EAP in Tanzania: unique effort is helping developing African Nation.
Tanzania, an impoverished country in East Africa, did not have any EAP providers or even a master's- level training program in psychology or social work until eight years ago. Today, this nation of 47 million people (National Bureau of Statistics, 2015), located on the Indian Ocean in East Africa, has five locally owned EAP companies and two master's level psychology programs.
Local and multinational companies have spent more than $5 million on EAP services for their workforces since 2008. Thus, the evolution of an emerging EAP industry in Tanzania offers insights into efforts to alleviate poverty in a developing nation.
Need Creates Demand
In 2006, a need arose for an EAP to help Barrick Gold (a mining company) pass a health and safety audit. However, there were no such programs available at the time, especially not in Swahili. I was living in Tanzania, and was asked by this company to serve as a consultant to explore how an EAP could be put together for its staff.
After visiting the mine site, I recommended an external model with extensive on-site presence. I then began pursuing ways to put it together in a format that would be desirable for not only this firm, but also others to purchase. I decided it would be best to integrate physical and mental health into one program. Therefore, what might have been called "Employee Assistance and Wellness Programs" became Employee Wellness Programs (EWP) or Programmu ya Ustawi wa Mwajiriwa (PUM).
In developing nations, multinational mining companies typically register local firms as subsidiaries. These companies have multiple needs that EAPs in Africa can address:
* To develop and sustain local suppliers for a targeted percentage of goods procured;
* To provide corporate responsibility services in surrounding communities (which includes psycho-social needs);
* To provide local cross-cultural training, orientation, and support for expatriates;
* To implement sexual harassment and assault prevention programs;
* To increase compliance with corporate health and safety requirements; and
* To design and implement culturally relevant EA services for all employees.
Insurance Company as a Partner
The private health insurance industry began in Tanzania in 2002. Six years later, behavioral health and chronic disease management programs were not yet offered, although they did exist in South Africa. At that time, the majority of efforts of the Ministry of Health in Tanzania were concentrated on communicable diseases such as AIDS, malaria, and tuberculosis (TB). The department had not yet begun to focus on non-communicable lifestyle diseases, as it does today.
Therefore, when I approached a local insurance company with a proposal for an internal Employee Wellness Program Division, they were ready to invest in this novel idea. The rationale for this proposal was to meet both current employer needs and to sell new services. The idea was to improve the claims ratio, create a new income stream, and increase their competitive advantage.
Public-Private Partnerships in Development
The United Nations Development Program (UNDP) is an international government organization funded by voluntary contributions from member nations. Its charge is to help countries "to simultaneously reduce poverty and achieve sustainable development that leads to transformational change, bringing about real improvements in people's lives." Their goal is to do this in "ways that are sustainable from economic, social, and environmental standpoints." (United Nations Development Program, 2016).
There are many projects that help meet the objectives of this organization, with the African Management Services Company (AMSCO) being one of them. In the case of AMSCO, both a private sector company, which has a management contract with AMSCO, and an expatriate employee hired to work for the private sector firm, receive tax benefits. This is an example of how public-private partnerships that are utilized extensively in international development work. All actual dollars came from the private health insurer in this case, but the work permit and taxfree status for hiring an expatriate to train local people came from a government organization (that being UNDP).
In 2008, I was employed by AMSCO as a technical expert. I then became the Employee Wellness Program (EWP) Development Manager, with the objective of training Tanzanian psychologists and EAP practitioners, as well as creating a EWP Division within a local health insurance company.
This matched the goals of the UNDP for reducing poverty in sustainable ways. The new employment opportunity category of "professional counselor" was established, as well as a new private sector infusion of money into the economy through the purchase of EWP services. In a nation with fewer opportunities for formal employment than in the West, increasing the number of available jobs reduces poverty substantially. It is sustainable because the money infused into the economy is not reliant on donor money, but private sector demand.
Training to Build Mental Health Capacity
First, some background is in order. Training of mental health professionals in Tanzania traditionally relied on money from donors. Prior to 2005, Tanzanian psychiatrists were sent abroad for training. The same idea was attempted for individuals undergoing training for careers in clinical psychology.
But overseas training resulted in an absence of psychological counseling and substance abuse treatment services in Tanzania. The exception was HIV/AIDS counseling which, by 2008, was well established. Pre- and post-test HIV counseling is typically performed by nurses or doctors with a six-week training course on the disease process and on counseling skills.
To implement the EWP Division, extensive staff training was needed along with financial support for trainees. Ten bachelor's level social work and psychology graduates were initially hired full time by the insurance company. A one-year in-house psychology and EAP training program was created. Trainees staffed a local toll-free counseling call center. The same group of employees worked in the call center, in-house counseling center, and provided on-site services.
After seeing the demand for professional counseling and EWP services in the workplace, the Government University for Health and Allied Services and a private university each began master's-level programs: a MS in Clinical Psychology and a MA in Counseling Psychology. Many individuals in the first group of EWP employees completed the MS and some are now lecturers in the two master's programs. These programs are now producing graduates with the requisite skills to be hired by the growing and highly competitive local EAP industry.
Outcomes and Indicators of Success in Tanzania
When launching an EWP in a company that has never had one, with HR managers who have never heard of one, the opportunity to create a set of benchmarks as indicators of success is both exciting and challenging. For example, in most of the client companies, absenteeism data was unavailable, as it was not tracked and collected systematically.
Challenges arose from difficulty in the counselors collecting data at the initial contact (pre-intervention) and then contacting clients at the post-intervention time. These are the same difficulties encountered everywhere the Workplace Outcome Suite * (WOS) is used. However, in Tanzania it led to abandoning the original use of the measure, and utilizing it in a way it was not intended.
(* Workplace Outcome Suite is a free and validated tool to help EA providers measure the workplace effects of EA services. It is now in use by over 600 EAP organizations and stands apart from other outcome measures as it is psychometrically tested, validated, workplace-focused, and easy to administer.)
The questions were given to the entire worker population during the initial face-to-face EWP orientations and results were used as a measure of the five WOS constructs in the workforce: absenteeism, presenteeism, work engagement, workplace distress, and life satisfaction. For many companies in Tanzania, this was the first time they had collected such data.
The self-reported absenteeism data was multiplied by the hourly cost of the average employee, which was supplied by the client company. These findings always showed a large monetary loss attributed to absenteeism, which was always higher than the cost of the EWP.
This data helped justify the cost of the EWP, which was both preventative (80%) and curative (20%). Annual capitated EWP contracts in Tanzania have a large number of hours in preventative psycho-educational training (and health education sessions).
Therefore, participants in these group sessions are included in utilization reports as prevention training, and counseling cases as curative. The total, divided by the number of employees, was the utilization rate. This clearly demonstrated an acceptable utilization value to HR, finance, and management departments.
Comparisons of clinical utilization rate (utilizing the traditional formula) to the developing nation's rate was provided as well. However, to purchasers with little EAP experience, the widely held expectation is that the EAP should be used by the majority of the workforce, just like it is with health insurance (and not 10%-40% like with EAP). Therefore, after some years of experience, the combined utilization rate was used more often.
International EAP companies often have difficulty finding qualified affiliates and other service providers in developing nations. Under-utilized resources include missionary psychiatrists, psychologists, and therapists. This is due to two reasons:
* They are difficult to find if you are not already "in the know" since they are typically working "under the radar" (e.g. you won't find them advertising online); and
* When approached by EAP companies, they often say "no." That's because these individuals see spending time in "private practice" as incompatible with, or keeping them from, providing services to local or targeted populations.
In working with companies in Tanzania and in other African nations, once they better understand the potential of EAPs to help impoverished people through employment opportunities and by increasing previously unavailable or limited services, these individuals become more open to working with international EAPs. As multinational corporations have increasingly begun to extend EAP benefits for their local staff, the missionary community can also begin to see their role in assisting international EAP firms.
Marketing the Tanzanian EWP
Marketing EA services is also different in Tanzania, as it is in many non-US locations. To this day, there have been only three companies issuing RFPs, or Tenders as they are called in Tanzania. Companies considering an EWP typically contact the EWP provider organizations directly, call them for presentations, and then ask them to submit proposals. This allows the provider to specifically design and customize the schedule of services.
Unfortunately, corruption in the procurement process is the norm, not the exception. The health insurance-embedded EWP product is now well established. While the number of health insurers launching an internal EWP is increasing, the PEPA (Per Employee Per Annum) price for all EWP programs is decreasing. However, there is still a large market of medium and large Tanzanian companies that do not have any type of EWP. This creates unique marketing opportunities for EWPs.
Design and Implementation of the Tanzanian EWP
EWPs in Tanzania are designed as a worksite resource with all services included in a capitated product. Besides unlimited face-to-face and telephonic counseling, training, consulting, and organizational development services are included in large session numbers. Program designs are flexible and customized for the various concerns that a work organization is trying to solve in purchasing an EWP, such as:
* Personal financial management;
* Partner relationships;
* Sexual harassment and assault prevention;
* Alcohol abuse;
* Work/life balance; and
* Suicide prevention.
All of these services were included in the capitated price, which was prepaid annually in most cases, and quarterly in others.
As the industry in Tanzania became more competitive and mature, service offerings have decreased, as well as the price and extent of roll-out orientations. However, everything is negotiable in Africa--even the scope of services after a contract is signed.
From 2008 to 2016, Tanzania has progressed from zero to five locally-owned EWP companies with over 60 individuals having been fully employed in an industry that did not previously exist. Over 12,000 Tanzanian families have access to professional counseling for the first time in their history. The banking, manufacturing, and mining industries in Tanzania are now very accustomed to having an EWP, so it appears the industry is well-positioned to continue to provide employment and services long-term.
National Bureau of Statistics (2015). Tanzania in figures. Retrieved July 22, 2016, from http://www.nbs.go.tz.
United Nations Development Program (2016). Retrieved July 5, 2016, from http://www.undp.org/eontent/undp/en/ home/ourwork/sustainable-development/ overview.html.
By Lisa Finke, MS, CEAP, SAP
Lisa Finke, MS, CEAP, SAP, lived in Tanzania for 17 years with her husband and children, and worked in Christian development. After recently selling her company in Tanzania, she now resides in Reedley, California, where she performs EAP consulting and training. She can be reached at email@example.com.