Country Profile

Botswana

Health Care and Promotion in Botswana

by Dr. Emmanuel O. Owolabi and Dr. S. Shaibu

 

Background Information

Botswana is a Land-locked country in the southern African region. According to the 1994 estimates, with an annual growth rate of 2.45%, it currently has a population of 1.570 million people (Central Statistics Office, Botswana, 1996). The Kalahari Desert covers eighty-four percent of Botswana land area (American Womens International Association, 1994). A former protectorate of Britain, it gained its independence in 1966 and became a republic.

Politically, Botswana is a bastion of western democracy and is arguably a model for, particularly, developing countries. Indeed the Botswana Government is guided by four cardinal principles in its policy-making decisions. These are democracy, development, self-reliance, and unity (Owolabi & Kalui 1997). The Botswana Government is truly a government of the people and for the people. Since independence, Botswana has leapt from being one of the poorest countries of Africa to be one of the fastest growing economies in the continent (American Womens International Association, 1994). The major economic activities and foreign currency earners are mining, mainly of diamond, livestock processing, and Agriculture.

The level of literacy among the populace is 68.9 percent with the women being 70.3 and men, 66.9 (Central Statistics Office, Botswana, 1993). The average life expectancy at birth, for males is 64.8 years while for females, it is 68.4 years (Central Statistics Office, Botswana, 1996). However, there are recent suggestions that these values may now be below 50 years due to the high incidence of HIV/AIDS.

 

Health Care Delivery: Overview

The Botswana Health Care (BHC) delivery system comprises government health institutions, missionary, mine and private-commercial health institutions. The Government, through its Ministry of Health, is the main provider of health care. The health care delivery system, which is arguably one of the best in Africa, is based on the principles of Primary Health Care (PHC) as described in the Alma- declaration of 1978 (Ministry of Health, 1996). PHC in Botswana emphasizes and ensures community participation inter-sectoral collaboration and equity. It also ensures that health care is affordable and accessible to the people. Further Botswanas commitment to social justice and equity lends itself to the operationalization of the PHC concepts.

The National health care system is organized hierarchically into Mobile stops at the bottom, Health posts, Clinics, Primary Hospitals, District hospitals, and Referral hospitals at the apex. While the Referral hospitals are located in the two cities of Gaborone (the capital) and Francistown, the district hospitals are located in the headquarters of the 11 districts and town councils. The Primary Health Care (PHC) system is mainly run by the Ministry of Local Government through the Council Health Departments. The lower the level of the health care system, the smaller is the population it is serving. For instance, while each health clinic serves households within a kilometer radius, health posts serve those residents in remote areas, and in cattle posts. The health and medical personnel are also evenly distributed across these tiers of health care organization with, specialized professionals being located mainly at the referral (apex) hospitals, while the general medical and other health professionals are located in the district and primary hospitals. The clinics, health posts and mobile stops are manned mainly by experienced registered nurses, midwives and family welfare educators. The PHC system is periodically supervised and monitored by the District Health Team (DHT), which is set up by the Local Government Council Health Department. The DHTs are composed of multidisciplinary health professionals including medical officers, environmental health officers, nutrition officers, health educational officers and others. The curriculum of nursing education and preparation in Botswana, particularly at advanced level courses, includes the diagnosis of, and prescription of treatment for the common infectious and non-infectious diseases. The nurses, who form the backbone of the health care delivery system, are thus adequately and technically prepared for the services in the PHC system. This is more so when there is a big shortage of qualified medical and other health professionals. For instance, while the ratio of qualified physicians to the population is 1:4130, that of nurses is 1:404. These values are however, substantially better than the sub-Saharan Africa average (18,488 & 6504) respectively and all developing countries average (5,767 & 4,715)((UNDP, 1996) respectively. There are however plans underway to expand both the infrastructure and human resources to bring health care, even closer to the people.

 

Program Integration and Human Resources Management

The PHC delivery system is decentralized. Each level of the PHC system is semi-autonomous, particularly at the district level, with the central ministry of health playing supervisory and coordinating roles, in addition to formulating the national policies on health care. The ministry of health also defines the relationship between itself and district and town councils.

The health services provided by mission hospitals, hospitals and private-commercial hospitals are governed by relevant legislation and their relationship with the ministry is well-defined (Ministry of Health, 1995). The Ministry of Health is in firm control of the PHC system, despite the decentralization. The available medical and health professionals are equitably distributed among all levels of the PHC system. The decentralization process ensures that every ill patient at grassroots receives prompt medical attention while at the same time, problems unique to particular regions are collated and referred to the district Health teams and the central administration at the Ministry of Health. National health policies are actually based on the communications between the regional health offices and the central Ministry of Health.

The consolidated model of health planning and delivery is adopted in national health manpower planning. The integrated model promotes cooperation between all government branches providing health services, provide opportunities for service rationalization in order to minimize duplications and provide for re-investments in program expansion or new program development, promotes ownership by local authorities, increases compliance and maximizes achievement of targets.

 

Health Promotion: An Overview

Health promotion is a major aspect of health care in Botswana. Every level of health care delivery has a component of health promotion. Health promotion and avoidance of ill health, through behavioral modification service, include health education, environmental sanitation, and disease prevention, care of vulnerable groups and maintenance of special disease control. Health counseling is a standard service usually given to patients and their relations. This is with a view to changing the behavior of the people away from a risk-inducing one. Data collection, evaluation, and epidemiology are parts of community health services, with each district having health education officers and nutrition officers. The high emphasis on health promotion in the PHC delivery system is premised on the Governments concession that Botswana may still be at a level of development where the disease pattern is predominantly determined by poverty, poor nutrition, low levels of education, and undesirable environmental conditions such as poor sanitation. However, Botswana seems to be undergoing an epidemiological transition characterized by chronic illnesses related to changes in lifestyle, particularly among urban dwellers. These diseases may include chronic stress, hypertension, obesity and diabetes (NDP 8) ( Ministry of Health 1996.). The Ministry of Health further has a department of Family Health Education, which is specifically involved in health promotion of the individuals, families, and communities.

The involvement of the communities in health care delivery is a major key to the identification of cultural attitude and practices, which may hinder the success of the health promotion program. Such health-hindering cultural practices are normally dealt with through cultural brokering and re-patterning.

 

The Prevalence of health-hindering behavior

For instance in 1996, of a total of 4,507 deaths registered in hospitals, 13.1 percent were caused by pneumonia, 11.9 percent by AIDS, and 11.5 percent by pulmonary tuberculosis (Central Statistics Office 1997). AIDS appears to be the leading cause of death in Botswana. The incidence of HIV/AIDS in Botswana is being speculated to be between 25 and 30 percent of the total population. This seems to be corroborated by the recent submission of United Nations (UN) that AIDS has overtaken malaria as Africas main killer disease (Ditshwang, 1999). The peoples culture plays a big role in peoples attitude and behavior towards health. Batswana (natives of Botswana, the singular is Motswana) people generally love eating lots of vegetables while they are averse to lean meat and food high in fat. Thus, the average Motswana tends to eat a nutritionally balanced diet while avoiding the health-threatening foods. This may be partly responsible for the low blood pressure among Batswana. According to the data collected on ordinary working class Batswana of both sexes in the Human Performance Laboratory of the Department of Physical Education, University of Botswana, the average systolic BP was 105 mmHg while the corresponding diastolic BP was 65 mmHg. Thus, the average Motswana is characterized by low blood pressure. However, this is despite the fact that the average Motswana particularly, the ladies tend to be obese.

The typical Motswana appears to be averse to habitual participation in physical exercises as a way to develop and maintain physical fitness. However, a relatively small number particularly the males, participate in social sports on Sunday mornings. Studies on Batswana indicate that the average Batswana have low levels of physical fitness when compared with their international counterparts. There is a common saying among Batswana that "in Botswana there is no hurry". Owolabi and Kalui (1997) speculated that this common saying, suggesting a tendency of the average Motswana, not to want to exert oneself, might be a reflection of the peoples low level of fitness. This speculation is further reinforced by the various private and Government employers? open and frequently expressed concerns on the low level of productivity of the average Motswana (Ministry of Health, 1996, Owolabi 1999). The Botswana labor market was ranked 16th in terms of productivity, among the top 20 African nations by the Africa Competitiveness report of 1997 (Lloyd, 1999). However majority of commentators and Government officials and employers blame this low productivity on the attitude of the average Motswana to work.

Corporate health fitness programs are almost non-existent although some private employers provide recreational facilities for their employers use in the evenings and at weekends. Even, in these few cases, there is no corporate policy compelling or encouraging employers to participate in recreation. It is left to individual worker?s decision. Alcohol consumption is very prevalent. It, in most cases, takes the form of social drinking and is fast becoming a regular cultural celebration every weekend from Friday to Sunday. This appetite for alcohol, which appears to be enjoying some cultural acceptance, is fast degenerating into cases of alcohol abuse and alcoholism. In fact, many of the social problems rampant, particularly among the youths, are being traced to and blamed on alcohol misuse and abuse. These problems include juvenile delinquency, drug abuse, auto-mobile accidents, early sexual intercourse, teenage parenthood, wife-bashing and criminal tendencies like burglary, rape and vandalism (Owolabi & Kalui, 1997).

The absence of recreational opportunities has been implicated by researchers and sociologists, as a major contributor to the social problems. Most youths have also, often blamed the lack of recreational skills and facilities, as the major hindrances to their participation in sports and recreation (Masala et al, 1997). All the social problems traceable to lack of recreational skills can be directly and indirectly linked to the absence of Physical Education in the school curriculum. Empirical and well-designed studies have associated early exposure to Physical Education and physical activities with positive exercise habits throughout adult life (Trudeau et al; Taylor et al, 1999). Physical Education is not currently being taught as a formal subject in Botswana schools. Although Physical Education has since the last ten years always existed as scheduled subject on the schools timetables, there is little or no evidence of its being formally and professionally taught due to various omissions in the implementation process (Owolabi & Sewane, 1998). The department of Physical Education at the University of Botswana only began offering Physical Education programs at Certificate, Diploma and Degree level, four years ago.

 

Health Promotion: What is currently being done

Health promotion activities form a major pillar of the Primary Health Care (PHC) delivery system of Botswana. Special committees are in place to address specific health promotion issues at all the tiers of operations on health matters. This is in line with the system of governance in Botswana where the grassroots at the remote areas of the country have an immediate governing body which is accountable to the district governing body which in turn, is accountable to the central government based at the capital of the country. Whenever any specific health problem has been identified, the District Health Team or the Central Health Committee either uses a Committee in place to deal with the issue or sets up another, depending on the uniqueness and emergency nature of the heath problem. Student clubs and other voluntary organizations are launched in schools and higher institutions and among other high-risk groups in the society. The Health promotion committees formed at the central level are also replicated at the district level with the Central one playing coordinating and supervisory roles.

Specialized Government agencies such as the Botswana National Productivity Center (BNPC), organize regular training workshops and seminars for different cadres of employees and employers in order to enhance individual and national productivity. In addition, they set aside a week in the year during which intense activities on public enlightenment and awareness programs are carried out. Such weeks often have multi-organizational flavor, including cultural activities. Youth clubs and other voluntary organizations, particularly in institutions of learning, periodically organize cultural activities and festivals and use these as forums for disseminating the message on the health-promoting behavior. They may also celebrate special weeks during which activities on public enlightenment and awareness are intensified using multimedia approaches. The youth clubs and voluntary organizations currently existing in schools and higher institutions include: Anti-smoking clubs, No-to-Alcohol clubs, HIV/AIDS awareness club, No-early sex clubs etc. These health promotion clubs and organizations, in conjunction with the parent central committee at the Ministry of Health, also spread their ?gospels? to the populace through posters, handbills.

Immunization of children is free and people who are ill but cannot afford the meager fee charged are never turned away for lack of funds.

 

Organization and Coordination of Health Promotion Activities

The Ministry of Health, through its department of Family Health Division, plays leadership and coordinating roles. For example, on an annual basis, this department of health education, in collaboration with WHO?s office, spearheads the celebration of world health-related events like, world health day, world no-tobacco day, world AIDS day etc. On such days, the National Health Promotion Committee advocates health promotion on a very wide scale with multi-organizational activities including cultural shows, workshops, symposia and seminars. Specialist resource persons are usually involved in these activities. Multi-sectoral collaboration is encouraged through community participation by sharing of responsibilities with the community, different sectors and Non-Governmental Organizations (NGO). Community participation is also encouraged, to empower the people.

 

Recent Reforms and Investment

A recent health care reform is the provision of Home Based Care (HBC) program for the chronically ill in the community. The majority of the patients under the HBC are AIDS patients. The HBC program also seeks to promote healthful living by providing health education and support to family members who are involved in their care.

The design and development of community HBC is predicated on the facts that:

a. The family is the traditional caring unit in the African society.

b. A vast majority of patients with terminal illnesses prefer to die at home.

c. There is inadequacy of institutional health services for the total population. It is thus expected that the HBC for the terminally ill should free useful but scarce health resources for other needy patients.

Indeed the community HBC model places the main responsibility for care on the family, which is supported and facilitated by the health personnel (Ministry of Health, Botswana 1996). Peer education programs are regularly organized for volunteers and a training manual on "women and HIV/AIDS prevention" has been produced to assist the peer leaders and group members (WHO Collaborating Center for international Nursing, 1997).

According to Government sources, over 27 million pula (the Botswana currency. 1 P = 0.214 US$) has been secured for implementing HBC for 1999 (Botswana Daily News, 1999).

A department of Sports & Recreation was created in 1997, within the Ministry of Labor and Home Affairs to promote health and fitness among Botswana youths through sports and recreation. This department organizes periodic seminars, workshops, and symposia in order to enlighten the public on the needs for regular participation in sports and recreation as a way to improve individual health and fitness.

From the year 2000, Physical Education will be a curriculum subject in junior secondary schools. Adequate preparations and provisions have been made to ensure successful implementation.

To encourage the use of condom as a preventive behavior against HIV/AIDS, condoms are supplied free in institutions, hotels, and other public places. As a demonstration of its commitment to protecting and enhancing the health of its citizens including, the future generation, the Mother-To-Child-Transfer (MTCF) program was recently introduced. In this program, pregnant women are counseled and voluntarily screened for HIV/AIDS.

If the test id positive, the patient is post-counseled and offered AZT at certain stages of the pregnancy. The goal of the AZT is to protect the unborn child, that is, the next generation of Batswana from being infected with HIV/AIDS. Although the screening and AZT treatment are expensive, they are given free to infected mothers.

 

Evaluation, Monitoring and Development

Periodic evaluations and epidemiological studies are used to monitor the success of the PHC program. Where weak areas or deficiencies are detected, they are immediately catered for. It is through these processes that the shortage in manpower is detected and procedures for staff training and recruitment are set in motion. The new innovative HBC system recently designed for the chronically and terminally ill patients also arose from the evaluation process.

The in-built-evaluation process coupled with the continuous in-puts from the districts and communities are the main keys to the success of the national health promotion programs. The contents and procedures of healthcare and health promotion programs are always discussed and agreed with the direct consumers before being implemented. This is in line with the practice of governance in Botswana. It is the practice and convention that before any new policy or service is implemented, there must be wide consultations among the stakeholders in order to obtain their contributions and reactions, as the ultimate consumers.

A large majority of national health problems are presented and discussed with the children through the school curriculum in primary and secondary schools. Such issues are normally incorporated into biology and social studies subjects. Health-hindering culturally based attitudes and behavior are analyzed and corrected during social studies in particular. It is expected that these efforts in health care and health promotion in the schools and communities coupled with the Governments willingness to provide a qualitative, happy and healthy life for the people would accelerate the attainment of universal health.

The Government through the Ministry of Health acknowledges expertise in its health care and health promotion efforts. They regularly seek and use he expertise of teachers & researchers in educational institutions particularly on the needs to review curriculum programs, evaluation studies and epidemiological trends. This class of experts also plays prominent roles as resource persons and lead speakers in workshops, seminars and special public education programs.

 

Health Promotion: The Future

It is certain that Botswana, through its health care and health promotion efforts and continuous reforms, is on the right track to attaining universal health for its people. Furthermore, its acknowledgment of the fact that preventive health is always better and cheaper than curative and the fact that the Government continues to show political will and commitment to giving the majority of the populace, if not all, a happy and good life, health promotion will very soon, be the main emphasis in Botswana Primary Health Care system.

Dr. Emanuel Owolabi may be reached at University of Botswana, Department of Physical Education, Private Bag 0022, Gaborone, Botswana or e-mail: owolabie@noka.ub.bw
 
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