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

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”.

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

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

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

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

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 groupsLessons 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

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