Botswana Health Profile 2012

HEALTH & DEVELOPMENT
Socio-economic situation and Determinants of Health
The stable democratic governance coupled with the natural endowment with mineral resources is facilitating very high rates of economic growth in Botswana, which is classified as a middle-income country. In the period 1999/2000 and 2004/2005, the total GDP grew at an annual rate of 8%.
However poverty rates are fairly high for a country of Botswana’s income level and income inequality is also high. Nationally, 23.4% of the total population lives on less than a dollar a day. The percentage ranges from 5.1% of cities/towns, to 19.3% of the urban villages and as high as 36.1% of the rural populations.1 Nevertheless, poverty rates have been falling steadily as the economy has grown. Unemployment also remains high for a middle-income country. About 23.8% of the labour force in Botswana was unemployed in 2002/2003. These included 60.4% of the senior secondary school leavers (aged 20 to 24 years)1. It was also reported that the number of unemployed graduates is on the rise. The Government encourages private sector development in its efforts to create job opportunities. There is however the need to collect up to date data on poverty and unemployment so as to accurately assess the rate of poverty reduction, which is the measure related to MDG 1 (Eradicating extreme poverty). The national literacy rate in 1993/94 was 68.9%, and increased to 81.2% in 2003/04. Botswana’s education policy has focused on achieving universal access to primary education, and more recently on providing ten years of universal education. It has also aimed at eliminating gender disparities in educational access and on providing the skills needed to meet the demands of a modern economy. Considerable progress has made with regard to gender equality, in that many previously discriminatory laws have been reformed and women enjoy reasonably equal access to jobs, education and health care. Nevertheless, women experience higher poverty rates than males, higher unemployment, lower pay for similar work, and are victims of
violent crimes (rape and femicide), partly because cultural attitudes that hinder women’s progress are changing more slowly than the formal legal environment. Therefore attaining MDG 3 (Gender Equality) in Botswana requires more to be done with regard to female empowerment in the economy and decision-making. As in 2007 about 90% of the rural and all the urban populations have access to improved drinking water supply.  Improved sanitation coverage is 60% in the urban and 30% in the rural areas. Vulnerable populations in Botswana include people with disabilities and orphans; the latter increasing rapidly as a result of HIV and AIDS. However, Government programmes to support orphans and those caring for them appear to have been effective at reducing, although not eliminating their vulnerability to poverty and abuse. More generally, opportunities for the youth are limited once they leave school, resulting in twin problems of youth unemployment and rising crime rates.

Development Policies and the MDGs
The overall guiding document for national development in Botswana is Vision 2016, a broad based national approach adopted in 1996 focusing on the aspiration of Botswana towards the 50th anniversary of their Independence. Vision 2016 comprises seven pillars that resonate strongly with the Millennium Development Goals. The principles and objectives of Vision 2016 guide the formulation of revolving 6-year National Development Plans (NDP). The current NDP 9 expires in 2009, and the follow up NDP 10 is being formulated. Strategic and annual performance plans are developed towards attaining the health goals set in the National Development Plans. The process of revising the national health policy commenced with WHO technical support, and more support is required for its completion. A formal assessment of Botswana’s progress towards the Millennium Development Goals was conducted in 2004 in line with the Vision 2016 objectives. It was noted that the country was making good progress towards achieving the MDGs (UNDP & GoB, 2004). The monitoring of progress towards some of the MDGs is hampered by data inadequacies.

Health Systems issues and challenges in organization and management
The Ministry of Health (MoH) is responsible for the formulation of Policies, norms, standards and guidelines for health services delivery as well as  the provision of secondary and tertiary care whiles the Ministry of Local Government (MLG) is responsible for the delivery of Primary Health Care services through District Health Teams. In addition 2 Departments of MoH (Public Health and AIDS Prevention and Care) manage programmes that are largely implemented at the District levels and have to deal directly with District staff. Thus the responsibilities of the 2 Ministries can be said to meet at the Districts. The precise roles and responsibilities and coordination between the two Ministries are however still not clearly defined at the operational levels.

Restructuring of the Ministry of Health
WHO has provided both financial and technical support to the restructuring of the Ministry of Health to address the changing health environment and improve performance. Intense advocacy was also provided for the adoption of the revised structure. The Ministry of Health now has six Departments (each comprising of Divisions and some having Units), all headed by Directors. (The Department of Policy, Planning, Monitoring and Evaluation; Department of Health Sector Relations and Partnership; Department of Clinical Services; Department of Public Health; Department of HIV & AIDS Prevention and Care; Department of Ministry Management). The two new Departments are vital in coordination and monitoring of wider stakeholders in health development. However two years following the recruitment of Directors the creation of appropriate structures at the Departmental level, particularly in the new ones, is yet to be realized.

Access and quality of health services: In addition to an extensive network of 101 clinics with beds, 171 clinics without beds, 338 health posts and 844 mobile stops PHC services in Botswana are integrated within overall hospital services, being provided in the outpatient sections of Primary, District and Referral hospitals. These facilities should be enough to provide optimal services for the population however factors affecting access and quality include unequal distribution of health facilities per population, low ‘after hour’ services, and variable utilization of services (bed-occupancy, length of stay for in-patients etc). In  addition the commodity supply chain has also been problematic and stock outs of various commodities have been experienced. There is a need to establish set norms for distribution of PHC and hospital facilities and their use per population. This will be done within the context the comprehensive integrated services delivery plan that is currently under development. The availability and management of staff, mix of skills, equipments, medical supplies and the referral system are among the other issues that need to be addressed to improve access and quality of services.

Human resources
Shortages of Human Resources for Health remains one of the major “bottle necks” in health improvement as it is a cross-cutting issue that influences the delivery of services. Despite government’s efforts in increasing the capacities of health training institutions, human resources for health have been in short supply largely to work conditions of health staff, attrition is thought to be high (precise data on the rate of national attrition is not available) and some de-motivating factors affecting skilled staff. The Government has begun to address these issues. There are also increasing demands on the already over-stretched skilled work force due to HIV/AIDS. A long term Master Plan for Human Resources for Health has been finalized. Efforts will now be directed towards the implementation of the Plan in a sustainable manner by the full participation of all relevant stakeholders.

Health financing
National Health Accounts has been developed for the identification and monitoring of public, private and donor health financing so as to assess efficiency, effectiveness and equity. A National Health Accounts Report for based on data up to 2002 has been produced. The report highlighted the need to diversify the sources of funding for sustainability. A large proportion (Over 80% of Total Health Expenditure (THE) is provided by the Government. THE as a percentage of Gross Domestic product gradually increased from 6.43% in 2000, to 9.27% in 2001 and 10.54% in 20021.
Current reports indicate that Government spending has exceeded the 15% set by the AU during the 2001 Abuja Summit. Government funding for health in 2002 is delivered through the Ministry of Health (56%), Ministry of Local Government (7.88%), National AIDS Coordinating Agency (9.42%) and Ministry of Education (2.96%), the rest received by private health financing agents, (Insurance schemes, Household, NGOs and private firms). In the public services, a cost recovery system has recently been increased from P 2 per person per visit to P 5 for Botswana. Foreigners pay more, depending on the services. Services such are ART services are offered free to citizens, but foreigners are expected to pay. The international agencies contribute modestly but growing amounts to health care in Botswana

Health Management Information Systems
The paucity of relevant health information necessary for planning, timely interventions and monitoring and evaluation remain a big challenge in the Health Sector. Progress has been made in some programmes, particularly HIV/AIDS, but generally there is low articulation and use of data, which results in inadequate evidence-based planning monitoring and evaluation. In addition there are inconsistencies in the health information, particularly related to the main indicators, reported by different programmes and partners, including the UN agencies. Generally there is shortage of skilled staff in data management in all sectors and low capacity in the Health Statistics Unit. The partnerships in health development and the current momentum for scaling up of interventions towards achieving the set targets of the health related MDGs provides good opportunities for improving health management information systems.