Botswana

1. Botswana

2. Thabo Seleke University of Botswana Has Donor Funding Been able to Shift AIDS Policy Agenda in Botswana ?

3. The recognition of AIDS as an epochal crisis has led to the proliferation of international and donors organizations' now directly involved in governance, tracking, management

4. Overview ACHAP : Bill & Melinda Gates Foundation Merck Cie Foundation + 120 millions $ each over the years CDC Botswana-Harvard Partnership PEPFAR (20 millions in 2004 ; 40 millions in 2005 ; 70 millions in 2007) Global Fund : 65 million withdrawn due to alledged mismanagement

5. Sources of Funds for HIV/AIDS in Botswana (2003/04 to 2005/06) in Botswana National AIDS Spending Assessment (NASA) 2003-04 to 2005-06, final draft, 26 septembre 2007

6. Botswana health ratios expenditure has increased over the years, focusing predominantly on HIV/AIDS. For ex. budget allocation of P 981 Million for 2011/12, P 188 Million for ARV alone.

7. World AIDS day 1st dec 2011 : President Ian Khama warned the nation on self-discipline as a drive that can be used to fight HIV/AIDS. He argued « prevention starts with you, today prevention is your choice. But our prevention efforts must deliver greatest return to investment. We must focus our efforts where they are most needed and can make an impact. In these difficult economic situation we have to make hard decisions and such decisions do not present many options, as a developing country we do not have the capacity to extend free ARVs to everybody forever. As the economy performs below expectations for now there are some areas of expenditure that come under further scrutiny, however, extending these services to everyone is one thing, but whether the country can afford is another »

8. Although Botswana never faced structural adjustment programs imposed by the IMF, it has generally been unfortunate in that since its classification as upper middle income country in 1992 aid has declined considerably. This has forced the country to finance 96% of it current health budget over the years, thus stretching it far with severe constraints.

9. The success of ARV and PMTCT are a clear demonstration that whilst Botswana has recorded phenomenal economic growth with good GDP, foreign donor assistance does contribute significantly. However, as President Ian Khama noted in his speech, Botswana is experiencing financial shocks as a result of having to shift their policy agenda and trying to focus more on trying to achieve zeop levels of HIV and AIDS, ensure that it is on track with MDGs.

10. Fanny Chabrol Iris EHESS Projet CORUS/ Gouvernance Marseille, 14 décembre 2011 Action publique et coopération biomédicale au Botswana

11. Public action and HIV/AIDS in Botswana : the national Antiretroviral Treatment (ARV) program: from international collaborations to care practices (doctoral thesis – dir. Pr D. Fassin) • Health care policies and practices • The role of international biomedical partners (CDC, Harvard School of Public Health, U-Penn, Baylor School of medicine, etc) • Existence of attractive sites for international research • Genealogy of Harvard School of Public Health Partnership with Botswana

12. Key facts • Botswana is known as an « exception » in Africa • Democratic institutions ; fair elections • Diamond extraction and exportation • Well developped health care system • « Autoritarian liberalism » (Good 1996) • HIV/AIDS : dramatic epidemic • 37% of pregnant women are HIV positive in 1999 • « We are threatened by exctinction », AIDS as a national emergency in 2000

13. National Treatment Programs for HIV/AIDS • Almost universal access to antiretrovirals • Prevention of Mother to Child Transmission from 1999 : the rate of transmission reduced to less than 4% in 2009 • National antiretroviral program (2002) with the support of ACHAP (government, B &M Gates Foundation, Merck Cie Foundation): brand names drug ; 2nd and 3rd line treatments available ; In 2006, national coverage of 85% • Pediatric ARVs (Baylor Centre of Excellence, Texas) • 90% of public expenditure comes from government, national ressources : unprecedented • Limited mutlipolarisation ?

14. Scientific research & Public health : « When it moves that rapidly, there are many things you can do about it » (A. Fauci, 2000, director of NIAID). « AIDS Researchers Look to Africa for New Insights» (J. Cohen, 2000): promising results • Language of opportunities, of promises and the intersections between capital, investment and public health expectations • Rise of Global health initiatives and international funds Global Fund for Tuberculosis, Malaria & AIDS (2002) President Emergency Plan for AIDS relief, PEPFAR (2003)

15. Virology: « so something got into our mind and we said we got to work in Africa with primates, look at every primate and let's see who's infected with what and our lab began to describe monkey retroviruses » (executive director HSPH) • Collaboration HSPH with Senegal (and Hospital Bretonneau, Tours) • Identification of HIV-2 in Senegal in 1985 • Scramble for African viruses and atypical serums : identification of new retroviruses: HIV-O in 1994 and HIV 1-N

16. An epidemiological shock: HIV 1-C « this was little bit of a good news things were leveling off (…) then there was this point down here, a line that was way up above the other lines, from 1990 to 1994 and said "Francistown-Botswana", it had names for each of these Kiffu, Kampala, Kinshasa were leveling of and this line was like this and[ we] looked at each other and we are suppose to know Africa a little bit and this is like 10 or 15 years later, and we were like "where is Botswana? Where is Francistown?“ (idem) Molecular study of HIV 1- C ; vaccine trials projects

17. Public Health «The government ministry came to us and said: you guys have your research lab and you're helping us at looking at HIV tests and looking at CD4 levels can you train to be the reference lab for the country and we said well you should have a reference and we'll help do it partnership help train and whatever but it should be your lab, they said yes it would be our lab but will refer to you and build what you'll need so how much space do you need? (executive director,HSPH) - « It should be your lab » : the laboratory as a metaphor of the collaboration - Public health expectations of local authorities

18. “We will need at least twice as more space and the planners looked at each other and said "are you sure? I think you'll need more space than that. I say “well what do you think I guess three times that space, we started calculating how much tests would be done HIV, CD4 and the planners said we'll come back to you, we'll interview some people, we will come back. About 3 weeks later they came back with their blueprints and their architects, and their designs and we put them out on the table and they had this huge floor plan and we try to get perspective and we say “it's a huge building you know it's a lot of space we were really excited and we got up cause we thought the meeting was over and they said "don't you want to see the other floors?" We didn't know there were going to be four floors … and here is your BL3 you said you needed the Bio containment lab and we said "we can't pay for this" they said "No don't worry about paying for”, and they were laughing, “don't worry” (…) It was built in a year”. Peformance of the bureaucratic and developmental state

19. Botswana-Harvard Laboratory « It was built in a year » - Funded by Governement & « Secure the Future » (Bristol Myyers Squibb) - Divided into two parts : National Reference laboratory Harvard Research Lab

20. Paradigm Shift : from prevention only to access to medications in Africa ? International activism moral blame on Big Pharma and high prices • New actors : Pharma. company : Merck & Co. Inc Philanthropy : Bill & Melinda Gates Foundation … + the Botswana government = African Comprehensive HIV/AIDS Partnerships (ACHAP)

21. It's small enough... “I kept telling Merck, we’ve got to do more, let's add countries, and Botswana, which now we have our partnership with I say I can take you to Botswana in one night, two days and one night, you can meet everybody that you'll need to meet you'll see that they can put together a team in Botswana like in Senegal it's small enough - Senegal is not small but the people you need to meet… the leaders that would be on a team, you could do it in a couple of days let's go to Botswana we even go to a game park I'll took him on a game drive in the morning before he jumped on a plane” (Executive Harvard School of Public health)

22. We are ready to pick “We had narrowed it down to two countries that best met the criteria, Botswana and Uganda but with over a million HIV positive people, Uganda was just too big for the resources we had committed whereas Botswana had a total population of only a million and a half. We called Gates and said we are ready to pick”. (Executive Merck & Co, in Harvard Business Review Case Study, 2001)

23. Treatments: • Evolution of international ethics and politics of treatment • Public health intervention closely monitored by the clinical trial : “A Proportion of the persons receiving treatment in these programs would also enroll in intensive clinical trials, which would collect state- of- the- art virological, immunological, and clinical information; this information, such as CD4 cell counts and viral loads, would optimize treatment protocols and determine treatment efficacy through scientific methodology » (Harvard Consensus Statement, April 4th 2001).

24. Political Imagination Densification, redeployement of biomedical research « We’re attracting a lot of research. Make them do research, research develops infrastructures (...) Certain countries have certain conditions. In the West, the problem is with heart disease, so it’s a national focus for example for the US (...) We want to create a research industry » Interview with Director of Hospital services, ministry of Health, Gaborone, 24 September 2009

25. Botswana Innovation Hub

26. “Let industry fund innovative science … your science agenda is moved forward and you make money on it and your science program is funded, it’s brilliant actually (...) I always say, there’s a group of us that say: we have the most successful HIV program in the world : this program and its molecular biology, we have samples, we have laboratories, we have scientists, we have all of this infrastructure, do not take our samples away anymore! Come here!” (Interview with clinical research coordinator, ministry of Health, Gaborone) Political Economy

27. «  I don't think this can be just introduced from scratch, I think you have to have a well established functioning health system at a high level before you can start offering that there are countries like Dubai can do it, they can just transplant a whole hospital with all the staff but I don’t think Botswana can do it.” Interview with senior public health official, ministry of Health, Gaborone