Botswana has one of the best public health care systems in Sub-Saharan Africa, and sustained investments continue to be made in the sector to enable access to quality health care services.
Botswana’s Health Care Strategy (2017-2023) consists of a four-pronged strategic approach to service delivery. The key components comprise: strengthening prevention interventions; improving access to quality health care services for all; strengthening rehabilitation services; and providing sustainable health and health care services for all. This includes policies and strategies such as the School Health Policy; Sexual and Reproductive Health (SRH)/HIV Linkages; Malaria Elimination; Early Child Development Programme and Eye Health Care Strategy in order to attain the United Nation’s Sustainable Development Goals (SDGs).
In terms of health financing, Botswana has achieved the Abuja target of allocating 15 percent or more of the total budget to health. In 2021/22, the third-largest share of the proposed ministerial recurrent budget of P7.90 billion (15.6 percent) was recommended for allocation to the Ministry of Health and Wellness; an increase of 2.1 percent over the 2020/21 budget. It mainly covers the cost of provision for drugs, dressings and vaccines, including the anti- retroviral therapy programme, and laboratory supplies. Other substantial budget items include medical specialist fees, budgetary provision for the Public Officers’ Medical Aid Scheme, and maintenance of health facilities.
Additional funding has been included in the budget to further support interventions to contain the Covid-19 pandemic and to mitigate the risks of new infections, spread or resurgence of the disease. The funding comprises personal protective equipment for public health personnel and other support frontline workers, medicines to combat the virus, quarantine costs and acquisition of vaccines in line with the agreement with the World Health Organisation (WHO).
Through the revised National Health Policy, Government is pursuing the delivery of quality universal health care services with the objective of attaining ‘Health for All’ by 2036. The policy is also consistent with the commitment of ensuring healthy lives and promoting well-being for people of all ages, in line with Sustainable Development Goal 3.
The e-Health Strategy for 2020-2024 was successfully launched in March 2020, and should improve access to healthcare, better patient outcomes, access to health information, as well as monitoring and evaluation. To this end, the development of a home-grown Centralised Electronic Medical Record (EMR) system is underway. It is envisaged that once complete, the system will replace the use of paper-based medical patient cards and assist in building an Electronic Health Record.
Government is planning to establish the Botswana Public Health Institute to assist in developing, strengthening and maintaining the country’s capabilities to detect, assess, notify and report events deemed to present public health risk and public health emergencies.
In order to reduce deaths and injuries from road traffic accidents, Emergency Medical Service (EMS) units have been established to provide life-saving out-of- hospital medical care and transportation of patients to definitive care. In implementing the EMS Policy, and in recognition of the time-sensitive nature of such services, nine EMS centres have been established at Gaborone, Lobatse, Mochudi, Mahalapye, Palapye, Selebi-Phikwe, Francistown, Maun and Kasane. The service is to be rolled out to other areas; namely, Molepolole, Jwaneng, Kang and Ghanzi. As a long-term strategy, Government will establish a centralised national EMS call centre to coordinate all emergency calls and dispatches.
In Botswana, life expectancy at birth had by 2019 increased to 69.6 years from a low of 50.6 years in 2000, according to the United Nations Development Programme (UNDP).
The index case of Covid-19 in the country was recorded on 31 March 2020. Almost a year later, as at 16 March 2021, Botswana had registered a cumulative total of 34 999 cases, with 29 916 recoveries and 447 Covid- related deaths.
In order to contain the spread and transmission of the virus, a Presidential Covid-19 Task Force, chaired by President Masisi and comprising cabinet, dikgosi, scientists, health experts, the private sector and civil society, was established to work in collaboration with Government and other
stakeholders to coordinate all Covid-19 related activities. As at the beginning of November 2020, a total of P2.134 billion had been directed to the Covid-19 Relief Fund, of which P2.0 billion was seed capital from Government and P134.557 million made up of contributions from individuals, civil society organisations, the private sector and development partners. The relief fund has been directed towards areas such as wage subsidy, food relief, health supplies, education, and support for citizens in the diaspora.
The key aspects of the control strategy for Covid-19 include: influencing behavioural change through public education; implementation of sanitary measures; and enforcement of face coverings; as well as contact- tracing, quarantining and testing those exposed. General movement restrictions were therefore imposed on non- essential travel and gatherings and a State of Public Emergency was approved.
Measures which have been taken to combat the pandemic include setting up porta cabins at six ports of entry to facilitate testing, sample storage and the temporary holding of suspected cases. Government also procured and installed thermo-scanners to facilitate screening at border gates, and has identified, maintained or converted various facilities across regions and zones into isolation centres to admit patients who have tested positive for Covid-19.
Covid-19 exposed a number of inadequacies in Botswana’s health system, specifically the ability to deal effectively with public health threats and emergencies. As such, the capacity of the National Health Laboratory was enhanced to process 5 000 tests per day against the previous 500. Further improvements to raise laboratory capacities to 10 000 tests per day are ongoing. Additional laboratories have been built at Mamuno, Kasane and Maun.
The availability of a safe and effective vaccine for Covid-19 is a critical step towards the control of the pandemic. Botswana is among the countries that have joined the COVAX Facility. On 9 March 2021, Botswana received a consignment of 30 000 Oxford-AstraZeneca vaccines, which were a donation from India. The plan for the vaccine rollout will be communicated at a later date.
HEALTH INDICATORS & PROGRAMMES
In Botswana, child health focuses on Integrated Management of Childhood Illnesses, the Expanded Programme on Immunisation, and Early Child Development Programmes. According to the WHO, there has been a significant reduction in the Infant Mortality Rate, from 51 per 1000 live births in 2001 to 17 per 1000 live births in 2019. Similarly, the under-five Mortality Rate has reduced from 76 per 1000 live births in 2001 to 41 per 1000 live births in 2019.
The SDGs commit countries to reduce the global maternal mortality ratio to less than 70 deaths per 100 000 live births, as well as advocating for births being attended to by skilled health personnel. Botswana’s Maternal Mortality Ratio Statistics Brief (2014–2019) states that 87 maternal deaths were reported in 2019 from 52 304 live births, translating to 166.3 deaths per 100 000 live births. This is despite the Maternal Mortality Ratio having declined steadily between 2016 and 2018, from 156.6 to 133.7.
The most common direct causes of maternal mortality are immediate postpartum haemorrhage (15 cases), followed by genital tract and pelvic infection as a result of abortion, ectopic or molar pregnancy (11 deaths). Among the indirect causes complicating pregnancy, childbirth and the puerperium, the most common were diseases of the circulatory system (ten cases), followed by other maternal infections and parasitic diseases (seven deaths).
The 2019 Statistics Brief indicates that an overwhelming majority of mothers, some 99.8 percent, gave birth in a health facility, supervised by a skilled health professional.
Substantial financial, human and material resources are allocated to treating communicable and non- communicable diseases. In the case of communicable diseases, tuberculosis (TB) remains a public health challenge in Botswana. As reported by the WHO, the incidence of tuberculosis is 253 per 100 000 population per year (2019).
In line with WHO targets, Botswana’s immunisation programme has maintained coverage above 90 percent for over a decade. Since 2010, several new vaccines have been introduced, including: Haemophilus Influenza Type B, Measles second dose, Pneumococcal, Rotavirus, Human Papilloma Virus (HPV), Inactivated Poliovirus Vaccine and Measles Rubella.
Botswana is reaching the elimination phase for both neonatal tetanus and measles. The last reported case of indigenous polio was in 1989 and of imported polio in 2004, with no further cases reported since then. Between 2000 and 2016, there was a 99 percent reduction in cases of malaria, from 17 555 to 716, accompanied by a 94.6 percent decrease in deaths, from 56 to just three. In 2018, the incidence of malaria per 1000 of the population at risk was 0.59.
In spite of the significant progress made towards achieving the elimination of malaria in the country, by the beginning of the malaria transmission season in October 2019, a total of 936 cases had been registered, surpassing the transmission rate of 585 cases recorded in the same period of 2018.
Non-Communicable Diseases (NCDs) have emerged as a leading cause of mortality, and now exceed deaths due to TB, malaria and HIV combined. NCDs include conditions such as hypertension, stroke, cancer, asthma and diabetes. Their main causes are smoking, harmful use of alcohol and drugs, an unhealthy diet and physical inactivity.
The increasing incidence of obesity among the population has been detrimental health outcomes; leading to reduced
quality of life and workforce productivity; chronic health problems such as high blood pressure, cardiovascular disease and diabetes; and escalating health costs. Among the contributory factors is the increased consumption of sugar-sweetened products, especially beverages.
The NCD Strategy (2017–2022), emphasises a multi- sectoral approach for diseases that are influenced by lifestyle choices. The Control of Smoking Act of 1992 is being reviewed in order to strengthen protection of citizens. To address the ongoing concern surrounding alcohol and substance abuse, and the urgent need for treatment of those affected, a draft National Health Rehabilitation Policy is being developed. In addition, the design and review process to convert an existing facility in Francistown to a specialised Health Rehabilitation Centre is ongoing. The centre will treat individuals with trauma and neurological conditions.
In response to the increasing incidence of cervical cancer, new screening and treatment methods have been introduced for pre-cancerous lesions of the cervix. These steps are being bolstered by the introduction of the HPV Vaccine. There has been a reduction in Pap smear turnaround times from six months in 2012 to the current six weeks. This has contributed to a reduced number of complications for women with pre-cancerous lesions.
THE HIV/AIDS EPIDEMIC
Botswana has demonstrated strong commitment in responding to its HIV epidemic. It was the first country in Sub-Saharan Africa to provide universal free antiretroviral treatment (ART) to people living with HIV, paving the way for many other countries in the region to follow. The impact of its treatment programme has been widespread. Although the main mode of HIV transmission is heterosexual, the epidemic has also spread along the fault lines of socioeconomic development such as gender inequality, poverty, food insecurity and gender-based violence, among others. According to the WHO, as at 2019, new HIV infections per 1000 of the uninfected population stood at 5.42 for females and 4.18 for males.
Botswana subscribes to UN’s Sustainable Development Goals (SDGs) which, among others, commit UN member countries to achieving universal access to health services and ending AIDS by 2030. Significant progress has been made over the years, and the country has reached a point where mother-to-child transmission is nearing elimination; free ARV treatment has been expanded to non-citizens; and other prevention programmes have been scaled up, such as TB preventive therapy and cervical cancer screening and treatment.
Botswana was the first country in eastern and southern Africa to provide free and universal treatment to people living with HIV. Adopted in 2015, the Option B+ Strategy aims to enrol all HIV positive women on ART for life in order to eliminate mother-to-child transmission. At the same time, Government adopted the Treat All Strategy, whereby all people testing HIV+ are put on treatment immediately, irrespective of their CD4 count. This is in addition to HIV Testing Services and community engagement programmes such as Communities Acting Together to Control HIV (CATCH).
The UNAIDS 90:90:90 Strategy aims to have 90 percent of people living with HIV knowing their HIV status, 90 percent of those who are HIV positive initiated on ARVs, and 90 percent of those on ARVs being virally suppressed. Botswana surpassed the 90-90-90 targets in 2019 and has now ascribed to the new targets of 95-95-95.
Currently, 92 percent of people living with HIV know their status, while 89 percent of them are on treatment, with 96 percent being virally suppressed. While 384 110 people in Botswana are estimated to be living with HIV, a 28 percent decline in HIV-AIDS-related deaths was recorded between the years 2010 and 2019. Botswana is also on track to eliminate Mother-To-Child Transmission, which by 2020 stood at 1. 9 percent against 2.5 percent in 2018.
The focus during NDP 11 rests squarely on prevention, with special focus on the youth and women. The health sector will continue to integrate HIV services with others, like TB and SRH, while strengthening the gender- sensitive response to HIV and AIDS. Government is also intensifying the rollout of Option B+ while implementing the Treat All Strategy nationwide. Development partners in this regard include the President’s Emergency Plan for AIDS Relief (PEPFAR), Global Fund, European Union (EU), US Centres for Disease Control (CDC), US Agency for International Development (USAID), Southern Africa Development Community (SADC) and others.
Since 2003, PEPFAR has donated more than a billion dollars to improve HIV testing, prevention, and treatment strategies in Botswana, and expanded capacity at the University of Botswana’s School of Allied Health Sciences and the National Public Health Laboratory.
In December 2019, the Botswana Government in collaboration with PEPFAR adopted a policy to provide free HIV/AIDS services to non-citizens living in the country. To date there are more than 2 965 non-citizens accessing free ART services. In order to further reduce new HIV infections, Government has introduced Pre- Exposure Prophylaxis (PrEP) to HIV negative individuals who are 18 years and older, and at risk of acquiring the infection. The PrEP is already being rolled out in phases to prioritised beneficiaries, such as Adolescents Girls and Young Women (AGYW).
On 26 February 2021, the national launch of the fifth Botswana AIDS Impact Survey (BAIS V) took place, following a substantial delay due to Covid-19. The survey is being conducted in accordance with the CDC’s Population- based HIV Impact Assessment (PHIA) methodology, and will provide high-quality data on HIV prevalence, incidence, viral load suppression, and morbidity to support evidence- based decision making for programme management and policy formulation.
INFRASTRUCTURE & RESOURCES
According to the latest figures released by Statistics Botswana, as of 2019 Botswana had 18 general hospitals, 17 primary hospitals, 357 clinics, 346 health posts and 1 117 mobile stops providing out-patient care. Five basic specialist services (general surgery, internal medicine, paediatrics, obstetrics and gynaecology and anaesthesiology) are offered in all district hospitals. Recent years have witnessed the introduction of new speciality services such as cardiac surgery, spinal surgery, arthroplasty and organ transplant, and managed care and specialist services units have been set up. Other areas of progress include the extension of service hours, with a number of clinics now offering a 24-hour service.
Despite these improvements, the scarcity of specialists in the health sector remains challenging, and sees the ongoing referral of patients to other countries, especially South Africa. In this regard, Government intends to improve local skills and services in areas such as cardiac surgery and organ transplant, among others. To achieve this aim, the training of medical specialists is being increased and appropriate medical equipment procured.
The 450-bed Sir Ketumile Masire Teaching Hospital located at the University of Botswana’s Gaborone campus is the first in the country to offer quaternary care, and aims to be a centre of excellence in radiation oncology and organ transplant. The hospital will relieve pressure on Botswana’s major public health care providers, and do away with the need to refer patients to South Africa or further afield. In addition to offering world-class medical services, it will work in conjunction with the University’s School of Health Sciences to provide top-level health education and serve as a hub for health research.
The 2021/22 development budget made provision for the construction of mini-health centres at Sir Seretse Khama International Airport, Maun Airport and Kasane Airport, as well as the upgrading of health care facilities in Maun and Kasane, redevelopment and repair of Lobatse Athlone Hospital, and further development of Mahalapye and Sekgoma hospitals.
Two new primary hospitals with 70-bed capacity are currently being built, with Shakawe 95 percent complete and Moshupa 25 percent complete as at November 2020. Some 69 staff housing units for Moshupa Hospital are also under construction, while the upgrading of Tutume and Gumare primary hospitals is still at the design stage. The refurbishment of three old hospitals in Mahalapye, Sefhare and Serowe is complete, while construction work is ongoing at the old Maun and Scottish Livingstone hospitals.
As at November 2020, the construction of seven clinics and associated housing units was ongoing at Makgophana in Mochudi, Toteng, Ngarange, D’kar, Dibete, Sepopa and Kauxwi, with progress ranging from 12 percent to 97 percent complete. Moreover, Government in collaboration with its development partners and donors has constructed and completed clinics in Kumakwane, Lotlhakane West and Magapatona in Tutume. Regarding donor-funded projects, progress at Letlhakane maternity ward stood at 90 percent, Borotsi at 42 percent, Makalamabedi at 30 percent, Maboane at 5 percent and Molalatau at 95 percent.
