WHO COUNTRY COOPERATION STRATEGY BOTSWANA

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1 WHO COUNTRY COOPERATION STRATEGY BOTSWANA

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3 Contents CONTENTS Map of Botswana... v Abbreviations... vii Foreword... xi 1. Introduction People and Government: Health Development and Challenges Demographic overview Governance Socioeconomic situation Development policies Health profile Health delivery system Determinants of health Health sector financing Health systems challenges Development Assistance and Partnerships Major development agencies in the health sector Mechanisms for donor coordination WHO Current Country Programme Priority Areas of Work for Human resources: profile and issues Financial resources for the WHO country office Strengths, weaknesses, opportunities and threats WHO Corporate Strategy: Global and Regional Directions Goal and mission iii

4 Contents 5.2 New emphases Strategic directions Core functions Global and regional priorities Making WHO more effective at country level Strategic Agenda for WHO in Botswana Health systems HIV/AIDS Human resources for health Disease prevention, surveillance and control Partnerships, poverty, macroeconomics and health Flexible response Supporting and Implementing the WHO Country Cooperation Strategy Strengthen long- and short-term country staff Resource mobilization and allocation Improving WHO's administration and management of health WHO Regional Office for Africa and headquarters technical support WHO Regional Office and headquarters system for support to the country Conclusion Selected References iv

5 Map of Botswana Botswana by District v

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7 Abbreviations ABBREVIATIONS AFRO ACHAP ANC AIDS ARI ARVT BHP BOCONGO BONASO BOTUSA CAH CCA CCS CMH CHBC CPC CSO DANIDA DFID DHT DOTS EHA EHO EPI FOS GDP GOB HMIS WHO Regional Office for Africa African Comprehensive Partnership on HIV/AIDS Antenatal clinic Acquired immunodeficiency syndrome Acute respiratory infections Antiretroviral therapy Botswana Harvard Partnership Botswana Coordination for Nongovernmental Organizations Botswana Network of AIDS service organizations Botswana United States of America project Child and Adolescent Health Common Country Assessment Country Cooperation Strategy Commission on Macroeconomics and Health Community home-based care Communicable Disease Prevention and Control Central Statistics Office Danish International Development Agency Department for International Development District Health Team Directly-observed treatment short-course Emergency and Humanitarian Action Environmental Health Officer Expanded Programme on Immunization Food Safety Gross Domestic Product Government of Botswana Health Management Information Systems vii

8 Abbreviations HIV HPR HR IMCI IMF IPT IVD MAL MDG MNH MO MOH NAC NACA NCD NDP NGO NORAD NPO NSPR NUT OIs OSD PEP PER PHC PHE PMTCT POW PSI Human immunodeficiency virus Health promotion Human resources Integrated Management of Childhood Illnesses International Monetary Fund Isoniazid preventive therapy Immunization and Vaccine Development Malaria Area of Work Millennium Development Goal Mental Health and Substance Abuse Medical Officer Ministry of Health National AIDS Council National AIDS Coordinating Agency Noncommunicable diseases National Development Plan Nongovernmental organization Norwegian Agency for Development National professional officer National Strategy for Poverty Reduction Nutrition Opportunistic infections Organization of Health Services Post exposure prophylaxis Public expenditure review Primary health care Programme of Health and Environment Prevention of mother-to-child transmission (of HIV) Plan of work Population Services International viii

9 Abbreviations RTA RB RBM REC RHR SADC SIDA SSA STD STP STI SWAp TB TBA UN UNAIDS UNDAF UNDG UNFPA UNHCR UNICEF USA USAID USD VCT WCO WHO Road traffic accident Regular budget Roll Back Malaria Resource Mobilization, External Relations and Cooperation Research and programme development in reproductive health Southern Africa Development Community Swedish International Development Agency Special service agreement Sexually transmitted diseases Short-term professional Sexually transmitted infection Sector-wide approach Tuberculosis Traditional birth attendant United Nations Joint United Nations Programme on HIV/AIDS United Nations Development Assistance Framework United Nations Development Group United Nations Population Fund United Nations High Commissioner for Refugees United Nations Children's Fund United States of America United States Agency for International Development United States dollar Voluntary counselling and testing WHO Country Office World Health Organization ix

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11 Foreword FOREWORD In the year 2000, the Executive Board of the World Health Organization (WHO) approved a Corporate Strategy to guide the work of the WHO Secretariat. This Corporate Strategy emphasized the central role of countries in the work of WHO; hence, the global strategy was revised and adapted to the needs of each country. These measures constitute the basis for the WHO Country Cooperation Strategy (CCS). The Country Cooperation Strategy describes WHO strategic priorities for each country in order to obtain an integrated response from the three levels: country office, regional office and headquarters. The CCS is a clear expression of the WHO country focus: the strategic agenda will guide cooperation between WHO and Member States for the medium term. The CCS will serve as a reference for WHO workplans and resource allocations, whether those resources are from countries, region, HQ or other sources such as collaborating centres. The WHO Cooperation Strategy was developed through an extensive consultative process involving the Organization at all levels, the Ministry of Health, other government agencies, private sector and civil society organizations, training and research institutions, development partners and other key stakeholders in health. The process involved questioning, in-depth analysis of key health and development challenges of each country and consideration of the WHO comparative advantage. I acknowledge the exhaustive process that has led to the formulation of this document, and I would like to thank the government and all stakeholders in health for their efforts and active participation. I have no doubt that the CCS process will help countries in their efforts to focus on priority health issues and coordinate the actions of different partners and stakeholders. Our challenge now is to transform these strategies into concrete actions, with a view to improving WHO performance at country level as well as the health outcomes for populations in greatest need. Dr Ebrahim Malick Samba Regional Director World Health Organization Regional Office for Africa xi

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13 Introduction 1 INTRODUCTION The aim of the WHO Country Cooperation Strategy (CCS) is to strengthen the efficiency and effectiveness of WHO's work in Botswana as it supports government efforts to achieve the national health goals. The CCS defines the strategic directions and medium-term strategic agenda in the country for the entire WHO Secretariat including all of the Organization's three levels (headquarters, Regional Office for Africa and the country office) covering the period This period coincides with the National Development Plan Nine (NDP9) as well as the current UN Development Assistance Framework in Botswana. The CCS was developed through a consultative process involving the WHO country team, national counterparts from the Ministry of Health, the Ministry of Local Government, the UN family, other government ministries, the Southern Africa Development Community (SADC), civil society, international partnerships, representatives from the WHO Regional Office for Africa and WHO headquarters, national and international development partners, NGOs, and other key stakeholders in health. The objective of the Country Cooperation Strategy is to enable WHO to be more responsive to country needs by being more selective and focused on national health priorities. The Organization aims to provide an optimum balance between the needs and expectations of the country on the one hand, and the comparative advantage of WHO on the other, fully taking into account the activities of other development partners. In setting out the medium-term strategic agenda, the CCS has been inspired by the WHO Corporate Strategy, the WHO African Region Strategic Framework ,the NDP 9, the National Health Policy (1995), the Strategic Plan of the United Nations Development Assistance Framework (UNDAF ), the Common Country Assessment report (CCA 2001) and the draft National Strategy for Poverty Reduction (NSPR). It provides a framework for the Organization to address the health component of the Millennium Development Goals (MDG) in Botswana. WHO will work to maximize synergies and achieve optimum complementarities with all stakeholders and development partners, in line with the strategies developed in this document. Thus, the CCS provides general guidelines for WHO operations in Botswana for the medium term and will influence the work of the Organization at all its levels. 1

14 People and Government 2 PEOPLE AND GOVERNMENT: HEALTH DEVELOPMENT AND CHALLENGES 2.1 Demographic overview Botswana is a landlocked country, sharing borders with Namibia, South Africa, Zambia and Zimbabwe. It has a surface area of 581, 730 square kilometres. The average climate of Botswana is described as semi-arid. The rainfall is unreliable, highly erratic and seasonal. Water is therefore scarce, with rivers that are ephemeral and subterranean. Botswana is one of the least populated countries in Africa. The 2001 Population and Housing Census put its population at The population density was found to have increased from 2 persons per square kilometre in 1991 to 3 persons per square kilometre in The population growth rate has declined from 3.50% between 1981 and 1991 inter-census period to 2.38% between 1991 and 2001 inter-census period. The total fertility rate declined from 4.2 births in 1991 to 3.3 births per woman in The population of Botswana is unevenly distributed. About 89% of the population lives in the eastern part of the country where rainfall is better, and the soil reasonably fertile for farming. In 2000, the primary school enrolment rate was 92%. There is a slight difference between male and female primary school attendance, which stands at 84% and 86% respectively. 2.2 Governance Botswana attained independence from Britain in The Botswana Constitution established a non-racial democratic republic, which maintains freedom of speech, press and association, and affords all citizens equal rights. The government is headed by an executive president and has three separate branches: the executive, the legislature and the judiciary. The house of chiefs is consulted by parliament on matters affecting custom and tradition. Administratively, Botswana is divided into 15 districts that include two cities and four towns. The country is also subdivided into 24 health districts. There is a local government structure, which works through District Committees, Village Development Committees, and the local tribal structure, such as the kgotla. The central level formulates policies and guidelines, while the district and village committees implement programmes. 2

15 People and Government 2.3 Socioeconomic situation The economy of Botswana is one of the strongest in the African Region. Between 1966 and 1996 Botswana's gross domestic product (GDP) grew by an average of 6% the highest sustained real GDP growth rate in the world during this period. 12 This is mainly attributed to growth in the mining sector, in particular the diamond industry, which currently accounts for about 80% of export revenue. In the period 1999/2000 and 2000/2001, the real GDP growth rate increased from 8.1% to 9.1%, the highest growth rate in the SADC region. Figure 1: Structure of the Botswana Economy 2000/2001 Source: Republic of Botswana Annual Economic Report 2002, Ministry of Finance and Development Planning The gross domestic product in 2001 was P 16.9 billion, which translates to a GDP per capita of Pula and classifies Botswana as a middle-income country. However, according to the last poverty survey in 1993/94, 47% of the population is living below the poverty line of 100 Pula* per person per month. This unequal distribution of income and wealth is further exacerbated by the fact that about 44% of the country's population is rural based. Botswana has a large land area. However, only 5% of the land is suitable for agriculture and less than 1% is actually cultivated. The agricultural sector accounts for 2.4% of the GDP and the weakness of this sector has contributed to high levels of poverty in the rural areas. *US$ 1 equals to P6.30 on 12 November

16 People and Government Botswana has an average inflation rate of 6.6% (2001 figures), a decline from 8.6% in the previous year. This decline is mainly due to a tight monetary policy. In the same period, the average cost of living increased by 5.8%. 33 In addition, unemployment is a problem for 15.8% of the workforce, most of whom are young people. 3 The government's economic policy has two broad goals of economic diversification and balanced budgets. It recognizes the need for fiscal and monetary policies that will control inflationary pressures and thus maintain the competitiveness of its exports. The future economic prospects for Botswana look good, and the health of its citizens, if further improved, could make a significant contribution to the development of the country. 2.4 Development policies The development of Botswana is being guided by several policy documents, in particular, Vision 2016; NDP 8 (a draft NDP9 is now available); sectoral development plans, including the Ministry of Health's Health Policy and Strategy Framework-2000 and the Corporate Performance Plan, Vision 2016 sets out the following key national aspirations to be attained by 2016: An educated, informed nation; a prosperous, productive and innovative nation; a compassionate, just and caring nation; a safe and secure nation; an open, democratic and accountable nation; a moral and tolerant nation; and a united and proud nation. In addition, the vision proposes that by 2016 Botswana will be a caring nation, distributing income equitably, and will have eradicated poverty through, amongst other things, the institutionalization of an efficient social safety net for those who suffer misfortune. The vision foresees that all Batswana will have access to good quality health services, sanitation and nutrition. The medium-term Eighth National Development Plan operationalized part of the vision. NDP 8 aimed to achieve the following in the medium term: To improve the efficiency and cost-effectiveness of health care delivery; to ensure equitable distribution of services; to improve the quality of health care; to train appropriate skilled personnel; and to strengthen primary health care programmes. The Ninth National Development Plan is now being formulated and will address the issues that could not be finalized during NDP8 plus new ones, including the HIV/ AIDS pandemic. According to the draft NDP 9, the following issues are priorities to be 4

17 People and Government addressed during the period of the plan: human resources development; health sector reform; strengthening of primary, secondary and tertiary health services; and HIV/ AIDS. The Ministry of Health Corporate Plan sets out the following goals for the next six years: (a) (b) (c) (d) (e) (f) To provide quality health services to Batswana in order to improve their health status; To improve life expectancy of Batswana through the implementation of the PHC strategy; To provide customer focused health services in order to increase customer satisfaction; To improve quality service delivery through the development and implementation of comprehensive health policies and standards by the end of NDP9; To enhance the Ministry of Health's efficiency and effectiveness through the implementation of innovative performance improvement initiatives; To review existing human resources for health plans in order to come up with a comprehensive plan consistent with the current health needs of the country. National health development is therefore carried out within this framework. 2.5 Health profile It is important to appreciate and recognize that health status in Botswana, until the advent of the HIV/AIDS epidemic, had been improving steadily and the vital health indicators were amongst the best in the Region until the late 1980s. There was a general decline in the incidence of childhood immunizable diseases. The crude birth rate per 1000 dropped from 39.3 in 1991 to in Many of these good achievements have now been reversed by the HIV/AIDS epidemic. The crude death rate per 1000 increased from 11.5 in 1991 to in The infant mortality rate and the under five mortality rate were found to be 57 and 75 per 1000 live births in respectively. Life expectancy also declined from 65 years in 1991 to 56 years in The maternal mortality ratio was estimated at 350 per live births 2 in the early 1990s. The general fertility rate per 1000 dropped from 161 in 1991 to in

18 People and Government The 1999 Health Statistics Report shows that the major causes of inpatient morbidity (excluding neonatal conditions) in all ages were ill-defined intestinal infections, pneumonia, pulmonary tuberculosis, AIDS and malaria. The major causes of inpatient mortality, excluding neonatal conditions, were AIDS, pneumonia, pulmonary TB and ill-defined intestinal infections. Major health issues and challenges impacting on health Communicable diseases HIV/AIDS HIV/AIDS is the most important public health challenge for Botswana, and the biggest threat to the country's development. The first case of HIV/AIDS in Botswana was diagnosed in 1985 and the prevalence has increased rapidly since then. Figure 2 shows the HIV/AIDS trend. In the first HIV sentinel surveillance in 1992, 18.1% of pregnant mothers tested (14-49 years of age) were HIV positive and by 2001 this percentage had risen to 38.6%. In some districts such as Tutume and Selebi-Phikwe and in certain age groups the HIV prevalence rate is over 50%. Figure 2: HIV Prevalence (15-49 years) trends in Botswana, Source: Botswana 2001 HIV Sero-Prevalence and STD Sentinel Survey. NACA. Several programmes have been put in place to both prevent transmission and mitigate the impact of HIV/AIDS. These programmes include: Prevention: Behaviour Communication Change; Control of Sexually Transmitted Diseases; Isoniazid 6

19 People and Government Prevention Therapy (IPT) for TB; Prevention of Mother-to-Child Transmission (PMTCT); Post-exposure Prophylaxis (PEP) and HIV/AIDS in the Workplace programme; Care, counselling and support: Community Home-based Care (CHBC); Voluntary Counselling and Testing (VCT); Antiretroviral Therapy (ARVT) and Management of Opportunistic Infections (OIs). Table 1: HIV prevalence rates by age group, 2001 AGE GROUP (Years) % HIV PREVALENCE and above 26.9 Source: Botswana 2001 HIV Sero-Prevalence and STD Sentinel Survey. NACA Table 1 above shows age specific prevalence rates. Prevalence rates among ANC (antenatal clinic) women in the year 2001 were higher than 20% in women over the age of 15 years. The highest prevalence is observed in the age group. The national response to the epidemic The national response is multi-sectoral, multi-pronged and very strong. Government is committed to arresting transmission of the HIV virus by The president himself chairs the National AIDS Council (NAC) and the secretariat of the Council (the National AIDS Coordinating Agency) reports directly to the office of the president. Sectoral AIDS Subcommittees of the NAC coordinate the HIV/AIDS activities at the sectoral level. Apart from these there is a Parliamentary Select Committee on HIV/ AIDS as well as District Multi-sectoral AIDS Committees at the implementation level. The response to the HIV/AIDS epidemic has brought on an extraordinary strain to bear on the people (especially health workers), the health system and the government. Up to 70% of all in-patients in medical wards of referral hospitals are HIV-related cases. The extra functions that have to be performed by the health system have put great demands on the limited resources of the system. The human resources are especially overstretched, and the new skills expected to address the various aspects of the response still need to be acquired. Additional staff is required to provide comprehensive counselling services on a full-time basis. Human resource shortages exist throughout the health care system in the delivery of HIV/AIDS services, from the central AIDS/STD Unit to the district and community level where 7

20 People and Government home-based care and other services are delivered, before and after the HIV-testing. Laboratories require more personnel to perform the necessary tests associated with HIV. Due to the severe burden on health facilities, the health care system has introduced community home-based care to complement services provided by health facilities. Tuberculosis HIV has increased the burden of TB in most sub-saharan African countries including Botswana. Figure 3 below shows the TB trends in Botswana from In the decade , at the beginning of the HIV/AIDS epidemic, the number of TB cases fell by an average of 10.19% annually. However, between 1990 and 1996, TB prevalence doubled, at 595 per persons. TB prevalence in Botswana is now among the highest in sub-saharan Africa. Current studies show that 75% of HIV/AIDS patients are co-infected with TB. It is also the single leading cause of death among people with HIV/AIDS in the country, accounting for 36% of AIDS mortality. Figure 3: TB notification in Botswana, Source: TB Annual Report. Epidemiology Unit, Community Health Services Division, MOH Botswana Weaknesses have been identified in the TB programme. These include: shortage of human resources for health services in general and for the programme in particular, public health specialists, laboratory staff, and health education expertise for tuberculosis and HIV/AIDS; poor coordination and communication between the Ministry of Health which is in charge of technical policy, and the Ministry of Local 8

21 People and Government Government which is responsible for implementation at the local level; weak TB diagnosis and contact tracing; lack of refresher training in some aspects of lab diagnosis for tuberculosis; and inadequate supervision capacity at central and district levels. Malaria In Botswana, malaria transmission is unstable and closely related to the level of rainfall, which varies considerably each year. Figure 4 shows malaria notification from 1983 to There is, therefore, significant variation in the degree of transmission from year to year, and major epidemics may occur in years of heavy rainfall as experienced during 1993, 1996, 1997 and Transmission occurs in the rainy season between November and May and occurs mainly in the north of the country. Significant numbers of malaria cases generally appear in early January, peaking in the months of March and April. Transmission is most severe in the extreme north (Chobe, Okavango and Ngami) and less intense in adjacent districts to the south (Boteti and Tutume). There is a need for WHO to continue to support the Ministry to monitor and evaluate the performance of the malaria control programme. As shown in Figure 4, there has been an increase in malaria morbidity over the past decade. However, there still remains a difference between confirmed and unconfirmed malaria cases and clinical cases reported. This gap needs to be closed by improving capacity for confirmation of malaria diagnosis in the peripheral health facilities. As can be seen, the incidence of malaria has been increasing annually, although, fortunately, the case mortality rate has remained low. Malaria therefore remains a concern for the government. 9

22 People and Government Figure 4: Malaria notification, Source: Malaria Annual Report Epidemiology Unit, Community Health Services Division, MOH Botswana Vaccine-preventable diseases Table 2: Immunization coverage, Year/Antigen 22 BCG HBV3 DPT3 Polio3 Measles % 69% 82% 73% 80% % 70% 85% 82% 74% % 73% 85% 85% 84% % 64% 74% 75% 77% Source: Immunization Tally Sheets Report Family Health Division, MOH Botswana The low and falling immunization coverage (as observed from Table 2 above) is a concern for both WHO and MOH. It is acknowledged that this development is a symptom of a weak health system attributed largely to weak or absence of "district health management system". The review of MOH organizational structure is, amongst other things, intended to address this constraint. Furthermore, an external review of the EPI programme is required to fully understand the factors contributing to the fall in immunization coverage. 10

23 People and Government Noncommunicable diseases A draft report on the Botswana rapid situation analysis of noncommunicable diseases in 2001 showed that they are on the increase. 1 Health facility data were used for this study. There has been a significant upward trend in the notification of cardiovascular diseases over the last 20 years. Reported cases of hypertension increased from less than a hundred cases in 1980 to about 2000 cases in Equally, the 1600 cancer cases reported in 1996 are about four times more than the number reported in Reported cases of mental disorder increased from about 100 in 1980 to about 1500 in As far as diabetes mellitus is concerned, no conclusion could be drawn as data from only one health facility was available. More data is required. There is therefore a need for further situation analyses, to determine the burden of these diseases in the country. The country also has a problem of blindness among the elderly due to cataracts. Road traffic accidents could be Botswana's second major public health problem after HIV/AIDS. Road traffic accidents just like HIV/AIDS affect the young adults. There have been reports from the police of increases in both morbidity and mortality due to road traffic accidents every year especially during the festive seasons and public holidays. Reproductive health and gender Maternal mortality: The country does not have up-to-date statistics on maternal mortality. The latest estimate puts the maternal mortality rate at / live births. 29 The 1999 health statistics report showed that out of births, 41 women died from pregnancy- related causes in health institutions. 21 The major causes of death include HIV/AIDS, complications related to pregnancy and abortions. However, there is a need to conduct a study to ascertain the current maternal mortality rate. Mainstreaming of gender issues into health service delivery: Women in Botswana have made great gains in education, health and employment since independence. However, there are a number of economic and socio-cultural practices, as well as laws, which work against women's empowerment and full participation in society. Of particular concern are issues of unequal access to training and employment, rising levels of violence against women, and higher levels of poverty amongst women. Women are also greatly affected by the HIV/AIDS epidemic: young women have higher levels of HIV infection than young men, and female-headed households have more dependants than male-headed ones. Female-headed households also have fewer income earners and take on most of the care of the sick. 11

24 People and Government 2.6 Health delivery system Government partners in health The Republic of Botswana delivers health services through a network of hospitals, clinics, health posts and mobile stops (for hard-to-reach citizens). It is estimated that 90% of the health services are provided directly by government or by statesubsidized mission health facilities. The rest are either provided by private hospitals run by mining companies for their employees or by private practitioners. The public health services in Botswana are delivered by the Ministry of Health and by the Ministry of Local Government. The Ministry of Health is responsible for policy and guideline formulation and the provision of secondary and tertiary care, while the Ministry of Local Government is responsible for the delivery of PHC services. An arrangement between the Ministry of Health and the Ministry of Local Government for supervision of the PHC services is in place. The Ministry of Local Government has responsibility for delivering primary health care services through district health teams (DHT); policy is overseen by a PHC Unit at the central level, who take responsibility for adapting technical policy from the Ministry of Health into guidelines for use by district health teams. The MOH has seconded medical officers with public health expertise to the local government in all districts; most of these officers are expatriates. However, TB and EPI programme reviews showed that this way of sharing the health workload between two ministries does not always produce the desired results. WHO should facilitate improved partnerships between the Ministry of Health and the Ministry of Local Government on health matters. Table 3: Health facilities by type and numbers in Botswana Type and number of health facilities Government Private Mission National referral hospitals 3 1 District hospitals Primary hospitals 17 Clinics 239 Health posts 326 Mobile stops 810 Source: Master Health Facility List 2002, Ministry of Health, Botswana. 12

25 People and Government Private sector There is a good history of collaboration between the state and mission health services. Currently the state subsidizes all the running costs of the three mission hospitals operating in the country. There is however a strong private health sector developing in the country. The mining sector runs three hospitals for its employees, two of which also provide medical services to the surrounding population. A private hospital in Gaborone opened its doors in 1992, and several private medical surgeries are also operating in the country. With the current acute shortages of medical human resources there is a need to foster closer cooperation between the public and private health sectors, which WHO could support. Table 3 above shows that 80% of the nursing cadre, 11% of all medical doctors and about 25% of the dentists are Batswana. The situation is similar for other degree-trained cadres such as bio-medical engineers, pharmacists, physiotherapists, radiographers, etc. Staffing Table 4: Type of health workers and ratio by population in Botswana, 1999 Type of health worker Number Number of Expatriates Ratio per present citizens population available Medical doctors : 3440 Dentists : Nurses : 410 Family welfare educators : 649 Pharmacists : Environmental health officers : Source: Health Statistics Report 1998, Republic of Botswana 13

26 People and Government Table 5: Government health manpower profile as of Health Establish- Filled Number Vacancy No. of Number Expatriate personnel ment posts of vacant rate locals of expa- rate register posts triates Medical doctors % % Dentists % % Nurses % % Other health (-141) (-7%) % professions Total % % Source: National Health Manpower Plan for Botswana The public health sector has a significant vacancy rate as shown in Table 4. The health staff shortage situation has been aggravated by recent events, including the migration of Batswana nurses to developed countries, changing of professions by nurses and additional workload brought about by the HIV/AIDS epidemic. New HIV/AIDS interventions such as voluntary counselling and testing services, prevention of mother-to-child transmission and antiretroviral treatment of people living with HIV/AIDS have also placed additional burdens on the system. Essential drugs and laboratory services Pharmaceuticals are supplied through a central medical stores that purchases these supplies in bulk. A system of regular distribution of drugs from the central medical stores to outlying health facilities is in place. However, the system has started to show signs of strain, due to long distances that have to be covered, the increased frequency of deliveries to facilities and the limited storage space in the pharmacies of these facilities. The network of district laboratories in the country, supported by a state of the art laboratory in the country's referral hospital, is functioning well, although there are staff shortages from time to time. Safe blood transfusion services have been maintained, with a good quality control system in place. 14

27 People and Government 2.7 Determinants of health Access to health services Eighty-eight per cent of the population lives within 15km of a health facility, although the new target is set at 8km. The health services are heavily subsidized by government. Only a standard charge of Pula 2 (30 US cents) is payable for utilization of outpatient services. However, no one is denied services for lack of the fee. Most preventive services such as antenatal care for pregnant women, child welfare care services, TB, HIV/AIDS treatment and care for children below 12 years are exempted from user-fees at government facilities. There are recent moves, however, aimed at cost recovery. These include higher fees for services for non-nationals. The high health-care subsidy has facilitated universal access and utilization of health-care services, especially primary health-care services. Water and sanitation Botswana has made great strides in the area of safe water provision and good sanitation. Ninety- seven per cent of the population has access to safe drinking water (100% in urban areas and 94% in the rural areas). Eighty-four per cent of Batswana use sanitary means of excreta disposal. Poverty According to the BIDPA report of 1996, 47% of the population is living below the poverty line of 100 Pula per person per month. The poverty is rooted in the country's adverse climate, narrow economic base, and high levels of unemployment. About 15.8% of the labour force is unemployed 3. This has been further exacerbated by the impact of the HIV/AIDS epidemic. Government has put in place several safety nets to assist the elderly, the destitute, needy children, orphans, remote areas dwellers, TB patients, people with disability and war veterans. Access to health services in Botswana is generally good. A Poverty Reduction Strategy Paper has also been drafted. Droughts and nutrition As noted earlier on, the erratic and low rainfall is responsible for frequent droughts and consequently low food production in the country. Government has measures in place to mitigate the effects of the famine on people. Drought relief programmes are in place to address food shortages, including labour-based public works programmes for adults and food supplementation for all other vulnerable groups. Nevertheless, 15

28 People and Government 15% of children under the age of five are underweight. Twenty-three per cent of children are stunted or too short for their age and 5% are wasted or too thin for their height. 2.8 Health sector financing Health expenditure in Botswana for the last two decades has averaged 5-8% of the national budget. 3 On average, the country spends 2% of its GDP on the health sector. Seven per cent of national public expenditure is allocated to health. This overall health expenditure includes expenditure by government, the private sector, local governments and the traditional health sector. Due to the HIV/AIDS epidemic, government expenditure on health has risen sharply in the recent past. In 2000/2001, the public health budget increased by 32% the largest increase in any sector. 3 The previous year, this increase was 26%. The Government of Botswana has provided funding for about 90% of national HIV/AIDS prevention and care activities. Total recurrent expenditure on health during the 2000/2001 financial year was Pula. Total recurrent public health expenditure (by the Ministry of Health) in 2000/2001 was P which represents a per capita health expenditure of P (US$ 109.3). During the same financial year (2000/2001), recurrent expenditure on health by the Ministry of Local Government (PHC services) amounted to P The P budgeted under the Ministry of Local Government is not the only allocation to PHC at district level. Other major PHC interventions and their expenditure {which include primary hospitals (17), district hospitals (6), drugs and medical supplies (centrally procured and distributed without costing this to any cost-centre), seconded staff, supervision of and refresher training for national primary health-care programmes such as EPI/IMCI, Malaria, TB, MCH, Mental Health, Environmental Health} are all directly undertaken and financed from the MOH recurrent budget. It is therefore important to note that apart from health expenditure by the Ministry of Local Government on PHC services, a significant proportion (15.8%) of recurrent MOH expenditure is on PHC. There is a need for the development of national health accounts in Botswana to disaggregate health expenditure. 16

29 People and Government The National Development Plan for the period (NDP 8) has provided an estimated Pula 2.67 billion for the development of the health sector (new initiatives, programmes, physical infrastructure, etc) during the same period. Of this amount, 14.9% is allocated to the National AIDS Coordinating Agency (NACA), 70.5% to the Ministry of Health and 14.6% to the Ministry of Local Government. This expenditure on the health sector represents 10.3% of the government's total expenditure on development. Table 6: Health expenditure in Botswana, 2000/2001 (6a) Ministry of Health Expenditure 2000/2001 Actual Recurrent Expenditure Hospital services 64.6% Headquarters 18.4% Primary health care 15.8% Special programmes 0.7% (6b) Ministry of Local Government Expenditure 2000/2001 Actual Recurrent Expenditure Clinics, health posts & mobile services 68.4% Community-based health care 5.2% Environmental health 26.4% Source: Government of Botswana Estimates of Expenditure from Consolidated Development Funds The government finances almost the entire budget of the public health sector. It provides 90% of the HIV/AIDS budget and 100% of expenditure on PHC and all curative services. The rest (10%) of the HIV/AIDS budget is financed by bilateral and international organizations. 2.9 Health systems challenges Human resource challenges The objective of the human resource development policy of the Ministry of Health is "to ensure that the right numbers of staff are available at the right place, at the right time, and with the appropriate skills and motivation to deliver health-care to the population." 28 However, there have been major problems in its implementation. 17

30 People and Government (i) The development of physical infrastructure has outpaced the development of human resources to service it. This has been compounded by the HIV/AIDS epidemic, which has created massive needs to be met by the public health system. There is a high attrition rate of heath workers in general and nurses in particulmar. (ii) Manifestations of the human resource crisis in the health sector include: (a) High attrition rate due to natural wastage (deaths, retirement and abnormal resignations); (b) Obligation for nurses to perform the functions of doctors, laboratory technicians, pharmacy technicians, cleaners, porters, etc. because of the general acute shortage of cadres of health professionals/ technicians; (c) Non-respect of traditional nursing staffing norms as a result of a high proportion of long-term 'dependent patients' suffering from HIV/AIDS, TB and noncommunicable diseases; (d) High proportion of sick health-care providers, especially nurses. (iii) Other contributing factors are: (a) Rigid registration, legislation, accreditation and recruitment requirements that have negatively affected the number of nursing staff, especially nurse midwives, tutors, etc; (b) Changes in remuneration packages, e.g. reduction of inducement allowances for expatriate expertise, have reduced our capacity to recruit, attract, motivate and retain professionals in service, especially doctors, biomedical scientists, public health specialist, nurses, etc; (c) Introduction of new interventions and programmes for prevention and mitigation of the spread of HIV/AIDS epidemic has increased the workload of the already overstretched workforce, e.g. nurses and doctors. These additional tasks include: VCT, ARVT, PMTCT and CHBC. All this has resulted in increases in the 'burnout syndrome', which is impacting negatively on the levels of staff motivation and performance as well as on the retention of critical health personnel in service. 18

31 People and Government To help alleviate this human resource crisis in Botswana, WHO has over the years been assisting the country in the areas of pre-service training (including sponsoring of 20 medical students in Ghana), in-service training, short courses, workshops and more recently a study on the review of the salary structure for public health workers, and an organizational review of the Ministry of Health. Human resource development remained a top priority during NDP 8. However, there is a need to assist the country to address the current staff shortages so as to handle the additional workload effectively. The present assistance with restructuring of the Ministry of Health should be continued to address some of the new challenges identified. The issues of human resources policy, strategies, and management also need to be addressed critically. Health-care financing Cost sharing 6 A study whose general objective is to determine the performance of the existing medical aid systems regarding efficiency, equity and sustainability of the health sector has been commissioned. The results of this study will provide guidance on how health costs could be shared between the government and individuals. Health insurance Growth in private health care services in Botswana has been partly linked to the expansion of medical aid schemes, which include public service, parastatals, and large and medium size companies. Participants in these schemes are more likely to use private health care services, especially for acute illnesses, than public health facilities. Low-income employees are usually excluded from medical aid schemes because of their limited capacity to afford the required contribution. Community contributions Botswana has no experience with community-based health financing because the country has not undergone the health-care financing crisis faced by many countries in the African Region. However, in the past decade it has instituted various components of health sector reforms and now wants to explore the feasibility of adding more components, including cost-recovery. 19

32 People and Government Essential drugs The availability of drugs in health care institutions is perceived by the general public as one of the main components of quality health care. The supply of drugs to the public and mission health facilities is largely the responsibility of the central medical stores, the main unit of the Division of Pharmaceutical Services. The supply of drugs is entirely subsidized by the MOH. Effectively, there is no cost recovery system (drugs are provided free to patients). The relative 'abundance' of drugs has been quoted as having a negative bearing on the prescribing practices of health workers; sometimes leading to wastage (due to overstocking and subsequent expiry of drugs). This situation raises the issue of allocative efficiency. 14 Some shortages of both pharmaceuticals and especially vaccines have been reported. 2 Although commodities may be available at the central medical stores, the same may not be available at the peripheral health facilities. A thorough review of the pharmaceutical distribution and general logistical system is needed. Health management information system and evaluation of health service performance WHO has been assisting the Ministry of Health with the evaluation and assessment of its various programmes as well as with the setting up of a surveillance system for priority diseases. This support needs to be strengthened. The Ministries of Health and of Local Government expressed the need to be supported to review and strengthen the Botswana health management information system in order to enable them to monitor their operations better. 20

33 Development Assistance and Partnerships 3 DEVELOPMENT ASSISTANCE AND PARTNERSHIPS 3.1 Major development agencies in the health sector Nongovernment partners: private and UN A number of bilateral and multilateral partners and NGOs support the Ministry of Health to fulfill its mandate. These partners are coordinated through the Ministry. However, its capacity to coordinate a growing number of partners is limited. United Nations in Botswana United Nations Development Assistance Framework [UNDAF] ( ): This has recently been finalized and covers three priority areas: poverty, HIV/AIDS and environment. The UN resource allocation for this period is US$ , of which US$ (20%) is from WHO. A further US$ is projected to be mobilized for the three UNDAF priorities, of which US$ (44%) is earmarked for HIV/AIDS. Whilst considerable joint effort has gone into developing the Common Country Assessment (CCA) and UNDAF and all the UN agencies are housed in one building, strategic planning still takes place on an agency-by-agency basis. However, Botswana is one of the United Nations Development Group (UNDG) priority countries whose systems have to be harmonized. UNDP focuses on the three UNDAF priority areas that include some projects on HIV/AIDS. At the request of the government, it was involved in the development of the first draft National Strategy for Poverty Reduction Botswana. It is about to coordinate support to the government in the development of indicators for 'Vision 2016'. UNICEF is currently formulating its strategic priorities for the future. It has handed over much of its programmes to government and partners in Botswana. Its work in health now focuses on HIV/AIDS, in particular PMTCT and technical support to breast and substitute feeding policy. UNAIDS secretariat has new leadership in the country and will be the body through which the United Nations effort on HIV/AIDS prevention and control will be coordinated within the country. 21

34 Development Assistance and Partnerships UNFPA focuses its efforts on the introduction of HIV/AIDS into the reproductive health agenda of the country. It also tackles the significant problem of violence against women by promoting more inclusive polices aimed at men. A concern expressed by UNFPA is the lack of reliable information on the level of maternal mortality in Botswana. UNHCR takes care of the health of refugees. It ensures, among other things, that areas concerning child health are covered. WHO is the main partner providing leadership in health development. FAO and ILO, though not resident in the country, are active development partners. Others In the past, bilateral and multilateral agencies played a role in financing the development of the physical health infrastructure and providing technical support for health activities and programmes. Among the several bilateral agencies that were involved in the health sector were NORAD, SIDA, USAID, and DANIDA. Since the 1990s, there has been a discernible decline in external funding for the health sector in Botswana because the country was reclassified as a lower middleincome country. However, several agencies are returning to Botswana due to the burden of the HIV/AIDS epidemic. Multilateral and bilateral agencies that are currently involved in health and health-related activities are: (a) (b) Multilateral agencies: The European Commission is supporting HIV/AIDS preventive programmes. Bilateral agencies: The Department for International Development (DFID) is providing limited funds for HIV/AIDS. Cuba and the Peoples Republic of China have been providing an increasing number of health professionals to work as specialists in Botswana. The US Government provides support mainly through funding the technical collaboration of the Centers for Disease Control (see BOTUSA below). Subregional cooperation SADC has defined three priorities in health for the region: HIV/AIDS, TB and malaria. It is already implementing some projects in these areas, and is hoping to increase the number of projects by enlisting the help of the Global Fund for HIV/AIDS, TB and Malaria. The SADC health desk will soon move from Pretoria to Gaborone, providing an opportunity for the WHO country office to improve two-way communication 22

35 Development Assistance and Partnerships between SADC, the WHO Regional Office for Africa and the other 14 WHO country offices in SADC, in line with the Memorandum of Understanding agreed upon between SADC and the Regional Office. International foundations and partnerships The African Comprehensive HIV/AIDS Partnership (ACHAP) has been set up with funds from the Merck Company and the Bill and Melinda Gates Foundation. It works closely with the Government of Botswana and is also directly funding a comprehensive set of HIV/AIDS interventions such as prevention, mitigation, care, counselling and support. It will provide US$ 100 million over a period of five years, principally to support the ARV project in the Ministry of Health. The Botswana Harvard Partnership (BHP) is overseeing a variety of highquality research programmes, including the development of a diagnostic test and the setting up of a preventive HIV/AIDS vaccine trial which is due to start later this year. In partnership with the Government of Botswana and Bristol Myers a state-of-the-art HIV/AIDS reference laboratory was set up. BOTUSA is US backed collaboration with the Government of Botswana involving the Centers for Disease Control in Atlanta. BOTUSA also provides HIV/AIDS, TB and STD programme support, including research. Bristol Myers Squibb support funding of community-based projects for HIV/ AIDS and research through the 'Secure the Future' programme. 3.2 Mechanisms for donor coordination (a) (b) (c) Health sector coordination: Mechanisms to coordinate all of the government's health programmes, together with those funded by international agencies, are currently weak. The Minister of Health has proposed the creation of a health sector coordination mechanism in the form of a health partnership forum. A SWAP mechanism has been recommended in the recent review of the reorganization of the Ministry of Health. HIV/AIDS: (i) National Aids Coordinating Agency (NACA): This is the national agency for HIV/AIDS coordination. WHO will provide technical support to the agency as required. 23