Botswana Voices Inspiring Change: Part 2
Moagi Kenosi – NAHPA
Mr. Moagi Kenosi is the Program Planning Manager at the National AIDS and Health Promotion Agency where he establishes relationships with funders and mobilizes domestic and external funding sources for the national HIV response. The ACS project has worked closely with NAHPA to support the national HIV/AIDS response.
What is the goal of NAHPA? Over the years, what have been the biggest successes and barriers in coordinating the implementation of strategies for Botswana’s HIV/AIDS response?
There are many players in this process- the public sector (government departments), civil society organizations, development partners, communities- and these different stakeholders make various contributions to the national response. NAHPA’s role is to coordinate the role of each of these entities. Ultimately, our goal is to have no new HIV infections by 2030.
The greatest achievement has been the Treat All strategy as this is an achievement of universal access to HIV treatment by everyone who tests positive, regardless of their CD4 count and viral load. As a result, HIV deaths and new infections have been reduced because of the effectiveness of the treatment received by people living with HIV (PLHIV).
On the flip side, the biggest constraint is the dated data we are using for planning and implementing the national response. The last Botswana HIV/AIDS Impact Survey was supposed to have been completed in 2018, but for a variety of reasons it was postponed. This means that we’re relying on data that dates back to 2013/14. It no longer reflects the current status of the virus, which impacts our ability to plan and assess the effectiveness of our interventions to reduce the spread of HIV.
Another challenge we face is that while we work closely with civil society organizations (CSOs) to reach communities, there are many places throughout the country in which CSOs are not present; they’re considered hard to reach places. It becomes challenging when we’re trying to distribute condoms and don’t have a trusted CSO in a particular community.
What do you think are the main challenges within the country’s health system?
The first challenge is training of personnel for health services. In certain areas, there are shortages of pharmacists and doctors. In fact, many doctors move to other countries to find work. Another challenge is procurement and distribution of medicines. Stock levels aren’t always maintained at their desired level at health facilities. Procurement isn’t always completed in time, delivery of medicines can often be delayed, tracking stock levels may not always be done effectively and efficiently. When clinics run out of medicines, it often forces patients to travel long distances to access medicines. Finally, laboratory services are not available in every district, which means specimens have to be transported to other places, which takes time. We still have many challenges in our health system that need to be addressed.
What has been the impact of the ACS team in supporting NAHPA work towards its mission of reducing new HIV infections?
We’ve been grateful for ACS’s contribution as we’ve worked together to identify how we can provide services more effectively and efficiently. One particular area that ACS has greatly contributed to is identifying where savings can be realized in using resources in Botswana’s HIV response. We’re actively working with ACS to implement our procurement system to help the country in saving a substantial amount on what it spends to purchase antiretroviral drugs (ARVs). ACS is helping us to strategize and implement pooled procurement. If we use this approach, we can anticipate saving up to 50% of the current amount we spend every year on ARVs.
What populations in Botswana are disproportionately impacted by HIV/AIDS and what is being done to address the health needs of vulnerable populations?
The key and vulnerable populations encompass commercial sex workers, men who have sex with men (MSM), people living with disabilities, adolescent girls and young women, and long distance truck drivers. These are the populations that we’ve found to be at highest risk of HIV.
We have a 5-year national strategic plan that focuses on the country’s HIV response, which guides the implementation of the national response. It identifies the key and vulnerable populations that should be given priority when it comes to provision of HIV services.
There are CSOs that NAHPA funds who work directly with key populations to ensure they have access to services and are not denied services based on their sexual orientation or because they’re sex workers. We’ve also developed a human rights plan that protects their rights and works to prevent discrimination. Unfortunately, Botswana still has some laws that criminalize sex work and MSM but these laws were inherited from colonial rule and were never changed after we gained our independence in 1966. In the human rights plan that I mentioned, one of its goals is to work towards changing this discriminatory legislation so that it’s friendlier and more supportive of key and vulnerable populations in Botswana.
What is hindering the country’s progress in reaching epidemic control despite tremendous investments in the HIV/AIDS response and broader health programs?
We have not achieved much success in bringing about behavior change within communities. People continue to engage in risky behavior that leaves them vulnerable to HIV infection. We want to focus and invest more resources and time in promoting behavior change and thereby prevent new HIV infections.
In addition to achieving epidemic control, universal health coverage (UHC) is also a priority of the Government of Botswana. How do you define UHC and what aspects of health systems strengthening do you think are most important as the country moves towards UHC?
Health services must benefit the highest possible proportion of the population, which is consistent with the principle of social justice. The services that the government provides should benefit the highest number of people as possible, regardless of their ability to pay or their location. Health services must be of good quality and comprehensive. Unfortunately, conversations about UHC in the government and community have largely been limited to only discussing access to services.
For health systems in Botswana to be strengthened, we should pay particular attention to the issue of health personnel. We have good health facilities in the country but are experiencing a major shortage of health personnel. We must also strengthen integration of services so that, for example, when someone presents with TB symptoms, they should also be tested for HIV since co-infection is so common. To achieve UHC will entail addressing these gaps.
“UHC means that each and every person in Botswana should have access to health services- preventative, promotive, curative, and rehabilitative. People should be able to access services that are of good quality at a cost they can afford. Regardless of where you live, you should be able to access quality health facilities and services.”
– Dr. Onalenna Seitio-Kgokgwe
Dr. Onalenna Seitio-Kgokgwe – IDM
Dr. Onalenna is the Country Director at the Botswana Institute of Development Management (IDM), which provides human resources training. Dr. Onaleena joined IDM because she was inspired by an institution that was well established in the community that trains health workers. She shared with ACS her extensive experience working in Botswana’s health sector and the progress she has seen in the country’s movement towards UHC.
IDM has been providing leadership training in human resources for over 40 years. Can you share the institute’s greatest successes and challenges?
An institute only becomes successful because it adapts as the context in which it operates changes. IDM has been responding to the needs of the population and has grown in scope in the number and breath of programs we’re offering, which are in line with government priorities. We offer a number of courses in diverse disciplines, such as business and financial management, public health, community development, and education, among others.
We face challenges like any institution. One in particular is that we’re competing for finite resources. Although we’re a government entity, we function like a private institution. The government funds our infrastructure but not our day-to-day expenses.
How have you seen Botswana’s health system evolve over time, specifically as it relates to health service delivery, health financing and governance?
The health system started from humble beginnings. Our post-independence period was highly curative, with limited resources and infrastructure. As the government improved, it began focusing on making health services available to the people, and through that, created a national development plan that focused on infrastructural development across the country as well as human resource development. This is when the national health institutes were established, to train human resources for health. From this period, Botswana’s health system gradually improved and began to focus on primary health care (PHC). Community health workers (CHWs) played a critical role, especially in the villages, where they knew everyone.Unfortunately, as our health sector grew, we lost aspects that I believe we should have kept, like CHWs, who were community-based and had strong relationships with the people they served.
One thing that has been consistent is the government’s contribution to the financing of the health system. The government has always been a major contributor to health. What has changed has been the structure of the health system. There was a time when the health system was decentralized, where PHC was managed in one ministry, and hospital care in the then Ministry of Health (MoH). It was more efficient this way because the Ministry of Local Government had control over PHC and could finance it appropriately. With time, the country recentralized, and brought back PHC into the MoH, which has complicated health financing of our health system.
The government has always worked to provide necessary health services at a cost that the population can afford- and in many cases, people don’t have to pay anything or at most, only a nominal fee. The challenges and inefficiencies remain
How do you define UHC?
To me, UHC means each and every person in Botswana should have access to health services-preventative, promotive, curative, and rehabilitative. People should be able to access services that are of good quality at a cost they can afford. These services should be able to improve the health outcomes of people. Regardless of where one lives, they should be able to access quality health facilities and services.
What messages about UHC do you think resonate with community members?
I think access to health, understanding that it’s their right to access or have services available. Most importantly, people must take personal responsibilities because if facilities are available and people don’t use them, that presents a challenge. The community should demand access to quality care and hold their political leaders accountable for the health services they receive.
What do you believe is needed to achieve UHC in Botswana?
I think we must look at the issue of human resources for health to ensure they’re available, that we have the right number, at the right time, and at the right place. We need to ensure that they’re appropriately qualified and aligned with the needs and priorities of where they’re working and are equally distributed across the country. We need to ensure the skillsets of those working in rural areas are comparable to those working in urban regions.
Another priority for me is the availability of medicines and medical products. This has a big impact on UHC. This also means that we need to focus on health financing and improve the efficiency of the resources available. If you look at the amount Botswana spends on health and compare it to our outcomes, there are countries spending less who have better health outcomes.
What aspects of health systems strengthening do you believe are most important in Botswana, especially in maintaining HIV/ AIDS epidemic control and in moving the country towards UHC?
Health information systems strengthening is a critical component of the health system that needs to be addressed or else it will be difficult for the system to respond if information isn’t available at the right time and of the right quality. We also have to strengthen our capacity to lead the health system and to make the right decisions at the right time. This is one of our greatest challenges. We have very experienced people in their profession, like nurses and doctors, who are now in government leadership positions without any leadership training.
Diversity and inclusiveness are important elements of health policy decision-making. To what extent is this applied in the context of health systems strengthening in Botswana? How could the government better incorporate underrepresented voices?
I feel that not all relevant stakeholders are being engaged and policies are created without proper consultation. If you look at our constitution, it clearly outlines how decisions need to be made. Everything is supposed to start at the community level.
I think it’s a matter of leadership, of mindset, to know that when you’re developing a policy, you need to engage the community. It’s also a matter of engaging interest groups who can push for inclusion. We must sensitize political leadership on their role in representing their populates. They must take a multi-pronged approach to ensure people, particularly the most marginalized, are represented in peacemaking.
Photo Credit: Moagi Kenosi , and Dr. Onalenna Seitio-Kgokgwe