USAID ASSIST Project Country Report FY17

Cooperative Agreement Number: AID-OAA-A-12-00101

Performance Period: October 1, 2016 – September 30, 2017

OCTOBER 2017

This annual country report was prepared by University Research Co., LLC for review by the United States Agency for International Development (USAID). The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project is made possible by the generous support of the American people through USAID.

USAID ASSIST Project

Applying Science to Strengthen and Improve Systems Botswana Country Report FY17

Cooperative Agreement Number AID-OAA-A-12-00101 Performance Period: October 1, 2016 - September 30, 2017

OCTOBER 2017

DISCLAIMER This country report was authored by University Research Co., LLC (URC). The views expressed do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Acknowledgements This country report was prepared by University Research Co., LLC (URC) for review by the United States Agency for International Development (USAID) under the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project, which is funded by the American people through USAID’s Bureau for Global Health, Office of Health Systems. The project is managed by URC under the terms of Cooperative Agreement Number AID-OAA-A-12-00101. URC's global partners for USAID ASSIST include: EnCompass LLC; FHI 360; Harvard T. H. Chan School of Public Health; HEALTHQUAL International; Initiatives Inc.; Institute for Healthcare Improvement; Johns Hopkins Center for Communication Programs; and WI-HER, LLC. For more information on the work of the USAID ASSIST Project, please visit www.usaidassist.org or write [email protected]. Recommended citation USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. 2017. Botswana Country Report FY17. Published by the USAID ASSIST Project. Chevy Chase, MD: University Research Co., LLC (URC).

Table of Contents List of Figures and Tables ...... i Abbreviations ...... ii 1 INTRODUCTION ...... 1 2 PROGRAM OVERVIEW ...... 2 3 KEY ACTIVITIES, ACCOMPLISHMENTS, AND RESULTS ...... 2 Activity 1. Strengthen the community health system response to HIV/AIDS to contribute to epidemic control in Botswana ...... 2 4 SUSTAINABILITY AND INSTITUTIONALIZATION ...... 15 5 KNOWLEDGE MANAGEMENT PRODUCTS AND ACTIVITIES ...... 15 6 GENDER INTEGRATION ...... 16 ANNEX 1: ASSIST-SUPPORTED COMMUNITY IMPROVEMENT TEAMS IN BOTSWANA ...... 17 ANNEX 2: OVERVIEW OF ASSIST BOTSWANA IMPROVEMENT AIMS ...... 18 ANNEX 3: TECHNICAL ASSISTANCE TO PROVIDER-BASED QUALITY IMPROVEMENT: BOCAIP 19 ANNEX 4: SUPPORT TO COMMUNITY IMPROVEMENT TEAMS IN BOTSWANA ...... 21

List of Figures and Tables Figure 1. ASSIST’s approach in Botswana to institutionalise community-led improvement and improved coordination of HIV care and health services at the community level ...... 3 Figure 2. Results from Boikanyo Community improvement team in Block 9, , demonstrating an innovative community/facility collaboration to return ‘lost HIV patients’ (Jan-Apr 2017) ...... 6 Figure 3. Replication, adaptation and spread of care innovations within and across districts – to clarify care status of ‘lost HIV patients’ and return them to the cascade (Oct 2016 - Aug 2017) ...... 7 Figure 4. Results from the BOCAIP quality improvement team efforts to optimise HIV linkage performance through clarified, streamlined and intensified client follow up (Jan - July 2017) ...... 8 Figure 5. Refocused strategic approach to district partner coordination around HIV and related service delivery, as illustrated by Greater Gaborone TAC meeting agenda (June-Aug 2017) ...... 11

Table 1. Priority areas for ASSIST technical assistance to improve patient-centred HIV care and support epidemic control in Botswana ...... 4 Table 2. Overview of ASSIST-supported communities representing urban, peri-urban, rural and semi- remote settings across PEPFAR priority districts (for details see Annex 1) ...... 5 Table 3. Dedicated ASSIST support to service delivery innovation and improve performance of APC targets to scale up quality HIV services in Gaborone communities (Oct 2016-Sep 2017) ...... 8 Table 4. Overview of learning sessions convened under the ASSIST project (Aug 2016-June 2017) ...... 9

USAID ASSIST Botswana Country Report FY17 i Abbreviations AIDS Acquired immunodeficiency syndrome APC USAID Advancing Partners and Communities Project ART Antiretroviral therapy ASSIST USAID Applying Science to Strengthen and Improve Systems Project CATCH Communities Acting Together to Control HIV/AIDS CBO Community-based organization CIT Community improvement team DAC District AIDS Coordinator DC Differentiated care DHMT District Health Management Team FY Fiscal year HIV Human immunodeficiency virus LTFU Lost to follow-up M&E Monitoring and evaluation MLGRD Ministry of Local Government and Rural Development MMRI Maternal Mortality Reduction Initiative MOHW Ministry of Health and Wellness (renamed in 2016) NGO Non-governmental organization PDSA Plan-Do-Study-Act PEPFAR U.S. President’s Emergency Plan for AIDS Relief PLHIV People living with HIV QI Quality improvement SD Service delivery TA Technical assistance URC University Research Co., LLC USAID United States Agency for International Development VDC Village Development Committee VHC Village Health Committee WHC Ward Health Committee

ii USAID ASSIST Botswana Report FY17 1 Introduction The USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project has been providing support to the Botswana Ministry of Health and Wellness (MOHW) since 2012, initially with a focus on applying and institutionalizing quality improvement (QI) approaches in support of the national Maternal Mortality Reduction Initiative (MMRI). At the request of the USAID Mission in Botswana, ASSIST shifted its focus at the beginning of fiscal year (FY) 2016 to support the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) efforts toward epidemic HIV control through the expansion of treatment and overall improvement of HIV care. Coordinating closely with government counterparts and other PEPFAR partners, the ASSIST project was designed to provide technical assistance to district health managers and community leaders to revive and reconnect local health system structures to address acute gaps and barriers around the availability of quality HIV services (see overview of improvement aims in Annex 2). This included targeted efforts to improve local coordination to develop innovative service delivery models with non-governmental providers to bring quality HIV care closer to communities, beyond the walls of facilities and the formal health system. Community improvement teams formed and facilitated by ASSIST since early 2016 have mobilised existing community networks and resources to test simple but locally appropriate changes in how community members living with HIV could be most effectively identified, enrolled, and retained in antiretroviral treatment (ART) under the national Treat All strategy. During FY17, the project also intensified assistance to a provider-based QI team in Gaborone at the request of the Advancing Partners and Communities (APC) Project managed by FHI 360, to systematically review and improve low linkage- to-care rates. Designed to complement the APC service delivery mission, ASSIST itself did not provide actual services but supported government facilities, APC, and other PEPFAR service implementing partners to adjust their service delivery to be more effective and differentiated along both patient preferences and evolving system contexts. During the final quarter of FY17, the project intensified its efforts to institutionalise community-based QI teams; their effective long-term support from district mechanisms; and the identified service delivery innovations ASSIST had tested and confirmed at the community level. In the context of a national Treat All “Surge” Initiative to accelerate case identification and ART initiation, the transition of ASSIST’s coaching and coordination roles coincided with district health management team (DHMT) interests in strengthening community-based service delivery, including community-led mobilization and coordination. The ASSIST team concluded transition activities with central and district-level MOHW partners at the end of September, with corresponding activities planned for other USAID and PEPFAR partners to ensure that gains at systemic level are sustained.

USAID ASSIST Botswana Country Report FY17 1 Scale of USAID ASSIST’s Work in Botswana

MOHW, MLGRD at national and district level; District and Tribal Administration; other IPs under PEPFAR-B

7 PEPFAR priority districts with high- burden of ART and HIV

40+ facilities with highest volume of ART (no direct TA) and associated

referral sites

2-5 communities for each of the high- volume facilities across urban, peri-

urban and rural contexts

40 community-based QI teams as of 30 September 2017; 1 provider-based

team Direct and indirect beneficiaries: majority of Botswana’s HIV population through improved delivery systems

2 Program Overview

What did we try to accomplish? At what scale? 1. Strengthen the community health system response to HIV/AIDS to contribute to epidemic control in Botswana • Contribute to epidemic control of • Communities linked to the facilities with the highest HIV in Botswana through the volume of ART in the 7 PEPFAR priority districts targeted application of quality • Facilitation of dedicated improvement teams at the improvement methods to improve community level; work with DHMTs to institutionalise QI linkage, retention, and adherence to practices and service delivery innovations for improved HIV care for people living with HIV care in coordination across providers and partners; and support the development and implementation of new and refined models of integrated differentiated care at national level

3 Key Activities, Accomplishments, and Results Activity 1. Strengthen the community health system response to HIV/AIDS to contribute to epidemic control in Botswana BACKGROUND

In spite of significant progress in reducing HIV-related mortality and morbidity in Botswana, the country continues to have the world’s second-highest HIV prevalence rate. In addition, the rate of new infections remains high, further limiting the epidemiological impact of one of Africa’s largest treatment and care programs. In response to this challenge, PEPFAR has been supporting the Government of Botswana in

2 USAID ASSIST Botswana Report FY17 moving to universal treatment under its Treat All strategy, with PEPFAR investing in both facility and community service delivery platforms to scale up the delivery of quality HIV care. ASSIST’s project design was developed in FY15 for best fit with the country’s HIV epidemic and government-dominated health sector context and to work through local and central government counterparts across seven of the most HIV-affected districts of Botswana. Aligned with relevant Government and PEPFAR Botswana strategies, the project aimed at addressing acute quality gaps in and barriers to HIV care; at analysing their underlying systemic components; and at generating concrete change ideas to improve the effectiveness of existing mechanisms to provide genuinely people-centred quality HIV care. At the centre of ASSIST efforts in Botswana was a community health system approach with improvement teams that were formed jointly with community leaders, involving representatives from existing community structures, groups and networks, as well as staff from local clinics and community- based providers. An illustration of the broad composition of these teams is included in Annex 4. In addition to reconnecting communities with local facilities that serve them around shared acute problems and interests, the project reinstated functioning community-level coordination that also involved non- governmental service providers funded by PEPFAR to scale up the availability of testing and other HIV services outside of the formal system. By facilitating intensified local collaboration around acute issues of inadequate quality of care and service, ASSIST provided a basis for the institutionalization of community- based QI collaboratives that fit into Botswana’s unique governance context and a perspective of lasting sustainability (see Figure 1; red arrows indicate primary areas of ASSIST technical assistance). Figure 1. ASSIST’s approach in Botswana to institutionalise community-led improvement and improved coordination of HIV care and health services at the community level

In parallel to its QI support in communities, ASSIST supported the APC Project in adapting and improving non-governmental service delivery models, as measured against ambitious PEPFAR testing, care and treatment targets. Charged with scaling up the delivery of quality HIV services at the community level through seven sub-implementing providers, the APC-ASSIST collaboration focused on identifying

USAID ASSIST Botswana Country Report FY17 3 opportunities for practical service delivery innovation and improved relationships, collaboration, and coordination with government facilities. At the system level, ASSIST’s work was further aimed at promoting the growing relevance of community-based HIV services that were integrated within broader primary health care; improving a mutual understanding of comparative advantages between public sector and non-profit private sector service providers; guiding the adaptation of existing service delivery models on the basis of what works best for patients; and providing pathways for addressing key challenges associated with operationalising large scale, long term service delivery transformation in the context of uncertain donor and government fiscal commitments to HIV control and health development. ASSIST’s work and experience at community and district levels expanded during FY17. At the central level, the project received a growing number of requests from the Government and PEPFAR to provide inputs into relevant normative processes. These focused on operationalising declared government objectives to achieve HIV epidemic control in the context of revitalised primary health care, and a return to greater community involvement in integrated care delivery and prevention (as articulated also under the Government-led CATCH [Communities Acting Together to Control HIV/AIDS], initiative]). ASSIST contributions focused on supporting aspects of managing complex multi-layered decentralised systems; of differentiating health care delivery modalities along patient needs and preferences; of realigning health workforce frameworks with new guidelines and changing delivery models; and of integrating HIV and related chronic and overall primary care. An overview of all inter-related areas for ASSIST’s technical assistance in Botswana is shown in Table 1. Table 1. Priority areas for ASSIST technical assistance to improve patient-centred HIV care and support epidemic control in Botswana

Community District National •Address acute service •Improve SD coordination •Support quality-oriented SD delivery (SD) gaps and across facility/community innovations at national scale barriers to locally available platforms •Systematically transform SD quality care •Spread & scale up through differentiated care •Test, monitor, implement successful innovations approaches and coordinate local SD within the district •Help MOHW to translate innovations •Support quality and data- new SD models into •Support providers in driven district coordination practice, on the basis of QI exploring people-centred and action and costing data care in community and at home

Toward the end of FY17, the Botswana USAID mission requested ASSIST Botswana to apply resources to estimate actual implementation and running costs of the USAID-funded community platform under PEPFAR. This distinct costing exercise was supported by the ASSIST Research and Evaluation team and meant to inform PEPFAR’s and the Government of Botswana’s planning regarding alternative service delivery models and their associated costs. As such, the costing also supports the institutionalisation objectives of ASSIST for long term sustainability of its work in Botswana. KEY ACCOMPLISHMENTS AND RESULTS

During FY17, the Botswana ASSIST Project intensified and expanded its technical assistance per the 2017 improvement plan, aligned with USAID and PEPFAR strategies following the Country Operational Planning (COP16). In addition, the project maintained close consultations with the Government of Botswana’s counterparts at central, district and local levels to adapt to changing circumstances, to maximise ASSIST’s relevance, and prepare for effective and sustainable ‘handover’ mechanisms at the end of the project. Most notably, ASSIST intensified its management support to DHMT leadership in key

4 USAID ASSIST Botswana Report FY17 districts during the joint 2017 MOHW/PEPFAR Surge Initiative to scale up case identification and ART initiation under Government’s Treat All strategy. The project documented key accomplishments and result areas during FY17: 1. Facilitated community-led improvement collaboratives (Oct 2016- Aug 2017) ASSIST worked with 40 community-based improvement teams in different settings across seven districts, to facilitate the practical application of QI methodologies at the community level (see Table 2). ASSIST coaches provided hands-on coaching to community teams twice a month. Community teams were taken through focused PDSA cycles to identify local solutions to acute gaps in and barriers to quality HIV care as experienced by both community members and local facility staff. The meetings also provided important opportunities to share information, build relationships and improve mutual understanding of facility-related questions including: Why does the clinic operate the way it does? Why do patients not return for treatment or stop taking their pills? What can we do together to have more people test for HIV? In addition, facility and local service provider NGOs took the opportunity to inform community team members (and through their networks, the community at large) about planned health campaigns, policy changes and other questions around care as they came up during team interactions. Table 2. Overview of ASSIST-supported communities representing urban, peri-urban, rural and semi-remote settings across PEPFAR priority districts (for details see Annex 1)

District # of Profiles Key characteristics (by DHMT teams sub-district) Greater 11 Covering large parts of Gaborone Urban and peri-urban with large Gaborone City, especially areas indicated by domestic and external migration DHMT as underserved or otherwise populations, predominantly with low considered hot spots; as well as to lower-middle income classes town (administratively part of , but under Greater Gaborone DHMT) Kweneng East 7 Covering village, the Peri-urban, rural, semi-remote, largest village in Botswana, as well including with minority populations, as hot spots indicated by District predominantly of low income AIDS Coordinator (DAC) and DHMT classes Southern – 2 Covering key communities in Rural village with low to lower- Moshupa Moshupa village identified in middle income populations DAC/DHMT consultations Southern – 4 Covering key communities of Kanye Rural village with low to lower- Kanye Village identified in DAC/DHMT middle income populations consultations Southern – 6 Covering key communities within Rural and semi-remote villages at Goodhope Goodhope and neighboring villages low income level identified in DAC/DHMT consultations (one team was split in 2 at community request)

USAID ASSIST Botswana Country Report FY17 5 District # of Profiles Key characteristics (by DHMT teams sub-district) Kgatleng 2 Covering communities identified in Village communities in the DAC/DHMT consultations in the commuting vicinity of Gaborone City context of ongoing DHMT plans to and facilities, low to middle income re-establish Village Health population Committees Central – 8 Covering key wards across Peri-urban, rural and remote rural Mahalapye Mahalapye village, as well as communities at low to lower-middle villages identified by DAC/DHMT as income level representative of the larger district 7 priority 40 Across full urban to rural and remote (but not fully remote) spectrum, but districts limited to lower to lower-middle income populations (as per district partner estimation), broadly proportionate to district population numbers and PEPFAR targets for estimated PLHIV in need of identification and ART

While earlier teams formed during FY16 had generated a range of original change ideas – specifically around more client-oriented HIV testing approaches and practical community/facility collaboration to trace, reconnect with and return lost-to-follow up HIV patients – many newer teams adapted and replicated what they had learned from others (see illustrative results in Figures 2 and 3). Figure 2. Results from Boikanyo Community improvement team in Block 9, Gaborone, demonstrating an innovative community/facility collaboration to return ‘lost HIV patients’ (Jan-Apr 2017)

6 USAID ASSIST Botswana Report FY17 Through this learning approach teams could successfully test, monitor and confirm the effectiveness of simple but powerful innovations in their own local context and circumstances: The most successful change ideas, in particular around revitalised community/facility collaboration to return ‘lost ART patients’, were adapted and spread to other communities in coordination with DHMTs (see Figure 3). Figure 3. Replication, adaptation and spread of care innovations within and across districts – to clarify care status of ‘lost HIV patients’ and return them to the cascade (Oct 2016 - Aug 2017)

Beginning in August 2017, active ASSIST coaching transitioned to a “co-coaching mode” with local government facility staff and backstopping from DHMTs. 2. Guided quality-driven improvements in linkage to care by HIV service provider under APC (Oct 2016-Sep 2017) At the request of FHI 360 as implementer of the USAID-funded APC project under the PEPFAR community platform, ASSIST dedicated specific coaching resources to help BOCAIP (Botswana Christian AIDS Intervention Programme) establish its own internal QI team (see Table 3), with a focus on improving internal processes to maximise linkage rates from HIV testing to treatment referral. Under this separate provider-based QI effort, ASSIST supported the formation of the QI team, the establishment of clear improvement aims, and controlled application of PDSA cycles to identify improved processes for effective linkage and client follow up. While team members quickly embraced the methodology and appreciated their direct role in improving service, the overall effort was hampered by difficult circumstances for the organization, including rapid turnover of staff, low staff motivation and weak management practices. Nonetheless, the new QI focus applied and promoted by the BOCAIP QI team helped both BOCAIP management and the frontline provider staff to better appreciate the importance of understanding (in detail) their own processes; contributed to improved linkage results against the background of increased numbers of positive-tested clients (i.e., the denominator); and achieved the full institutionalization of a key service delivery innovation for enhanced (face-to-face) client follow up (Figure 4, see also Annex 3); and has begun to provide a more solid basis for organization-wide orientation toward client satisfaction and service efficiency based on client interests, while also improving against PEPFAR targets.

USAID ASSIST Botswana Country Report FY17 7 Table 3. Dedicated ASSIST support to service delivery innovation and improve performance of APC targets to scale up quality HIV services in Gaborone communities (Oct 2016-Sep 2017) Organization # of Profile Key characteristics teams BOCAIP (Botswana 1 Lead community-based Serving community members in Christian AIDS service provider under the Gaborone City, predominantly Intervention APC project for Gaborone urban and peri-urban populations Programme) City, covering HTC and HIV from low to lower-middle income prevention programs status

Figure 4. Results from the BOCAIP quality improvement team efforts to optimise HIV linkage performance through clarified, streamlined and intensified client follow up (Jan - July 2017)

3. Conducted district learning sessions across all 7 PEPFAR priority districts in Botswana (Oct 2016 - March 2017) Joint learning, the sharing of improvement experience, and dialogue across improvers and with senior level managers of the health system are known to be critical factors in quality improvement – especially for institutionalizing and sustaining change in complex systems. A first district level learning session with all community-based improvement teams, traditional leaders and district level government and other stakeholders from Mahalapye sub-district had already been conducted in August 2016 (see Table 4). During FY17, the ASSIST team convened another four equivalent learning sessions, for the remaining project districts in Southern, Greater Gaborone, Kweneng East and Kgatleng districts. At each learning session, the number of participants from the national level government (at increasing level of seniority) increased since these sessions were increasingly seen as opportunities to witness the capacity of communities to lead their own ‘bottom up’ problem solving. By the end of the project, all community improvement teams had been given a chance to present their results and experience to at least one learning session at the district level.

8 USAID ASSIST Botswana Report FY17 Photo: A member of the Tshwaragano Community Improvement Team in Gamodubu Village in , presenting the team’s results to district and health management leadership at their district learning session in March 2017; Credit: Thapelo Manale, URC/Botswana

Almost all DHMTs committed to involving existing community teams more into their own efforts to better coordinate locally for revitalised primary health care and improved community health. In all districts, ASSIST and various community teams were invited to periodically present to district level committees and mechanisms, as well as District Council sessions and other meetings. ASSIST supported local team representatives and facility staff to lead all presentations on their own improvement efforts as a way to build local ownership and prepare long-term sustainability of these teams and district support. Table 4. Overview of learning sessions convened under the ASSIST project (Aug 2016-June 2017)

Learning Session Dates 1 Mahalapye Sub-District August 3-4, 2016 2 Southern District October 11-12, 2016 3 (covering Kanye, Moshupa, Goodhope Sub-Districts) October 25-26, 2016 4 Gaborone District December 7-8, 2016 5 Kweneng East Sub-District March 1-2, 2017 Kgatleng District 6 National June 21-22, 2017

USAID ASSIST Botswana Country Report FY17 9 4. Convened a national learning session on community-led improvement in Botswana (June 2017) Against the background of five successful district learning sessions, ASSIST’s work in Botswana culminated in a final, national level learning session. A total of 11 community improvement teams from across seven districts were invited to present their local efforts to improve local services and community coordination. They were joined again by their traditional chiefs and district administration officials, as they presented to a packed hall of district and central government representatives from the Ministry of Health and Wellness, Ministry of Local Government, and the Office of the President. The session was opened by a keynote address on behalf of the Permanent Secretary of the MOHW, with other statements from senior government officials connecting what they saw and heard from community-led improvement to broader challenges in public sector service delivery and longer-term national development (see photo below from the opening session).

Photo: Senior government representatives at the opening section of the Botswana National Learning Session: John Phatshwe from the Office of the President (Government Implementation Coordination Office), Kgosi (Chief) Charles Koitsiwe from Gaborone Urban Ward, and Thandie Kgosiesele, Acting Deputy Permanent Secretary, MOHW (June, 2017); Credit: Cecil Haverkamp, URC/Botswana

Central to all statements and discussions was a genuine sense of appreciation of the power and potential of community-led ‘bottom up’ problem solving, and that the collaborative approach demonstrated by ASSIST was in sync with Botswana’s traditions and governance context. Most importantly, there was strong agreement on the strategic importance of emphasising community-led volunteerism within a context of good community governance to coordinate quality services and system functions at local level. This was in stark contrast to mainstream perceptions in Botswana that volunteerism was either ‘dead’ or limited to doing unpaid health messaging in the community. Instead, the learning sessions demonstrated: where local leadership was strong, so was volunteerism and its ability to improve services in the community in a sustainable fashion. Ministry of Health officials in particular, hailed this lesson as central to their policy objective of revitalising community-led primary health care, and invited the project to intensify and extend its work beyond the seven PEPFAR districts and HIV care. 5. Contributed to Treat All strategy implementation and national “Surge” efforts (March-Sep 2017) Following the launch of the national Treat All strategy in June 2016 to advance universal antiretroviral treatment in Botswana, the health system experienced a significant initial increase in the number of

10 USAID ASSIST Botswana Report FY17 people living with HIV being initiated on ART. As a result, however, the burden on a fragmented delivery system and frontline facility staff increased as well - further underlining a more fundamental need to review and streamline existing service delivery modalities and associated processes because they reflected national ART program priorities from the previous decade. In the face of lagging care indicators, in particular around case identification (HIV testing) and ART initiation, and in the context of the 2017 PEPFAR country operational planning process, the MOHW and PEPFAR jointly launched a concerted ‘national surge’ effort to identify opportunities for further streamlining processes. Primary attention was given to district level reviews and implementation of ‘surge strategies’ to remove bottlenecks in order to: (i) increase testing yields across both facility- and community-based platforms, (ii) more efficiently and effectively link those found positive to facility-based care, and (iii) ensure actual treatment initiation at minimal delays, supported by streamlined differentiated treatment algorithms. At the request of DHMTs, ASSIST focused its technical assistance on supporting senior managers in ensuring more effective and strategic coordination of all service partners for the uniform operationalization of strategies on the basis of more stringent monitoring and analysis of data, to drive result-oriented problem-solving across government and partners, and to ensure a coherent system-wide approach to Treat All across facility and community platforms. Figure 5 illustrates the efforts of the ASSIST project to sharpen existing government-led coordination of Treat All implementation at the district level (here for Greater Gaborone, under the Special Technical Advisory Committee [TAC] convened jointly by District AIDS Coordinator and DHMT). Figure 5. Refocused strategic approach to district partner coordination around HIV and related service delivery, as illustrated by Greater Gaborone TAC meeting agenda (June-Aug 2017)

USAID ASSIST Botswana Country Report FY17 11 6. Institutionalised healthcare improvement mechanisms under local Government (July-Sep 2017) From the beginning of ASSIST’s work with community, district and national counterparts, the institutionalisation and long-term sustainability of improvement thinking, methods and structures has been an overarching objective. Based on its 2017 improvement plan, as well as continuous dialogue with the central Ministry of Health and Wellness, the project prepared for a transition process that would see primary coaching responsibilities shift from ASSIST to the Government. In a series of consultations with district managers at seven DHMTs, agreements were reached on how to best institutionalise not only existing community improvement teams that had been formed under ASSIST, but to also build momentum for broader DHMT efforts to follow the same approach in revitalising village and ward health committees across all other communities in the district. Aligning with the MOHW policy priorities around its medium to long-term revitalisation and transformation agenda, ASSIST and the DHMTs agreed on a period of ‘co-coaching’ for improved community care. ASSIST supported this critical transition to full Government ownership by offering dedicated QI training to help prepare newly assigned (but already experienced) DHMT improvement coaches: at the local health post, clinic or hospital through (senior) health education assistants and community health nurses, as well as matrons and nurses-in-charge – many of whom had already been active members of the community improvement teams since inception, and at the DHMT senior management where experienced officers will provide mentoring and backstopping as district coaches.

Photo: Acting head of Greater Gaborone District Health Management Team, Josephine Mosimanewakgosi, Nursing Superintendent, opening the joint DHMT-ASSIST Improvement Coaching and Mentoring Program for facility- and DHMT-based improvement coaches (Sep 2017); next to her Ikko Sebilo, Head of Health Education, DHMT (left), and Chalebiwa Nfila, Senior Adviser for Improvement Learning, USAID ASSIST Botswana; Credit: Mpho Zwinila, URC/Botswana

7. Provided QI-generated, evidence-based inputs to the development of the guideline for integrated community service delivery (Oct 2016-Sep 2017) Throughout FY17, USAID Botswana has been supporting the central MOHW in developing integrated community service delivery guidelines, through direct support via the APC project, and technical system insights from ASSIST’s perspective. The envisaged guidelines will be critical in helping to adapt the country’s service delivery models to become more patient-centred, community-based, and quality- oriented in line with broader government objectives to revitalise primary health care. Importantly, they also aim at integrating services at community level across 11 disease program areas, with a strong

12 USAID ASSIST Botswana Report FY17 emphasis on prevention, early detection and sustainability. ASSIST contributed to the process and conceptual framing of the Technical Working Group, with a focus on applying a differentiated care perspective to adapting existing service delivery models in line with relevant advanced experiences in other Southern African settings. Alongside the guideline development, a Ministry-led consultancy focused on the harmonization of community health worker cadres for which ASSIST also provided specific inputs, on the basis of our close role in reorganizing community/facility collaboration across seven districts. ASSIST has also been asked to support the necessary re-alignment of health workforce policies and practices for new delivery models, and their eventual operationalization at DHMT level in FY18 – with implications also for PEPFAR planning regarding the long-term sustainability of its community platform. 8. Conducted dedicated costing of the PEPFAR-funded “community platform” for scaled up HIV care (June-Sep 2017) At the request of the Botswana USAID mission in early 2017, the ASSIST team with the support from the ASSIST Research and Evaluation division prepared a multi-phase costing study to estimate costs for the USAID-funded community platform under PEPFAR. The ASSIST team contracted a qualified local health care management consultant to work with ASSIST headquarter-based experts on a costing model; convened a first community health service delivery seminar with the Botswana Government and PEPFAR stakeholders; and worked with FHI 360 as implementer of the APC project. Together with APC, the team reviewed complex costing data to establish a clear overview of cost categories across both the APC and ASSIST projects (together making up the PEPFAR community platform for scaled up quality HIV care). The analysis will inform future planning considerations of both the Government of Botswana and PEPFAR regarding the relative costs and implications of alternative service delivery models. Reliable, realistic and transparent information on associated costs is a key element in supporting the long-term institutionalization and sustainability of community-based care as demonstrated by APC and ASSIST work – a core objective also for the global project. SPREAD OF IMPROVEMENT

The need for effective mechanisms to not only identify but spread successful ASSIST-generated improvement ideas across different levels of the system and geographic priority areas was central to ASSIST’s project design from the start. During FY17, the final year of ASSIST’s implementation, it became the core business under a flexible phased approach that was informed by both current ASSIST experience in other countries and decades of preceding USAID-funded improvement programs. During ASSIST’s first phase, community-led improvement teams in seven districts further expanded from 32 in FY16 to 40 by mid-FY17 across urban, peri-urban, rural and remote area settings that represented hot spots and or were otherwise relevant to inform system-wide changes. The selection of supported communities was based on a range of criteria to ensure a largely representative set of contexts relevant for the particular challenges of spread and scale up. Aligned with PEPFAR and MOHW priority classifications of high-volume facilities providing ART, the project agreed with government partners at the district level on the communities – with DHMTs being periodically updated on progress. During district learning sessions, jointly convened by ASSIST and respective DHMTs (phase 2), community improvement teams presented their results and experiences together with local clinic and NGO provider staff. District managers and national government officials were favorably astonished about the focus and depth of locally-led improvement efforts that had been undertaken sustainably without any additional district or national resources. Consequently, DHMTs followed up by starting to involve

USAID ASSIST Botswana Country Report FY17 13 community teams more consistently in district activities related to HIV, in some cases even adjusting district action plans and human resource allocations. During the third phase, kicked-off by dialogue between ASSIST and the MOHW leadership in the run up to the national learning session in June 2017, the focus shifted further from the spreading of service delivery innovations (as generated by ASSIST’s community application of QI) within and across districts, to the system-wide scaling up of such improvements for integrated quality services under the broader national health system. The national learning session facilitated, as intended, the Government’s full recognition of the broader relevance and potential of ASSIST’s model: community-led quality improvement collaboratives involving both government facilities and NGO providers, to develop local solutions to the most pressing service delivery gaps and barriers in and beyond HIV care. The national learning session also led to direct requests by senior Government officials for separate briefings, resulting in commitments to integrate QI with the Government’s own Welcome poster to the June 2017 National Learning CATCH (Communities Acting Together Session in Gaborone, attended by more than 100 to Control HIV/AIDS) Initiative to government officials, traditional leadership and community transform the national health system improvers; Credit: Billy Kgosikwena, URC/Botswana around a revitalised focus on communities, primary health care and prevention. During the project’s final quarter of FY17, ASSIST implemented joint institutionalization plans developed with DHMT leadership across all seven districts, each tailored to respective district context. These plans identified facility focal points and improvement coaches to take over ASSIST coaching roles under a period of “co-coaching”, as well as DHMT senior managers charged with providing district-level backstopping and mentoring. As per MOHW policy directions, these mentors have since been coached by ASSIST to sustain existing community improvement teams (CITs) in the district; to expand equivalent teams across the district in line with DHMT annual performance plans; and to gradually broaden their scope from improved HIV care to broader quality primary care and prevention. As of October 2017, with the closing of the ASSIST project in Botswana, all community improvement teams formed and coached by ASSIST since 2015 were successfully transitioned to facility coaches under DHMT management and mentoring, to continue to generate, spread and scale up locally-developed change ideas for better care and health in Botswana.

14 USAID ASSIST Botswana Report FY17 Complementing this “bottom up” approach to spread and scale collaborative improvement, ASSIST channeled the vast insights into the service delivery dynamics and community capacity to lead their own improvement to national level technical working groups, guideline committees and other normative settings concerned with the intended reorientation of health care and health development in Botswana. ASSIST’s cumulative experience with the concrete, real world challenges but also successes in reviving community volunteerism and community-led problem solving was widely recognised and seen as directly relevant to inform the way forward. 4 Sustainability and Institutionalization ASSIST’s technical assistance and approach in Botswana were carefully designed to be embedded within the existing governance, development and epidemiological context of the country with a view to address both short-term service gaps and barriers, and achieve longer term objectives around the broader institutionalization of appropriate quality frameworks able to sustain epidemic control beyond PEPFAR’s presence. This approach required a deeper reading and appreciation of Botswana’s unique and evolving governance, as well of broader government trends in rethinking decentralisation, and the history of health system development since before the arrival of HIV/AIDS. One of the key aspects the project faced at its inception – whether or not to pay members of the community improvement teams – indeed became an important factor for the project’s efforts to transition the support of QI teams to Government coaches. By rejecting conventional project practices of paying community volunteers a sitting allowance, project and traditional community leaders had agreed to limit ASSIST support to only nominal transport reimbursements in order to avoid adverse effects on any later efforts to institutionalise and ensure lasting sustainability. As of the project’s end in October 2017, all but a few community teams have continued their improvement work under the transitional ‘co-coaching’ arrangement with the DHMTs. The extent to which DHMTs and community leaders will be able to indeed continue supporting community collaboratives depends on how ongoing Government efforts to transform service delivery will be operationalised. Facility staff at local clinics, however, have enthusiastically reaffirmed their commitment (and need) to collaborate systematically with existing community structures, as well as local NGOs. ASSIST and DHMTs agree that a page was turned, with powerful momentum to transform community-led health service delivery for a new era of post-AIDS health development in Botswana. Overall, we notice a marked difference in the appreciation of improvement as a method to manage health systems and their outcomes on the part of our Government counterparts at all levels. The focus of ASSIST’s work with communities and providers across seven districts has contributed to a broader recognition of the kind of system adjustments the country needs to make to its existing health service delivery models in order to achieve its twin top-level policy objectives: to reach HIV epidemic control to end AIDS in Botswana, and the long-term transformation of the health system as a whole. Government counterparts have expressed strong interest in emulating and spreading ASSIST’s approach of collaborative improvement to other, non-PEPFAR, districts in the context of broader efforts to revitalise community-led primary health care and prevention. 5 Knowledge Management Products and Activities • Telling the story: During FY17, the project was able to intensify its efforts to tell the evolving story of community-based improvement in Botswana, through a range of media products that received wide coverage, including TV (with a special episode under a Government-sponsored TV program dedicated to health, called Tsa Botsogo meaning ‘Health Issues’), newspapers, and the internet, both in Setswana and English. ASSIST was also featured in the May 2017 edition of Tsogang, the PEPFAR country magazine.

USAID ASSIST Botswana Country Report FY17 15 • Blog postings: In addition, ASSIST was featured in several blogs showcasing experiences in applying improvement work to revive community health systems, improve services and contribute to HIV epidemic control, including on the Huffington Post and on the occasion of World Health Worker Week. • Case studies: During FY17, the team revised a key case study on the experience in Palla Road to document and disseminate key lessons from the Botswana ASSIST experience. The case study is available on the global ASSIST website. https://www.usaidassist.org/resources/strengthening-hiv- linkage-and-retention-through-improved-communityfacility-collaboration • Change package for community-led improvement in HIV care as part of national efforts to achieve epidemic HIV control: At the end of the ASSIST project’s implementation period in Botswana, the team developed a summary document of service delivery innovations, their identification, spread and institutionalization, as well as related lessons learned around the introduction of quality improvement practices across community, district and national levels in Botswana. The package will be available on the global ASSIST website. 6 Gender Integration ASSIST’s experience in implementing this project in Botswana over the past two years confirms the deep underlying socio-economic and cultural dynamics of the HIV epidemic. It also confirms the need for dedicated gender-based analyses and systematic efforts to adapt existing service delivery models to the reality of different requirements and needs by sub-populations. Through our direct work with communities, the project has gained a practical appreciation of how gender norms and roles in Botswana affect how men and women perceive and respond differently to risks, seek care, and accept (or avoid) services. Importantly, and increasingly over the past six months, we also gained insights into how gender-sensitive adaptations make a difference in addressing some of the gaps that are critical for achieving epidemic control. Several community improvement teams coached by ASSIST generated gender-sensitive change ideas, aiming at getting more men (older and young) to test for HIV, and to come forward to enrol in treatment. The results from ASSIST’s gender-sensitive QI work have helped to inform broader discussions on how to adjust existing HIV testing campaigns and approaches. Concrete results from community-tested ideas also clarified long-standing myths (e.g., regarding the alleged unwillingness of men to test). As CITs demonstrated, men in Botswana (like anywhere else) simply have different preferences, health-seeking behaviours and needs than women. Within PEPFAR Botswana, ASSIST continued to play a key role in facilitating discussions around ‘differentiated care’ as an approach to refine and adapt many of the current ‘one-size-fits-all’ modalities to specific needs and preferences of sub-populations, such as young women under age 25, or older men. This will require a deeper understanding of relevant gender dimensions, associated stigma and perceptions, as well as more sex-disaggregated data and gender-sensitive indicators to make services more easily accessible and appealing. While ASSIST did not provide any services directly and has no direct access to clinical facilities, the project has been collecting and reviewing service-related data from across different relevant sources from the start with a particular interest in gender disaggregation and what can be learned from it for improvement. Unfortunately, the quality of available data remained a major problem throughout the project’s time. Under PEPFAR Botswana, considerable efforts are being made to improve the quality and management of data; however, much more needs to be done to understand what matters most for closing gender gaps to achieve epidemic control.

16 USAID ASSIST Botswana Report FY17 Annex 1: ASSIST-supported Community Improvement Teams in Botswana By district and community (with local team name), as of formal MOHW/DHMT handover in September 2017

GABORONE KWENENG DISTRICT GREATER GABORONE DHMT KWENENG EAST DHMT Gaborone Urban (Bakgothatsi) Molepolole (Family Empowerment) Block 8 (Tlhagiso) Gamodubu (Tshwaragano) Gaborone West (Ya Tsie) Molepolole (Boitshokelo Phenyo) Old Naledi (Tsema le thata) Molepolole (Re ka kgona) Block 9 (Boikanyo) Molepolole (Lentlole) Phase II (Lesedi) Molepolole (Re tswela pele) Old Naledi (Tsholanang) Gakgatla (Tlhwaa-tsebe) Broadhurst (Lion Hunt) Broadhurst (Batsibosi) SOUTHERN DISTRICT Mogoditshane (Bakaedi) MOSHUPA DHMT Mogoditshane (Maikaelelo) Moshupa (Tswelelopele) KGATLENG DISTRICT Moshupa (Bosa)

Bokaa (Tokahatso Maduo) Artesia (Mphe Lesedi) KANYE DHMT

Kanye (Boikarabelo) CENTRAL DISTRICT Kanye (Kgatelopele) MAHALAPYE DHMT Kanye (Masedi) Palla Road (Pusetso) Kanye (Itshekatsheke)

Mahalapye (Remmogo) GOODHOPE DHMT Mahalapye (Mosekaphofu) Goodhope (Kago) Mahalapye (The Pathfinders) Gamokoto (Dijammogo) Mahalapye (Bophelo) Pitsane (Tsoga o Phatshime) Rakhuna (Walk the Path) Dibete (Bosabosele) Mmathethe (Ntsu ya dikaka) Ramokgonami (Waoesi) Mogwalale (Dijammogo) Kalamare (Reyapele)

USAID ASSIST Botswana Country Report FY17 17 Annex 2: Overview of ASSIST Botswana improvement aims In support of targeted efforts to address acute gaps in and barriers to quality HIV care

18 USAID ASSIST Botswana Report FY17 Annex 3: Technical Assistance to Provider-Based Quality Improvement: BOCAIP Institutionalization of identified delivery process innovations in the organizational Linkage-to-Care Guidelines

USAID ASSIST Botswana Country Report FY17 19

20 USAID ASSIST Botswana Report FY17 Annex 4: Support to community improvement teams in Botswana Team profile example: Tokahatso Matshelo, Kgatleng DHMT Tokahatso Matshelo Working for the community to improve care and coordinated health services in Bokaa Village Kgosi Gofaone Basima Kabo Thankane Sue Mosinyi District Coach Improvement Coach Kgatleng District Bokaa Village Bokaa Clinic, DHMT URC Botswana (ASSIST)

Botlogile Motswagole Onnameditse Phaladi Michael Nthibane Dorah Motswagole Regina Chabaesele Sepora Molefhe

VMSAC Are Chencheng Men Sector BORNUS Village Extension Team Red Cross

Babo Taolo Maria Modidi Kamogelo Mokalake Gorata Irene Moremi Elizabeth Metlhaleng Itumeleng Masaile

Disability Organization Home-based Care Volunteer Bokaa VDC Bokaa Choirs Bokaa VDC

Tokafatso Matshelo was formed by the community leadership to revitalise community structures, in order to collaborate with facilities and other service providers for better Kelebogile Letsebe Bontle Metlhaleng Malebogo Molome Phana Mogome care and coordinated services in the Health Care Assistant, Baletsa Phala Bokaa Parent Tribal community. Bokaa Clinic Support Group Teacher Association Administration

USAID ASSIST Botswana Country Report FY17 21

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