Your commentary entitled “Is the ARV Programme financially sustainable?” that you featured in your edition of 22nd March 2009 caught my eye. This is because I have been asking myself the same question, and have actually asked the same question to some friends who are still in Government or somehow connected to decision making. This is not to say I am opposed to the ART rollout, but rather to interrogate if the government has analysed the long-term financial implications of this commendable programme. Your question on whether the ART programme is financially sustainable therefore really begs answers.
ART has changed HIV related illness from a terminal disease to a chronic condition, rather like diabetes or hypertension. Once a patient is enrolled, he/she has to take the drugs for life. The cost is therefore cumulative, as HIV infected individuals survive indefinitely, and the numbers on treatment continue to grow. It also means the prevalence rate will only drop at a slow rate, and therefore the future lies in reducing the incidence rate (new infections). Hence the prevalence figures of the latest Sentinel Surveillance haven’t come as a surprise to many of us. The critical factor is that of prevention of new infections, which because of its absolute reliance on behavioural change, is the big challenge to tackle than the provision of treatment.
A year or two ago, writing in a Botswana daily newspaper, I proferred the opinion that Botswana is not taking full advantage of free international money available for health services as aid. For HIV/AIDS, Tuberculosis and Malaria, the Global Fund has become the major funding mechanism for developing countries. While our sister countries, like Lesotho and Swaziland, are getting tens of millions of dollars from the Fund to fight these diseases, Botswana has to date only got a pittance from one round, which has not even been properly closed.
PEPFAR is a bilateral fund which can be terminated by the US at any time, and funds from foundations or drug firms are short term and lack predictability. A big surprise has been the recent World Bank loan, which in my humble opinion, the country should not have rushed into without first getting “free money”, particularly from the Global Fund. One accepts the Global Fund has tedious and demanding processes because it is performance based, but the money it gives makes it all worthwhile. Botswana can access much more funds from this source.
There has been no culture of analysing long-term financing strategies in our sectors, and the health sector is a case in point. After all the ART programme is a health programme. The authorities need to analyze exactly what they spend per capita in health services, and if the results in health outcomes reflect value for money. I have argued before that our health outcomes do not reflect the fact that our Government is the second highest per capita spender on health in Africa after South Africa. The ART programme may just be the trigger that catapults the Government into doing some thorough analysis of financing of the health sector and developing a health financing strategy.