Botswana’s heavy spending on HIV/AIDS has failed to translate consistently into better health outcomes across the country. This is the finding by the World Bank which raises questions about resource allocation, programme management and the efficiency of the country’s HIV response by Botswana.
The assessment is contained in the World Bank’s Botswana Health Public Expenditure Review. It warns that Botswana’s health system is suffering from low efficiency, with the HIV/AIDS programme providing some of the clearest evidence of weaknesses in the way public resources are converted into health outcomes. According to the report, there is a weak correlation between HIV expenditure at district level and actual results, including HIV awareness, condom use, the proportion of people receiving treatment and HIV prevalence. The World Bank says the findings raise the possibility of inefficiencies and disparities in the implementation of HIV programmes across districts, despite Botswana’s substantial investment in the fight against HIV/AIDS.
‘With higher investment in HIV programs, one would expect greater HIV awareness, more people on treatment, and lower HIV prevalence. However, this link does not seem to hold true across all districts in Botswana,’ the report states. The finding is striking because Botswana has long invested heavily in combating HIV/AIDS making the disconnect between expenditure and outcomes a major concern for policymakers. The World Bank points to Kweneng and Greater Gaborone as examples.
The two districts recorded some of the highest HIV expenditure, yet their performance on key indicators was far from exceptional. The report says they recorded average levels of HIV awareness and treatment coverage, while condom use was among the lowest reported.
The report identifies several possible explanations, including poor resource distribution, differences in programme management effectiveness, varying local health determinants and inconsistencies in data quality. The World Bank also found that Botswana spends more on HIV/AIDS programmes than its regional peers, suggesting significant room to improve efficiency. Evidence from the National AIDS Spending Assessment (NASA), according to the report, shows that Botswana’s spending on key inputs per patient receiving antiretroviral treatment is higher than in countries including Zambia, Mozambique and South Africa. This means Botswana is spending more to achieve outcomes that should warrant closer scrutiny of procurement, treatment protocols and the design of its HIV services. The World Bank recommends examining procurement arrangements for antiretroviral medicines, including the possibility of pooled procurement, reviewing patient testing guidelines and reassessing the HIV/AIDS Basic Services Package.
The report also warns that Botswana’s HIV response remains vulnerable because of its dependence on external funding.In 2019/20, external sources accounted for 37 percent of total HIV/AIDS expenditure, compared with 61 percent from domestic public sources.The United States President’s Emergency Plan for AIDS Relief (PEPFAR) alone accounted for 30 percent, 32 percent and 33 percent of total HIV/AIDS financing in the 2017/18, 2018/19 and 2019/20 financial years respectively.
The World Bank calculates that replacing PEPFAR funding would require Botswana to increase its own expenditure by about 50 thebe for every P1 currently spent on HIV/AIDS. With Botswana facing slower economic growth, fiscal pressures and declining mineral revenues, the report warns that such a burden could prove difficult to sustain.
The World Bank further questions the government’s ability to translate approved HIV/AIDS budgets into actual funding. On average, only 68 percent of the approved HIV/AIDS budget under the Ministry of Health was released during the period reviewed. This compares sharply with the National AIDS and Health Promotion Agency (NAHPA), which received about 96 percent of its allocated funding over the same period. The discrepancy, according to the World Bank, creates serious challenges for effective budget execution and ultimately service delivery. Ironically, despite weak releases, overall HIV/AIDS budget execution averaged 93 percent during the period under review.
The report says NAHPA’s lower execution rate was partly linked to its practice of sub-warranting funds to other implementing organisations, potentially creating inefficiencies where additional funding depends on performance reports.