Monday, January 24, 2022

Changing faces: What’s next for Khama’s Health Policy Reforms?

The past six years that he has been at the helm of the country’s highest political office, President Ian Khama has been ruling with a firm hand, coming up with bold socio-economic reforms that are geared towards eradicating poverty and ensuring good health for all. Since assuming office, Khama’s leadership style has been very unique, sort of withdrawn and detached from the status quo.

As a result of this there has been a mixed bag of reactions towards his style of leadership both locally and abroad. Some say he is non-confrontational leader, while others argue that he is a reluctant President who shy’s away from being engaged on debates, avoids media, and is a threat to democracy, a schemer who rewards sycophants, prefers to work closely with a cabal of friends and close family members. His opponents say his rule has come at a cost, by throwing money at problems instead of formulating long term sustainable programs and projects that are cost effective and its outputs measurable.

His critics have been a constant thorn on him and have argued further that President Ian Khama has traits of an autocratic leader where democracy and human rights are trampled upon and dissenters are harassed, victimized for holding a different view. In support of their arguments his critics join the dots and find a pattern that includes state sponsored victimization and military authoritarian style of leadership where the “Yes Sir” reigns supreme. Despite the criticism that Ian Khama has attracted domestically, at international level he remains a figure that seems to fascinate many people. At the international level he is seen as an icon, a “Game Changer”. Most international institutions of good governance tout Botswana as one of the best democracies in the modern world with some labeling him as An African Democratic Darling.

President Ian Khama has continued to mesmerize the International community with the country continuing to receive high index ratings. He is viewed as “An Excellent Man”. Others view him as a visionary leader, and as one of the greatest leaders of the time, a prophet of development. At party level he is seen as the rain maker of BDP, is worshipped and treated as some super natural being who is holier than thou. They give him credit for introducing bold reforms that many label as draconian and out of touch with reality and thus by so doing has embarked on an orgy of self congratulation and triumphalism. In his inaugural speech on April day 2008, Khama made his intensions clear. Khama set the record straight that the fight against alcohol abuse will be one of his key priority areas. Khama proposed laws to raise minimum drinking age, limit in trading hours and introduced tax levy on alcohol.

Although Khama’s tough stance against alcohol abuse was met with much skepticism with some legislators referring to it as government’s war on fun, recent reports have shown that the consumption level of alcohol in the country has gradually been declining. It is worth noting that despite the much criticism that has been leveled against President Khama with his tough stance against abuse of alcohol consumption, in May 2010, the World Health Organization Assembly (WHA), representing all 193 WHO member states approved a resolution to endorse the global strategy to reduce the harmful use of alcohol. The strategy includes an array of evidence based policies and interventions that many countries recognize the serious problem caused by the harmful use of alcohol and have taken steps to adopt preventive policies and programs, particularly to reduce drink ÔÇô driving and the carnage that it causes.

Despite the continued fight that has been undertaken by President Ian Khama against alcohol abuse and HIV/AIDS for instance, he has not been very lucky. Khama has been unfortunate in that he came in at the time in which the country was going through an epidemiological transition, having to deal with both infectious and non-infectious diseases and now there is Ebola. His administration is compelled to deal with the double disease burden with minimal budget and worse still at the time in which Botswana’s diamonds are no longer sparkling like they used to, due to the severe knock and a decline in their sales. The country is also going through an HIV/AIDS financing fatigue with clear signs that the days of glamour aid are also nearing to an end as evidenced by the recent closing shop of PSI and minimal support from ACHAP. The honey moon period is coming to an end and in the near future Botswana will be compelled to come up with innovative new methods for health financing to procure ARVs.

Already the writing is clear on the wall, there is a dramatic shift in the Global Health financing architecture and now focus is on fighting the silent epidemic, Non Communicable Diseases, which for a long time have been considered as diseases of affluence. The recent outbreak of Ebola in West Africa also has the potential to bring more misery than hope. Faced with such compelling health financing challenges in fighting HIV/AIDS and the procurement of live saving ARVs and probably also alerted by the (red flag) early warning signs from glamour aid/philanthropic funders about their imminent departure, and now faced with having to deal with NCDs and Ebola, Khama’s administration needs to refocus by making health his key priority.

It is evident that Khama has been un lucky in that he inherited an expensive treatment model dubbed “ The Rolls Royce Model” from his Predecessor Festus G Mogae, which although performed miracles by saving many lives, reducing morbidity and mortality rate of HIV/AIDS is not financially sustainable. This treatment campaign was undertaken by Botswana through partnership with Merck and its foundation the Bill and Melinda Gates Foundation, there are already clear signs that the rosy relationship is coming to an end, which compels the Khama administration to act as a matter of urgency.

Botswana’s health care system and service delivery remains arguably one of the best in Africa and the world. A closer scrutiny of Botswana’s National Health Accounts bears testimony to this with a large proportion that is over 80% of Total Health Expenditure (THE) provided by government. Botswana is known as a country that has responded well to the HIV/AIDS pandemic. Although faced with health financing challenges, to this day Botswana’s “Rolls Royce” Treatment model continues to be a model of success having started from the humble beginnings with an enrolment of 21 431 people in 2004 to a 95% enrolment rate of people in need of ARVs in 2011. As at September 2011, a total of 172 920 clients were on the ARV treatment. This number translates to 95% of adults and children receiving treatment out of the eligible 182 127 people eligible nationwide. Of these clients 82% were provided for under the public health services, while the rest were either outsourced or covered by the private sector.

Currently Botswana is spending tremendous amounts of money to keep people on treatment. For example, the total AIDS budget allocation of P981 Million for 2011/2012, ARV alone accounts for P188 Million. Botswana has had exceptional breed of competent leaders who appear to have put the interest of their country first. A plethora of studies that have been undertaken on the political and economic development of the country have labeled it as a heaven of prosperity and stability. The country appears to be an exception that some praise scholars continue to describe as a “deviant” or a special case compared to the rest of Africa. There is need for continuum of this political capital without favor, patronage and sycophancy. Time is now for us to work together as a collective, engage in dialogues and hold meaningful conversations needed to assist the country as it goes through the epidemiological transition, more so that Global Health Agenda is also going through a change process.

The onus is on President Khama to introduce health care reforms that are bold, that takes into account aspect of health as human right to ensure inclusion of high risk population groups such as Men who have Sex with other Men (MSM), that is non discriminatory and one that embrace decriminalization of sex work, provision of condoms in prisons amongst others. There is also an urgent need to develop national strategic frameworks, actions plans to deal with NCDs as well as Ebola in order to strengthen its health system. Because there are already signs that Botswana is going through AIDS financing fatigue, going the generic route in the procurement of ARVs may assist, there is also an urgent need to develop new innovative ways of health care financing, cost sharing should not be considered as the best option. Such can also be achieved by developing human capital needed to carry this country forward through enhanced scholarship, research and development.

*Thabo Lucas Seleke is a researcher in health policy & Health Systems

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