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Making up for lost time

BMJ 2005; 331 doi: (Published 29 September 2005) Cite this as: BMJ 2005;331:719
  1. Pat Sidley
  1. Johannesburg

    In Botswana—land of Precious Ramotswe and the No 1 Ladies' Detective Agency—the health services are fighting one of the highest rates of HIV infection in Africa

    “We are so grateful. These days we are burying old women again,” a village chief said with noticeable relief to Botswana's minister of health, Sheila Tlou. It was anecdotal evidence of an improvement in the country's mortality figures, which have been dominated in recent years by the AIDS epidemic.

    Before Botswana introduced an antiretroviral treatment programme for its large population of people with HIV or AIDS, the chief was burying young people.

    A feature of the epidemic in the region is the high proportion of young people who die, filling cemeteries and leaving their children to be cared for by their grandparents.

    Dr Tlou had been responding to a question put to her about the effect of the treatment programme. Despite the success claimed for the programme, Botswana continues to have proportionally one of the largest epidemics in the world, with about 38% of adults infected.

    Embedded Image

    Botswana's health minister, Sheila Tlou, says: “HIV sprang up from nowhere.” Now the government is tackling the epidemic with antiretroviral drugs and health education, exemplified by the poster above


    The government's response to the epidemic has been hailed internationally as exemplary—as has its system of democratic government, its lack of conflict, and general levels of wealth, making Botswana one of the better off countries in Africa.

    A positive image of the country has also been promoted by the hugely successful series of novels by the Scottish author Alexander McCall Smith about Precious Ramotswe, a woman who sets up a women's detective agency in the country's capital, Gabarone. The books have become best sellers in the United States and Europe and give a picture of a prosperous and peaceful country.

    Botswana has also been successful in getting funds from the Bill and Melinda Gates Foundation, the Harvard School of Public Health, and Merck, one of the drug companies making antiretrovirals. The country now has a large programme supplying antiretrovirals where they are needed, as well as continuing to work on prevention.

    But the response to control the spread of the disease came late. “HIV sprang up from nowhere,” said Dr Tlou, reflecting on the fact that when few cases had been reported much earlier in the epidemic “you were working in a situation where nobody was doing anything about it.”

    “It takes good governance and political will to control it,” she said, but added that at that point Botswana, like most other countries confronting the epidemic in its early stages, was in a state of denial.

    At that time Dr Tlou was working in a non-governmental organisation, the Society for Women with AIDS in Africa, and her voice was to be heard urging her government to do more about the disease.

    Now about 50 000 people are receiving free antiretroviral treatment, and it is planned to increase this number by another 110 000. An aggressive programme encouraging people to get tested is also in place.

    One of the many problems in starting an antiretroviral treatment programme was the lack of professionals able to deliver it. Thus Botswana initially found itself with waiting lists for treatment of up to four months at its hospitals, said Dr Tlou.

    With a large area and small population, Botswana also faced the problem of access to services in rural areas. To overcome this problem the government opted to pay private doctors to test for infection, carry out the laboratory work, and supply antiretrovirals to people who were not able to access health care in the public sector.

    An advantage, said Dr Tlou, is a good road network and high quality hospitals and clinics. Botswana's infrastructure, unlike that of many of its neighbours, has not been damaged by war or internal conflict. Botswana always had better figures than its neighbours in such areas as infant and child mortality; that remains the case, although the figures have increased in line with the growth of the AIDS epidemic.

    However, given that the prevalence of HIV in Botswana is similar to that in neighbouring South Africa, with its ambivalent approach to treatment, and Zimbabwe, seen by some as a pariah state and currently under sanctions from many countries, what can be said to be the result of its good governance and interventionalist strategy?

    “It is as though we are being punished for being exemplary”

    “Teenage pregnancies are going down,” Dr Tlou answered. There are signs too, that among people aged between 15 and 49—those likely to become parents—that the epidemic has stabilised, she said.

    It is too early to provide sound statistical evidence that the antiretroviral treatment programme has led to changes in death rates, said Dr Tlou. But anecdotal evidence tends to bear out a drop in mortality. It is at this point that she quotes the chief in a small village relieved that he is no longer burying only young women. “Mortality has gone down. There is a real decrease,” she added.

    But the “exemplary” nature of the way Botswana operates has created its own problems. “It is as though we are being punished for being exemplary,” said Dr Tlou about the fact that other funding has now dried up, as donors see that Botswana is not classed as one of the poorest nations. Thus health problems other than HIV and AIDS—such as non-communicable diseases—are harder to address.

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