Regional Research–Policy Partnerships for Health Equity and Inclusive Development: Reflections on Opportunities and Challenges from a Southern African Perspective

This article critically reflects on the experience and lessons from a health-focused social policy research project (PRARI) involving a partnership spanning multiple countries across southern Africa and Europe. It asks what factors condition the efficacy of the partnership–policy nexus. The PRARI-SADC partnership case study used participatory action research (PAR) to create a regional indicators-based monitoring ‘toolkit’ of pro‑poor health policy and change for the Southern African Development Community (SADC). The article addresses the partnership drivers, features, methodological context, and process of the project, and the wider implications for constructing partnerships for social change impact. Lessons drawn from this case study underscore the importance of PAR-inspired partnership structures and working methods while querying assumptions that the relationship between PAR and policy change is ‘seamless’. We argue that greater focus is needed on the wider institutional context conditioning the work of partnerships when considering the efficacy of the partnership–policy nexus

Estimated HIV Trends and Program Effects in Botswana

Background: This study uses surveillance, survey and program data to estimate past trends and current levels of HIV in Botswana and the effects of treatment and prevention programs. Methods/Principal Findings: Data from sentinel surveillance at antenatal clinics and a national population survey were used to estimate the trend of adult HIV prevalence from 1980 to 2007. Using the prevalence trend we estimated the number of new adult infections, the transmission from mothers to children, the need for treatment and the effects of antiretroviral therapy (ART) and adult and child deaths. Prevalence has declined slowly in urban areas since 2000 and has remained stable in rural areas. National prevalence is estimated at 26 % (25–27%) in 2007. About 330,000 (318,000–335,000) people are infected with HIV including 20,000 children. The number of new adult infections has been stable for several years at about 20,000 annually (12,000–26,000). The number of new child infections has declined from 4600 in 1999 to about 890 (810–980) today due to nearly complete coverage of an effective program to prevent mother-to-child transmission (PMTCT). The annual number of adult deaths has declined from a peak of over 15,500 in 2003 to under 7400 (5000–11,000) today due to coverage of ART that reaches over 80 % in need. The need for ART will increase by 60 % by 2016. Conclusions: Botswana’s PMTCT and treatment programs have achieved significant results in preventing new child infections and deaths among adults and children. The number of new adult infections continues at a high level. More effective prevention efforts are urgently needed

The cost and impact of male circumcision on HIV/AIDS in Botswana

The HIV/AIDS epidemic continues to be a major issue facing Botswana, with overall adult HIV prevalence estimated to be 25.7 percent in 2007. This paper estimates the cost and impact of the draft Ministry of Health male circumcision strategy using the UNAIDS/WHO Decision-Makers' Programme Planning Tool (DMPPT). Demographic data and HIV prevalence estimates from the recent National AIDS Coordinating Agency estimations are used as input to the DMPPT to estimate the impact of scaling-up male circumcision on the HIV/AIDS epidemic. These data are supplemented by programmatic information from the draft Botswana National Strategy for Safe Male Circumcision, including information on unit cost and program goals. Alternative scenarios were developed in consultation with stakeholders. Results suggest that scaling-up adult and neonatal circumcision to reach 80% coverage by 2012 would result in averting almost 70,000 new HIV infections through 2025, at a total net cost of US$47 million across that same period. This results in an average cost per HIV infection averted of US$689. Changing the target year to 2015 and the scale-up pattern to a linear pattern results in a more evenly-distributed number of MCs required, and averts approximately 60,000 new HIV infections through 2025. Other scenarios explored include the effect of risk compensation and the impact of increasing coverage of general prevention interventions. Scaling-up safe male circumcision has the potential to reduce the impact of HIV/AIDS in Botswana significantly; program design elements such as feasible patterns of scale-up and inclusion of counselling are important in evaluating the overall success of the program

Measuring Regional Policy Change and Pro-Poor Health Policy Success: A PRARI Toolkit of Indicators for the Southern African Development Community (SADC)

PRARI is a social development research project that looks at world-regional social governance, politics, and policy. PRARI brings together an international team of researchers studying the scope for enhancing the effectiveness of the contributions of Southern regional organisations to poverty reduction. It receives funding from the ESRC

Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysis

Background Short-term mortality rates among patients with HIV receiving antiretroviral therapy (ART) in sub- Saharan Africa are higher than those recorded in high-income countries, but systematic long-term comparisons have not been made because of the scarcity of available data. We analysed the eff ect of the implementation of Botswana’s national ART programme, known as Masa, from 2002 to 2010. Methods The Masa programme started on Jan 21, 2002. Patients who were eligible for ART according to national guidelines had their data collected prospectively through a clinical information system developed by the Botswana Ministry of Health. A dataset of all available electronic records for adults (≥18 years) who had enrolled by April 30, 2010, was extracted and sent to the study team. All data were anonymised before analysis. The primary outcome was mortality. To assess the eff ect of loss to follow-up, we did a series of sensitivity analyses assuming varying proportions of the population lost to follow-up to be dead. Findings We analysed the records of 126 263 patients, of whom 102 713 had documented initiation of ART. Median follow-up time was 35 months (IQR 14–56), with a median of eight follow-up visits (4–14). 15 270 patients were deemed lost to follow-up by the end of the study. 63% (78 866) of the study population were women; median age at baseline was 34 years for women (IQR 29–41) and 38 years for men (33–45). 10 230 (8%) deaths were documented during the 9 years of the study. Mortality was highest during the fi rst 3 months after treatment initiation at 12·8 deaths per 100 person-years (95% CI 12·4–13·2), but decreased to 1·16 deaths per 100 person-years (1·12–1·2) in the second year of treatment, and to 0·15 deaths per 100 person-years (0·09–0·25) over the next 7 years of follow-up. In each calendar year after the start of the Masa programme in 2002, average CD4 cell counts at enrolment increased (from 101 cells/μL [IQR 44–156] in 2002, to 191 cells/μL [115–239] in 2010). In each year, the proportion of the total enrolled population who died in that year decreased, from 63% (88 of 140) in 2002, to 0·8% (13 of 1599) in 2010. A sensitivity analysis assuming that 60% of the population lost to follow-up had died gave 3000 additional deaths, increasing overall mortality from 8% to 11–13%. Interpretation The Botswana national HIV/AIDS treatment programme reduced mortality among adults with HIV to levels much the same as in other low-income or middle-income countries

Monitoring Pro-Poor Health-Policy Success in the SADC Region

Policy Conclusions Monitoring pro-poor health policies at the regional level can support both the countries and the regional bodies themselves by identifying gaps in addressing poverty and health, strengthening the link between regions and member states, holding actors accountable to their commitments and identifying better mechanisms for data sharing, monitoring and evaluation of activities. In the area of health, the Southern African Development Community (SADC) has conducted important work in understanding how poor health and poverty coincide, are mutually reinforcing, and socially-structured by gender, age, class, ethnicity and location, demonstrated by the key health policy documents that have been facilitated by the secretariat. Yet the time lapse between the formulation of guidelines and policies and their implementation has at times been uneven. The “Poverty Reduction and Regional Integration” (PRARI) project seeks to support the development of a monitoring system to measure the contribution of regional governance in the development of pro-poor health policies in collaboration with key stakeholders in the region. This system will build on existing efforts in the region and focus on policy areas such as the social determinants of health; HIV/AIDS, TB and malaria; non-communicable diseases; maternal and child health; human resources for health; pharmaceuticals; among others. Global developments such as those related to the incoming Sustainable Development Goals (SDGs) will also be considered. In order for this indicator-based monitoring system to be effective and to have an impact, it requires ‘regional ownership’, active participation of national and regional experts throughout the process of indicator development, implementation and evaluation, and evidence that it will be addressing health priorities for the region. For this, the institutional leadership from the SADC secretariat and the support from its Member States that are the main beneficiaries of the process is crucial. The strength of a regional body lies in the relevance that member-states see in it addressing their needs and managing the disparities between regional and national priorities. Monitoring existing processes would demonstrate the value-added by such integration efforts

Monitoreo del éxito de las políticas de salud en favor de los pobres en la región de la SADC

El monitoreo de las políticas de salud en favor de los pobres a nivel regional puede apoyar tanto a los países como a los organismos regionales identificando brechas en cuanto al tratamiento de la pobreza y la salud, lo cual fortalece el vínculo entre las regiones y los estados miembro; hace que los actores se responsabilicen por sus compromisos; e identifica mecanismos más eficaces para el intercambio de datos, el monitoreo y la evaluación de actividades. En el área de la salud, la Comunidad de Desarrollo de África Austral (SADC) ha llevado a cabo trabajos importantes para comprender cómo la mala salud y la pobreza coinciden, se agravan mutuamente y están estructuradas socialmente por género, edad, clase, etnia y ubicación, lo cual está demostrado por los documentos clave de políticas de salud que la Secretaría ha facilitado. Sin embargo, los plazos entre la formulación de las pautas y las políticas y su implementación han sido irregulares. El proyecto “Reducción de la pobreza e integración regional” (PRARI/REPIR) busca apoyar el desarrollo de un sistema de monitoreo para medir la contribución de la gobernanza regional en el desarrollo de políticas de salud en favor de los pobreza en colaboración con las partes interesadas clave de la región. Este sistema se creará sobre la base de los esfuerzos existentes en la región y se centrará en áreas de la política como los determinantes sociales de la salud; el VIH/SIDA, la tuberculosis y la malaria; las enfermedades no contagiosas; la salud maternal e infantil; los recursos humanos para la salud; los medicamentos; entre otras. Los desarrollos globales, como los relacionados con los próximos Objetivos de Desarrollo Sostenible (ODS) también se tendrán en cuenta. Para que este sistema de monitoreo basado en indicadores sea eficaz y tenga un impacto, se requieren un “compromiso y responsabilidad regional”, una participación activa de los expertos nacionales y regionales a través del proceso de desarrollo de indicadores, una implementación y evaluación de este y pruebas de evidencia que abordará las prioridades de salud de la región. Para esto, son esenciales el liderazgo institucional de la Secretaría de la SADC y el apoyo de los estados miembro que son los beneficiarios principales del proceso. La fuerza de un organismo regional yace en la relevancia que los estados miembros ven en el abordaje de sus necesidades y en la gestión de las disparidades entre las prioridades regionales y las nacionales. El monitoreo de los procesos existentes demostraría el valor agregado de dichos esfuerzos de integración

HIV prevalence among women attending antenatal clinics, 1991–2007.

<p>Data from urban clinics (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0003729#pone-0003729-g001" target="_blank">Figure 1a</a>) and rural clinics (<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0003729#pone-0003729-g001" target="_blank">Figure 1b</a>) are shown in the gray lines. The smooth curve produced by EPP is shown in the dark dashed line for each region.</p

Annual number of new adult HIV infections and AIDS deaths, 1980–2007.

<p>Annual number of new adult HIV infections and AIDS deaths, 1980–2007.</p

Key HIV/AIDS Indicators and Plausibility Bounds, 2007

<p>Key HIV/AIDS Indicators and Plausibility Bounds, 2007</p