and the company’s bottom line with deeply into communities.
corporate decisionmakers helps make the case
for continual re-investment in employee and Example: The recent US$10 million
community health. agreement between USAID and Total to
improve adolescent health and women’s
Recommendations to move empowerment in Cabo Delgado is a powerful
example of multiplying impact through
forward co-financing. Total’s global social responsibility
The government can influence the program already focused on sustainable
reach of each individual workplace HIV development of the communities where they
program and/or expand the number of work, especially on health, education, and
companies involved in such programs youth. They leveraged their existing capabilities
by promoting them via success stories; and their US$5 million commitment to
by making the business case known to
community health to mobilize an additional
employers that may be hesitant to make
US$5 million from USAID for greater impact
the upfront investment in employee
(USAID, 2020). Together, USAID and Total
health; and by disseminating guidelines to
advise organizations on how to introduce are taking an integrated health programming
these types of programs. For employee approach to do more than would have been
engagement programs, the government possible otherwise, working in additional
can share approved information, education, sectors— such as economic, social, and
and communication materials with education—that enable better health and
companies to vet key messages that would well-being.
be shared with staff and communities.
Opportunities and challenges for
implementation: Existing programs can be
Option 3. Co-financing for Scale used to mobilize additional funds from donors
Company HIV programs typically serve and foundations, which can cover difficult-
employees and their dependents even as to-reach communities surrounding mines,
the broader community may experience other production sites, and beyond. While
gaps in coverage for key health services. increased funding will allow companies to
Companies currently providing HIV services generate greater impact, companies seeking
Diagram of Option 3. Co-financing for Scale
Company and donor agree upon
desired outcomes and sign a
formal agreement (MoU) with the
government’s support.
Company Government
Company and donor co-create the intervention,
leveraging each others’ unique capabilities to develop an
Donor integrated approach. Co-financing allows for expanded
access into communities.and mobilizing additional funds to grow
8 Option 4. Systemic Private Sector
their programs will need to balance their
objectives and preferred approaches with Engagement
those of the co-funder. Both parties will A systemic approach to driving sustainable
benefit from formalizing expected roles and engagement in the response to HIV involves
responsibilities. In order to maintain program a third-party organization—typically a
scale beyond the original contract period, worker’s union, professional association,
companies will want to have a sense of the or federation—leading an engagement with
potential for the co-financing to continue the goal of driving a common private sector
and, if not, what the strategy will be to secure agenda. Leveraging a market-leading industry
additional funding to sustain their expanded association to catalyze corporate engagement
efforts. in the HIV response can leverage the full
power of the private sector to accelerate and
Recommendations to move sustain positive impact.
forward Example: In 2008, the global union of
The government can provide technical International Federation of Chemical, Energy,
recommendations and help steward a Mine and General Workers’ Unions worked
successful programmatic approach for in India through its affiliate, the Indian
this model. It can serve as a matchmaker National Mineworkers’ Federation, to form
between programs and funders, a comprehensive response to HIV and AIDS
identifying communities with a high (ILO, 2013). They sought technical assistance
need for HIV services and highlighting from the International Labour Organization
the credibility of the private sector in (ILO) to develop a strategic plan, design a
delivering quality HIV services. It may training of trainers program, and support the
also choose to evaluate potential gaps in engagement of employers and India’s State
otherwise strong company programmatic AIDS Prevention and Control Societies. They
operations and can suggest co-funders co-designed the strategy with people living
that will help round out an approach or
with HIV and representatives from Coal India
bring a complementary perspective to
Ltd, the National AIDS Control Organization,
drive impact.
and the Delhi State AIDS Control Society.
Diagram of Option 4. Systemic Private Sector Engagement
Technical assistance and
strategy co-design.
Intergovernmental Industry association/
organization federation
Technical assistance to
unify, improve, and/or
standardize HIV efforts.
Company Company Company
Whole system operates with the same Government
guiding HIV policies and delivers more
coordinated, consistent, and quality care.Opportunities and challenges for HP+ has recommended four options for the 9
implementation: This approach involves Mozambican government’s consideration.
driving systemic change across a sector These aim to stimulate a broader private
without a requirement of long-term financing. sector involvement in HIV response efforts
It requires limited operational engagement of while not requiring considerable time
the government beyond the start-up phase. investment by the government. The options
Furthermore, ILO technical guidelines are range from increasing funds from the
available to guide a step-by-step approach for private sector (either directly or indirectly
formulating HIV policies and programs for the through trust funds); expanding efforts
mining sector (ILO, 2013). It is, however, the already underway by a number of companies;
most complex of the four options and poses leveraging an enhanced level of private sector
challenges to kick-start implementation. That engagement through external investment;
is because it requires a concerted focus from a and catalyzing systemic change through
lead organization that has the full support of various market actors. The four options span
the government, requires targeted technical the spectrum of opportunity to engage the
assistance, and relies on continued motivation private sector and to leverage its experience in
and engagement from the private sector. operating and supporting HIV services. The
options are accompanied by recommendations
Recommendations to move on how to move them forward in alignment
with the government’s desired objectives for
forward private sector engagement in HIV.
The government can conduct a series
of discussions with key stakeholders
involved in the mining and other sectors
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Health Policy Plus (HP+) is a seven-year cooperative agreement funded by the U.S. Agency for
CONTACT US International Development under Agreement No. AID-OAA-A-15-00051, beginning August 28,
2015. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for
AIDS Relief (PEPFAR). HP+ is implemented by Palladium, in collaboration with Avenir Health,
Health Policy Plus Futures Group Global Outreach, Plan International USA, Population Reference Bureau, RTI
1331 Pennsylvania Ave NW, Suite 600 International, ThinkWell, and the White Ribbon Alliance for Safe Motherhood.
Washington, DC 20004 This publication was produced for review by the U.S. Agency for International Development.
www.healthpolicyplus.com It was prepared by HP+. The information provided in this document is not official U.S.
policyinfo@thepalladiumgroup.com Government information and does not necessarily reflect the views or positions of the U.S.
Agency for International Development or the U.S. Government.You can also read
