Former President Ian Khama, noted in his speech at the commemoration of the World HIV/AIDS Day in Moshupa 2011, that Botswana was experiencing financial shocks as a result of having had to shift her policy agenda and focus more on trying to achieve zero levels of HIV and AIDS. The warning by Khama was a clear signal that the honey moon period was coming to an end, in that Botswana’s diamonds were no longer sparkling as before to enable it to go on with its HIV and AIDS treatment model somewhat aptly called “the Rolls Royce Model”. It is important to note that, during the reign of Festus Mogae, Botswana was considered a global celebrity in its HIV and AIDS policy response.
The unprecedented devastating impact of the HIV/AIDS epidemic in Botswana seems to have placed the country at the centre of the worldwide fight against the disease. In the late 1990s, Botswana became a fundamental test case for the effectiveness of the HIV/AIDS global response. Government efforts to overcome the epidemic were favorably viewed by the international community of donors, multilateral agencies and NGOs. Although Botswana has received many accolades of being an African Economic Success Story, HIV/AIDS has had devastating effects on its health budget over the years. Despite the remarkable strides that Botswana has made there are still significant health gaps between different sectors of the population, with the inhabitants of rural areas being highly disadvantaged.
The African Comprehensive HIV/AIDS Partnerships (ACHAP) played a major role in initiating Botswana’s antiretroviral (ARV) program in 2001. ACHAP is a prominent public-private partnership involving Merck and its foundation, the Bill and Melinda Gates Foundation, and the government of Botswana, the first and most advanced in sub-Saharan Africa.
In the context of declining resources for HIV/AIDS, the opinion piece speaks to the need to integrate responses to the structural drivers of HIV/AIDS into future HIV investments, with both initiatives to integrate HIV into broader gender and development initiatives, as well as adaptations of current service models, to ensure that they are sensitive to and able to respond to the broader economic and social responsibilities that their clients face.
There has been growing recognition of the importance of interventions that seek to address the social and economic forces that underpin much HIV vulnerability. These forces often referred to as social or structural drivers, have been defined as “core social processes and arrangements, reflective of social and cultural norms, values, networks, structures and institutions that operate in concert with individuals behaviors and practices to influence HIV epidemics in particular settings.
Research and available data are show that the country is going through an epidemiological transition having to deal with the double burden of disease with limited financial resources. NCDs are now the leading cause of death worldwide and can no longer be perceived as diseases of affluence. Despite the growing recognition and the devastating effects these have had on the nation there was a drastic departure and deliberate policy shift from health to security under Khama’s administration. Trying to understand Khama’s commitment to HIV and AIDS is more like playing chess game and or trying to solve a jigsaw puzzle. It was different during Mogae’s era.
The transfer of power from Sir Ketumile Masire to Festus Mogae in April 1999 represented a watershed event in Botswana’s HIV/AIDS national response. Mogae’s proactive role at the NAC gave new impetus to Botswana’s HIV/AIDS response. In the first year of the new administration, the government of Botswana, under the directive of the President’s office, put in place the National AIDS Coordinating Agency (NACA). This new organ replaced the outdated National Aids Control Programme (NACP) of the Ministry of Health. In terms of the political management of HIV/AIDS, the most important institutional change brought by NACA was the shift in the locus of leadership from the Ministry of Health to the Office of the President. Chaired by President Mogae himself, NACA became responsible for mobilizing material and human resources and coordinating the national response at all levels of decision-making. In collaboration with many national and international partners, NACA set up a national committee to revise the MTP II and formulate a new strategic framework to facilitate its further implementation. This new framework aimed to provide clear guidance for ministries, NGOs and the private sector as well as to enable them to work in a collaborative manner under the centralized authority of NACA.
Masire had epitomized the kind of transformational political leadership that has sustained Botswana’s political stability since independence. Masire’s political philosophy, his leadership style and the underlying internal and external factors that faced the country present valuable lessons to the rest of Africa and the world with respect to the success and failures of the country in diminishing the HIV/ AIDS scourge. Masire, however, it must be noted must have been fatigued or stressed in his health policy response to the epidemic.
Mogae therefore, inherited a public health system that was fatigued. Almost all the intervention treatment and prevention programmes that were introduced during Masire’s time had failed to perform wonders. Mogae confronted the situation with seriousness and vigour. Previously, Masire had made attempts to confront the situation without much success. During his tenure, there was an explosive rate of HIV/AIDS infections, leaving many people dead and families devastated. When Mogae came into office, most people had lost hope, almost every weekend there were burial of HIV/AIDS victims.
Mogae was passionate and committed on fighting HIV/AIDs. Such was done with a clear mandate specifying the relationship between aggregate health expenditures and health outcomes. Mogae’s HIV and AIDS speeches were not just talk shows. His successor Ian Khama however, appeared to be someone who was not bothered on carrying on with the fight against HIV/AIDS. His body language told a different story and his actions demonstrated that indeed he was least passionate about health as a priority issue.
Khama came across as a reluctant and complacent leader showing no political commitment and drive in prioritizing health as a number one policy issue. As a result of his reluctance and detachment some pessimists wrote Khama’s administration off. They argued that the focus was no longer on the health of the nation but rather too much attention on Khama’s personal security and military.
They argued that while Khama claimed to be focused on poverty eradication, there appeared to be some disconnection between his poverty eradication drive and health. They stated that a healthy nation is a wealthy nation and vice versa and that one of the social determinants of health is poverty which is linked to economic growth. His detachment on health has long term negative effects which are bound to exacerbate the already existing inequalities and disparities in terms of achieving vertical equity both in terms of access to health services and ability to pay which may also give rise to allocative inefficiency.
It is important to note that HIV has long-term implications for treatment costs because it is a chronic condition that requires medical attention throughout the life of the patient. In addition, as an infectious disease, it requires sustained resources for prevention. The recent global recession, coupled with increasing competing demands for new causes such as non-communicable diseases, climate change, and the environment, might further jeopardize increased donor funding for HIV. The Global Fund to Fight AIDS, Tuberculosis and Malaria, PEPFAR, and other donors have already begun to consolidate and focus their funding on certain priorities and are demanding greater counterpart participation.
In 2011 the Global Fund issued eligibility and counterpart financing guidelines, requiring countries to match the grant funds with a contribution based on their income level. For example, low-income countries are required to match only 5% of their Global Fund financing, while upper middle-income countries are required to match 60%.
The above trends require policymakers of national health sectors to expand their fiscal space to address the financial sustainability of the HIV programs as their donor funding is set to decline. A long-term financial sustainability plan should include cost reduction, improved allocation of funding both of tax money and within health programs, and resource mobilization through concessionary loans amongst other things.
As Alex de Waal 2003 wrote ‘the AIDS industry is a prisoner of political circumstance, and as a result, may be trapped in a cycle of ineffectiveness.’
*Thabo Lucas Seleke is a Researcher and Scholar, Global Health Policy and Health Systems Strengthening