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Botswana's efforts offer cautionary tale on HIV funding

Speed in spending aid has fallen short of expectations

PRETORIA -- The Commission for Africa, a group brought together by Prime Minister Tony Blair of Britain, has called for massive investment in the world's poorest continent, including the doubling of international aid to $50 billion annually. But before the leaders of the world's richest nations tackle the issue next month at a Scotland summit, leaders of a widely praised AIDS program warn that spending huge infusions of cash comes with challenges.

Some AIDS specialists say the program in Botswana serves as a cautionary tale about expectations from new aid.

In 2000, the Bill & Melinda Gates Foundation and the pharmaceutical giant Merck & Co. launched a five-year, $100 million program to prevent the spread of HIV and treat AIDS patients in the southern African nation.

By the end of 2004, the program had spent just $33.5 million out of $90 million earmarked for programs -- 37 percent of the total. The other $10 million goes toward operational costs.

Now Gates, Merck, and Botswana officials believe it could take eight or nine years to spend the $100 million.

''If people think they can throw $100 million at a problem and expect everything to work perfectly and quickly, well, it won't happen with AIDS," Jeff F. Ramsey, spokesman for Botswana's president, Festus Mogae, said in a telephone interview last week from Gaborone, the capital.

''There are all kinds of organizational bottlenecks, training people, and retraining them,'' he said. ''It takes time. People can learn from our mistakes and our successes."

Yet compared with many other HIV programs, the effort in Botswana looks speedy. Many programs funded by both the World Bank and the Global Fund to Fight AIDS, Tuberculosis, and Malaria have spent far lower percentages of their money than Botswana's program has.

In Nigeria, less than 10 percent of a $100 million World Bank AIDS grant awarded four years ago has been spent, largely because of foot-dragging inside the Ministry of Health.

The Scotland meeting, led by Blair, will focus on several initiatives for Africa, not just HIV programs, and on global warming. The Commission for Africa recommends billions of dollars in additional aid for Africa's infrastructure, health, education, and debt relief. But the fight against AIDS remains a centerpiece because of its corrosive impact across all sectors of society.

For the Gates Foundation and Merck, the selection of Botswana to try to establish a state-of-the-art AIDS program seemed a natural choice. The country has just 1.7 million people, making it easier to manage than most African countries.

The need was huge; Botswana and Swaziland have the world's highest HIV prevalence rates, about 35 percent among those between 15 and 49 years old. And it had a political leadership strongly committed to the fight.

In January 2001, project leader Donald de Korte launched the program. He had no office or staff, but had orders to spend whatever it took to start getting people on antiretroviral medicines and initiate prevention programs. Harvard University joined the project, helping train health workers and lab technicians. Many in the Botswana government were extraordinarily happy for all the help.

Still, the initiative -- the African Comprehensive HIV/AIDS Partnerships -- started sluggishly.

De Korte and his staff found there were not enough health workers, laboratories, or rooms in hospitals and clinics. One of their most laborious tasks was to train hundreds of people to handle a wide array of tasks, from managing programs to collecting data and overseeing patients on antiretroviral drugs.

The Ministry of Health, while stronger than most of its sister ministries across Africa, was woefully short of personnel. Many had left for higher-paying jobs in Europe and the United States; some had died of AIDS. It took 18 months to put the first 500 people on antiretroviral treatment.

One example of the ministry's slow handling of funds was a project to promote condom use. Three years ago, the initiative committed $6.8 million for that purpose; so far, the ministry has spent $1.1 million.

''The condoms proposal, on paper, made a lot of sense," said Brad Ryder, ACHAP spokesman. ''But the ministry needs more staff."

But in the past year, the program has grown exponentially, largely because the country now has enough people and the proper structures in place. Now, more than 36,000 people in Botswana receive free treatment, and AIDS specialists cite Botswana, along with Uganda, as running the continent's most extensive treatment networks.

The specialists say the lesson from both countries is that it takes time to set up a treatment program, but once the proper system is in place, the effort can take off. So far this year, Botswana has added 2,000 patients a month, in part because of President Mogae's push in early 2004 to routinely test people for HIV when they went to a hospital.

''You need a critical mass of resources to go forward," said Linda M. Distlerath, Merck's vice president of global health policy, in a telephone interview from Washington, D.C.

''It allows people to think more freely, to figure out the right way to do things. . . . We also learned there is a buildup time in planning and implementation,'' she said. ''To do it right, and long-term, you have to do it carefully."

John Donnelly can be reached at

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