A heavy burden, across many rivers borne
Mbongeni Mguni | Friday December 1, 2017 15:46
Barely a decade after the first case was positively identified in Selebi-Phikwe in 1985, HIV had silently risen to become the single greatest existential threat to Botswana. It would also, naturally, become the public health sector’s single greatest challenge, one requiring the most urgent deployment of funds to restrain.
Following pronouncements by former President Festus Mogae, Ntwa e Bolotse was the rallying call and HIV shot to prominence in the public spending priorities.
There was really no alternative. HIV was eating away at the country’s productive labour force, breaking down family structures, eroding the public and private health sector and dulling the country’s investment allure.
Everything that could be spent had to be spent for the very survival of the country and Mogae’s speeches became increasingly chilling on the challenge the country was facing.
“We really are in a national crisis,” he told a World AIDS conference held in Durban in 2000.
“We are threatened with extinction. People are dying in chillingly high numbers. We are losing the best of young people.
“It is a crisis of the first magnitude.”
The fiscus responded, with spending on prevention, education, care and later interventions such as PMTCT and ARVs. Today, millions of pula are being spent on a cutting edge HIV superdrug and campaigns such as the Safe Male Circumcision.
All in all, Botswana is today held up globally as an example of a country that was pushed to the brink by HIV, but rebounded and is now beating a once-dreaded foe into retreat.
In the last 10 years alone, Botswana spent at least P5 billion directly on public health sector-led HIV interventions, a figure that is highly conservative as expenditure for at least half of that period is not publicly available.
The P5 billion also excludes overall spending on public health infrastructure, which caters for all diseases, but was heavily weighed on by the epidemic.
Between 2007 and 2010, spending specifically on HIV programmes amounted to P2.57 billion or an average of P857 million annually. Those years are significant given that the local economy crashed in 2009 in line with the global recession.
While government cut numerous programmes, deferred others and borrowed heavily, funding for HIV was maintained in line with national priorities.
Funding was maintained even as other threats to the economy emerged, such as the widespread national blackouts that began in 2008 and the droughts between 2014 and 2016.
Just last year, current finance minister, Kenneth Matambo revealed that HIV funding would take up the lion’s share of the P6.59 billion allocated to the Ministry of Health for its development budget. However, numerous authorities, from Gaolathe to Mogae, have warned that the levels of funding for the fight against HIV/AIDS were not sustainable in any way.
Former finance minister, the late Baledzi Gaolathe noted the costs of the fight against HIV frequently in his budget speeches.
“Government’s budget continues to be stretched by the heavy costs imposed by the HIV/AIDS epidemic,” he said in his 2007 speech to Parliament. Mogae was equally concerned about the sustainability of the levels of spending.
“The affordability and sustainability of our response programmes remains one of the major long term challenges,” he said in his 2006 State of the Nation Address.
Gaolathe’s successor, Kenneth Matambo has also issued warnings. “A major threat to gains in combating HIV and AIDS is the decline in donor funding. This means that government will be facing increasing financial responsibilities to fill in the financing gap,” he said in his 2013-2014 budget speech.
Coupled with projections of lower budget revenues going forward due to declining mineral earnings, the outlook for sustained HIV funding looks dim.
Meanwhile, some 301,000 Batswana are dependent on this sustained HIV funding to provide free ARVs and other support, which enables them to positively contribute to the economy.
The funding is managing incidence rates through the provision of free condoms, PMTCT and Safe Male Circumcision, while the introduction of superdrugs means those infected are living longer and healthier.
A USAID-linked thinktank believes it may have some answers to the country’s dilemma.
In a recent report handed over to the Ministry of Health (and Wellness), the research group, known as Health Finance and Governance, recommends that Botswana overhaul the funding of its public health sector. One key recommendation is the introduction of national health insurance.
“Enrolment in a new Botswana insurance system should be mandatory for all Batswana in order to ensure that the population can access health services and contribute to the financing of the health sector,” the researchers said.
“Mandatory enrolment can mitigate the challenges of adverse selection – the phenomenon where healthy individuals do not enrol in health insurance while the sick, or those who anticipate having greater medical needs, do enrol.
“This leads to a sicker and more expensive beneficiary population for the insurer, which can force an increase in premiums, further discouraging young and healthy individuals to enrol.”
The thinktank also recommends that Botswana finance a new public insurance system through a mix of payroll contributions from the formal sector, general taxation, and from innovative mechanisms such as an earmarked VAT or other levies.
Government, for its part, has revised the National Health Policy, and by 2014, was in the process of developing a health financing strategy. It is under this strategy, reportedly, that a failed effort was made to stop public health support for alcohol-related conditions and others.
Areas being explored for sustainable health funding going forward, according to Matambo, include Public Private Partnership in health services, raising revenues for health and securing greater efficiencies.
Ultimately, however, the future of sustainable HIV funding is dependent on changed behaviour. As Mogae noted, HIV funding will only become sustainable when new infections are kept low or eliminated.
“We need to reduce new HIV infections in order to have fewer patients to treat, fewer orphans and therefore more resources to address other development challenges facing our nation”.