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“Test and treat”; a very exciting and welcome move for Botswana

On the 12th of May this year, Ministry of Health through its Permanent Secretary released a memorandum informing all the DHMTs of its decision to adopt the new World Health Organization (WHO) recommendation of treating all HIV infected individuals regardless of their CD4 count or clinical staging. This was to be effective from the 1st of June 2016.

Botswana is one of the countries in the world to be hard hit by HIV for the past three decades with the current national HIV prevalence standing at 18. 5% and the incidence rate at 1. 35 %. However, Botswana continues to be the pioneer in the world of HIV and has managed to put up a good fight against this epidemic and surpass the set targets. Botswana was bound to follow suit in keeping with international standards and WHO recommendations as it has set high standards in the whole wide world. Botswana was the first country in sub-Saharan Africa to provide free antiretroviral treatment to people with HIV, in 2002 through the MASA Program.

A study recently published in The Lancet HIV by a Motswana doctor Dr Tendani Gaolathe and others, revealed that Botswana is already close to reaching the 90-90-90 target for testing, treatment and viral suppression, and is ahead of the United States and most European countries in its efforts to improve treatment coverage. Of note is that this study was carried out with the old guidelines where treatment was initiated at CD4 count of less than 350.Now with WHO recommendation of treatment for all, which undoubtedly has good scientific back-up, Botswana is expected to shine even more. However like they always say all great changes are preceded by chaos.

This article is meant to inspire the debate and look at both sides of the newly implemented “Test and Treat” Policy.

PROs

Good treatment outcomes – The primary aim of ART is the prevention of the mortality and morbidity associated with chronic HIV infection at low cost of drug toxicity. It is a known fact that the earlier the treatment is started, the more improvement in the physical and psychological wellbeing of people living with HIV infection. It has all along mainly been about balancing the benefit with the economic implications of starting HAART early; but research has showed overwhelming benefits of starting every HIV positive on treatment, both economical and medical.

Prevention – ART is usually started for the health benefit of the individual, but in certain circumstances it may be beneficial to start ART to primarily reduce the risk of onward sexual transmission of HIV. Test and treat will act as both a PMTCT strategy and reduce vertical transmission (from mother to child) as well as reduction in the sexual transmission of HIV. For some patients (discordant couples, most at risk populations like commercial sex workers etc.) this may be the primary aim. A study carried out in UK revealed the size of the effect of ART on reducing the risk of sexual transmission of HIV to be estimated at greater than 95%. At a population level, test and treat will definitely reduce the rate of new HIV infections.

Economical – I cannot emphasize the economic benefits of test and treat any further. It will reduce the burden of treating opportunistic infections like TB, meningitis, recurrent pneumonias and others that are rampant in ART-naïve HIV sufferers. Estimates of the cost effectiveness of antiretroviral therapy have been assessed in studies in North America and Europe. Their findings have been consistent with an estimated incremental cost effectiveness ratio of about US$20,000 per quality adjusted life year for combination antiretroviral therapy compared to no therapy based on drug costs and treatment patterns in the USA and Europe. In short, “test and treat” is cost effective!

CONs

Cost – With its high HIV prevalence rate (the second highest in the world), the question on everyone’s lips is will Botswana afford to have such a large number of people on ARVs? And will the ARV treatment be sustainable over the next years?

Pill fatigue – One may argue that the earlier patients are started on treatment the sooner they will get tired of taking daily medications. With the previous guidelines of monitoring one’s CD4 count until it reaches 350 or they develop an opportunistic infection before starting on treatment, it might have helped with buying time and prolonging years of one living with HIV without treatment.

High defaulter rate – due to pill fatigue (and having started medications when physically and mentally fit), we might find ourselves in a situation where we have a lot of patients that have been initiated on treatment but not necessarily maintained on it. Thorough education and counseling to our people will be needed to ensure patients are really ready when they start HAART, and they understand that they do not need to become unwell to start or resume it.

Overburdened health care system – We will surely see an influx of patients populating IDCCs and crowding our already overburdened (public) health facilities. This is something that the government should be prepared for and have a stern plan in place in regards to the facility spaces, staffing, drug supplies etc.

Increased drug reactions – There are some drugs that cannot be started at high CD4 count levels like Nevirapine as the chances of severe drug reactions are high. This would be an issue if that drug has to be used on someone who is newly diagnosed of HIV and still has a very high CD count. However, with Botswana’s guidelines that have changed overtime, such drugs are no longer used as first line therapy and chances of them being used at initiation are very slim.

Increased drug toxicities – Some of the ARVS that we have in the market have documented long-term or cumulative side effects. The longer one uses them the more the side effects start being prevalent. For instance, AZT overtime causes changes in the body fat distribution, affects peripheral nerves and causes constant burning or pricking sensation under feet and discoloration of the nails. This is something that can potentially worsen the longer someone stays on that same treatment.

However, this is not much of an issue as overtime Botswana has moved from using such drugs as first line and opted to adopt newer drugs with less side-effect or toxicity profile. In the same memorandum, it was announced that the first line drug of choice shall be Dolutegravir, a drug that I first got into contact with in 2014, during my visit to UK. UK had long started using Dolutegravir as their first line drug as it has been shown to have very minimal side effects.

Despite all the challenges that may ensue with implementation of “test and treat” at the beginning, this is a move that we should all welcome with both hands as it surely harbors enormous benefits in the long run. Myopic complications should not distract us from looking at the bigger picture but rather help in making the best use of this policy.

For comments or questions please email HYPERLINK "mailto:agboima@yahoo.com" agboima@yahoo.com
 

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Opinions

Can we cure ourselves from the cancer of corruption?

28th October 2020
DCEC DIRECTOR: Tymon Katholo

Bokani Lisa Motsu

“One of the saddest lessons of history is this: If we’ve been bamboozled long enough, we tend to reject any evidence of the bamboozle. We’re no longer interested in finding out the truth. The bamboozle has captured us. It’s simply too painful to acknowledge, even to ourselves, that we’ve been taken. Once you give a charlatan power over you, you almost never get it back.” Carl Sagan

Corruption is a heavy price to pay. The clean ones pay and suffer at the mercy of people who cannot have enough. They always want to eat and eat so selfishly like a bunch of ugly masked shrews. I hope God forgives me for ridiculing his creatures, but that mammal is so greedy. But corruption is not the new kid on the block, because it has always been everywhere.

This of course begs the question, why that is so? The common answer was and still is – abuse and misuse of power by those in power and weak institutions, disempowered to control the leaders. In 1996, the then President of The World Bank, James D. Wolfensohn named the ‘C-Word’ for the first time during an annual meeting of the Bretton Woods Institutions. A global fight against corruption started. Transparency International began its work. Internal and external audits mushroomed; commissions of inquiry followed and ever convoluted public tender procedures have become a bureaucratic nightmare to the private sector, trying to fight red tape.

The result is sobering corruption today is worse than it was 25 years ago. There is no denying that strong institutions help, but how does it come that in the annual Transparency International Ranking the same group of countries tend to be on the top while another group of countries, many African among them, tend to be on the bottom? Before one jumps to simple and seductive conclusions let us step back a moment.

Wolfensohn called corruption a cancer that destroys economies like a cancer destroys a body. A cancer is, simplified, good cells in a body gone bad, taking control of more and more good cells until the entire body is contaminated and eventually dies. So, let us look at the good cells of society first: they are family ties, clan and tribe affiliation, group cohesion, loyalty, empathy, reciprocity.

Most ordinary people like the reader of these lines or myself would claim to share such values. Once we ordinary people must make decisions, these good cells kick in: why should I hire a Mrs. Unknown, if I can hire my niece whose strengths and weaknesses I know? If I hire the niece, she will owe me and support my objectives.

Why should I purchase office furniture from that unknown company if I know that my friend’s business has good quality stuff? If I buy from him, he will make an extra effort to deliver his best and provide quality after sales service? So, why go through a convoluted tender process with uncertain outcome? In the unlikely case my friend does not perform as expected, I have many informal means to make him deliver, rather than going through a lengthy legal proceeding?

This sounds like common sense and natural and our private lives do work mostly that way and mostly quite well.

The problem is scale. Scale of power, scale of potential gains, scale of temptations, scale of risk. And who among us could throw the first stone were we in positions of power and claim not to succumb to the temptations of scale? Like in a body, cancer cells start growing out of proportion.

So, before we call out for new leaders – experience shows they are rarely better than the old ones – we need to look at ourselves first. But how easy is that? If I were the niece who gets the job through nepotism, why should I be overly critical? If I got a big furniture contract from a friend, why should I spill the beans? What right do I have to assume that, if I were a president or a minister or a corporate chief procurement officer I would not be tempted?

This is where we need to learn. What is useful, quick, efficient, and effective within a family or within a clan or a small community can become counterproductive and costly and destructive at larger corporate or national scale. Our empathy with small scale reciprocity easily permeates into complacency and complicity with large scale corruption and into an acquiescence with weak institutions to control it.

Our institutions can only be as strong as we wish them to be.

I was probably around ten years old and have always been that keen enthusiastic child that also liked to sing the favourite line of, ‘the world will become a better place.’  I would literally stand in front of a mirror and use my mom’s torch as a mic and sing along Michael Jackson’s hit song, ‘We are the world.’

Despite my horrible voice, I still believed in the message.  Few years later, my annoyance towards the world’s corrupt system wonders whether I was just too naïve. Few years later and I am still in doubt so as to whether I should go on blabbing that same old boring line. ‘The world is going to be a better place.’ The question is, when?

The answer is – as always: now.

This is pessimistic if not fatalistic – I challenge Sagan’s outlook with a paraphrased adage of unknown origin: Some people can be bamboozled all of the time, all people can be bamboozled some of the time, but never will all people be bamboozled all of the time.

We, the people are the only ones who can heal society from the cancer of corruption. We need to understand the temptation of scale and address it. We need to stop seeing ourselves just a victim of a disease that sleeps in all of us. We need to give power to the institutions that we have put in place to control corruption: parliaments, separation of power, the press, the ballot box. And sometimes we need to say as a niece – no, I do not want that job as a favour, I want it because I have proven to be better than other contenders.

It is going to be a struggle, because it will mean sacrifices, but sacrifices that we have chosen, not those imposed on us.

Let us start today.

*Bokani Lisa Motsu is a student at University of Botswana

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Opinions

Accounting Officers are out of touch with reality

19th October 2020

Parliament, the second arm of State through its parliamentary committees are one of Botswana’s most powerful mechanisms to ensure that government is held accountable at all times. The Accounting Officers are mostly Permanent Secretaries across government Ministries and Chief Executive Officers, Director Generals, Managing Directors of parastatals, state owned enterprises and Civil Society.

So parliament plays its oversight authority via the legislators sitting on a parliamentary committee and Accounting Officers sitting in the hot chair.  When left with no proper checks and balances, the Executive is prone to abuse the arrangement and so systematic oversight of the executive is usually carried out by parliamentary committees.  They track the work of various government departments and ministries, and conduct scrutiny into important aspects of their policy, direction and administration.

It is not rocket science that effective oversight requires that committees be totally independent and able to set their own agendas and have the power to summon ministers and top civil servants to appear and answer questions. Naturally, Accounting Officers are the highest ranking officials in the government hierarchy apart from cabinet Ministers and as such wield much power and influence in the performance of government.  To illustrate further, government performance is largely owed to the strategic and policy direction of top technocrats in various Ministries.

It is disheartening to point out that the recent parliament committees — as has been the case all over the years — has laid bare the incompetency, inadequacy and ineptitude of people bestowed with great responsibilities in public offices. To say that they are ineffective and inefficient sounds as an understatement. Some appear useless and hopeless when it comes to running the government despite the huge responsibility they possess.

If we were uncertain about the degree at which the Accounting Officers are incompetent, the ongoing parliament committees provide a glaring answer.  It is not an exaggeration to say that ordinary people on the streets have been held ransom by these technocrats who enjoy their air conditioned offices and relish being chauffeured around in luxurious BX SUV’s while the rest of the citizenry continue to suffer. Because of such high life the Accounting Officers seem to have, with time, they have gotten out of touch with the people they are supposed to serve.

An example; when appearing before the recent Public Accounts Committee (PAC), Office of the President Permanent Secretary, Thuso Ramodimoosi, looked reluctant to admit misuse of public funds. Although it is clear funds were misused, he looked unbothered when committee members grilled him over the P80 million Orapa House building that has since morphed into a white elephant for close to 10 successive years. To him, it seems it did not matter much and PAC members were worried for nothing.

On a separate day, another Accounting officer, Director of Public Service Management (DPSM), Naledi Mosalakatane, was not shy to reveal to PAC upon cross-examination that there exist more than 6 000 vacancies in government. Whatever reasons she gave as an excuse, they were not convincing and the committee looked sceptical too. She was faltering and seemed not to have a sense of urgency over the matter no matter how critical it is to the populace.

Botswana’s unemployment rate hoovers around 18 percent in a country where majority of the population is the youth, and the most affected by unemployment. It is still unclear why DPSM could underplay such a critical matter that may threaten the peace and stability of the country.
Accounting Officers clearly appear out of touch with the reality out there – if the PAC examinations are anything to go by.

Ideally the DPSM Director could be dropping the vacancy post digits while sourcing funds and setting timelines for the spaces to be filled as a matter of urgency so that the citizens get employed to feed their families and get out of unemployment and poverty ravaging the country.
The country should thank parliamentary committees such as PAC to expose these abnormalities and the behaviour of our leaders when in public office. How can a full Accounting Officer downplay the magnitude of the landless problem in Botswana and fail to come with direct solutions tailor made to provide Batswana with the land they desperately need?

Land is a life and death matter for some citizens, as we would know.

When Bonolo Khumotaka, the Accounting Officer in the Ministry of Land Management, Water and Sanitation Services, whom as a top official probably with a lucrative pay too appears to be lacking sense of urgency as she is failing on her key mandate of working around the clock to award the citizens with land especially those who need it most like the marginalised.  If government purports they need P94 billion to service land to address the land crisis what is plan B for government? Are we going to accept it the way it is?

Government should wake up from its slumber and intervene to avoid the 30 years unnecessary waiting period in State land and 13 years in Tribal land.  Accounting Officers are custodians of government policy, they should ensure it is effective and serve its purpose. What we have been doing over the years, has proved that it is not effective, and clearly there is a need for change of direction.

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Is it possible to make people part of your business resilience planning after the State of Public Emergency?

12th October 2020

THABO MAJOLA

His Excellency Dr Mokgweetsi EK Masisi, the President of the Republic of Botswana found it appropriate to invoke Section 17 (1) of the Constitution of the Republic of Botswana, using the powers vested in him to declare a State of Public Emergency starting from the 2nd April 2020 at midnight.

The constitutional provision under Section 17 (2b) only provided that such a declaration could be up to a maximum of 21 days. His Excellency further invoked Section 93 (1) to convene an extra- ordinary meeting of Parliament to have the opportunity to consult members of parliament on measures that have been put in place to address the spread and transmission of the virus. At this meeting Members of Parliament passed a resolution on the legal instruments and regulations governing the period of the state of emergency, and extended its duration by six (6) months.

The passing of the State of Emergency is considered as a very crucial step in fighting the near apocalyptic potential of the Novel COVID-19 virus. One of the interesting initiatives that was developed and extended to the business community was a 3-month wage subsidy that came with a condition that no businesses would retrench for the duration of the State of Public Emergency. This has potentially saved many people’s jobs as most companies would have been extremely quick to reduce expenses by downsizing. Self-preservation as some would call it.

Most organisations would have tried to reduce costs by letting go of people, retreated and tried their best to live long enough to fight another day. In my view there is silver lining that we need to look at and consider. The fact that organisations are not allowed to retrench has forced certain companies to look at the people with a long-term view.

Most leaders have probably had to wonder how they are going to ensure that their people are resilient. Do they have team members who innovate and add value to the organisation during these testing times? Do they even have resilient people or are they just waiting for the inevitable end? Can they really train people and make them resilient? How can your team members be part of your recovery plan? What can they do to avoid losing the capabilities they need to operate meaningfully for the duration of the State of Public Emergency and beyond?

The above questions have forced companies to reimagine the future of work. The truth is that no organisation can operate to its full potential without resilient people. In the normal business cycle, new teams come on board; new business streams open, operations or production sites launch or close; new markets develop, and technology is introduced. All of this provides fresh opportunities – and risks.

The best analogy I have seen of people-focused resilience planning reframes employees as your organisation’s immune system, ready and prepared to anticipate risks and ensure they can tackle challenges, fend off illness and bounce back more quickly.  So, how do you supercharge your organizational immune system to become resilient?

COVID-19 has helped many organisations realize they were not as prepared as they believed themselves to be. Now is the time to take stock and reset for the future. All the strategies and plans prior to COVID-19 arriving in Botswana need to be thrown out of the window and you need to develop a new plan today. There is no room for tweaking or reframing. Botswana has been disrupted and we need to accept and embrace the change. What we initially anticipated as a disease that would take a short term is turning out to be something we are going to have to live with for a much longer time. It is going to be a marathon and therefore businesses need to have a plan to complete this marathon.

Start planning. Planning for change can help reduce employee stress, anxiety, and overall fear, boosting the confidence of staff and stakeholders. Think about conducting and then regularly refreshing a strategic business impact analysis, look at your employee engagement scores, dig into your customer metrics and explore the way people work alongside your behaviours and culture. This research will help to identify what you really want to protect, the risks that you need to plan for and what you need to survive during disruption. Don’t forget to ask your team members for their input. In many cases they are closest to critical business areas and already have ideas to make processes and systems more robust.

Revisit your organisational purpose. Purpose, values and principles are powerful tools. By putting your organisation’s purpose and values front and center, you provide clear decision-making guidelines for yourself and your organisation. There are very tough and interesting decisions to make which have to be made fast; so having guiding principles on which the business believes in will help and assist all decision makers with sanity checking the choices that are in front of them. One noticeable characteristic of companies that adapt well during change is that they have a strong sense of identity. Leaders and employees have a shared sense of purpose and a common performance culture; they know what the company stands for beyond shareholder value and how to get things done right.

Revisit your purpose and values. Understand if they have been internalised and are proving useful. If so, find ways to increase their use. If not, adapt them as necessities, to help inspire and guide people while immunizing yourself against future disruption. Design your employee experience. The most resilient, adaptive and high performing companies are made up of people who know each other, like each other, and support each other.

Adaptability requires us to teach other, speak up and discuss problems, and have a collective sense of belonging. Listening to your team members is a powerful and disruptive thing to do. It has the potential to transform the way you manage your organisation. Enlisting employees to help shape employee experience, motivates better performance, increases employee retention and helps you spot issues and risks sooner. More importantly, it gives employees a voice so you can get active and constructive suggestions to make your business more robust by adopting an inclusive approach.

Leaders need to show they care. If you want to build resilience, you must build on a basis of trust. And this means leaders should listen, care, and respond. It’s time to build the entire business model around trust and empathy. Many of the employees will be working under extreme pressure due to the looming question around what will happen when companies have to retrench. As a leader of a company transparency and open communication are the most critical aspects that need to be illustrated.

Take your team member into confidence because if you do have to go through the dreaded excise of retrenchment you have to remember that those people the company retains will judge you based on the process you follow. If you illustrate that the business or organization has no regard for loyalty and commitment, they will never commit to the long-term plans of the organisation which will leave you worse off in the end. Its an absolutely delicate balance but it must all be done in good faith. Hopefully, your organization will avoid this!

This is the best time to revisit your identify and train your people to encourage qualities that build strong, empathetic leadership; self-awareness and control, communication, kindness and psychological safety.  Resilience is the glue that binds functional silos and integrates partners, improves communications, helps you prepare, listen and understand. Most importantly, people-focused resilience helps individuals and teams to think collectively and with empathy – helping you respond and recover faster.

Article written by Thabo Majola, a brand communications expert with a wealth of experience in the field and is Managing Director of Incepta Communications.

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