VZCZCXRO7224
PP RUEHBZ RUEHDU RUEHJO RUEHMR RUEHRN
DE RUEHOR #0997/01 3491329
ZNR UUUUU ZZH
P 151329Z DEC 09
FM AMEMBASSY GABORONE
TO RUEHC/SECSTATE WASHDC PRIORITY 6214
INFO RUCNSAD/SOUTHERN AF DEVELOPMENT COMMUNITY COLLECTIVE
RUEAIIA/CIA WASHDC
RHEFDIA/DIA WASHDC
RHMFISS/HQ USAFRICOM STUTTGART GE
RUEHPH/CDC ATLANTA GA
RHEHNSC/NSC WASHDC

UNCLAS SECTION 01 OF 02 GABORONE 000997 
 
SIPDIS 
 
STATE FOR S/GAC, AF/S 
STATE PLEASE PASS USAID 
PRETORIA PLEASE PASS USAID 
 
E.O 12958: N/A 
TAGS: EAID KHIV KWMN KOCI BC
SUBJECT: Botswana Offers Bright Prospects for GHI Success 
 
REF: STATE 125761 
 
GABORONE 00000997  001.2 OF 002 
 
 
¶1. This is an action request.  Please see paragraph 6. 
 
¶2. Summary and Action Request.  The U.S.-Botswana PEPFAR partnership 
has yielded tremendous results over the past five years; 80 percent 
of citizens who need treatment receive it and 94 percent of infected 
mothers receive drugs to prevent their babies from contracting HIV. 
The Global Health Initiative (GHI) offers promising possibilities 
for successful expansion of our ongoing health partnership in 
Botswana.  The GOB's track record of leadership in responding to 
AIDS demonstrates that an USG investment in Botswana on broader 
health matters would pay real and long-term dividends.  Mission 
Botswana has formed an interagency team to further explore broader 
health access needs here.  We believe our perspective would help 
inform the successful development of the GHI, and we request to be 
included as field participants in the GHI woking groups.  End 
Summary and Action Request. 
Prospects Bright for GHI Success 
-------------------------------- 
¶3.  Botswana has used our PEPFAR assistance wisely and its 
leadership on HIV/AIDS demonstrates the country's capacity to make 
good use of donor funds.  The Global Health Initiative (GHI) program 
could bolster our existing efforts under PEPFAR and improve and 
expand access to health services in Botswana.  Botswana's status as 
a middle income country is highly misleading; the UNDP reports that 
about half of Botswana's citizens still live on less than two 
dollars per day.  Mission Botswana's Interagency Health Team 
recommends that GHI assistance could be used in the following 
areas: 
 
--Gender Equity and Maternal and Child Health: Women in Botswana 
generally have less access to important health services, and family 
planning services are desperately needed within both ARV clinics and 
the broader primary care system.  Despite  successes in the PMTCT 
arena, Botswana must confront other maternal and child health 
challenges including unacceptably high rates of pregnancy-related 
maternal deaths, infant and childhood deaths due to diarrheal 
diseases, as well as significant morbidity and mortality due to 
vaccine-preventable diseases, a situation further complicated by the 
high underlying HIV rate.  Gender-based violence also remains a 
serious issue.  Through the GHI, the U.S. could build on the strong 
health service delivery foundation that PEPFAR has supported for HIV 
care to broadly strengthen health and nutrition services for women, 
infants, and children, potentially building an infrastructure to 
provide comprehensive primary care and preventive interventions for 
all women and children.  Although we are already working to address 
these areas where they are linked with HIV/AIDS support and 
treatment, a more comprehensive approach to maternal and child 
health issues, family planning, and other gender-related health 
promotion and health care access issues, is a critical need. 
 
--Integration and Coordination: The health sector in Botswana is 
fragmented between Ministry of Health hospitals and primary care 
facilities run by the Ministry of Local Government.  This division 
results in gaps in continuity of care, disconnected strategic 
planning, and duplication of information systems which affect all 
aspects of health, not just HIV.   Despite limited initiatives to 
improve coordination, the GOB sorely needs additional assistance in 
Qimprove coordination, the GOB sorely needs additional assistance in 
this area.  Strengthening coordination among all Botswana's health 
services would improve continuity of care and access through better 
patient record management, and more integrated and cost-effective 
service delivery models. 
 
--Multilateral Institutions: Botswana has about 2 million citizens 
but it also hosts hundreds of thousands of economic migrants, 
refugees, and other foreigners who often lack access to 
anti-retroviral therapy and other health care.  To reach highly 
mobile populations across the Southern African region, we recommend 
that the GHI work with the Southern African Development Community 
member states to address shared public health issues, such as 
providing access to health services to non-citizens and other mobile 
populations.  With limited resources and high demand on health 
services within SADC countries, this approach has not received the 
attention it needs. 
 
--Country-Led Plans: Botswana has shown great leadership in 
developing plans for HIV and AIDS, but has not had the resources or 
technical assistance to give the same attention to broader national 
health care issues affecting women, infants and children.  Given the 
history of strong country ownership of Botswana's HIV/AIDS program, 
we believe that under GHI the USG should spend additional resources 
 
GABORONE 00000997  002.2 OF 002 
 
 
toward supporting country-led initiatives for broader health 
services planning, which the GOB would effectively utilize to 
improve the overall health system. 
 
--Sustainability:  An ongoing challenge in Botswana is the limited 
capacity of local organizations to provide community-level health 
services.  To date, efforts have been made to build capacity in 
organizations to provide mostly OVC and HIV prevention services at 
the community level, but gaps exist in addressing numerous other 
community health needs.  Assistance in this area could strengthen 
the sustainability of the overall health services by increasing 
access at the community level to a broader range of services. 
 
 
--Metrics, Monitoring and Evaluation: Botswana lacks a comprehensive 
electronic medical records system for all aspects of primary care, 
not simply HIV/AIDS.  Various information systems related to 
HIV/AIDS were developed to track patients through ARV treatment. 
However, for example, as TB co-infections have quickly emerged as a 
critical health need, we have found that the separate monitoring 
systems are not linked nor are they linked for PMTCT or general 
primary care.   While clinical guidelines clearly outline procedures 
for managing TB/HIV patients in an integrated fashion, the data 
systems have not kept up.  Botswana's monitoring systems could be 
strengthened through an integrated health information system. 
 
--Research, Development and Innovation: The U.S. Government has been 
working closely with the Ministry of Health in Botswana for more 
than 15 years through the Botswana-USA Partnership (BOTUSA), 
conducting clinical and operations research trials.  With the strong 
epidemiologic, clinical, and laboratory capacity and long standing 
collaborations with the GOB, we can successfully build on this 
existing capacity to expand into priority areas for GHI. 
 
Background 
---------- 
¶4. Botswana was one of the original 15 PEPFAR countries, and since 
the program's launch in 2004, the U.S. has supported the GOB's 
existing national HIV/AIDS program.  Botswana is almost in a class 
of its own as a PEPFAR partner nation demonstrating true national 
leadership on HIV/AIDS.  The GOB spends more of its own resources on 
AIDS than it receives from any donor.  An illustration of this 
commitment can be seen in maternal HIV care where, over the past 
decade, the transmission rate among infants of HIV-infected mothers 
has declined from over 40 percent to less than 4 percent, a 
particularly impressive achievement given that one out of three 
mothers who present for delivery in Botswana is infected with HIV. 
 
 
¶5. Throughout the first phase of PEPFAR, we focused on strengthening 
Botswana's HIV/AIDS program, and we were able to assist the GOB to 
reach over 80 percent of citizens with lifesaving drugs, and achieve 
a 94 percent success rate with the prevention of mother to child 
transmission (PMTCT) program.  Our commitment continues in the 
second phase of PEPFAR, though with an increased focus on 
sustainability and health system strengthening.  Unfortunately, with 
current PEPFAR resources we must focus solely on one aspect of the 
health system and are limited to interventions only with HIV 
infected individuals, so despite our potential reach we currently 
have limited ability to address other emerging gaps in Botswana's 
overall health system. 
 
Action Request: Include Botswana in GHI Planning 
QAction Request: Include Botswana in GHI Planning 
--------------------------------------------- --- 
¶6.  Action Request: Mission Botswana has formed an interagency team, 
comprised of CDC, USAID, Peace Corps and the State Department, to 
actively engage the Government of Botswana, civil society, and other 
stakeholders to better understand Botswana's overall health system 
needs and coordinate with Washington GHI staff.  Botswana is a 
leader in effective utilization of PEPFAR resources and has a 
long-standing relationship with the U.S. in the area of global 
health, pre-dating the PEPFAR program.  We believe Mission 
Botswana's perspective would help inform the development of the GHI 
program, and therefore we request to be considered as field 
participants on the GHI working groups. 
 
 
HAMILTON