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 17 th 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 “ 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 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

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