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Comprehensive Analytical Profile: Botswana

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This analytical profile provides a health situation analysis of the Botswana and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:

1. Introduction to Country Context
2. Health Status and Trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants(trC)
LocationBotswana.gif

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Profil statistique
Introduction au Contexte des Pays

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Botswana is a landlocked southern African country sharing borders with South Africa in the south and east, Namibia in the west, and Zimbabwe and Zambia in the north. It is a semi-arid country covering an area of 581 730 square kilometres. About 70% of the total area is covered by the Kgalagadi desert.

The country has a mean altitude of 1000 m above sea level. The climate ranges from mild to semi-arid. Summers are hot with an average temperature of around 39°C. Rains are usually from October to April. The winter season runs from May through July and is dry and very cold at night.(trC)

Status sanitaires et tendance

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Morbidity and mortality for all ages are dominated by infectious diseases that, together with AIDS and tuberculosis, account for 45% of all deaths. HIV/AIDS accounts for 50% of all deaths. However, deaths due to AIDS have declined during the past few years following effective antiretroviral therapy.

Conditions related to pregnancy, childbirth and the puerperium account for 16% of inpatient morbidity, while injuries and poisoning account for 11% of inpatient morbidity for all ages, excluding neonatal conditions. A review of progress towards the Millennium Development Goals (1990–1994 and 2002–2006) showed significant progress in reducing the number of underweight children aged under 5 years and in increasing access to safe drinking water (see table). However, during the same period, mortality rate for infants and for children aged under 5 years increased from 48 to 56 per 1000 and from 63 to 74 per 1000, respectively.(trC)

Progrès
Progress on SDGs(trT)
Le Système de Santé
Résultats du Système de santé

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The Government of Botswana's revised National Health Policy (2011) places emphasis on health system strengthening through integration and coordination of existing policies for the improvement of performance. Key result areas are:

  • leadership and governance
  • health service delivery
  • behavioural determinants of health
  • health resources
  • health information management system.(trC)
Leadership et gouvernance

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The Ministry of Health in Botswana has the responsibility for the overall improvement and maintenance of national health. It sets broad policy directions, goals and strategies for health development and delivery.

The Ministry of Health is headed by the Minister, who provides political leadership. He is assisted by the Assistant Minister. The Permanent Secretary is the head of the executive arm of the Ministry. Under the Permanent Secretary there are four Deputy Permanent Secretaries one being the Director of Health Services and the remaining three heading Clinical Services, Preventive Services and Corporate Services.(trC)

Appropriation et participation communautaires

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In Botswana, structures for community participation at the district level include chieftaincy, village development committees and village health committees. Other community structures that act as the voice of the communities are community home-based care committees. The village development committees' function is to identify and prioritize village needs as well as to liaise between the villagers and the politicians and local authorities. The village health committees focus on matters directly related to health.

Chieftaincies dialogue through open community fora (dikgotla) where community members may make development decisions and have the chiefs pass them on to the local authorities. Through these fora, politicians, including the President and his cabinet ministers, public officers and development partners may dialogue with community members. Concerns, needs and feedback on Government’s programmes can be discussed and civil servants may disseminate the Government’s policy. Thus, through a web of institutions and personnel, health concerns are communicated between the health decision-making bodies and the citizens.(trC)

Partenariat pour le développement de la santé

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The largest external donor in Botswana's health sector is the United States of America through:

Other donors are the European Commission, United Nations agencies, especially the United Nations Children's Fund and United Nations Population Fund, the Japan International Cooperation Agency and the Global Fund to Fight AIDS, Tuberculosis and Malaria.(trC)

Information sanitaire, bases factuelles et connaissances

Botswana has an enabling environment to support information and communication technology (ICT). Public and private funding for ICT has been in place since 1997. Health professionals have access to international electronic journals. In 2005, the Botswana National ICT policy was developed to guide, integrate and coordinate all ICT initiatives.

The major areas addressed by the policy include community access and development, government, learning, health, economic development and growth of the ICT sector, infrastructure, security, legislation and policy. The policy stipulates, as one of its objectives, an enhanced disease control and health care programme.(trC)

Système de financement de la santé

Botswana operates a democratic system in which Parliament oversees the Government’s budgetary process. Budget ceilings are based on annual fiscal forecast. A dual budget process of separately reconciled recurrent and capital budget, all coordinated by the Ministry of Finance and Development Planning, is adopted. The ministries select projects based upon programme priorities determined by sector strategies. Government funding for health is distributed to the Ministry of Health (64%), National AIDS Coordinating Agency (9%) and the Ministry of Education and Skills Development (3%).

The remaining 24% goes to private financing agents such as insurance schemes, households and nongovernmental organizations. A cost recovery consultation fee of US$ 70 is charged for clients visiting public health facilities. Foreigners pay a little more (US$ 4). Antiretroviral and sexual and reproductive services are offered free to citizens.(trC)

Prestations de services

In Botswana, health services are delivered in public, private for-profit, private non-profit and traditional medicine practice settings. The public sector is the main provider of services delivered through a network of health facilities using the primary health care approach. Other health care providers complementing the public sector are faith-based organizations (two district hospitals), mining companies (three hospitals) and a few nongovernmental organizations. The health facilities are spread over 29 health districts operated by the district health management teams.

In 2006, referral and district hospital beds constituted 69% of total bed capacity while primary hospitals and clinics constituted 19% and 15%, respectively. Health services are accessible in both rural and urban areas with 95% of the population living within 8 km radius of a health facility. The private sector mainly provides services to insured clients. However, the uninsured do access private sector service through out-of-pocket payment.(trC)

Ressources humaines pour la santé

In Botswana, human resource development has been a priority in national development plans with the aim of increasing both the numbers and the skill mix. The health workforce has therefore steadily increased over time. The ratios of nurses and doctors to population have also improved (see table). Only about 10% of the medical doctors are local. Botswana remains dependent on foreign doctors, mainly from other parts of Africa.

In 2000, highly trained professionals such as doctors, dentists, radiographers and pharmacists who were foreigners together accounted for 70% of all filled posts in the public health sector.[1](trC)

Produits médicaux, vaccins, infrastructures et équipements (matériels)

Botswana has a National Drug Policy that was first developed in 1999. This Policy provides a framework for incorporating the objectives of the pharmaceutical sector into the National Health Policy, service structure and operations. The overall aim of the Policy is to provide drugs of acceptable safety, efficacy and quality, that are available and affordable to all who need them, and to ensure their rational use by providers, dispensers and users.

The National Drug Policy and the drugs regulatory and administrative frameworks strive to create a conducive partnership environment for the public sector, the private sector, and regional and international agencies to allow maximization of scarce resources and cross-fertilization of ideas. The system promotes, supports and encourages the development of a local pharmaceutical industry.(trC)

Politique nationale de santé

The master policy for the health system is the National Health Policy that was first formulated in 1995 to guide the development of the health sector toward attainment of the highest level of health. In response to changes in the health status of the population, health care technologies and the organization of the health system, the National Health Policy was revised in 2011.

The revised policy puts emphasis on:

  • quality of care
  • optimum health services utilization
  • fair distribution of services across the population spectrum
  • protection of disadvantaged and vulnerable populations
  • social determinants of health
  • partnerships of the public sector, private sector, civil society and communities.

Plans are underway to establish a National Health Council to coordinate and oversee all health sector activities.(trC)

Couverture universelle

For ease of management and coordination, Botswana's public health sector is organized into 29 health districts through district health management teams. Each district is responsible for taking stock of its population to ensure accessibility of health services to all. The National Health Policy incorporates socioeconomic determinants of health such as poverty and lifestyle such that the economically disadvantaged populations have access to quality health care.

The involvement of local structures such as village development committees ensures identification of populations that need special attention, such as the poor, orphans and vulnerable populations, young people, older people and people with disability. The organization of the health care delivery system by facility level and the referral system provides some degree of standardization of service packages at different levels of facilities.(trC)

Programmes Spécifiques et Services
VIH/SIDA

Botswana has one of the highest rates of HIV infection in the world. From 1985 when the first case of HIV infection was recorded in the country to 2009, there were about 331 000 people infected with HIV and over 8700 AIDS-related deaths. The impact of HIV/AIDS has been extensive, ranging from reduced life expectancy and reduced population growth to an increased number of orphans.

The number of patients, especially those who are taking antiretroviral therapy, has put strain on the health system and caused concerns about the Government of Botswana's apparent neglect of other system programmes. Women and children have taken a larger share of home caregiving, thus have less time to participate in income-generating activities and in educational pursuits.(trC)

Tuberculose

Botswana has one of the world’s highest burdens of tuberculosis (TB) per capita, with a notification rate of 470 per 100 000 population (see table). TB is one of the most common opportunistic infections in those infected with HIV, with 75% of TB patients being HIV positive. TB rates started rising with increasing prevalence of HIV/AIDS in the 1990s, with an increase of 200 cases per 100 000 population in 1990 to 620 cases per 100 000 in 2002. Botswana’s response to TB has been influenced by both national commitment and regional and international resolutions and targets for controlling TB. The country has also had strong support from development partners. The development of the current strategic plan document was also informed by the global Stop TB Partnership strategy that empowers people living with TB and their communities and devolves responsibility to them. The TB control guidelines provide a framework for guiding implementation of the TB control strategy and define responsibilities of the different players.(trC)

Paludisme

Malaria is a notifiable disease endemic in the northern part of Botswana and is second to diarrhoea in the number of death recorded over the years. Transmission mainly occurs in five districts. Even though malaria is a seasonal disease, trends in clinical and laboratory diagnoses suggest that the disease occurs throughout the year. The malaria vector in Botswana is the Anopheles mosquito and the main parasite is Plasmodium falciparum, which is responsible for over 98% of cases. Other parasites are P. ovale and P. malariae.

Diagnosis is based on a set of clinical criteria, supplemented by detection of the parasite in the blood. Epidemics occurred in 1988, 1993, 1996 and 1997. Since then, the disease burden has gone down, with a progressive decline in the prevalence and number of deaths (see figure). In line with the regional and international efforts, Botswana has made a commitment to achieve universal coverage and to eliminate malaria by 2015. Recent Government of Botswana's initiatives have been the development of:

Vaccination et développement de vaccins

In Botswana, the Expanded Programme on Immunization is fully funded by the Government and has maintained high coverage for all recommended vaccines since 2000. A survey conducted in 2007 showed that 90% of surveyed children aged 12–23 months had received all valid doses of recommended vaccines and had under-five card retention of 98%.[2]

There has been a decline in cases of diphtheria, pertussis and neonatal tetanus. Since 1992, there have been no cases of diphtheria reported. Similar trends have been observed for neonatal tetanus, pertussis and polio.

However, the country faces a challenge in maintaining the cold chain in its extremely hot weather. Another challenge is that vaccines such as hepatitis B have not yet been introduced in the country, even though pneumonia is a leading cause of mortality among children aged under 1 year.(trC)

Santé des enfants et des adolescents

Besides programmes for pregnant women, neonates and children aged under 5 years, the Government of Botswana has established policies, programmes and procedures to protect the health of older children and adolescents. The Early Childhood Care and Education Policy of 2001 aims to provide preschool children with stimulation and play.

The School health policy and procedure manual[3] provides a guide for monitoring the growth and health status of schoolchildren. Some of the major services provided in the school health programme are feeding and immunization.(trC)

Santé maternelle et des nouveaux-nés

Preventive health care for children is part of the integrated primary health care services under sexual and reproductive health services and starts before the child is conceived, through family planning and antenatal care with prevention of mother-to-child transmission where appropriate.

Childbirth occurs under skilled care. A course of immunization is provided to children aged under 5 years (see Table 1), and the child’s growth and development is monitored. Breastfeeding is encouraged where it is appropriate and supplementary feeding is provided for at-risk children. Insecticide-treated bednets are provided to pregnant women and infants in malaria-prone areas.(trC)

Genre et santé des femmes

Botswana is committed to the improvement of the socioeconomic conditions and the health status of men and women across the age spectrum. The country has acceded to the 1996 Convention on Elimination of All Forms of Discrimination Against Women. Gender equality has been addressed in a number of policy documents, including Vision 2016, National Population Policy, Revised National Policy of Education, National Policy on HIV and AIDS, and National Policy on Culture.

The National Policy on Culture 2001 has provided men and women with equal access to inheritance, ownership of property, leadership and decision-making. However, it will take some time to address existing gender inequalities that, for the most part, put women in a disadvantaged position relative to men. For instance, women’s political leadership falls far short of the Southern African Development Community's target of 30%, being only 7.9%.(trC)

Maladies épidémiques et pandémiques

Part III (special provisions regarding diseases) of the Public Health Act of Botswana (Chap 63.01) incorporates provisions for international health regulation with specific application to smallpox (including alastrione or variola minor), plague (all forms), cholera (including that due to EI Tor vibrio) and yellow fever. In addition, since 2006, the Ministry of Health has developed the Hepatitis B vaccination guidelines for health care workers in Botswana.[4]

The development of the guidelines was a fulfilment of the World Health Assembly resolution on viral hepatitis. They are aimed at ensuring that health care workers at risk of acquiring hepatitis are immunized to protect both the health worker and other patients whom he or she may infect. The Ministry of Health has developed guidelines to deal with infectious disease that cover equipment needed, possible symptoms that may give rise to suspicion, training of staff (lay personnel) on handling the suspicious case, and action to be taken before arrival at the nearest port of entry.(trC)

Maladies Tropicales Négligées

A few tropical diseases are endemic to certain parts of Botswana but are of a magnitude that does not warrant deliberate control programmes similar to those of tuberculosis, malaria and HIV/AIDS. Such diseases tend to be concentrated in the northern part of the country where the moisture conditions of the 20 000 km2 Okavango delta present a favourable environment for their proliferation and transmission.

Major factors determining the prevalence and distribution of the majority of the water contact diseases include:

  • surface water availability and permanence
  • human water contact behaviour such as the risk of water contamination
  • environmental and climate factors such as rainfall and temperature.

The prevalence and distribution of the diseases therefore vary from time to time, depending on the rainfall and water flow pattern.(trC)

Maladies non transmissibles et états de santé connexes

Although morbidity and mortality of noncommunicable diseases in Botswana is not well documented, they are estimated to account for 31% of all deaths in the country. The most common ones are cardiovascular disease, hypertension, cancer, chronic obstructive pulmonary disease and diabetes. Before the 1980s, common diseases in Botswana were infectious diseases and those associated with unsanitary conditions, poverty and inadequate hygiene.

From the 1980s, new patterns of conditions associated with affluent lifestyles such as hypertension, diabetes and cardiovascular diseases emerged, although the magnitude of such diseases has been overshadowed by the re-emergence of infectious diseases such as tuberculosis and HIV/AIDS. For instance, cases of hypertension increased from barely 100 to 2000 in 1996. It has been reported that hypertension increased fivefold between 1980 and 1998.(trC)

Déterminants majeurs
Facteurs de Risque pour la Santé

The Government of Botswana's revised National Health Policy 2011 recognizes lifestyles that play an important role in health, particularly those linked to the increasing rates of noncommunicable diseases or their risk factors, such as obesity and stressful living conditions. Lifestyles of major concern in the country include smoking, unhealthy eating, alcohol use and abuse, and risky sexual behaviours.

The Global Youth Tobacco Surveys, conducted in 2008 on young people aged 13–15 years from 50 schools across the country, showed a smoking prevalence rate of 14.3% among the survey participants. The average adult per capita consumption of alcohol in Botswana is estimated at 8 litres of pure alcohol per inhabitant per year while the regional average is 7 litres per year. Alcohol has been linked to gender-based violence and the spread of HIV.(trC)

Environnement physique

Botswana has factored environmental sustainability into the national agenda. One of the major milestones for the country has been the establishment of the Environmental Impact Assessment legislation in 2005 that requires that all new developments be assessed for their impact on the environment.

The Government of Botswana has developed the Okavango Delta Management Plan to protect the wetlands in the Okavango and the Community Based Natural Resources Management Strategy aimed at facilitating community involvement in managing wildlife and natural resources. Botswana has ratified several international agreements aimed at protecting the environment. These include UN Convention to Combat Desertification, and the Convention on Biological Diversity.(trC)

Sécurité alimentaire et nutrition

Almost all of Botswana’s food supplies are imported, with beef being the major local food product. Although a strong foreign exchange and the Government of Botswana's strategy of keeping a stock of grain reserves to ensure adequate supplies have cushioned the country against immediate food security threat, low birth weight is common in Botswana and contributes to the high infant mortality rate.

The Multiple Indicator Survey 2000 showed that 2.4% of children had severe undernutrition while 7.9% were severely stunted.[5] The prevalence of anaemia was 38% in children and 33% among women in 1994. Nutritional status of children aged under 5 years is shown in the table.
Nutritional status of children aged under 5 years. BFHS, Botswana Family Health Survey; MIS, Multiple Indicator Survey[6]


Notwithstanding the adverse climatic and soil conditions, the long focus on traditional rain-fed arable farming and the reluctance of farmers to adopt modern farming methods have contributed to a decline in the yield of the agricultural sector.(trC)

Déterminants sociaux

Besides health, education and employment can be considered to be important determinants of health status in Botswana as they influence access to resources and alleviate poverty. In addition, HIV/AIDS must be recognized as a threat that has reversed the gains that Botswana achieved after independence.

Botswana may have the highest public spending on education in the world, with the education sector taking an average of 25% of the total budget (10–11% of gross domestic product). The county’s education policy has long emphasized access to primary education and recently the Government of Botswana has embarked on 10 years of universal education and inculcation of skills to match the demands of the job market.(trC)



References(trT)
  1. Second common country assessment for Botswana. United Nations systems in Botswana. Final report, 2007
  2. National Expanded Programme on Immunization survey. Gaborone, Government of Botswana, Ministry of Health, 2007
  3. Botswana national school health policy and procedure manual. Gaborone, Government of Botswana, Government printers, 1999
  4. Hepatitis B vaccination guidelines for health care workers in Botswana. Gaborone, Government of Botswana, Ministry of Health, 2010
  5. Multiple Indicator Survey (pdf 413.99kb). Gaborone, Government of Botswana, Central Statistics Office, 2000
  6. 2007 Botswana Family Health Survey IV report. Gaborone, Government of Botswana, Central Statistics Office, and United Nations Children’s Fund, 2009