Botswana Offers Bright Prospects for GHI Success

UNCLAS SECTION 01 OF 02 GABORONE 000997

SIPDIS

STATE FOR S/GAC, AF/S
STATE PLEASE PASS USAID
PRETORIA PLEASE PASS USAID

E.O 12958: N/A
TAGS: EAID KHIV KWMN KOCI BC
SUBJECT: Botswana Offers Bright Prospects for GHI Success

REF: STATE 125761

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1. This is an action request. Please see paragraph 6.


2. Summary and Action Request. The U.S.-Botswana PEPFAR partnership
has yielded tremendous results over the past five years; 80 percent
of citizens who need treatment receive it and 94 percent of infected
mothers receive drugs to prevent their babies from contracting HIV.
The Global Health Initiative (GHI) offers promising possibilities
for successful expansion of our ongoing health partnership in
Botswana. The GOB's track record of leadership in responding to
AIDS demonstrates that an USG investment in Botswana on broader
health matters would pay real and long-term dividends. Mission
Botswana has formed an interagency team to further explore broader
health access needs here. We believe our perspective would help
inform the successful development of the GHI, and we request to be
included as field participants in the GHI woking groups. End
Summary and Action Request.
Prospects Bright for GHI Success
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3. Botswana has used our PEPFAR assistance wisely and its
leadership on HIV/AIDS demonstrates the country's capacity to make
good use of donor funds. The Global Health Initiative (GHI) program
could bolster our existing efforts under PEPFAR and improve and
expand access to health services in Botswana. Botswana's status as
a middle income country is highly misleading; the UNDP reports that
about half of Botswana's citizens still live on less than two
dollars per day. Mission Botswana's Interagency Health Team
recommends that GHI assistance could be used in the following
areas:

--Gender Equity and Maternal and Child Health: Women in Botswana
generally have less access to important health services, and family
planning services are desperately needed within both ARV clinics and
the broader primary care system. Despite successes in the PMTCT
arena, Botswana must confront other maternal and child health
challenges including unacceptably high rates of pregnancy-related
maternal deaths, infant and childhood deaths due to diarrheal
diseases, as well as significant morbidity and mortality due to
vaccine-preventable diseases, a situation further complicated by the
high underlying HIV rate. Gender-based violence also remains a
serious issue. Through the GHI, the U.S. could build on the strong
health service delivery foundation that PEPFAR has supported for HIV
care to broadly strengthen health and nutrition services for women,
infants, and children, potentially building an infrastructure to
provide comprehensive primary care and preventive interventions for
all women and children. Although we are already working to address
these areas where they are linked with HIV/AIDS support and
treatment, a more comprehensive approach to maternal and child
health issues, family planning, and other gender-related health
promotion and health care access issues, is a critical need.

--Integration and Coordination: The health sector in Botswana is
fragmented between Ministry of Health hospitals and primary care
facilities run by the Ministry of Local Government. This division
results in gaps in continuity of care, disconnected strategic
planning, and duplication of information systems which affect all
aspects of health, not just HIV. Despite limited initiatives to
improve coordination, the GOB sorely needs additional assistance in
Qimprove coordination, the GOB sorely needs additional assistance in
this area. Strengthening coordination among all Botswana's health
services would improve continuity of care and access through better
patient record management, and more integrated and cost-effective
service delivery models.

--Multilateral Institutions: Botswana has about 2 million citizens
but it also hosts hundreds of thousands of economic migrants,
refugees, and other foreigners who often lack access to
anti-retroviral therapy and other health care. To reach highly
mobile populations across the Southern African region, we recommend
that the GHI work with the Southern African Development Community
member states to address shared public health issues, such as
providing access to health services to non-citizens and other mobile
populations. With limited resources and high demand on health
services within SADC countries, this approach has not received the
attention it needs.

--Country-Led Plans: Botswana has shown great leadership in
developing plans for HIV and AIDS, but has not had the resources or
technical assistance to give the same attention to broader national
health care issues affecting women, infants and children. Given the
history of strong country ownership of Botswana's HIV/AIDS program,
we believe that under GHI the USG should spend additional resources

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toward supporting country-led initiatives for broader health
services planning, which the GOB would effectively utilize to
improve the overall health system.

--Sustainability: An ongoing challenge in Botswana is the limited
capacity of local organizations to provide community-level health
services. To date, efforts have been made to build capacity in
organizations to provide mostly OVC and HIV prevention services at
the community level, but gaps exist in addressing numerous other
community health needs. Assistance in this area could strengthen
the sustainability of the overall health services by increasing
access at the community level to a broader range of services.


--Metrics, Monitoring and Evaluation: Botswana lacks a comprehensive
electronic medical records system for all aspects of primary care,
not simply HIV/AIDS. Various information systems related to
HIV/AIDS were developed to track patients through ARV treatment.
However, for example, as TB co-infections have quickly emerged as a
critical health need, we have found that the separate monitoring
systems are not linked nor are they linked for PMTCT or general
primary care. While clinical guidelines clearly outline procedures
for managing TB/HIV patients in an integrated fashion, the data
systems have not kept up. Botswana's monitoring systems could be
strengthened through an integrated health information system.

--Research, Development and Innovation: The U.S. Government has been
working closely with the Ministry of Health in Botswana for more
than 15 years through the Botswana-USA Partnership (BOTUSA),
conducting clinical and operations research trials. With the strong
epidemiologic, clinical, and laboratory capacity and long standing
collaborations with the GOB, we can successfully build on this
existing capacity to expand into priority areas for GHI.

Background
--------------

4. Botswana was one of the original 15 PEPFAR countries, and since
the program's launch in 2004, the U.S. has supported the GOB's
existing national HIV/AIDS program. Botswana is almost in a class
of its own as a PEPFAR partner nation demonstrating true national
leadership on HIV/AIDS. The GOB spends more of its own resources on
AIDS than it receives from any donor. An illustration of this
commitment can be seen in maternal HIV care where, over the past
decade, the transmission rate among infants of HIV-infected mothers
has declined from over 40 percent to less than 4 percent, a
particularly impressive achievement given that one out of three
mothers who present for delivery in Botswana is infected with HIV.



5. Throughout the first phase of PEPFAR, we focused on strengthening
Botswana's HIV/AIDS program, and we were able to assist the GOB to
reach over 80 percent of citizens with lifesaving drugs, and achieve
a 94 percent success rate with the prevention of mother to child
transmission (PMTCT) program. Our commitment continues in the
second phase of PEPFAR, though with an increased focus on
sustainability and health system strengthening. Unfortunately, with
current PEPFAR resources we must focus solely on one aspect of the
health system and are limited to interventions only with HIV
infected individuals, so despite our potential reach we currently
have limited ability to address other emerging gaps in Botswana's
overall health system.

Action Request: Include Botswana in GHI Planning
QAction Request: Include Botswana in GHI Planning
-------------- ---

6. Action Request: Mission Botswana has formed an interagency team,
comprised of CDC, USAID, Peace Corps and the State Department, to
actively engage the Government of Botswana, civil society, and other
stakeholders to better understand Botswana's overall health system
needs and coordinate with Washington GHI staff. Botswana is a
leader in effective utilization of PEPFAR resources and has a
long-standing relationship with the U.S. in the area of global
health, pre-dating the PEPFAR program. We believe Mission
Botswana's perspective would help inform the development of the GHI
program, and therefore we request to be considered as field
participants on the GHI working groups.


HAMILTON