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Botswana's strategy in the fight against HIV/AIDS

Statement by his excellency, Mr. Festus Mogae President of the Republic of Botswana

International conference on Botswana's efforts to combat HIV/AIDS,
sponsored by the Centre for Strategic and International Studies (CSIS)

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I welcome the opportunity to address this important International Conference on Botswana's efforts to combat HIV/AIDS that has been kindly hosted by the United States Centre for Strategic and International Studies (CSIS) and funded by the Bill and Melinda Gates Foundation. As partners, we should regularly interact with each other at political, managerial and operational levels.

I should also take this opportunity to congratulate Ambassador Randall Tobias on his recent appointment as United States Global AIDS Coordinator. With his distinguished career in the Private Sector, Ambassador Tobias is particularly well placed for this leadership role. My government and I look forward to working in close collaboration with him. I am particularly pleased that Ambassador Tobias visited Botswana in early October and was able to make an on the spot assessment of our HIV/AIDS programmes.

As many of you may be aware, Botswana is severely affected by the HIV/AIDS pandemic, and we have the unfortunate distinction of having one of the highest HIV/AIDS seroprevalence rates in the general population globally. The 2002 sentinel surveillance studies estimated that we have an HIV seroprevalence rate of 35.4% in the 15 - 49 age group, with about 258 000 people infected out of a total population of 1.7 million. This marks a decline from 38.5% in 2000 and 36.5% in 2001.

HIV/AIDS is therefore undoubtedly the most serious development and health challenge that Botswana is facing. The impact of HIV/AIDS on socio-economic development is already being felt. It is estimated that economic growth as measured by GDP could be slowed by up to 1.5 percentage points annually. Life expectancy has declined from 65 years to about 56, as shown by the 2001 national population census. And several health and social indicators such as infant mortality rate have suffered a reversal. As the epidemic affects mainly those in their most productive years, national productivity has declined, and the workforce in all sectors has been significantly affected.

In the early years of this pandemic, its effects were not so clear to the ordinary person. Its impact is now clear for all to see; our cemeteries are filling with the headstones of people in their 20s and 30s. Our health and social services are struggling to cope with the strain. Adult and pediatric medical wards are frequently running above capacity. HIV/AIDS related illnesses account for about 60% of acute medical beds, and our meagre human resources in the health sector are severely stretched.

Faced with an unprecedented challenge that threatens the very fabric of our society, we in Botswana have had to develop a comprehensive multi-sectoral response to this pandemic. In the year 2000, I declared HIV/AIDS a national emergency and began to chair the National AIDS Council, the policy making body on HIV/AIDS. In the same year, the National AIDS Coordinating Agency was established to lead the co-ordination of the multi-sectoral response.

To cope with a pandemic of so massive a scale requires resources well beyond the capability of a small economy such as ours. Therefore, the people of Botswana and personally, are extremely grateful for the support that has been provided to us by, among others, the US Government.

Our thanks also go to private sector corporations such as the Bill and Melinda Gates Foundation, the Merck Company Foundation, Pfizer Incorporated, Bristol Myers Squibb, and academic institutions such as the Harvard AIDS Institute, the Baylor College of Medicine and others. We are also grateful to other development partners including the United Nations agencies for their committed support in our struggle. The UN system is particularly helpful in bringing to us best practices from other parts of the world in both the management and co-ordination aspects of the pandemic.

While we greatly appreciate this support, we firmly recognise the importance of commitment of our own resources as a nation to the fight against HIV/AIDS. Hence government has significantly increased funding for the national HIV/AIDS response, and currently direct expenditure is estimated to be about US$ 70 million annually, which is about 70% of total HIV/AIDS expenditure.

From the outset we have recognised that with a generalised, mature epidemic such as ours, any long-term control must focus on strong, comprehensive and innovative preventive strategies. Prevention of HIV/AIDS transmission therefore remains our most important priority, and is a key aspect of the mobilisation of our society.

In this regard, key interventions in the current National Strategic Framework for HIV/AIDS include significantly increasing the number of people within the sexually active population, especially those in the 15-24 years age cohort, who adopt key HIV prevention behaviours. It is also our stated aim to decrease HIV transmission from HIV positive mothers to their babies and adopt safe blood transfusion practices.

Prevention is further predicated on promoting abstinence, faithfulness to partners as well as use of condoms. Capacity building of teachers in order for them to impart key prevention messages to the youth at an early age is a key aspect of prevention. Furthermore, specific population groups considered more vulnerable to HIV infection are having targeted programmes.

Condoms are freely available in all health facilities, work places and other places of convenience throughout the country. In the past two years female condoms are being provided in government facilities in order to increase options available to women in terms of protection against sexually transmitted infections including HIV/AIDS. Consistent use of condoms during each sexual encounter still remains our greatest challenge in this area. It is our hope that with persistent information and education our people will use condoms more regularly as well as more effectively.

As a nation, we are cognisant of the fact that our future lies in protecting adolescents and youth from HIV/AIDS transmission. In fact our national Vision 2016, has the ambitious goal of achieving an AIDS-free generation by 2016. We have thus attached great importance to strengthening youth and adolescent sexual reproductive health programmes.

The Ministry of Health, in partnership with the African Youth Alliance (AYA), funded by the Bill and Melinda Gates Foundation coordinates a project strengthening shared responsibility for adolescent sexual and reproductive health, and adapting sexual and reproductive health programmes to make them more accessible and attractive to the youth.

Botswana is one of four countries benefiting under this programme in Africa, which has a budget of US$ 7.9 million over five years in Botswana. Implementing partners are UNFPA, Programme for Applied Technology in Health (PATH) and Pathfinder International. This programme is currently being implemented in 10 out of 24 districts in the country and is in its third year of implementation. The plan is to roll it out to the rest of the country as and when resources permit.

Another intervention my government introduced was the Prevention of Mother to Child Transmission Programme in 1999. The programme was slow to take off due to the problem of stigma. Many women were thus unwilling to test. Manpower has also been a major constraint. I am happy to inform you that introduction of lay counsellors has helped in increasing the number of women counselled and tested. Currently more than 90% of women coming to our antenatal care clinics are being pre-test counselled.

However, we are still facing the challenge of increasing our testing figures to above the current 60% and increasing the uptake to above 39%. To further minimise transmission of HIV in the community, treatment of sexually transmitted infections has been strengthened. As a result of this, there has been a downward trend in the prevalence of sexually transmitted diseases.

Mr Moderator, prevention of new infections alone is not sufficient. It is for this reason that 18 months ago my government, with the support of ACHAP, introduced anti retro viral therapy in our public health facilities at no cost to citizens. As a result of this partnership, 14 000 people have been enrolled of which over 9 000 are receiving anti retro viral drugs in government health facilities and a further 5 800 in private health facilities. The 12 sites offering ARV will be increased to 18 by the end of 2004. This should extend coverage significantly.

It is encouraging to note that as a result of this intervention many people who were on their deathbed are back on their feet and are productively engaged and fending for their families. We are grateful that Bristol Myers Squibb, through Secure the Future, has offered to assist us introduce the anti retro viral therapy in one of our rural areas.

The major challenges in the introduction of ARV therapy have been manpower constraints, infrastructure, stigma, drug and the cost of reagents. We are grateful for the price reduction in the cost of these life saving drugs by the multi national pharmaceutical companies and hope to see further reductions particularly in the area of reagents. Human resource constraints especially, pharmacists, doctors and health technicians continue to be a challenge. We look to our friends and well-wishers for support in this area as well.

Mr Moderator, introduction of all these interventions has made us realise that the entry point for all these programmes is knowledge of one's HIV status. It is for this reason, that in collaboration with the USA government, we introduced Voluntary Counselling and Testing Centres. A total of 16 centres are in operation. So far well over 65 000 people have taken advantage of the services offered in these centres and have tested. As we roll out all our programmes to the rest of the country there is need for more of these centres.

We hope it shall be possible to establish more of these centres all over the country under the auspices of President Bush's Emergency Plan for AIDS Relief. To further increase the numbers of those testing, we have decided to introduce routine HIV testing in our facilities starting early next year. It is our hope that placing HIV on the same level as other diseases will help reduce stigma.

Mr Moderator, in order for us to sustain the gains we have so far made, it is critical for us to address the behaviour of our people. We shall use every means possible to strengthen our social behaviour change strategies.

With the assistance of our other collaborators such as Baylor College of Medicine, University of Pennsylvania, Harvard AIDS Institute, we are carrying out a number of research projects. These include, inter alia, development of resistance to ARV drugs, viral structure of our local strain, response to certain drug combinations in children, use of anti retro viral in breastfeeding mothers and tuberculosis. In addition to these areas of research, these partners are also helping in the training of our health care providers in the area of HIV/AIDS.

Mr. Moderator, we have had successes and challenges in our anti-HIV/AIDS programmes. The level of HIV/AIDS awareness and its socio-economic implications in the public has risen considerably. There is more public discussion and openness than 3 years ago. All community leaders have become active proponents of our various programmes. This is assisting to break down barriers and promote common understanding and buy in by the general public. This is a major success although we still have a long way to go, especially in reducing stigma.

We have initiated the Prevention of Mother to Child Transmission Programme; Community Home Based Care; Orphans and ARV programmes. We trained and recruited skilled human resources. And as many of you will bear me out, we have established solid partnerships with the International Community, the Private Sector, NGOs, Community Based Organisations, Faith Based Organisations, the Youth, Women's Groups, People Living with HIV/AIDS as well as academic institutions.

Our co-ordination mechanisms at Central and Local government, the National AIDS Council and District Multi Sectoral AIDS Committees, among others, are fairly well established and functioning quite well. But without question, these are being tested by the scale of the pandemic as well as the number of programmes introduced. Retention of skilled human resources is problematic. When our development partners require expertise, they too recruit from government and other national institutions. This is the dilemma that we face.

We intend to address this through more training of our own people, recruiting suitably qualified personnel from other countries and multi-skilling our available personnel. Information Technology (IT) capability will also be enhanced. Decision making will be decentralised to the Local Authorities and other levels in line with their capacity to take on the roles being delegated. We are constantly adapting our administrative procedures for procurement, staff recruitment, infrastructure development etc. to improve speed of delivery and effectiveness. And we remain open to considering whatever new initiatives that could further improve delivery.

Mr. Moderator, Distinguished Guests, Ladies and Gentlemen, Government of Botswana and other stakeholders will need the support of development partners to adequately staff, operate and manage our HIV/AIDS programmes and to improve their efficacy. It should be borne in mind that one adverse impact of the pandemic has been to reduce our administrative capacity to deal with it.

On infrastructure development, we have not developed the number of facilities we had planned. Neither have we developed them at the pace we wanted because of technical capacity constraints within our construction industry. Again, it is partly a question of available skills. Government will continue to accord high priority to HIV/AIDS projects. But as it will be appreciated, the development of other key infrastructure such as roads, power, water supplies etc. are also indirectly linked with the delivery of HIV/AIDS programmes.

Mr. Moderator, Distinguished Guests, Ladies and Gentlemen, my Government and I are determined to wage a decisive battle against HIV/AIDS. Every effort is being made to substantially increase enrolment in the various HIV/AIDS programmes. But at times, resource constraints-human, material, financial and infrastructure, frustrate our efforts. And on other occasions, our own procedures have not been helpful to the speedy delivery of HIV/AIDS programmes. The same applies to procedures and processes of partners, each of whom would like to be met individually as often as possible, especially by me.

All these have contributed to the slow utilisation of resources provided by partners and ourselves - the so-called absorptive capacity constraints. I am confident that we can all work together and strengthen co-ordination mechanisms so that we can achieve the goals of our National Strategic Framework. It is critically important that for the various programmes to be scaled up and new ones introduced, the constraints I have referred to be fully addressed.

In conclusion, I should emphasise that mitigating the effects of HIV/AIDS on our population is also a major concern. People whose lives are prolonged, must lead fully productive lives for as long as possible. They too must benefit from opportunities for employment, training and self-actualisation. In addition, they require care, support and most importantly our love and respect. Caring for orphans, of whom 42 000 are presently registered, will be a particularly daunting, but not insurmountable challenge. People living with HIV/AIDS and those affected are human beings no less deserving of human dignity.

Mr. Moderator, Distinguished Guests Ladies and Gentlemen, I am accompanied by the Honourable Assistant Minister of Local Government, and various Government officials and representatives of civil society organisations who shall later on speak to you on various topics of interest. We hope to continually engage with you in the implementation of our National Strategic Framework for HIV/AIDS (NSF). The NFS outlines our major policy and programme interventions. It is a document I commend to all our partners. I trust you will all stay the course with us and remain committed to more innovative and forward looking approaches to the fight against HIV/AIDS.

Together we shall overcome.

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