HEALTH CARE IN BOTSWANA IN THE ERA OF HIV/AIDS

UNCLAS GABORONE 000884


DEPT FOR OES/PCI, OES/FO, OES/ENV, OES/IHA
DEPT FOR AF/S, AF/EPS AND EB

E.O. 12958: N/A
TAGS: KHIV TBIO ECON EAID SOCI BC
SUBJECT: HEALTH CARE IN BOTSWANA IN THE ERA OF HIV/AIDS


1. Summary: Botswana just celebrated its National Day on September
30 and the country has made significant progress in the fight
against hunger, poverty, injustice, illiteracy and unemployment over
the last forty two years. The rate of progress is, however,
threatened by the HIV/AIDS epidemic, and could be reversed in the
absence of a concerted national fight against the epidemic. The
HIV/AIDS epidemic has also imposed a considerable burden on the
public health system. Concerns have been expressed that HIV/AIDS
programs, especially the, ART treatment program, have squeezed the
resources available for other important health needs and programs.
End Summary.

Background
--------------


2. Botswana has made significant progress in the fight against
hunger, poverty, injustice illiteracy and unemployment over the last
forty two years. The country rose from being one of the poorest in
the world at the time of independence, to becoming a middle-income,
developing nation. Nonetheless, this progress is now threatened by
the HIV/AIDS scourge, and could be reversed in the absence of a
concerted national fight against the epidemic. Botswana is one of
the countries hardest hit by HIV/AIDS epidemic. The Botswana AIDS
Impact Survey of 2004 estimated HIV prevalence in the general
population at 17.1 percent. The prevalence rate among pregnant
women aged 15- 49 years was 32.4 percent, with Chobe district having
the highest rate (42 percent) and Kgalagadi the lowest (19.1
percent). The HIV/AIDS epidemic has also imposed a considerable
burden on the public health system such as: a) an increase in the
number of patients being treated for HIV/AIDS-related illnesses and
their social impacts; b) a rise in the death rate; c) a reduction in
the population growth rate and life expectancy; and d) a substantial
increase in the number of orphans and vulnerable children (OVC).
This is having adverse implications for the health and other
development sectors. Furthermore, Botswana's health infrastructure,
despite efforts made by the government of Botswana (GOB) and
development partners, continues to perform insufficiently in
granting access, equity, quality, effectiveness, efficiency and
sustainability in health care delivery. The health system thus
continues to bear the brunt of the impact of the HIV/AIDS pandemic.


3. Significant, however, is the government's deep commitment to high
levels of expenditure on meeting the basic needs of the population.
Since the mid-1970s, 30-40 percent of the annual budget has been
allocated to the social sector. Government health facilities
provide primary health care and top-level hospital treatment free,
including anti-retroviral treatment (ART) for only a token payment.
Providing communities with safe drinking water is another high
priority for the GOB. Much of this additional expenditure has been
directed to HIV and AIDS, and there are concerns that this has
caused a diversion of health resources away from other health needs.
This remains a major worry among some health practitioners, who
have expressed fears that the focus on HIV/AIDS has allowed other
equally dangerous diseases such as cancer, hypertension, diabetes
and diarrhea to ravage populations unabated and unnoticed. (Note: A
long article in the Botswana Gazette edition of 20-26 February 2008,
titled "Health System Hobbled by Focus on HIV and AIDS" spelled out
these concerns in sobering detail. End Note).

Health challenges
--------------


4. Botswana still faces major health challenges in managing other
diseases such as cancer, diabetes, diarrhea, high blood pressure and
others as listed below. A concerted effort by the GOB, development
partners and civil society is needed in order to focus attention on
these diseases and on the improvement of health care service
delivery.


5. Tuberculosis (TB): TB is often associated with HIV and AIDS as
one of the main opportunistic infections in those who are HIV
positive. After many years of decline, TB notifications started
rising in the early 1990s and increased from 200 per 100,000 people
in 1990 to 620 per 100,000 in 2002; and by 2007, approximately 80
percent of patients were co-infected with HIV. TB prevalence in
Botswana is thus now one of the highest globally. Moreover, TB drug
resistance is a challenge: there are multi-drug resistant TB
(MDRTB),and extensively drug resistant TB (XDRTB) manifesting
themselves in patients. MDRTB refers to resistance against
first-line drugs-isoniazid and rifampicin. XDR indicates a
resistance to almost all of the effective anti TB drugs. One
hundred cases of MDRTB have been identified and put on treatment in
Botswana. There were two cases of XDRTB that were recorded and the
patients put on treatment, but one died. According to a Ministry of
Health (MOH) 2006 assessment, MOH 2005 data also reports significant
progress in immunizing against TB, with BCG immunization coverage
reaching 99 percent. Additionally, health facility reports of March
2007 indicate coverage of 88 percent, according to MOH statistics
from the Child Health Unit.


6. A number of initiatives have been put in place such as: i)
isoniazid TB preventative therapy (IPT) for people living with HIV
and AIDS; ii) the establishment of improved TB diagnostic capacity
with the development of a TB reference laboratory with drug
resistance capacity; and iii) the strengthening of TB surveillance
capacity through the development and implementation of a national
computerized TB transmission in health care facilities. However,
efforts still need to be intensified in order to reach 100 percent
coverage. Botswana has made commendable progress in making TB
treatment accessible, attaining adequate case identification through
an electronic TB register, keeping resistance below 1 percent and
maintaining an effective DOT strategy and community mobilization.
All of these efforts and results demonstrate positive progress
towards reducing morbidity and mortality caused byTB.


7. Malaria: The occurrence of malaria in Boswana is seasonal, and
is related to rainfall peiods. The number of cases thus varied
between 202 and 2006. Botswana recorded 3,453 confirmed cases in
2004, but only 53 confirmed cases in 2005, a record low. A Malaria
Indicator Survey (MIS) conducted in March, 2007 rvealed that the
current level of malaria control in Botswana needs to be pushed to a
new frontier, with the current IRS coverage of 67.6 percent; this
needs to rise to above 80 percent. In addition, vector control
through Insecticide Treated Nets (ITNs) was identified as an area
that needs improvement. The survey showed levels of 26 percent ITNs
coverage at household level, with 15.4 percent for pregnant women
and 12.9 percent for children under five. In order to attain this
target, an increased coverage of prevention measures over and above
those currently used will be necessary. The house-to-house
community education initiatives, such as the one carried out last
August by students and teachers of the Gaborone Senior Secondary
school and Alexander Dawson School, Colorado, in collaboration with
the U.S. Embassy, are commendable examples of this extra effort.


8. Maternal and Reproductive Health: For a number of years, the
percentage of women availing themselves of the antenatal services
have been over 90 percent. In addition, more than 90 percent of
deliveries are conducted by skilled health practitioners. The
Sexual and Reproductive Health Program incorporates a strong
component of IEC and Safe Motherhood Initiative (SMI) elements.
Moreover, family planning was designed to improve maternal health in
Botswana. Data on maternal mortality is poor, with various
estimates of the maternal mortality ratio (MMR) from different
sources. For instance, government health facilities data for
2005/2006 indicates a rate of 150 per 100,000 live births, a marked
improvement from the 330 rate in the 1991 census. The establishment
of a Maternal Mortality Audit System, which is focused on collecting
facility based data on maternal deaths, is a development that will
also indirectly address issues of quality of services and
inefficiency.


9. According to the joint March 2007 IATT draft report, existing
opportunities to optimize access to HIV infected women to family
planning have not been fully explored. Data from surveys in
Gaborone and Francistown revealed that 65 percent of pregnancies
among HIV positive and negative women were unplanned and 35 percent
unwanted. Additionally, although CD4 testing is available to
pregnant women, the proportion of HIV-infected pregnant women
accessing ARV therapy for their own health is lower (16 percent)
than the target of 25 percent. Given the policies, frameworks and
strategies towards maternal health that have been put in place, the
GOB has made significant strides in improving this sector. However,
there are major gaps in the ability of health institutions to
deliver, both in terms of the health systems, resources, supplies
and equipment, as well as sufficient staff with the requisite
knowledge and skills. Family planning needs to be integrated with
the Prevention of Mother To Child Transmission (PMTCT) program in
order to ensure that they are not run as parallel programs.
Moreover, PMTCT and ARV programs need a high-level coordination
forum to ensure that implementation bottle necks are addressed and
program planning and training are well coordinated.


10. Child Health: Child health indicators showed steady improvements
through the 1970's and 1980's; but since then, there has been a
reversal in the trend. Between the 1991 and 2001 census, infant
mortality rose from 48 to 56 per 1000 live births, and under-five
mortality increased from 63 to 74 per 1000. Many believe this is
mainly due to the HIV/AIDS pandemic, which accounts for nearly half
of all under-five deaths. The remainder is due to diarrhea, acute
respiratory infections, pneumonia and neonatal causes. Nonetheless,
demographic projections indicate that the peak in infant and under
five mortality rates should have declined to 28 and 58 per 1000
respectively in 2007 due to the roll out of ART and PMTCT.


11. Non-communicable Diseases: There are indications that
non-communicable diseases are on the rise, notably cardiovascular
diseases, hypertension, cancer, mental disorder and diabetes. While
the data may be partially a result of improved diagnostic methods,
it may also be attributable to lifestyle changes that are
encouraging the growth of such diseases. The government needs to
provide the population with health information on diet and exercise
in order to encourage them to live healthy life styles. There is
also a need to do further situation analysis of communicable disease
to facilitate and inform program planning and response and determine
the true burden to the country. The World Health Statistics 2008
indicates that leading infectious diseases like tuberculosis, HIV,
neonatal infections and malaria will become less important causes of
death globally over the next 20 years.


12. Death and injuries from car accidents also constitute a major
problem for the health sector; they are largely due to driver error
and alcohol abuse. According to the Central Statistical Office
(CSO) statistical brief No 3/May, 2008, the number of road accidents
rose from 65 per 10,000 in 1995 to 108 per 10,000 in 2003. It
decreased to 106 per 10,000 2004, and further 98 per 10,000
population in 2006. Though there are signs of a drop in road
accidents, they still need to fall them further.

Challenges
--------------


13. Given the aforementioned disease burden and other health
infrastructure issues in Botswana, the health sector will continue
to face major challenges in the foreseeable future. They include:
a) the need to respond appropriately to the country's changing
demographic profile. For instance, there is a need to look at task
shifting to respond to new health areas such as a) consider male
circumcision; b) prioritize disease programs, such as striking a
balance between HIV and AIDS and other serious diseases; and c)
ensure appropriate resource allocation between primary health
care(PHC) and hospital-based services. There is clear need to place
emphasis on PHC to avert the cost related to hospital care; d)
harmonize the current range of health sector policies and strategies
into an integrated health policy, and the development of a strategic
plan to guide the implementation of health care in Botswana; d)
improve the referral system and reduce distances and delays between
primary, secondary and tertiary facilities; and e) develop a
long-term, cost-sharing strategy.


14. At the service delivery level, the health sector also faces a
shortage of manpower, and slow implementation of policies,
strategies and programs. The availability and use of timely health
information for policy and planning is equally weak across all
health sectors and programs. Consequently, the effective
implementation of policies formulated for various health programs is
low and lacks proper monitoring and evaluations of outcomes and
impacts. For instance, in a damning headline titled "Shortage of
Medical Supplies Blights our Nation Reputation", the September 7
edition of the Sunday Standard detailed the lamentable situation of
patients unable to access medical supplies due to shortages at
public health centers. The author urged the President to use his
powers to "ensure that Botswana's health system is saved from ...a
slide towards eventual crumble." Nonetheless, the GOB and development
partners are trying to respond to all these health challenges, with a
special effort to strengthen Botswana's health infrastructure despite
the difficulties posed by the HIV/AIDS epidemic and other development
challenges.


15. Final Comment: Stronger linkages between the MOH and other line
ministries, development partners and key stakeholders should seek to
strengthen the health system response in order to achieve Botswana's
Vision 2016 and the UN's Millennium Development Goals. Some have
voiced concerns that HIV/AIDS programs, especially the provision of
ART, have squeezed the resources available for other important
health programs. This unease is not without foundation. In a July
23, 2008 health article on the Science and Development Network
newsfeed (i.e., SciDEV.Net),the author asserts that "chronic
diseases such as cancer, diabetes and heart disease are quickly
overtaking infections as the biggest killers of the world's poor,"
and in fact kill a higher proportion of people than infectious
diseases. In short, the author concludes, under-resourced health
systems in developing countries must now cope with the twin burden
of infectious and non-communicable diseases. However, most funding
from donors is directed toward the former, with comparatively little
going to the latter. The GOB would do well do take cognizance of
this emerging reality.


GONZALES