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

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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

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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