Enabling Continuity of a Public Health ARV Treatmentprogram in a resource limited setting:The Case of the transition of the African ComprehensiveHIV/AIDS Partnerships support to the National ARTProgram to the Government of Botswana
Third International Conference for Improving Use of Medicines
17th November 2011
Themba L Moeti
Introduction: The Epidemic in Botswana
•Botswana has suffered one of the world’s worstHIV/AIDS epidemics globally:
•1990s: four fold increase in mortality amongyoung people
•60% medical beds occupied by patients withHIV/AIDS related diseases
•Year 2000: 38.5 % pregnant women HIV +ve
•Economic impact study (BIDPA 2000): projectingreduction in GDP by 24 – 38% by 2021
•Life expectancy at birth reduced from 65.3 years1991 to 54.4 in 2006 (NACA 2010)
•25% of adults 25 – 49 HIV positive
•2009: 33.1% pregnant women 15 – 49 HIV +ve
•ACHAP: Public Private partnership between theGovernment of Botswana, Merck/The MerckCompany Foundation and the Bill and MelindaGates Foundation
•Phase I 2001 – 2009
•Phase II 2010 - 2014
“ HE Former President Festus Mogae”
“Never had we experienced a situation
in which mortality was highest in
20 – 24 year olds!”
Botswana Human Development Report
2000: “Botswana had the option to
either fight back or surrender all her
development
gains to AIDS”.
Could significant investment through a public private partnershipachieve major health and social development impacts with goodprospects for sustainability of initiatives?
2000/2001
•Absence of national treatmentprogram; major gap in response;
•< 5% needing treatment had accessin private sector;
•Middle income country withdevastating epidemic ,
•Limited external support - majorfinancial, skilled human resource andinfrastructure challenges
concerns:
–affordability, operational feasibilityand sustainability
•Potentially devastating socio-economic & developmentconsequences of not providingtreatment
Strategy:
•provide comprehensive support –across prevention, treatment and care
•Private sector partners extensivelyinvolved in the project implementationand design
•providing technical expertise,management skills, processes,
•contributing to strategy development
•Build institutional capacity leading tosustainable initiatives
Results: ARV Programme: Capacity development, health systemstrengthening, community education & information
•Training Programme: MOH &Harvard School of Public Health
•8000 Health workers , 2000 laypersonnel
•Infrastructure development,
•35 Infectious disease care clinics
–Laboratory infrastructure and equipment
•Human resource recruitment
•over 200 health workers
•>90% positions transitioned to Govt
Charles Hill Satellite Clinic 2008
Results : National ARV treatment programme
•>150,000 placed on treatment collaborativeeffort between GOB & partners
•National in scope, all districts, > 200 facilities
•Treatment access increased from < 5% (2002)to 94% (2010)
•>53,000 deaths averted over 5 year period(2002 – 2007) (Stover et al 2008)
•ART has offset some of negative economicimpacts of HIV by 25 – 33%
•
ART
Annual Deaths due
to Advanced AIDS
*The economic impact of HIV/AIDS In BotswanaJefferies et al NACA 2007
Transition process
Phased approach
•Staff – about 200 positions overseveral years
•Infrastructure
•supplies and equipment
•Programme integral part of publichealth service, management offacilities & programmes govtresponsibility
•Ongoing negotiation, clarity on goalsto be achieved
•Flexibility important for success
•Factoring in time for government toput resources and systems in place
–Training programme
–Service delivery
–Technical expertise
•Operational research to provideinformation, estimate resourceimplications: financial, humanresource , infrastructure
•Post transition period; joint monitoringof programme quality and coverage
Conclusion
•Large scale treatment programmes inSSA feasible and can be successful
•Important contribution to enablingtreatment access
•Treatment investments have helpedstrengthen health system
•Benefits for PMTCT programme
•Possible contribution to incidencereductions and prevalence reductions inyounger age groups
Lessons Learnt
•Public Private partnerships have animportant role to play in health anddevelopment
•Political commitment, effectivegovernance structure critical
•Catalyst role an important enableroptimising health benefits of programmes
•Transition of support challenging; needscareful management, planning
Implications for policies andprogrammes:
•Consensus on approach and governmentbuy in critical to success
•For success support to be linked tonational priorities
•Partner support should complement andreinforce rather than replace localinvestment
•Capacity development is critical forsustainability of initiatives
•Private sector resources effectivelyapplied can play a major role in publicsector interventions in middle and lowincome countries
•Building trust enables positivecontributions to strategy development
Thank you for your attention
Acknowledgements :
Co Authors: I Chingombe, C Olenja , G Musuka, L Busang, T Phologolo, Thabo AAvalos,
Partners: Bill & Melinda Gates Foundation, Merck/The Merck Company Foundation,Government of Botswana