Sustainable Transition of ACHAP Support to National ART Program in Botswana

1. Enabling Continuity of a Public Health ARV Treatment program in a resource limited setting: The Case of the transition of the African Comprehensive HIV/AIDS Partnerships support to the National ART Program to the Government of Botswana Third International Conference for Improving Use of Medicines 17th November 2011 Themba L Moeti

2. Introduction: The Epidemic in Botswana • Botswana has suffered one of the world’s worst HIV/AIDS epidemics globally: • 1990s: four fold increase in mortality among young people • 60% medical beds occupied by patients with HIV/AIDS related diseases • Year 2000: 38.5 % pregnant women HIV +ve • Economic impact study (BIDPA 2000): projecting reduction in GDP by 24 – 38% by 2021 • Life expectancy at birth reduced from 65.3 years 1991 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 the Government of Botswana, Merck/The Merck Company Foundation and the Bill and Melinda Gates 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”.

3. Could significant investment through a public private partnership achieve major health and social development impacts with good prospects for sustainability of initiatives? 2000/2001 • Absence of national treatment program; major gap in response; • < 5% needing treatment had access in private sector; • Middle income country with devastating epidemic , • Limited external support - major financial, skilled human resource and infrastructure challenges concerns: • affordability, operational feasibility and sustainability • Potentially devastating socio-economic & development consequences of not providing treatment Strategy: • provide comprehensive support – across prevention, treatment and care • Private sector partners extensively involved in the project implementation and design • providing technical expertise, management skills, processes, • contributing to strategy development • Build institutional capacity leading to sustainable initiatives

4. Results: ARV Programme: Capacity development, health system strengthening, community education & information • Training Programme: MOH & Harvard School of Public Health • 8000 Health workers , 2000 lay personnel • 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

5. Results : National ARV treatment programme • >150,000 placed on treatment collaborative effort 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 economic impacts of HIV by 25 – 33% ART Annual Deaths due to Advanced AIDS *The economic impact of HIV/AIDS In Botswana Jefferies et al NACA 2007

6. Transition process Phased approach • Staff – about 200 positions over several years • Infrastructure • supplies and equipment • Programme integral part of public health service, management of facilities & programmes govt responsibility • Ongoing negotiation, clarity on goals to be achieved • Flexibility important for success • Factoring in time for government to put resources and systems in place • Training programme • Service delivery • Technical expertise • Operational research to provide information, estimate resource implications: financial, human resource , infrastructure • Post transition period; joint monitoring of programme quality and coverage

7. Conclusion • Large scale treatment programmes in SSA feasible and can be successful • Important contribution to enabling treatment access • Treatment investments have helped strengthen health system • Benefits for PMTCT programme • Possible contribution to incidence reductions and prevalence reductions in younger age groups Lessons Learnt • Public Private partnerships have an important role to play in health and development • Political commitment, effective governance structure critical • Catalyst role an important enabler optimising health benefits of programmes • Transition of support challenging; needs careful management, planning Implications for policies and programmes: • Consensus on approach and government buy in critical to success • For success support to be linked to national priorities • Partner support should complement and reinforce rather than replace local investment • Capacity development is critical for sustainability of initiatives • Private sector resources effectively applied can play a major role in public sector interventions in middle and low income countries • Building trust enables positive contributions to strategy development

8. Thank you for your attention Acknowledgements : Co Authors: I Chingombe, C Olenja , G Musuka, L Busang, T Phologolo, Thabo A Avalos, Partners: Bill & Melinda Gates Foundation, Merck/The Merck Company Foundation, Government of Botswana