VZCZCXRO7835
PP RUEHBZ RUEHDU RUEHJO RUEHMR RUEHRN
DE RUEHOR #0273/01 0921428
ZNR UUUUU ZZH
P 021428Z APR 09
FM AMEMBASSY GABORONE
TO RUEHC/SECSTATE WASHDC PRIORITY 5687
INFO RUCNSAD/SOUTHERN AF DEVELOPMENT COMMUNITY COLLECTIVE
RUEAUSA/DEPT OF HOMELAND SECURITY WASHINGTON DC
RUEAIIA/CIA WASHDC
RHEFDIA/DIA WASHDC
RUEHGV/USMISSION GENEVA 0345
RHMFISS/HQ USAFRICOM STUTTGART GE
RUCNDT/USMISSION USUN NEW YORK 0409

UNCLAS SECTION 01 OF 03 GABORONE 000273 
 
SENSITIVE 
 
SIPDIS 
 
STATE FOR AF/S, PRM, S/GAC 
STATE PLEASE PASS USAID 
HHS FOR CDC/GAP 
 
E.O. 12958: N/A 
TAGS: PREF KHIV EAID PGOV BC
SUBJECT: BOTSWANA: SEEKING CLOSURE ON ART/REFUGEE ISSUE 
 
REF: 08 GABORONE 1140 AND PREVIOUS 
 
¶1.  (SBU) SUMMARY:  Ambassador Nolan met with Minister of 
Health Lesego Motsumi to try to bring closure to the 
long-pending issue of whether and how to provide 
antiretroviral therapy (ART) to registered refugees in 
Botswana infected with HIV/AIDS.  The Ambassador explained 
that the USG's commitment to assisting Botswana with the 
HIV/AIDS crisis is both sincere and long-term, but reiterated 
that we cannot make any indefinite funding commitments due to 
the reality of our congressional appropriations process.  He 
empathized with the GOB's fears about the financial burden of 
sustaining the ART program for its own citizens during a 
period of shrinking revenue, and said he understood 
Botswana's prudent reluctance to expand its treatment 
program.  Though the USG believes including refugees in the 
national ART program is the best way to move forward, the 
Ambassador also noted that if the GOB chooses not to do so, 
we stand ready to fund an implementing partner to do so.  The 
Minister and her staff reiterated the GOB's fears about 
"taking on any extra load when their burden is already so 
heavy," and noted that once individuals are put on treatment, 
it is a lifetime commitment.  However, the Minister also 
recognized the GOB's treaty obligation to provide medical 
care to refugees and understood that there would be negative 
public health implications for Batswana if refugees are not 
given access to HIV treatment and other services.  Minister 
Motsumi promised to confer with her staff and Botswana's 
cabinet and come back to us "within a few days" with a 
decision on whether or not to include the refugees in the 
national treatment program.  Given the GOB's fears about its 
ability to pay for treatment, we believe it is likely that 
Botswana will maintain its  current redline and insist that 
the MOH's national treatment program remain only for 
citizens, and ask us to work with an implementing partner to 
provide for refugees.  END SUMMARY. 
 
BACKGROUND 
---------- 
¶2.  (SBU) The U.S. Embassy and office of the United Nations 
High Commissioner for Refugees (UNHCR) in Botswana have been 
working with the GOB on the question of access to ART for 
refugees for more than a year.  We have urged Botswana to 
live up to its treaty obligations to provide registered 
refugees the same social benefits as the government accords 
to its own citizens (including access to medical care). 
Botswana has approximately 3200 registered refugees, about 
1800 of whom reside in the Dukwe refugee camp north of 
Francistown.  Botswana has thus far refused to include any 
non-citizens in its national ART program administered by the 
Ministry of Health.  The USG (through the PEPFAR program) has 
offered to pay for treatment of registered refugees, and 
approximately $600,000 (cumulative) has been set aside for 
this purpose in the 2007-2009 country operational plans 
(COPs).  However, after exchanging letters and diplomatic 
notes on this issue, the GOB remains concerned about "the 
sustainability of the program post-PEPFAR" (reftel). 
Botswana provides ART to over 80% of its citizens who require 
treatment.  The GOB's national treatment program is 
exemplary, but the government is acutely aware that it is 
costly and the financial burden will become more and more 
difficult to sustain over the years.  The Botswana PEPFAR 
team recently worked with consultants to estimate the future 
costs of HIV/AIDS treatment in Botswana.  Given current 
assumptions about drug costs, size of population in need of 
treatment, and other factors, the annual cost of HIV/AIDS 
treatment in Botswana may reach $331 million by 2015. 
 
USG and UNHCR Proposal to GOB 
------------------------------ 
¶3.  (SBU) The Ambassador and UNHCR Resident Representative 
had been seeking a meeting with Minister Motsumi since early 
February in order to make one last attempt to convince the 
GOB to include registered refugees in the national ART 
program.  The purpose of the meeting was to bring closure to 
the issue and begin treatment for refugees soon, either 
inside the national program or as a fall-back through an 
implementing partner to be determined by the Botswana PEPFAR 
team.  Minister Motsumi agreed to meet in her office on April 
¶1.  Ambassador Nolan was accompanied by a BOTUSA Associate 
 
GABORONE 00000273  002 OF 003 
 
 
Director for GAP and Pol/Econ Chief.  UNHCR Representative 
Roy Herrmann also attended.  Minister Motsumi was accompanied 
by her Permanent Secretary Mr. Kahiya, Deputy Permanent 
Secretary Dr. Molefo, and Masa (national AIDS program) Deputy 
Director Dr. Thliowe. 
 
¶4.  (SBU) The Ambassador reminded the Minister of the long 
history of meetings and correspondence on this issue (dating 
back to both of their predecessors).  He noted that the USG 
has PEPFAR funds available to fund ARV treatment for 
refugees, but noted that the GOB had come to an impasse over 
whether to accept them due to a concern that the government 
would be burdened with an unfunded liability should our 
funding stop.  He empathized with the GOB's fears about the 
financial burden of sustaining the ART program for its own 
citizens, and said he understood Botswana's prudent 
reluctance to expand its treatment program.  The Ambassador 
explained that the USG's commitment to assisting Botswana 
with the HIV/AIDS crisis is both sincere and long-term, but 
reiterated that we cannot make any indefinite funding 
commitments due to the reality of our congressional 
appropriations process.  Mr. Herrmann also reminded the 
Minister that the GOB has a treaty obligation to provide the 
same social service, including medical care, to registered 
refugees as it provides to its own citizens.  Mr. Herrmann 
also reminded the Minister that we are talking about a small 
population (approximately 3200 registered refugees, of whom 
no more than 250 are estimated to require treatment) and this 
population is not expected to rise dramatically.  The 
Ambassador and Mr. Herrmann also pointed out that all of 
Botswana neighbors already provide ART to non-citizens, 
making it unlikely that there would be any increased refugee 
traffic to Botswana based on ART availability. 
 
¶5.  (SBU) Though the USG believes including refugees in the 
national ART program is the best way to move forward, the 
Ambassador also noted that if the GOB chooses not to do so, 
we stand ready to fund an implementing partner to provide 
treatment.  However, he explained that it is our strong 
preference to include refugees in the national ART program 
rather than create an outside treatment program.  The 
Ambassador praised Botswana for its strong and effective 
national ART program, and said that opening the door to 
treatment outside the national program by other partners may 
have an unintended negative effect and would be a step 
backward for Botswana. 
 
GOB Response 
-------------- 
¶6.  (SBU) The Minister allowed her Permanent Secretary and 
Deputy Permanent Secretary to speak first, and they expressed 
great fear that the GOB would not be able to pay for 
treatment of its own citizens in future, let alone treat 
foreigners.  They pleaded for guarantees of "sustainability" 
of the treatment program.  The Permanent Secretary also asked 
why the treatment should be provided in the national program, 
and seemed to prefer that treatment be provided by an 
implementing partner to avoid any government liability for 
future treatment costs.  He offered however that the 
implementing partner would have to collaborate with the MOH 
and conform to Botswana's national treatment standards. 
Minister Motsumi thanked the Ambassador and UNHCR for their 
attention to the refugee issue, but said that she "shares the 
sentiments of cabinet that Botswana cannot take on an extra 
load when its burden is already so heavy."  However, she 
acknowledged that the refugees residing in Botswana mingle 
freely with the citizens and if they remain untreated are a 
greater public health risk.  She also emphasized that 
beginning ART is a lifetime commitment, and said that "if you 
(the USG) start this project, you must continue because the 
government cannot afford to take this up."  The Minister 
thanked the USG and other development partners for their 
"huge contributions" to Botswana in health care, especially 
AIDS treatment.  The Minister acknowledged that there are no 
indefinite commitments in government, and admitted that even 
the GOB cannot make promises beyond the next 5 years, as 
government programs and priorities may change with new 
leadership.  She also agreed that it is time to bring the 
discussion about treatment of refugees to finality, and 
pledged to discuss the options first with her staff and then 
 
GABORONE 00000273  003.2 OF 003 
 
 
with cabinet and come back to us soon with the GOB's 
preferred way ahead. 
 
COMMENT 
------- 
¶7.  (SBU) COMMENT: The HIV/AIDS burden truly is heavy for 
this small though resource-rich nation.  The GOB is known for 
prudent management of its resources, and so it is no surprise 
that it is reluctant to take on new patients (albeit a small 
number of them) in an already large and expensive national 
treatment program, especially in a year when Botswana's 
government revenues are expected to decline by 50% due to the 
global economic crisis.  We hope to have some response from 
Minister Motsumi soon (realistically that is likely to be 
weeks rather than days from now), and with that answer we can 
move forward either to pay for incorporating refugees in the 
national ART program or allow the PEPFAR team to work with 
UNHCR and develop and fund a new, independent treatment 
program.  We believe from signals in the meeting that MOH 
staff and Botswana's cabinet have a strong preference to 
maintain their current redline-- that the national ART 
program is only for citizens.  Therefore, we anticipate that 
there is probably a 70% chance that the GOB will tell us to 
fund a partner to treat refugees.  This would be a step 
forward for refugees currently in need of treatment, but 
possibly a step backward for Botswana as its HIV/AIDS 
treatment program may become splintered through the precedent 
set by this first allowance of a non-governmental 
organization to begin HIV/AIDS treatment, wholly funded by 
the USG.  END COMMENT. 
NOLAN