Working Together: Fighting Pandemics Through Partnerships
<< Read it at capafrique.org >>
Published 08 January 2009
Like the pandemic itself, the logistics of care for the infected and affected is a veritable nightmare, but Botswana has been wildly successful on that front. To understand how, here’s a brief précis of Botswana’s HIV/AIDS history.
To organise a consolidated effort to combat the disease, a 1999 decree of the President’s Cabinet created the National AIDS Coordinating Committee. “NACA”, operating directly under the President’s National AIDS Council, would become the lynchpin in what the UN Special Envoy for HIV/AIDS in Africa called “the most dramatic experiment on the continent. If it succeeds, it will give heart to absolutely every country worldwide." Stephen Lewis saw great potential in President Festus Mogae’s 2001 plan: provide antiretroviral (ARV) therapy to all pregnant women and children born with the virus. While Mogae’s true utopia was coverage of all in need, these two groups seemed a good place to start.
NACA had much work to do to coordinate the myriad groups listed on its website. Some are Debswana mines, some are government Ministries, some are local theatre groups. Herding cats comes to mind. The programme was called “MASA”, the Setswana word for dawn.
One of the most important organizations involved in MASA was—and remains—ACHAP, the African Comprehensive HIV/AIDS Partnerships. ACHAP is a public-private partnership initiated by Mogae that brought together Merck Company Foundation/Merck & Co., Inc., the Bill & Melinda Gates Foundation, and the Government of Botswana. The organization’s prime directive was to provide technical assistance and expertise in the Government’s fight again HIV/AIDS.
Since ACHAP’s inception in 2000, Merck and Gates have each put up US $56.5 million to support ARV therapy. Merck pledged to underwrite the entire cost of two ARV drugs for the extent of the initiative (ACHAP is scheduled to run only through 2009). Following Merck’s example, GlaxoSmithKline donated all of the zidovudine (AZT) needed in the government’s campaign to prevent mother-to-child transmission of the virus. In a similar way to money, it seems drugs also make drugs.
Another partnership, appropriately called BOTUSA (“beau-TOO-sah”), was created between Botswana and the United States Center for Disease Control. BOTUSA looks at both TB and HIV/AIDS, and analyzes how public health initiatives and research can stem the diseases. PEPFAR—the President’s Emergency Plan for AIDS Relief—eventually took over for the CDC, and contributed US $55 million in FY2006 alone.
Within just a few months, the number of patients began to outstrip Botswana’s, the government realised it needed serious help, and fast. As President Mogae told journalists in April 2002, "We are short of doctors. We are short of nurses. We are short of pharmacists. We are short of health technicians.” Still, they had no choice but to continue opening clinics in an attempt to stop the pandemic. The BHP-KITSO Training Program provided HIV-care-specific knowledge to health workers in Botswana, and, supported by ACHAP and the Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education (BHP), had trained 1,941 health care workers in “HIV/AIDS clinical care fundamentals” by September 2005.
Another essential public-private partnership that eased resource pressure is Associated Fund Administrators (PTY) LTD. After an individual is tested and diagnosed, the first 20 months of treatment occur in Government facilities. After that, AFA assigns them to physicians in private practices to continue their care. The government funds AFA, AFA negotiates with doctors (“I can handle 20 patients per month.”), and the patients that need care get it without putting too much strain on the government to expand its capacity in the form of permanent hires.
There are many other participating institutions that deserve mention, e.g., the Botswana-Baylor Children's Clinical Center of Excellence, the Global Fund, and other faith- and community-based programmes. Again, I refer you to NACA’s list of participating institutions for a pretty decent catalogue.
One of the most interesting things about the organizational landscape is the emphasis on individuals. When you ask someone in the field about the public health ecology, a number of names surface: Drs. Thendani Gaolathe, Themba Moeti, Ndwapi Ndwapi, and Sheila Tlou, to name a few. Many have woven their careers between the public and private, national and international, and research and treatment sectors. The first thing a friend who runs a research project at BHP said was, “Botswana has had some very, very good people in high offices who were excited and proactive about partnerships.”
Botswana’s HIV/AIDS programme is arguably the most progressive in Africa, and would probably rank quite high in the entire world, too. Mother-to-child transmission is below 4%, which is about where the USA and Western Europe stand. The goal? Zero new cases by 2016. Lacking resources is clearly no excuse for failure.
All of this is to write that Botswana, the country with the second highest adult prevalence of HIV (23.9% as of 2007), has done something quite significant, and they did it through partnerships and good leadership. Some key lessons from this narrative for other countries to follow are the following:
- First, admit that HIV/AIDS (or a similar pandemic) is a reality, and that there is a very good chance you cannot effectively manage the disease without help;
- Second, create infrastructure that facilitates and coordinates the involvement of both outside and inside organizations;
- Third, forget cronyism, and put good people in positions of leadership within that infrastructure, from the top all the way down.
Just to the south of Botswana (and maybe to the east soon, too), there is a country on the brink of a revolution in HIV/AIDS thinking and action. It would behove both to follow the Setswana proverb that many in their populations already understand, at least figuratively: Mabogo dinku a thebana.
“Together, in partnership, we can.”
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