In their exchange in 2007 Paul Farmer from Partners in Health (PIH) and Garret Laurie stated that success in the delivery of health services is possible with the right program. Laurie had argued on the contrary that the influx of AIDS funding does not really translate into success stories. In support of statement Laurie noted that less than a decade ago, the biggest problem in global health seemed to be the lack of resources available to combat the multiple scourges ravaging the world’s poor and sick.
Today, thanks to a recent extraordinary and unprecedented rise in public and private giving, more money is being directed toward pressing heath challenges than ever before. But because the efforts this money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases — rather than at public health in general – there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground. As to whether Laurie’s assertion holds is something that requires further enquiry and analysis. I use in this piece Farmer and Laurie exchanges to help me assess Botswana’s fight against the HIV/AIDS by looking at the political commitment displayed by Masire, Mogae and Khama.
I attempt to make an assessment as to why it appears there is now lack of political will, passion and accountability that former President Dr Festus G Mogae had in the fight against HIV/AIDS. Unlike his predecessor President Ian Khama, appears to be lacking the passion and the drive that Mogae had. Khama perceived by many as a game changer is often accused of failing the nation, has his interest and priorities elsewhere. Although Botswana has made remarkable progress in the fight against HIV/AIDS, the country appears to be regressing and therefore, losing the battle. The latest BAIV IV report bears testimony to this. The alarm by ACHAP that it might close shop is frightening. Unless Khama administration change its mindset the country is headed towards the worst devastating health disaster it has ever experienced. Since President Ian Khama took over from Festus G Mogae, there was a shift of focus from public health to personal security of President Ian Khama. National projects and programs became personalized and branded in Khama’s name. Mogae had the passion and the drive, displayed high political commitment, something that is not visible in the presidency of Ian Khama.
Academicians alarmed us, scholars warned us, social and political commentators also had their part to say, and unfortunately the nation was hypnotized by some false prophecy about the existence of some magic in the current leadership. There were early warnings with respect to what was to come out of the leadership of Khama but not much attention was paid to it and now the nation has been befallen by disaster as pointed out by many of Khama’s critics. 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 a non-confrontational leader, while others argue that he is a reluctant President who is detached from reality and lives in the world of fantasy by thinking that poverty eradication and dignity can be achieved by giving people blankets, radios, shirts and dishing soup. His opponents have been a constant thorn on him and 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 with measurable outputs and has in the process neglected important issues of national concern.
Although Khama’s administration retained former President Mogae as the Chair of National AIDS Council (NAC) in the fight against HIV/AIDS, his voice is missing and thus signaling lack of political capital. The nation needs assurance and it is expected of Khama to show the high level of commitment that Mogae had. Khama is known to be a health freak, has a passion and love for outdoor sport activities and philanthropy, it is expected that he shows the same level of commitment and drive as he does in carrying out his philanthropic work or outdoor sport activities in confronting HIV/AIDS. The country is at cross roads, it is going through an epidemiological transition and this will come at cost, a heavy cost and this calls for Khama to take leave from country side visits. The nation needs him to provide the stewardship role. Khama could delegate such works of distributing blankets, shirts, radios and dishing soup to social workers and NGOs. This is mainly because placing HIV at the highest level of development and establishing a clear focus on results and accountability has been a priority for the HIV community. Mogae is a hero. He is a champion who pushed and shoved and frankly opened up to the international community for assistance.
Mogae made an international outcry at the UN General Assembly in 2001 and openly admitted that HIV/AIDS had caused major upsets killing many people in chilling high numbers and thereby causing high morbidity and mortality rates in his country. Mogae could not just wait and watch as his population was being wiped out by HIV/AIDS. Mogae was however, unfortunate, in that he came in at the time in which many Batswana were being wiped out by the HIV/AIDS scourge. There was a high morbidity and mortality rate with life expectancy dropping to scary proportions.
Mogae inherited a public health system that was fatigued; almost all the intervention treatment and prevention programs that were introduced during Masire’s time had failed to perform wonders. Mogae confronted the situation with seriousness and vigor and developed a national slogan “Ntwa E Bolotse” (The Battle has begun) and later introduced MASA program (New dawn), that provided free ARVs to Botswana through ACHAP. Mogae’s predecessor, Masire had made attempts to confront the situation without much success. During Masire’s tenure, there was an explosive rate of HIV/AIDS, living many people dead and families devastated. When Mogae came into office, people had lost hope, almost every weekend there were burial of HIV/AIDS victims. The country was going through health genocide and Mogae came in to save his nation.
Masire must have been stressed or perhaps clueless. He was in a helpless state. Although his administration had recognized the problem of AIDS soon after the first case was diagnosed in the country, followed by the development of a series of strategic plans, nothing much changed. Despite the booming economy, high GNP and GDP, the wealth of the nation did not translate into a healthy nation. HIV/AIDS awareness campaigns were promoted as an attempt to changing sexual behavior and many of these campaigns were carried out through national radio, car bumper stickers and T shirts to get the message across, but there was little success on their impact. In fact HIV/AIDS commonly came to be refereed as the Radio disease. The campaigns were followed by the ABC slogan (Abstain, Be Faithful and Condomise), they too failed to change the mindset of the people. There was so much stigma attached to those who had the virus. The promotion of condoms at an early stage proved to be counter-productive in Botswana, despite the collaboration with WHO, USAID and various international NGOs. There was surprisingly little understanding or awareness of what was happening. HIV/AIDS was a topic shrouded in stigma and silence at all levels of society.
Part of the problem as has been argued by scholars seems to have been with the health promotion campaigns themselves. However, there was surely also a financial element underlying these developments. By the mid- 1990s, the international agencies had largely withdrawn from Botswana, taking the view that, given the wealth of the country, their resources could be better deployed elsewhere. Botswana was then left to fund almost all of its HIV/AIDS control programmes, making them a much more immediate drain on national resources than has been the case in other African countries.
It is an undisputable fact that the introduction of life saving drugs ARVs performed miracles, restored hope by saving many lives, increasing life expectancy leading to a decline in morbidity and mortality rates in Botswana. In the year 2010, UNAIDS unveiled a long term vision for the Global AIDS response: Zero new infections, Zero discrimination, Zero AIDS related deaths. In this context, how effective will UNAIDS be in leveraging the global HIV and development community, including nation states, in pursuit of this vision? Moreover, how can accountability be enhanced to ensure that, in the medium term, relevant players are induced to take the steps required to ensure progress on the path to zero new HIV infections, zero discrimination and zero AIDS-related deaths.
Clues to how one might answer the above questions lie in the very special characteristics of the governance of the AIDS response. It is however, depressing to note that in Botswana achievement of the UNAIDS vision and mission may remain a farfetched dream. There are still challenges and the latest BAIV IV report is revealing. What is worrisome is the rise in the prevalence rates of HIV/AIDS as indicated in the report and these calls for an assessment of where and how we could be losing it. Although faced with such challenges President Ian Khama appears to be far detached and not bothered. Khama unfortunately will not have it easy. As a game changer, he must be well informed that there is now a global shift in health financing architecture which calls for a shift in health care financing priorities. Focus will no longer be on HIV/AIDS, but rather on Non communicable diseases.
Integrating the successes of HIV into health and development agendas more broadly and developing new approaches to health delivery are now pressing. His intervention strategies should build on new knowledge that is broadening our understanding of what is needed to confront not only HIV/AIDS but also other major health challenges. His administration must ensure that access to services for most at risk populations is scaled up. Khama’s involvement and commitment is required as opposed to the health system being under the hands and control of International NGOs. He must emulate Mogae.
Unfortunately Khama appears less interested, is far detached, has his priorities elsewhere and hence his critics constantly accuse him of leaving in the world of fantasy. At a time when money is tight, it is advisable before looking for places to cut spending on health care, look first for opportunities to improve efficiency. The onus is on Khama to change especially when the country is faced with the double disease burden, because certainly there will growing public demand for access to high quality, affordable care that will increase political pressure to make wise policy choices.
Thabo Lucas Seleke is a Scholar & Researcher in Global Health Policy, Health Systems strengthening and HIV/AIDS.
