November 11, 2004 | Read Time: 11 minutes
The Bill & Melinda Gates Foundation chose this southern African nation, roughly the size of Texas,
as the recipient for one of its earliest big international grants: $50-million over five years to treat and fight AIDS as part of an unusual alliance with the pharmaceutical giant Merck & Company. The country has one of the highest AIDS rates in the world, and was selected, in part, because of the government’s political will to deal with the disease and its relatively strong health-care system, which is supported by its diamond wealth.
Now, four years into that commitment, officials of the Seattle foundation are using their experience in Botswana to help shape much larger grants, such as the $200-million that Gates pledged to fight AIDS in India last year. Among the lessons so far: Progress can be slow, particularly at the start, and money for medical facilities and personnel needs to be a high priority. “We learned a lot about what it takes to build the proper infrastructure early on,” says Helene Gayle, director of the Gates Foundation’s HIV/AIDS programs.
Disease Continues to Spread
Results in Botswana so far have been mixed.
Thanks in part to the Gates Foundation, the United Nations now hails the country as a bright spot in sub-Saharan Africa’s mortal struggle with the pandemic. Botswana is the continent’s first nation to offer free antiretroviral therapy, the drug regime that slows HIV/AIDS in an infected person.
The treatment program Gates helped create, known as Masa, or “dawn,” provides drugs to almost 10 percent of the 300,000 people in Botswana with the disease and enrolls 1,000 new patients a month. (In Africa as a whole, the World Health Organization estimates about 5 percent of those infected have access to the vital medicines.)
At the Princess Marina Hospital clinic here — Africa’s largest AIDS treatment center — some 10,000 people have received medications from the Gates and Merck partnership to treat what some in the country refer to only as “the scourge.” Yet AIDS patients at the clinic still fill the waiting room to capacity and line the prefabricated structure’s gray walls, with some of them lying on gurneys, too sick to stand.
The prevalence of AIDS in Botswana has remained about the same since Gates started giving money to the country, with 37 percent of Botswana’s adults infected. In addition, 78,000 children among the country’s 1.7 million citizens require care because they have lost their parents to the disease.
Tsetsele Fantan, who oversees the country’s AIDS project with Gates and Merck, says the numbers reflect the increase in patients who have joined treatment programs. “The prevalence rate isn’t going to go down because you are postponing death,” she says.
Health experts say the better measure of Gates’s influence in the fight against AIDS in Botswana would be to look at the number of new infections. But those statistics do not yet exist. The government says it is working now to collect them.
Government in Driver’s Seat
Gates-supported programs also have generated a fair amount of controversy.
While government officials say they have forged a level of trust with the foundation, they still worry that the involvement of such an influential and well-endowed organization in a national health crisis can subvert the government’s authority by supporting an organization with an agenda that differs from its own.
“It is important for us to make sure that we do not end up in a situation where we lose control,” says Patson Mazonde, director of health services at the Botswana Ministry of Health. “Government is in the driver’s seat, and government will always stay in the driver’s seat. Partners must fit into our national agenda.”
In 2000, Gates joined with Merck & Company, in Whitehouse Station, N.J., and the Botswana government to establish the African Comprehensive HIV/AIDS Partnerships. Gates and the drug company both pledged $50-million over five years to the effort, known as Achap, and Merck also donates two AIDS drugs in addition to its cash contribution.
Merck had originally approached the U.S. government, the United Nations, and private grant makers with the idea of starting an AIDS program in sub-Sahara Africa, where 70 percent of the world’s HIV-infected population live. However, Gates was the only institution that said it was willing to collaborate with a pharmaceutical company that had little experience in public health, says Linda M. Distlerath, Merck’s vice president of global health policy.
“We approached a number of different organizations, but at the end of the day, it was really only the Gates Foundation that expressed willingness,” she says. “It was probably taking a risk.”
Ms. Gayle of the Gates Foundation says the grant maker had confidence in Merck in part because Gates officials had worked previously with the company to distribute Mectizan, a drug that treats a disease that causes blindness. Moreover, after talking with Merck, Gates officials became convinced that the partnership could demonstrate to the world that a coordinated, national AIDS project in Africa was possible.
But friction between the government and its philanthropic partners, along with other factors, has impeded officials overseeing the Gates and Merck money from spending it as quickly as initially planned. Of the $100-million pledge, Achap still has $29-million uncommitted in its coffers.
In response, Gates and Merck have decided to extend their grants an extra year, to the end of 2006. The two grant makers have made no decision about whether to continue their support after that.
Procedural Restraints
While several factors contributed to the slow pace of spending, such as a lack of trained medical doctors and nurses in Botswana, the government’s bureaucracy also impeded its efforts, says Ms. Fantan, who took over Achap last year after helping Botswana’s largest diamond company create an AIDS program for its miners and other employees.
Although it wanted to move quickly because of the size of the health crisis, the nonprofit group felt constrained by government procedures, which, like most countries, require new programs or policies to be vetted and approved at several levels.
“We don’t want to lose our private-sector image of getting things done efficiently and effectively,” Ms. Fantan says. “But you have to understand, we have to do that through government machinery.”
Mr. Mazonde of the Health Ministry agrees that Achap wants to move faster than his government. “By the time that money is approved, Achap wants to be three miles away, and this was really a big problem,” he says.
He defends his country’s decision to move slower, saying the pace helps the government maintain its national priorities while working with outside players.
“Government must always look at what it’s giving in light of the bigger picture, because at the end of the day, our problems as a country are not only HIV/AIDS,” he says.
Other differences of opinion have also emerged. For example, the AIDS partnerships’ board, which includes the Gates Foundation’s Ms. Gayle, threw out a Ministry of Health plan to use Gates and Merck dollars to pay for incinerators to dispose of medical waste.
“The board is saying, We want to see the Achap money going to programs that will have the most impact on the epidemic,” Ms. Fantan says.
At least one charity official in Botswana, who spoke only on condition that he and his organization not be named for fear of losing a grant, says he would prefer Achap to work even more independently of the government. “I appreciate Achap’s work very much,” he says by e-mail. But “Achap having to work with NACA [the government’s National AIDS Coordinating Agency] only creates more bureaucracy, confusion, and ineffective meetings.”
He continues: “White elephants are being created” and the “victims are the people relying on their services.”
Focus on Prevention
To be sure, Botswana’s AIDS problem cannot be solved through quick fixes.
Ms. Fantan says that in a relatively short time the Gates Foundation has vastly improved the country’s capacity to fight AIDS. “We’ve played in every field of HIV, from mitigation to prevention to treatment to capacity building,” she says.
While the Masa drug-treatment program is the crown jewel of Botswana’s AIDS strategy, Ms. Fantan says prevention may play an equal, or even more valuable, role in winning the struggle against the disease.
Achap has paid for numerous prevention efforts, including a television program that educates public-school teachers about AIDS, billboards that promote condom use, and even an annual “pageant” to choose Ms. Stigma Free, an HIV/AIDS-infected woman who speaks publicly about the disease.
Using the Power of Music
In Otse, a village of 3,000 people about 18 miles outside Botswana’s capital, Gaborone, Achap’s support of AIDS education means communicating with young people in a language they will appreciate: music.
On one cool, dry afternoon, about a dozen girls at a local after-school center for youngsters whose parents have died from AIDS wag their fingers in unison at their “boyfriends,” a group of boys also in the program.
“If you really, really love me,” the girls sing in harmony about abstinence, “you come back in another five years.” The program’s co-director and songwriter, Gill Fonteyn, accompanies them on an electronic keyboard.
The organization, called Dula Sentle, which means “Live Well” in Botswana’s native language, Setswana, currently has about 70 participants and plans to increase that number to 250 by the end of the year, thanks in part to grants totaling $250,000 from Achap.
Mr. Fonteyn praises Gates’s involvement in Botswana, saying his charity would be hobbled without its support. But some other AIDS activists are more critical of the foundation.
Khalil Elouardighi, a spokesman for the AIDS Coalition to Unleash Power, or Act-Up, in Paris, says Gates should not be supporting Botswana’s treatment program because it relies on patented drugs. Despite the fact that Merck donates two antiretroviral drugs, and other pharmaceutical companies provide other medicines used against HIV/AIDS at a reduced cost, generic medicines would be cheaper in the long run and set a better precedent for the rest of Africa, he says.
According to Ms. Gayle of the Gates Foundation, Gates supports both generic and name-brand drugs in the fight against HIV/AIDS. But ultimately, she says, the government of Botswana has the final say over which type of medicines are used.
Aside from the highly charged debate surrounding patented drugs, Botswana also has been criticized for making HIV/AIDS tests a required part of medical examinations, a rule Gates supports. The new policy dictates that Batswana, as the citizens are called here, who receive medical aid from the national health-care system will be asked to take a test regardless of the purpose of their visit.
Botswana is the first country in Africa to establish such a requirement, and Gates money will help pay for additional test kits, among other things.
While civil libertarians argue that routine testing violates citizens’ privacy rights, Ms. Fantan defends the plan. “Not enough people in Botswana know their HIV status,” she says. So “routine testing was proposed by Achap, government bought into it, and now it’s government policy.”
Unclear Future
The biggest unanswered question at the moment is what will happen after the Gates money runs out.
Ms. Gayle would only say that “we don’t comment on future funding decisions.” Similarly, Merck has said it has not decided whether to provide new funds to the effort.
If Gates does not pledge additional support, Brad Ryder, an Achap spokesman, says the end result will not hurt Botswana in part because additional funds are now available.
For example, one source of potential funds, he says, is the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which did not exist when Achap started. (The Gates Foundation has pledged $150-million to the global fund for its worldwide efforts.) “We would expect our programs to either be absorbed by government or other development partners would pick up the slack,” he says.
But Gordon Jonathan Lewis, the Unicef representative in Botswana, says if the government doesn’t plan properly for the loss of Gates and Merck, the risks are considerable.
“If preparations are already under way to reduce the shock, then the risks can be considered important, yet manageable,” he says. “If they are not under way yet, then clearly the risk will need to be considered significant and dangerous, and the impact will be much more negative.”
However, Achap and government officials in Botswana say they are hopeful additional money will be forthcoming, especially now that the early kinks in the relationship with Gates and Merck have been worked out.
“The first few years were actually difficult years because we had to study each other,” says Mr. Mazonde of the Health Ministry. “We now know how to deal with partners who want to be on the front line, rather than just offering funds.”
Adds Ms. Fantan: “We have found our feet.”
