enabling continuity of a public health arv treatment program in a resource limited setting: the case...
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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