BOTSWANA: SEEKING CLOSURE ON ART/REFUGEE ISSUE

UNCLAS SECTION 01 OF 03 GABORONE 000273 SENSITIVE SIPDIS STATE FOR AF/S, PRM, S/GAC STATE PLEASE PASS USAID HHS FOR CDC/GAP E.O. 12958: N/A TAGS: PREF KHIV EAID PGOV BC SUBJECT: BOTSWANA: SEEKING CLOSURE ON ART/REFUGEE ISSUE REF: 08 GABORONE 1140 AND PREVIOUS ¶1. (SBU) SUMMARY: Ambassador Nolan met with Minister of Health Lesego Motsumi to try to bring closure to the long-pending issue of whether and how to provide antiretroviral therapy (ART) to registered refugees in Botswana infected with HIV/AIDS. The Ambassador explained that the USG's commitment to assisting Botswana with the HIV/AIDS crisis is both sincere and long-term, but reiterated that we cannot make any indefinite funding commitments due to the reality of our congressional appropriations process. He empathized with the GOB's fears about the financial burden of sustaining the ART program for its own citizens during a period of shrinking revenue, and said he understood Botswana's prudent reluctance to expand its treatment program. Though the USG believes including refugees in the national ART program is the best way to move forward, the Ambassador also noted that if the GOB chooses not to do so, we stand ready to fund an implementing partner to do so. The Minister and her staff reiterated the GOB's fears about "taking on any extra load when their burden is already so heavy," and noted that once individuals are put on treatment, it is a lifetime commitment. However, the Minister also recognized the GOB's treaty obligation to provide medical care to refugees and understood that there would be negative public health implications for Batswana if refugees are not given access to HIV treatment and other services. Minister Motsumi promised to confer with her staff and Botswana's cabinet and come back to us "within a few days" with a decision on whether or not to include the refugees in the national treatment program. Given the GOB's fears about its ability to pay for treatment, we believe it is likely that Botswana will maintain its current redline and insist that the MOH's national treatment program remain only for citizens, and ask us to work with an implementing partner to provide for refugees. END SUMMARY. BACKGROUND -------------- ¶2. (SBU) The U.S. Embassy and office of the United Nations High Commissioner for Refugees (UNHCR) in Botswana have been working with the GOB on the question of access to ART for refugees for more than a year. We have urged Botswana to live up to its treaty obligations to provide registered refugees the same social benefits as the government accords to its own citizens (including access to medical care). Botswana has approximately 3200 registered refugees, about 1800 of whom reside in the Dukwe refugee camp north of Francistown. Botswana has thus far refused to include any non-citizens in its national ART program administered by the Ministry of Health. The USG (through the PEPFAR program) has offered to pay for treatment of registered refugees, and approximately $600,000 (cumulative) has been set aside for this purpose in the 2007-2009 country operational plans (COPs). However, after exchanging letters and diplomatic notes on this issue, the GOB remains concerned about "the sustainability of the program post-PEPFAR" (reftel). Botswana provides ART to over 80% of its citizens who require treatment. The GOB's national treatment program is exemplary, but the government is acutely aware that it is costly and the financial burden will become more and more difficult to sustain over the years. The Botswana PEPFAR team recently worked with consultants to estimate the future costs of HIV/AIDS treatment in Botswana. Given current assumptions about drug costs, size of population in need of treatment, and other factors, the annual cost of HIV/AIDS treatment in Botswana may reach $331 million by 2015. USG and UNHCR Proposal to GOB -------------- ¶3. (SBU) The Ambassador and UNHCR Resident Representative had been seeking a meeting with Minister Motsumi since early February in order to make one last attempt to convince the GOB to include registered refugees in the national ART program. The purpose of the meeting was to bring closure to the issue and begin treatment for refugees soon, either inside the national program or as a fall-back through an implementing partner to be determined by the Botswana PEPFAR team. Minister Motsumi agreed to meet in her office on April ¶1. Ambassador Nolan was accompanied by a BOTUSA Associate GABORONE 00000273 002 OF 003 Director for GAP and Pol/Econ Chief. UNHCR Representative Roy Herrmann also attended. Minister Motsumi was accompanied by her Permanent Secretary Mr. Kahiya, Deputy Permanent Secretary Dr. Molefo, and Masa (national AIDS program) Deputy Director Dr. Thliowe. ¶4. (SBU) The Ambassador reminded the Minister of the long history of meetings and correspondence on this issue (dating back to both of their predecessors). He noted that the USG has PEPFAR funds available to fund ARV treatment for refugees, but noted that the GOB had come to an impasse over whether to accept them due to a concern that the government would be burdened with an unfunded liability should our funding stop. He empathized with the GOB's fears about the financial burden of sustaining the ART program for its own citizens, and said he understood Botswana's prudent reluctance to expand its treatment program. The Ambassador explained that the USG's commitment to assisting Botswana with the HIV/AIDS crisis is both sincere and long-term, but reiterated that we cannot make any indefinite funding commitments due to the reality of our congressional appropriations process. Mr. Herrmann also reminded the Minister that the GOB has a treaty obligation to provide the same social service, including medical care, to registered refugees as it provides to its own citizens. Mr. Herrmann also reminded the Minister that we are talking about a small population (approximately 3200 registered refugees, of whom no more than 250 are estimated to require treatment) and this population is not expected to rise dramatically. The Ambassador and Mr. Herrmann also pointed out that all of Botswana neighbors already provide ART to non-citizens, making it unlikely that there would be any increased refugee traffic to Botswana based on ART availability. ¶5. (SBU) Though the USG believes including refugees in the national ART program is the best way to move forward, the Ambassador also noted that if the GOB chooses not to do so, we stand ready to fund an implementing partner to provide treatment. However, he explained that it is our strong preference to include refugees in the national ART program rather than create an outside treatment program. The Ambassador praised Botswana for its strong and effective national ART program, and said that opening the door to treatment outside the national program by other partners may have an unintended negative effect and would be a step backward for Botswana. GOB Response -------------- ¶6. (SBU) The Minister allowed her Permanent Secretary and Deputy Permanent Secretary to speak first, and they expressed great fear that the GOB would not be able to pay for treatment of its own citizens in future, let alone treat foreigners. They pleaded for guarantees of "sustainability" of the treatment program. The Permanent Secretary also asked why the treatment should be provided in the national program, and seemed to prefer that treatment be provided by an implementing partner to avoid any government liability for future treatment costs. He offered however that the implementing partner would have to collaborate with the MOH and conform to Botswana's national treatment standards. Minister Motsumi thanked the Ambassador and UNHCR for their attention to the refugee issue, but said that she "shares the sentiments of cabinet that Botswana cannot take on an extra load when its burden is already so heavy." However, she acknowledged that the refugees residing in Botswana mingle freely with the citizens and if they remain untreated are a greater public health risk. She also emphasized that beginning ART is a lifetime commitment, and said that "if you (the USG) start this project, you must continue because the government cannot afford to take this up." The Minister thanked the USG and other development partners for their "huge contributions" to Botswana in health care, especially AIDS treatment. The Minister acknowledged that there are no indefinite commitments in government, and admitted that even the GOB cannot make promises beyond the next 5 years, as government programs and priorities may change with new leadership. She also agreed that it is time to bring the discussion about treatment of refugees to finality, and pledged to discuss the options first with her staff and then GABORONE 00000273 003.2 OF 003 with cabinet and come back to us soon with the GOB's preferred way ahead. COMMENT -------------- ¶7. (SBU) COMMENT: The HIV/AIDS burden truly is heavy for this small though resource-rich nation. The GOB is known for prudent management of its resources, and so it is no surprise that it is reluctant to take on new patients (albeit a small number of them) in an already large and expensive national treatment program, especially in a year when Botswana's government revenues are expected to decline by 50% due to the global economic crisis. We hope to have some response from Minister Motsumi soon (realistically that is likely to be weeks rather than days from now),and with that answer we can move forward either to pay for incorporating refugees in the national ART program or allow the PEPFAR team to work with UNHCR and develop and fund a new, independent treatment program. We believe from signals in the meeting that MOH staff and Botswana's cabinet have a strong preference to maintain their current redline-- that the national ART program is only for citizens. Therefore, we anticipate that there is probably a 70% chance that the GOB will tell us to fund a partner to treat refugees. This would be a step forward for refugees currently in need of treatment, but possibly a step backward for Botswana as its HIV/AIDS treatment program may become splintered through the precedent set by this first allowance of a non-governmental organization to begin HIV/AIDS treatment, wholly funded by the USG. END COMMENT. NOLAN