Ambuja Cement

About the company

With a total production capacity of 15.5 million tones of cement, the Ambuja Cement Group has eight plants across seven States of India. The total workforce employed by the Group is around 4,500 people. Taking into consideration the number of secondary stakeholders (family members, truckers and the migrant labor community in the vicinity of the operations), the reach of Ambuja Cement is significantly larger than its workforce.

Ambuja Cement’s workforce has regular interface with the thousands of truckers operating at Ambuja’s plant locations. Another high risk group is a sizable number of migrant workers living in the same environment. The incidence of STIs among those groups has been found to be quite large, revealing the vulnerability of Ambuja’s workplaces and communities to HIV/AIDS.

HIV/AIDS in India

The epidemic in India has raised eyebrows because of the huge number of people living with HIV and AIDS. According to India’s National AIDS Control Organization (NACO), there were 5.1 million adults living with HIV or AIDS in the country by the end of 2004 – the second highest country case count after South Africa. India’s rate of infection is officially estimated between 0.4 and 1.3%, but in some areas (e.g. Mumbai) the rate is estimated to be as high as 4% according to unofficial sources. Rapidly scaling up and mainstreaming prevention and care initiatives are imperative in India, including in the private enterprises, as proactive engagement into HIV/AIDS in the private sector remains piecemeal. Widespread stigma and discrimination present tremendous challenges to prevention efforts. The main mode of transmission is heterosexual sex and the epidemic is largely being driven by high risk groups such as long distance truck drivers and commercial sex workers.

Background

In 2003, a baseline survey was conducted by an NGO at one of the plant locations of Ambuja Cement in Himachal Pradesh which highlighted some alarming facts:

• Although a large number of respondents had heard of HIV/AIDS, there were numerous misconceptions among it regarding its spread and preventive measures.
• Not even half of the respondents had ever heard of sexually transmitted infections (STIs); among those who were aware of STIs, most did not know whether STIs are curable or not.
• There was a great sense of denial among the respondents that they could ever get infected by HIV.

Following this one-off baseline survey, the company undertook in 2003 a pilot project in partnership with the Himachal Pradesh State AIDS Control Society (HPSACS) and UNDP for employees at the Himachal Pradesh plant. A number of peer educators were trained, meetings and events were organized and World AIDS Day commemorated. This experience has motivated the company to initiate a program across all its operations with IFC Against AIDS and thanks to the support from IFC's Corporate Citizenship Facility (CCF).

Project overview

The goal of the project is to proactively prevent and manage HIV/AIDS from affecting the Ambuja communities in eight manufacturing locations of the company across India.

Activities:

• Conducting a baseline survey in all 8 locations;
• Creating an enabling environment with all Ambuja personnel, and their families, at all eight locations, through regular meetings, discussions and events aimed at gaining knowledge and skills to prevent and manage HIV /AIDS;
• Undertaking events with the migrant worker community and the trucker community;
• Training personnel, peer educators and medical personnel;
• Developing a behavior change communication (BCC) strategy and information, education and communication (IEC) materials, for sustained continued education, in all 8 locations;
• Increasing the provision of services – particularly through treatment of STIs, referrals to HIV testing centers and treatment of HIV/AIDS services, availability of condoms through a network of vendors and free distribution in all 8 locations.

Expected outcomes

The following outcomes will be assessed through constant monitoring of project activities and evaluation against baseline data collected at the inception of the program.

Increased knowledge	- Knowledge that condoms protect against HIV/AIDS increases - Knowledge on how to use condoms increases - Knowledge that STIs increase the risk of HIV infection increases - Knowledge that STIs need correct and prompt treatment increases - Knowledge of various available services increases
Increased skills	- Condom use skills improve - Ability to identify when to seek treatment improves - Skills of medical personnel improve - Advocacy skills among staff improve
Increased motivation	- Motivation to use condoms increases - Motivation to seek STIs' treatment increases - Motivation to access services and express personal rights increases
Increased service provision	- Condoms are available, accessible and affordable - Quality STI clinics are available
Decreased barriers	- Barriers to condom use decrease - Barriers to seek STIs treatment decrease - Barriers to discuss HIV/AIDS decrease

Project progress as of January 2006 (six month progress report)

The program was launched in Ambuja Cement in July 2005. The program was started simultaneously at 8 factory locations of Ambuja Cements:

• Ambuja Nagar (Gujarat)
• Darlaghat (Himachal Pradesh)
• Chandrapur (Maharashtra)
• Rabriyavas (Rajasthan)
• Sankrail (West Bengal)
• Bhatapar (Chattisgarh)
• Ropar & Bathinda (Punjab)

Approximately Rs. 450,000 have been received from IFC as the first installment of the grant. The Ambuja Cement Foundation is supporting Ambuja Cement to implement the program.

The following detailed progress report on the project comes in part from a supervision visit at the Ambuja Cement plant at Darlaghat (Himachal Pradesh) on January 30, 2006.

Darlaghat in Himachal Pradesh is the single largest production site for Ambuja Cement; the factory is isolated, settled in a small village of approximately 2,000 inhabitants. The factory employs about 1,000 employees, virtually all men, and attracts daily about 900 trucks, i.e. close to 2,000 truckers and cleaners/helpers (all males also) transit in the area daily. A small vibrant community of mechanics, dhabas (i.e. small restaurants and convenience shops), and tyre distributors resides literally at the doors of the plant. Employees are housed in the factory compounds, in single family apartments or group hostels spread over several hectares.

Project management and infrastructure

• A Core Committee of 3 members was constituted to oversee the implementation of the program. The committee is headed by Mr. V. K. Jain (Director, Ambuja Cement Foundation), and also includes Ms. Pearl Tiwari (General Manager, Community Development for Ambuja Cement) and Mr. Vishal Bhardwaj (Regional Program Coordinator, Ambuja Cement Foundation). Mr. Bhardwaj has also been designated nodal officer (Program Coordinator) for the program.
• A Project Monitoring and Implementation Committee (PMIC) is in place at each project site, and is championed by the General Manager. Other members from the PMIC include Heads of Departments, one of the Master Trainers, and the local Ambuja Cement coordinator (Sameer Sharma at Darlaghat). The PMIC meets monthly.
• An HIV/AIDS policy was adopted by Ambuja Cement (within the UNDP pilot project implemented in 2003). The policy is communicated on the intranet of the company as well as through large board displays at various locations across operations. It will be translated into Hindi and advertised early February 2006.

Baseline

• A knowledge, attitude, behavior and practice (KABP) survey was undertaken at all of the 8 program locations at the beginning of the program. The study would not only assist the program planning, it would also be a tool to evaluate the program after it is completed.
• A sample size of 510 people was drawn from all locations (employees); about 400 truckers and migrant workers were also surveyed. The enumerators (i.e. employees in charge of administering the KAPB survey questionnaires in the workforce) were trained centrally with ILO’s assistance to maintain uniformity of approach.
• The data collected from all locations was then collated. Although the findings of the survey are available now, a detailed report is being prepared by ILO and will be available in February 2006. The KAPB survey was undertaken in cooperation between the Ambuja Foundation and ILO, hence a significant saving on the cost of the baseline study previously budgeted in the project proposal.

Internal advocacy towards senior management

• The program began with advocacy workshops conducted at all locations by the Core Committee. The objective was to sensitize the top management at each production site about the program launch and to advocate in favor of the need to implement such a program.
• Eight workshops were organized, which were attended by all General Managers and the Heads of Departments.
• Prior to these, a letter was also sent by the Managing Director of Ambuja Cement to all General Managers advising them to put their best foot forward while implementing the program.

Master Trainers and Peer Educators

• 40 Master Trainers have been trained in total at the 8 program locations with the assistance of the ILO. The training involved three phases of three days each and was conducted in one central location. All Master Trainers were brought together for these training sessions.
• These Master Trainers have in turn identified and trained 247 peer educators through workshops of 1 or 2 days duration.
• At Darlaghat, workplace peer educators come from a variety of functions: tax, accounting, design, IT, clinical facilities, mechanical department, production, security, environment, and the technical department.
• Not only do those peer educators reach to their co-workers, but they are also systematically engaging with other natural peers: room-mates (single employees are housed in “bachelors’ hostels”), friends, families, and people in their villages of origin. The reach of peer educator groups is enormous on this project.
• Until now Master Trainers and peer educators were not formally grouped or associated, except for training purposes. During the supervision visit, it was envisioned to link a group of peer educators to individual Master Trainers so that they can organize and schedule activities in a more systematic manner; this would also help passing on the relay from the Foundation staff to the company staff. Indeed, one of the objectives of the Foundation is to progressively seek sustainability of the project by, among others, passing the HIV/AIDS workplace program to human resources functions across operations.

Awareness

Ambuja Cement has launched a massive awareness program at all program locations. Activities include one-on-one and group contacts by peer educators, films, street plays, and exhibitions. Information Education and Communication (IEC) materials (leaflets, films) in local languages, have been provided by the local States AIDS Control Societies (e.g. Himachal Pradesh AIDS Control Society), ILO and UNDP. At Darlaghat, large billboards in Hindi are on display throughout the plant and truck yard, summarizing how HIV is spread and, and equally important, how it is not spread. Smaller signs indicate condom social marketing outlets.

Condom promotion and distribution

Promotion of condom use is an important component of Ambuja Cement’s AIDS program. As of January 2006, a total of 42 outlets had been set-up. The condoms are both provided free of charge and available for sale through social marketing channels. More than 30,000 condoms have been sold or distributed. The project buys condoms from two sources: 1) the local State AIDS Control Societies for 1 Rupee; and 2) the Hindustan Latex Manufacturing for 1 Rupees, in packs of four condoms. They are then sold at cost to contractors in the vicinity of the project, typically in little restaurants or convenience stores a.k.a. dhabas. Dhabas sell the condoms for 2 or 3 Rupees and are trained on educating their customers on proper condom use. At Darlaghat, condoms are handed to truckers along with their gate pass. This innovative idea is to be adopted at other project sites.

A multi-pronged condom distribution/sale strategy needs to be implemented, involving social marketing, free distribution (from peer educators, through boxes readily accessible in wash rooms, clinics) and alternative means (cf. with gate pass for truckers). Condoms need to be made available in the accommodation of employees (cf. bachelor hostels). Arrangements are being made to install automatic condom vending machines.

Community outreach: focus on truckers and migrant labor

General Managers, across operations, have endorsed the HIV/AIDS community outreach program targeting truckers and migrant labor. The motivation for this involvement is ingrained in the willingness to maintain a good relationship with the communities of Ambuja Cement operations. (“We want to communicate that Ambuja is more than just cement”). Drivers are considered as an important component of the Ambuja Cement community, which invests in their welfare through safety training in particular. HIV/AIDS is now perceived as a logical extension of those training activities, as it is well known among the management that AIDS is affecting trucking communities across India. The program focuses on the truckers, not the transporters (truck owners).

A group of community peer educators (all young men), have been hired for the needs of the outreach efforts of the project. All of them come from the nearby villages. They were trained by Master Trainers and are mostly active in the truck yard. They are paid according to the activities that they perform (they have daily/weekly/monthly targets to perform):

• Interpersonal communication sessions (IPC), i.e. one-on-one (target: 8 to 9 per day); each IPC session takes 20-30 minutes. Peer educators choose opportunities to undertake such sessions, for example during truckers’ lunch break, and while they are at the mechanic shop or at the dhaba shop. A self-reporting system requires providing information on the name of the driver/helper, truck number, and past history of the driver. Most common questions expressed by drivers during those sessions are related to condom use, STI symptoms, and the HIV test (in which case the peer educator refers the driver to the district hospital’s VCT center).
• Group discussions, one-to-group (target: 2 per week); again, peer educators choose opportunities to undertake group sessions during truckers’ break, meal times, etc. According to the peer educators, interaction with the target groups is much less spontaneous during such group sessions (for example questions about STIs never come up, in contrast to IPC sessions). They utilize them primarily as a way to deliver information.
• Street plays, where several peer educators come together for the performance and interaction (target: 1 per month)
• Films (target: 1 per week); with 4-5 films to choose from, available from HPSACS
• Audio tape distribution (on request or when there is interest from a trucker)
• Condom distribution, under two schemes: social marketing through the dhabas, or for free in IPC; peer educators are responsible for supplying the social marketing condom outlets.

On average, the community peer educators at Darlaghat spend about 8-9 hours a week on their outreach activities. A staff meeting with the Coordinator of the Ambuja Cement Foundation at Darlaghat takes place every Saturday to go through the reports and planning of activities.

Reasons for involvement: The community peer educators had been sensitized in school about HIV/AIDS (through biology class as well as extra-curricular workshops offered). The project gave them an opportunity to be involved in an issue which they consider as a “big problem”, and to get flexible employment.

Interactive response system

Encouraged by the program endorsement and progress, Ambuja Cement has taken another initiative, which was not included in the original project proposal: an interactive voice response system. The system has been set-up at Darlaghat where it is being piloted. The system might be adopted in other locations if the pilot is considered successful. Any one can get information about HIV/AIDS over the telephone/intercom (free call for the caller). After the initial greetings, the caller is given a choice of different options: press 1 for information on HIV/AIDS, 2 for information on STIs, 3 for condom use, 4 for myths about HIV/AIDS, and 5 gives the option to the caller to register a specific question; questions are collected periodically, posted on the system, and can be retrieved by pressing 0 and a personalized code.

As of January 2006, the system was available only in Hindi. It will be available also in English and other local languages if the scheme is to be replicated in other states. The system cost over 100,000 rupees. If similar questions tend to be frequently asked over the interactive response system, an additional option of “Frequently Asked Questions” could be offered from the initial menu, hence saving time to the counselor in charge of collecting and posting responses.

Recommendation: Given the cost of this system, it will be important to actively market it among employees and other targeted groups.

Advocacy with other corporates

At the initiative of the Confederation of Indian Industries (CII), Ambuja Cement had the opportunity to share its experience in establishing and implementing its HIV/AIDS workplace and community program with other corporations at a meeting of the CII in Punjab. Subsequently, the Ambuja Cement Foundation offered a presentation to senior managers of Colgate Palmolive, whose operations are headquartered in Himachal Pradesh, as well as a workshop in view of a program launch and implementation at Colgate Palmolive operations.

Outreach to commercial sex workers (CSWs):

In the Darlaghat area, like in all rural areas, CSWs are not brothel-based. They live in the community, sometimes have other jobs, and can be married women. Their CSW activity might not be known to their husbands. Outreach to this group is therefore very difficult, although some preliminary mapping of the CSWs in the area of Darlaghat is available. The project’s team envisions hiring a female peer educator specifically for these outreach efforts, which will be carefully assessed and planned for obvious reasons of confidentiality.

Counseling and active involvement of the medical staff:

Although not formally involved or trained by the project as of January 2006, the medical staff at Darlaghat is very supportive of the company and Foundation’s involvement in HIV/AIDS. The laboratory technician at Darlaghat is one of the peer educators of the project. The company clinic treats free of charge employees, their families and community members (including contractors, casual labor, truckers and migrant labor). The clinics operate primarily as an out-patient facility, with both male and female wards, a full laboratory, and a well-stocked pharmacy. Condoms are available in waiting areas. Posters on HIV/AIDS and various other preventive medicine awareness messages (e.g. hepatitis, vaccination campaigns) are also posted. Government medical employees periodically visit the company clinic for gynecological care, and vaccination campaigns.

Counselors are being identified at all eight program locations and will be trained in February 2006. This group of in-house counselors will be primarily made of medical doctors practicing in the company’s clinics. Training of all medical staff involved will be centralized and is likely to be provided by NACO (National AIDS Control Organization).

MONITORING & EVALUATION

Preliminary qualitative results:

• The truckers and their community (helpers, dhabas, etc.) are getting progressively aware that HIV/AIDS is a serious health problem that affects their community, but also a social problem, given the risks of being ostracized. They are not shy about asking questions.
• Likewise, employees have a lot of questions about HIV/AIDS. People are very keen to learn about the disease.
• Management is now well aware that AIDS is affecting trucking communities across India. Senior and operational management across sites have endorsed the HIV/AIDS program, including its community outreach component targeting truckers and migrant labor, which are considered as an important component of the Ambuja Cement community.
• General health awareness among workers, their families and the community has improved thanks to targeted messages and access to services. Perceptions of HIV/AIDS among target groups are also changing. The project team assesses that significant improvement over stigma related to HIV/AIDS have been made since the inception of the project.
• The example of Ambuja Cement at Darlaghat in particular shows that companies can achieve very effective results on HIV/AIDS with populations and in areas that are extremely difficult for government programs and NGOs alike to reach.

Quantitative details as of January 2006:

Activity/Item	Up to January 2006
One-to-one contacts	532
Group sessions	18
Sensitization workshops	65
Advocacy Workshop	20
Training workshops	24
Films & Street Plays	343
Condoms sold & distributed	30420
No. of Condom Outlets	42
No. of patients treated for STIs	Nil
Counselors	Trained Nil
Peer Educators	Trained 247
Medical staff	Engaged 8
No. of PLWHA among employees	Identified 7