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WHO COUNTRY COOPERATION STRATEGY 2008-2013
WHO COUNTRY COOPERATION STRATEGY 2008–2013
BOTSWANA
AFRO Library Cataloguing-in-Publication Data WHO Country Cooperation Strategy, 2008–2013 Botswana 1. 2. 3. 4. 5. 6. Health Planning Health Plan Implementation Health Priorities Health Status International Cooperation World Health Organization
ISBN: 978 929 023 1325 (NLM Classification : WA 540 HB4)
©
WHO Regional Office for Africa, 2009
Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Publication and Language Services Unit, WHO Regional Office for Africa, P.O. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507; E-mail: afrobooks@afro.who.int). Requests for permission to reproduce or translate this publication – whether for sale or for non-commercial distribution – should be sent to the same address. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use. Printed in India ii
CONTENTS MAP OF BOTSWANA .................................................................................................... v ABBREVATIONS ........................................................................................................... vi PREFACE ....................................................................................................................... xi EXECUTIVE SUMMARY ............................................................................................... xii SECTION 1 INTRODUCTION ........................................................................................ 1 SECTION 2 2.1 2.2 2.3 2.4 SECTION 3 3.1 3.2 3.3 3.4 COUNTRY HEALTH AND DEVELOPMENT CHALLENGES ........................ Socioeconomic Situation and Determinants of Health ................................ Development Policies and the Millennium Development Goals ................ Health System Issues .................................................................................. Major Health Issues .................................................................................... 2 2 3 4 7
DEVELOPMENT ASSISTANCE AND PARTNERSHIPS ................................ 17 Development Partners ................................................................................ 17 Coordination within the United Nations ..................................................... 20 Partner Coordination .................................................................................. 20 Challenges in Utilizing Development Partner Funding .............................. 21
SECTION 4 WHO CORPORATE POLICY FRAMEWORK: GLOBAL AND REGIONAL DIRECTIONS ............................................................................................. 22 4.1 Goal and Mission ....................................................................................... 22 4.2 Core Functions ........................................................................................... 22 4.3 Global Health Agenda ............................................................................... 23 4.4 Global Priority Areas ................................................................................. 23 4.5 Regional Priority Areas .............................................................................. 23 4.6 Making WHO more Effective at the Country Level ................................... 24 SECTION 5 5.1 5.2 5.3 5.4 5.5 5.6 CURRENT WHO COOPERATION ............................................................. 25 Main Contributions to Health, 2003-2007 .................................................. 25 Resources .................................................................................................. 26 Reporting and Information-Sharing ............................................................. 27 Information Security .................................................................................. 28 Minimum Operating Security Standards .................................................... 28 Strengths, Weaknesses, Opportunities and Threats .................................... 29
SECTION 6 STRATEGIC AGENDA: PRIORITIES FOR WHO-COUNTRY COOPERATION ........................................................................................ 30 6.1 Communicable Diseases ............................................................................ 30 6.2 HIV/AIDS ................................................................................................... 31 6.3 Tuberculosis ............................................................................................... 31 6.4 Malaria ...................................................................................................... 32 6.5 Noncommunicable Diseases, Mental Health, Violence, Injuries and Disabilities ................................................................................................ 32 iii
6.6 6.7 6.8 6.9 6.10 6.11 6.12 6.13 6.14 6.15 SECTION 7 7.1 7.2 7.3 7.4
Sexual and Reproductive Health ............................................................... 33 Making Pregnancy Safer ............................................................................ 34 Child and Adolescent Health ..................................................................... 34 Emergency Preparedness and Disaster Management ................................. 34 Health Promotion ....................................................................................... 35 Social Determinants of Health .................................................................. 35 Environmental Health ................................................................................ 35 Food Safety and Nutrition .......................................................................... 36 Health Systems Strengthening ................................................................... 37 Leadership and Governance ...................................................................... 39 IMPLEMENTATION OF THE STRATEGIC AGENDA .................................. 40 WHO Country Office ................................................................................ 40 WHO Regional Office ............................................................................... 41 WHO Headquarters ................................................................................... 41 Monitoring and Evaluation ........................................................................ 41
SECTION 8 CONCLUSION .......................................................................................... 42
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Map of Botswana
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ABBREVIATIONS AFP ACHAP ACT ANC AIDS ARI ART ASRH BFHS BHP BNTP BOCONGO BONASO BOTUSA CAH CBO CCA CCS CDC CIDA CMH CHBC CORD CPC CSO DANIDA DFID DHT DOTS DPC DST EHA EHO EPI : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Acute flaccid paralysis African Comprehensive Partnership on HIV/AIDS Artemisinin Combined Therapy Antenatal clinic Acquired immunodeficiency syndrome Acute respiratory infection Antiretroviral therapy Adolescent Sexual and Reproductive Health Botswana Family Health Survey Botswana Harvard Partnership Botswana National TB Control Programme Botswana Coordination for Nongovernmental Organizations Botswana Network of AIDS Service Organizations Botswana United States of America project Child and Adolescent Health Community-based organization Common Country Assessment Country Cooperation Strategy Centers for Disease Control, USA Canadian International Development Agency Commission on Macroeconomics and Health Community home-based care Chronic Respiratory Disease Communicable Disease Prevention and Control Central Statistics Office Danish International Development Agency Department for International Development District Health Team Directly-observed treatment short-course Disease prevention control officer Drug susceptibility testing Emergency and Humanitarian Action Environmental Health Office Expanded Programme on Immunization vi
FOS GDP GOB HACCP HMIS HIV HPR HR HRM HQ IST/ESA IDSR IMCI IMF IMR IPT ITN IVD MAL MD MDG MDR-TB MFDP MIS MLHA MLG MMR MNH MOE MOH MPS MTP NACA NCD NDP NGO NORAD NPO NSF
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
Food Security Gross Domestic Product Government of Botswana Hazard Analysis Critical Control Point Health Management Information System Human immunodeficiency virus Health Promotion Human Resources Human Resource Master Plan for Health WHO headquarters Intercountry Support Team for East and Southern Africa Integrated Disease Surveillance and Response Integrated Management of Childhood Illness International Monetary Fund Infant mortality rate Isoniazid preventive therapy Insecticide-treated bednet Immunization and Vaccine Development Malaria Medical officer Millennium Development Goal Multidrug-resistant TB Ministry of Finance and Development Planning Malaria Indicator Survey Ministry of Labour and Home Affairs Ministry of Local Government Maternal mortality ratio Mental Health and Substance Abuse Ministry of Education Ministry of Health Making Pregnancy Safer Medium Term Plan National AIDS Coordinating Agency Noncommunicable disease National Development Plan Nongovernmental organization Norwegian Agency for Development National professional officer National Strategic Framework vii
NSPR NUT PEP PEPFAR PER PHC PHE PMTCT PNC POW PSI RB RBM REC RED RHR RO RTA SADC SIDA SSA SSR STEPS STD STP STI SWAp TB TBA THE UMR UN UNAIDS UNDAF UNDG UNFPA UNHCR UNICEF USA
: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :
National Strategy for Poverty Reduction Nutrition Post exposure prophylaxis President’s Emergency Plan for AIDS Relief Public expenditure review Primary Health Care Programme of Health and Environment Prevention of mother-to-child transmission (of HIV) Post natal care Plan of Work Population Services International Regular budget Roll Back Malaria Resource Mobilization, External Relations and Cooperation Reaching Every District Research and Programme Development in Reproductive Health Regional Office Road Traffic Accidents Southern Africa Development Community Swedish International Development Agency Special service agreement Sexual and Reproductive Health Stepwise Approach to Surveillance Sexually transmitted disease Short-term professional Sexually transmitted infection Sectorwide approach Tuberculosis Traditional birth attendant Total Health Expenditure Under-five mortality rate United Nations Joint United Nations Programme on HIV/AIDS United Nations Development Assistance Framework United Nations Development Group United Nations Population Fund United Nations High Commissioner for Refugees United Nations Children’s Fund United States of America viii
USAID VCT VF WCO WHO XB XDR-TB
: : : : : : :
United States Agency for International Development Voluntary counseling and testing Voluntary funds WHO Country Office World Health Organization Extra Budgetary Source Extensively drug-resistant TB
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PREFACE The WHO Country Cooperation Strategy (CCS) crystallizes the major reforms adopted by the World Health Organization with a view to intensifying its interventions in the countries. It has infused a decisive qualitative orientation into the modalities of our institution’s coordination and advocacy interventions in the African Region. Currently well established as a WHO medium-term planning tool at country level, the cooperation strategy aims at achieving greater relevance and focus in the determination of priorities, effective achievement of objectives and greater efficiency in the use of resources allocated for WHO country activities. The first generation of country cooperation strategy documents was developed through a participatory process that mobilized the three levels of the Organization, the countries and their partners. For the majority of countries, the 2004-2005 biennium was the crucial point of refocusing of WHO’s action. It enabled the countries to better plan their interventions, using a results-based approach and an improved management process that enabled the three levels of the Organization to address their actual needs. Drawing lessons from the implementation of the first generation CCS documents, the second generation documents, in harmony with the 11th General Work Programme of WHO and the Medium-term Strategic Framework, address the country health priorities defined in their health development and poverty reduction sector plans. The CCSs are also in line with the new global health context and integrated the principles of alignment, harmonization, efficiency, as formulated in the Paris Declaration on Aid Effectiveness and in recent initiatives like the “Harmonization for Health in Africa” (HHA) and “International Health Partnership Plus” (IHP+). They also reflect the policy of decentralization implemented and which enhances the decision-making capacity of countries to improve the quality of public health programmes and interventions. Finally, the second generation CCS documents are synchronized with the United Nations development Assistance Framework (UNDAF) with a view to achieving the Millennium Development Goals. I commend the efficient and effective leadership role played by the countries in the conduct of this important exercise of developing WHO’s Country Cooperation Strategy documents, and request the entire WHO staff, particularly the WHO representatives and divisional directors, to double their efforts to ensure effective implementation of the orientations of the Country Cooperation Strategy for improved health results for the benefit of the African population.
Dr Luis G. Sambo WHO Regional Director for Africa
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EXECUTIVE SUMMARY The second generation Country Cooperation Strategy for Botswana provides strategic guidance for WHO work at all three levels (country, region, HQ) for the period 2008 to 2013. The CCS has been informed by WHO global and regional strategic documents and orientations; key national documents such as the National Development Plan 9 (NDP 9), the National Health Policy and the Human Resources for Health Plan; the UN Country Cooperation Strategy; and UNDAF. Implementation is aligned to that of the WHO Strategic Framework 2008-2013. The CCS was developed through a participatory process primarily involving Ministry of Health senior management and counterparts. The situation analysis depended heavily on the information collected for the Common Country Assessment, NDP 10, the Human Resources for Health Plan, the WHO integrated audit, among others, all of which are recent documents. Key challenges were identified during the implementation of the first CCS (2003-2007). These together with the assessment of existing partnerships, financing constraints of the health sector and the constraints of the WCO in terms of limited staffing and funding informed the priorities of the strategic agenda. Due to the middle-income status of the country, there are very few international development partners supporting Botswana in general, including the health sector. The overall objective of the CCS is to ensure that all the necessary actions are undertaken for the attainment of the highest possible level of health as reflected in the national aspirations set out in the national strategic documents on health. The areas of priority in the CCS are presented in line with the organization-wide strategic objectives 1–12. The strategic approaches for delivering on the agenda for the period 2008-2013 include provision of technical support for the development of policies, plans and guidelines based on scientifically-sound and evidence-based information; provision of technical support for programme implementation, monitoring and evaluation; capacity building; advocacy and fostering the sharing of best practices; and supporting resource mobilization and partnerships in tackling the key national health challenges. The strategic agenda focuses on the following key areas: 1. strengthening health systems, in particular supporting the development and revision of national health plans, policies and legislation as well as supporting their implementation, monitoring and evaluation; 2. supporting the development and review of programme-specific implementation plans in all key health programmes to ensure that they address the real health needs of the country and are in line with international standards and best practices; 3. strengthening health sector responses to HIV/AIDS towards universal access and sustaining the efforts; 4. scaling up interventions for malaria prevention and control towards the goal for elimination; 5. intensifying efforts for TB control in terms of expanding DOTS and minimizing the emergence of drug-resistant TB; 6. ensuring coordination and collaboration among programmes–HIV/AIDS, TB, malaria, and sexual and reproductive health services; xii
7. strengthening epidemic preparedness and response, including implementation of the International Health Regulations and pandemic influenza preparedness; 8. building upon and sustaining the successes achieved in addressing vaccinepreventable diseases and other efforts; 9. increasing access to sexual and reproductive health, and maternal and child health, in order to attain overall improvements in people’s health; 10. building capacity in all health programmes for leadership, coordination, management and delivery of services at national and local levels; 11. supporting the implementation of the Human Resources for Health Plan; 12. involving all health sector stakeholders in the planning, implementation, monitoring and evaluation of health initiatives; 13. emphasizing advocacy for hitherto neglected areas such as occupational health, noncommunicable diseases, oral health, food safety, mental health, environmental health and the social determinants of health. In the implementation of this CCS, all three levels of WHO will work closely together to ensure that the overall goal is achieved.
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SECTION 1 INTRODUCTION The aim of the WHO Country Cooperation Strategy (CCS) is to strengthen the efficiency and effectiveness of WHO work in Botswana as it supports government efforts to achieve the national health goals. This is the second CCS for Botswana. In addition to addressing the traditional public health issues, this CCS focuses on health as a development issue. The CCS has defined the strategic directions and medium term strategic agenda in the country for the entire WHO Secretariat, including all three levels of the Organization (headquarters, Regional Office for Africa and Country Office) covering the period 20082013. Even though the period of implementation of this CCS does not align precisely with the National Development Plan (NDP 10, 2010 to 2016) or the UN Development Assistance Framework in Botswana, it will nevertheless be implemented during the period of implementation of these important documents. The CCS was developed through a consultative process involving the WHO Country Team, national counterparts from the Ministry of Health and other partners. It was based on a thorough analysis of the situation as reflected in numerous national documents. The objective of the Country Cooperation Strategy is to enable WHO to be more responsive to country needs by being more selective and focused on national health priorities. The Organization aims to provide an optimum balance between the needs and expectations of the country on the one hand, and the comparative advantage of WHO on the other, fully taking into account the activities of other development partners. In setting out the medium term strategic agenda, the CCS was inspired by the Eleventh WHO Global Programme of Work, the Medium Term Strategic Plan 2008-2013, the orientations of the World Health Assembly and Regional Committee, the NDP 9, the National Health Policy (1995), the revised UNDAF for 2008-2009, the Common Country Assessment report (2007) prepared as part of the UNDAF process, and the draft National Strategy for Poverty Reduction (NSPR). The documents being prepared on health as part of the preparation of the NDP 10 also informed the development of this CCS. It provides a framework for the Organization to address the health component of the Millennium Development Goals in Botswana. WHO will work to maximize synergies and achieve optimum complementarities with all stakeholders and development partners, in line with the strategies developed in this document. Thus, the CCS provides general guidelines for WHO operations in Botswana for the medium term and will influence work at all levels of the Organization.
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SECTION 2 COUNTRY HEALTH AND DEVELOPMENT CHALLENGES 2.1 SOCIOECONOMIC SITUATION AND DETERMINANTS OF HEALTH Stable democratic governance coupled with a natural endowment with mineral resources facilitate very high rates of economic growth in Botswana which is classified as a middleincome 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 live on less than a dollar a day. This percentage ranges from 5.1% in cities and towns, to 19.3% in villages and is as high as 36.1% among 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, including 60.4% of the senior secondary school leavers (aged 20 to 24 years).2 The number of unemployed graduates is also on the rise. The government encourages private sector development in its efforts to create job opportunities. There is need to collect more recent data on poverty and unemployment so as to accurately assess the rate of poverty reduction which is Millennium Development Goal (MDG) 1 (Eradicating extreme poverty). The national literacy rate in 1993-1994 was 68.9%; it increased to 81.2% in 2003-2004. Botswana’s education policy has focused on achieving universal access to primary education and more recently has extended universal education to ten years. 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 been made with regard to gender equality: 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, higher unemployment and lower pay than men; women are victims of violent crimes (rape and murder), 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 efforts to enhance the economic empowerment and decision-making roles of women. As in 2007, about 90% of rural populations and 100% of urban populations have access to improved drinking water supply. Improved sanitation is experienced by 60% in urban areas and 30% in rural areas.
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Republic of Botswana, Household Income and Expenditure Survey 2002/2003, Gaborone, CSO. Mid-Term Review of NDP 9, 2004.
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Vulnerable populations in Botswana include orphans and people with disabilities; the numbers of orphans are increasing rapidly as a result of HIV and AIDS. Government programmes to support orphans and their care-givers appear to have been effective at reducing, although not eliminating, their vulnerability to poverty and abuse. More generally, opportunities for youth are limited once they leave school, resulting in the dual problems of youth unemployment and rising crime rates.
2.2 DEVELOPMENT POLICIES AND THE MILLENNIUM DEVELOPMENT GOALS The overall guiding document for national development in Botswana is Vision 2016, a broad- based national approach adopted in 1996 and focusing on national aspirations and achievements during the first fifty years of independence. Vision 2016 comprises seven pillars that closely coincide with the Millennium Development Goals. The principles and objectives of Vision 2016 guide the formulation of revolving six-year national development plans (NDPs). In pursuit of the Vision 2016 pillar “A compassionate, just and caring nation”, the following health-related goals were set for NDP 9 (2003/2004– 2008/09): 1. providing quality health care to Batswana in order to improve their health status; 2. improving life expectancy of Batswana through implementation of the Primary Health Care strategy; 3. providing client-focused health services in order to increase customer satisfaction; 4. improving quality service delivery through development and implementation of comprehensive health policies and standards by the end of NDP 9; 5. enhancing Ministry of Health efficiency and effectiveness through implementation of innovative performance improvement initiatives; 6. reviewing existing HRM health plans in order to come up with a comprehensive plan consistent with the current health needs of the country; 7. facilitating the combat against the HIV/AIDS pandemic in the country. Strategic and annual performance plans were developed towards attaining these goals. The implementation of NDP 9 was reviewed, and this formed the basis for the formulation of NDP 10. Gaps and challenges identified in the review of NDP 9 and the CCA were considered in the formulation of this second CCS. This assured alignment with NDP 10 as well as with the UNDAF. A formal assessment of Botswana’s progress towards the Millennium Development Goals was conducted in 2004 in line with Vision 2016 goals. It was noted that the country was making good progress towards achieving the MDGs. The monitoring of progress towards some of the MDGs was hampered, however, by data inadequacies. Progress made in selected indicators is summarized in Table 1.
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Table 1: Progress towards the MDGs–Selected Indicators MDG indicators 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Poverty rate (% of pop. below PDL)* Underweight under-five children (%) Net enrolment rate, primary school (%) Literacy rate, 15-24-year-olds (%) Ratio of males to females in primary schools Ratio of males to females in secondary education Ratio of literate females to males, 15-24 yr olds Infant mortality rate (per 1000) Under-five mortality rate (per 1000) Children immunized against measles (%) Births attended by skilled personnel (%) Maternal mortality rate (per 100 000) HIV prevalence among adults (%) Access to ART (% clinically eligible) TB notifications (per 100 000) Population without access to safe drinking water (%) 1990-94 47 17.0 96.7 89.5 NA NA 1.26 48 63 74 93 326 NA NA 200 23 2001-06 23.4 57.1 98.5 93.9 0.98 1.07 1.19 56.7 74 90 96 150-190 25 95 620 4 Target (2015) 23 (reduce by half) 100 100 H” 1.0 H” 1.0 e” 1.0 16 (reduce by 2/3) 21 (reduce by 2/3) 100 100 81 (reduce by 3/4) Falling H”100 Falling 12 (reduce by half)
* Poverty rates over time cannot be accurately compared due to changed basis for calculation. Sources: CSO (2003a, 2004b, 2006a); CSO and GoB (2004); NACA and CSO (2005); GoB (2007b) CSO HIES 2002-2003; MoH.
2.3 HEALTH SYSTEM ISSUES 2.3.1 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 while the Ministry of Local Government (MLG) is responsible for the delivery of Primary Health Care services through District Health Teams. Two MoH departments (Public Health and AIDS Prevention and Care) manage programmes that are largely implemented at district level and deal directly with district staff. Thus the responsibilities of the two ministries can be said to meet in the districts. The precise roles and responsibilities and the coordination of the two ministries are still not clearly defined at the operational levels, and the challenges identified in the first CCS persist. WHO will continue to advocate for policies and legislation to guide government sectoral partnerships that facilitate improvement in service delivery.
Restructuring the Ministry of Health WHO has provided both financial and technical support for restructuring the Ministry of Health to address the changing health environment and improve performance. Intense advocacy was required for the adoption of the revised structure. The Ministry of Health now has six departments headed by directors and comprising divisions or units: Department of Policy, Planning, Monitoring and Evaluation; Department of Health Sector Relations and Partnership; Department of Clinical Services; Department of Public Health; Department of AIDS Prevention and Care; Department of Ministry Management. The Department of Policy, Planning, Monitoring and Evaluation and the Department of Health Sector Relations and Partnership are vital in coordination and monitoring of wider stakeholders in health development. Two years following the recruitment of directors, the creation of appropriate structures at departmental level, particularly in new departments, is yet to be realized. WHO 4
should therefore increase efforts towards supporting the functionality of the new Ministry of Health structures.
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 (Table 2). These facilities should be enough to provide optimal services for the population but for the unequal distribution per population. Table 2: Health facilities in Botswana Type of facility Referral hospital District hospital Primary hospital Clinic Health post Mobile stop 2002 3 6 17** 242 340 810 Government 2007 3 7 17** 272 338 844 Private 2002 1 4* 2007 1 4* 2002 3 Mission 2007 2
* Including three mine hospitals ** Including one military hospital
The working hours of the PHC facilities are a critical issue as only 127 PHC facilities render services 7 days per week and only 33 clinics provide 24-hour service. This inequitable distribution and low “after hours” service increases the patient load in hospitals. The utilization of services also varies widely: as low as two PHC visits per 1000 population per year in Tutume District to as many as 12.8 PHC visits per 1000 population per year in Okavango. The optimal range for developing countries is from 4.1 to 6.8 PHC visits per 1000 population per year.3 In Botswana, although the national average hospital bed count per 1000 population is 2.06, there is marked unequal distribution of beds among the districts, ranging from as low as 0.66 in Gumare to as high as 5.09 in Athlone hospital, which contributes to the resulting underutilization of available facilities, especially at PHC level. In addition, the bed occupancy levels in 82% of hospitals (mainly primary) and the average length of stay levels in 69% of hospitals were shown to be outside the optimal range for developing countries. To improve the efficiency of services there is a need to establish set norms for distribution of PHC and hospital facilities and their use per population. This can be done within the context of developing a comprehensive integrated services delivery framework for Botswana. The availability and management of staff, mix of skills, equipment, medical supplies and the referral system are among the other issues that need to be addressed to improve access and quality of services.
2.3.2 Human resources Human resource shortages negatively affect health improvement as well as the functionality of all programmes and projects at both central and district levels (Table 3). 3
Human Resources Strategic Plan, Ministry of Health, 2008.
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Despite government efforts to increase the capacities of health training institutions and work conditions of health staff, high attrition rates and some de-motivating factors affecting skilled staff still persist from the first CCS. In addition, there are increasing demands on the already over-stretched skilled workforce by the introduction of new programmes and projects especially those related to HIV/AIDS. Precise data on the rate of national attrition is not available. Table 3: Type of health staff and ratio of health staff to population Type of health worker Number 1999 488 28 4090 1018 142 135 11 1 20 147 2004 339 38 4209 841 199 172 20 79 16 127 Nationals 1999 53 10 3556 1018 31 107 2004 285 28 3894 839 143 Expatriates 1999 435 18 534 0 111 28 2004 54 10 315 2 56 Ratio per population 1999 1:3440 1:44181 1:410 1:649 1:11823 1:12436 2004 1: 4993 1:44546 1:8099 1:2012 1:8506
Medical doctor Dentist Nurses Family welfare educator Pharmacist Environmental health officer Dental therapist Health education officer Medical technologist/ scientist Medical laboratory technician
17 72 11 102
3 7 5 25
1: 84637 1:21427 1:105796 1:13329
Source: Health Statistics Report 1998, Republic of Botswana
The development of a long-term Master Plan for Human Resources for Health for Botswana, which was planned for NDP 9, has been finalized. During NDP 10 efforts should be directed towards the implementation of the Plan in a sustainable manner by the full participation of all relevant stakeholders. Also, the targeted increase in the annual outputs for pre-service and in-service training institutions for NDP 9 were met, and new training programmes in ophthalmic nursing and family nursing were introduced in Molepolole and Kanye, respectively. Staff motivation is on-going; for example, doctor’s salaries have improved; nurses are paid overtime allowances and staff houses are being constructed in health facilities.
2.3.3 Health financing National Health Accounts have been developed for the identification and monitoring of public, private and donor health financing so as to assess efficiency, effectiveness and equity. Data up to 2002 were collected, analysed and published in a report which highlighted the need to diversify the sources of funding for sustainability. The government provided about 75% of Total Health Expenditure (THE) in 2002, which represented about 9.2% of the total government budget. However, THE per capita for that year was US$ 197, well above the US$ 34 estimated requirement per person per year as recommended by the WHO Commission on Macroeconomics and Health. THE as a percentage of GDP gradually increased from 6.43% in 2000 to 9.27% in 2001 and 10.54% in 2002.4
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Botswana National Health Accounts, Ministry of Health, 2006.
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Government funding for health in 2002 was 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 remaining funding for health came from private health financing agents (insurance schemes, households, NGOs and private firms). In public health services, a cost recovery system recently more than doubled health costs per person throughout the country. Foreigners pay more, depending on the services. International agencies have contributed modestly to health care in Botswana: 3.55% in 2000, 5.24% in 2001 and 6.85% in 2002.
2.3.4 Health management information systems The paucity of relevant health information necessary for planning, timely interventions, and monitoring and evaluation remains 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 lack of proper monitoring and assessment frameworks. In addition, there are inconsistencies in health information, particularly related to the main indicators, reported by different programmes and partners, including 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 interventions towards achieving the set targets of the health related MDGs provide opportunities for improving health management information systems.
2.3.5 Medical products and technologies Essential medicines and other health supplies were identified as priorities for WHO support to the country during the implementation of the first CCS. In 2002, the Ministry of Health developed the Botswana National Drug Policy, an essential drug list was completed with collaboration from CDC/BOTUSA, and the drug regulatory system was reviewed. The challenge was to develop MoH capacity in human resources and technical know-how to meet the national policy objectives.
2.4 MAJOR HEALTH ISSUES 2.4.1. HIV/AIDS HIV/AIDS situation Botswana faces one of the most severe HIV/AIDS burdens in the world with the national HIV prevalence estimated at 17%. HIV/AIDS is the leading health and developmental challenge facing the nation. HIV surveillance of pregnant women indicates that prevalence peaked around the year 2000 and significantly declined by 2006 (Figure 1). This decline was particularly significant in the younger age group 15-24 years. The decrease in HIV prevalence in younger women suggests that HIV incidence is also falling. About 300 000 people were living with HIV/AIDS in 2001, and about 110 000 were in need of ART. The first CCS (2003–2007) was implemented during a period when HIV infection had reached a peak and stabilized in the population, a time when the nation was experiencing the impact of HIV infection in terms of AIDS cases, increasing burden of opportunistic diseases (especially TB), AIDS-related deaths and the resultant socioeconomic consequences.
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Figure 1: Trends in age-specific HIV prevalence rates among pregnant women, 1992-2007
Source: MoH 2006 HIV Sentinel Surveillance Report
National response to HIV/AIDS Botswana has mounted a broad multisectoral response to HIV/AIDS, encompassing interventions from both health and non-health sectors. The National AIDS Council chaired by the President guides the overall national response and its secretariat, the National AIDS Coordinating Agency (NACA), coordinates the action of all sectors and stakeholders. The Ministry of Health coordinates all health sector interventions and the Ministry of Local Government coordinates the national response at district level. The national response was implemented in line with the Short Term Plan (1985–1988), the first Medium Term Plan (MTP 1, 1989-1993), MTP 2 (1997-2002), the NSF (2003–2009) and the Health Sector HIV/AIDS Strategy (2003–2009). There is a positive enabling environment for national response in terms of political support, conducive response and financial support from the government and international donor community. Thus, there were a number of achievements during implementation of the first CCS. ART was scaled up from an initial four sites in 2002 to 32 sites by December 2004. By November 2007, an additional 43 clinics were offering ART and over 90 000 patients were taking ARVs. This represents 82% of all estimated patients needing ART. Also, support was provided for the management of opportunistic infections. Services for PMTCT were extended to all (634) health facilities with ANC and maternity in the country. A PMTCT uptake rate of over 85% was attained, and mother-to-child transmission rates decreased from an estimated 40% to about 4.8%. Routine HIV testing and counseling were introduced in 2004, resulting in about 150 000 clients being tested through this programme annually. This initiative led to increased uptake of other HIV interventions such as PMTCT and ART. The second-generation HIV surveillance system was adopted; syndromic management of STIs was extended to all health facilities; and the capacity of CBOs, NGOs and other partners to implement HIV/AIDS activities at community and district levels was enhanced. The creation of the Department of HIV/AIDS in the MoH resulted in improved coordination and management of health sector responses to HIV/AIDS.
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The fight against HIV in Botswana is supported by high-level political commitment, availability of funds, relevant institutional structures and strong partnerships. Challenges remain in the scaling up of HIV prevention interventions, sustainable quality ART services and PMTCT.
2.4.2 Tuberculosis The Botswana National TB Control Programme (BNTP) is being implemented through an integrated Primary Health Care network supported by 48 diagnostic laboratories. The National TB Reference Laboratory is capable of performing TB culture and drug susceptibility testing (DST) for first-line anti-TB drugs only. While the programme performed well in the 1980s, the last two decades saw a resurgence of TB related to HIV co-infection as well as the deterioration of TB programme performance indicators. Although TB notification rates are still high (Figure 2), there is a downward trend. The BNTP 2005 report showed a high notification of 567 per 100 000 population, a low cure rate of 38%, a defaulter rate of 8.4% and a transfer rate of 9%. In addition, drug-resistant TB is emerging in Botswana. Three successive surveys in 1996, 1999 and 2002 showed increasing MDR-TB prevalence rates of 0.2%, 0.6% and 0.8%, respectively.5 Management guidelines for MDR-TB are available, but cases of XDR-TB are now been documented. There is therefore need to establish routine standardized surveillance systems for drug-resistant TB and build laboratory capacity to conduct susceptibility testing for second-line drugs. Figure 2: TB and HIV prevalence, 1990-2006
Source: BNTP Annual Reports and ANC Sentinel Surveillance Reports
The opportunity exists for closer collaboration with the health sector component of the HIV programme which has more capacity within the PHC system. Isoniazid preventive therapy targeting HIV infected persons who are asymptomatic for TB has already been initiated. Greater efforts are needed to improve the screening of TB in HIV patients and vice versa through a policy framework for TB/HIV collaboration. The absence of a human resource plan for BNTP remains an important challenge. 5
Botswana National TB Control Programme Report 2005, Ministry of Health.
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2.4.3 Malaria Malaria transmission in Botswana is unstable and closely related to the level of rainfall which varies considerably every year. About 32% of the population live in high malaria transmission areas in the north of the country, but during heavy rainfall, epidemics occur and other parts can be affected.6 Malaria trends over the last 20 years (Figure 3) indicate intermittent epidemic years interspersed with years of generally low transmission levels up to 1999. From 2000, there has been a progressive downward trend in malaria cases. Figure 3: Malaria trends, 1987-2007
Source: Malaria weekly surveillance data, Department of Public Health, MoH
The government’s aim is to move from malaria control to elimination as stipulated in the 2006- 2011 Malaria Strategic Plan. A policy shift towards ACTs for uncomplicated malaria case management was made in 2007. There are plans to improve diagnostic capacity by scaling up the use of rapid diagnostic tests and strengthening microscopy for early case detection and better quality of care. Vector control and personal protection are provided through residual house spraying and insecticide-treated bednets. However, the programme still has challenges in achieving the 2010 Abuja targets. For malaria in pregnancy, chemoprophylaxis (ProguanilÔ and chloroquin) is given to vulnerable groups. The coverage is only 43.5% compared to the Abuja target of at least 60%. ITN coverage for children under-five is 12.9% and for pregnant women is 15.4%, both below the Abuja targets of 60%.7
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Malaria Strategic Plan 2006-2011, Ministry of Health. Malaria Indicator Survey Report 2007, Ministry of Health.
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Opportunities are available to strengthen the existing structures that support the NMCP; for example, the Malaria Reference Group and the Malaria Epidemic Preparedness and Response Committee both meet regularly. Another opportunity is to increase the number of partners in malaria. The commemoration of SADC Malaria Day and Africa Malaria Day also boosts advocacy for increasing awareness and community mobilization for epidemic preparedness. WHO supported the development of the current 2006-2011 Malaria Strategic Plan and the 2007 Malaria Indicator Survey. The MIS report availed data on core indicators that monitor progress towards the Abuja targets and the MDGs. There is need to establish a malaria database to consolidate data from reviews and surveillance reports and thus allow better planning, monitoring and evaluation of interventions as well as facilitate operational research. It is also necessary to develop specific national strategies for malaria elimination as well as IEC and advocacy.
2.4.4 Sexual and reproductive health Botswana experienced high fertility rates during the 1970s and 1980s, with only a slight decline thereafter. Total fertility rate declined from 6.5 in 1971 to 3.3 in 2001. ANC and PNC attendances are 97% and 85.2%, respectively, while supervised attended deliveries stand at 99%. The lack of recent reliable data on maternal health in Botswana is posing a problem in determining the country’s performance towards the attainment of MDG 5. However, routine health facility data show an estimation of 175 and 167 deaths per 100 000 live births in 2004 and 2006, respectively (Figure 4). Figure 4: Maternal mortality ratios, 1991, 2004-2006
Source: 2004-2006 (Facility Based Maternal Mortality Annual Reports
Efforts have been made in the past to estimate maternal mortality ratios which will be used as a baseline for assessment of MDG 5. WHO has supported the training of health workers on the Maternal Death Review, revision of maternal mortality audit tools and the printing of the revised Maternal Mortality Audit Guide. A national committee to review all maternal deaths is now in place to monitor trends. In addition, WHO provided technical support to the MOH to undertake a national inventory of emergency obstetric care in health facilities in 2007, the results of which guided the development of the National Roadmap 11
Towards the Reduction of Maternal and Newborn Mortality. These efforts will assist the country to accelerate the attainment of MDG 5. Teenage child-bearing, unsafe abortions and other preventable complications of childbirth contribute to the high MMR. The percentage of teenagers who were mothers rose from 15.4% in 1971 to 24% in 1988, but declined to 16.6% in 1996 (BFHS III). Among teenagers who were pregnant, the average age at first pregnancy was 16 years. WHO is providing technical support for capacity-building in the Family Planning Programme. Updated training materials are available for use in a continuous training programme in all districts. Cervical cancer was recognized as an important cause of morbidity and mortality in Botswana following a situation analysis supported by WHO in eight districts in 2003. Up to 26.15% of Papanicolaou smears were reported as abnormal in 2001; as a result, the National Cervical Cytology Screening Programme was initiated. Botswana continues to improve women’s health via interventions that also target men. The latter do have critical roles in the decisions related to both women’s health and adolescent health.
2.4.5 Child and adolescent health Some of the gains in improving child mortality in Botswana before the 1990s were reversed mainly by the high HIV/AIDS prevalence (Figure 5). Figure 5: Infant and under-five mortality rates, 1985-2001
Teenage child-bearing and unsafe abortions contribute to the high mortality rates. Various strategies have been put in place to address the sexual and reproductive health problems of young people; these include provision of youth-friendly services, re-orientation of health workers and provision of relevant, specific ASRH materials. WHO will continue to assist the Ministry of Health to strengthen ASRH services.
2.4.6 Food safety and nutrition The precarious weather conditions characterized by recurrent drought and the fact that Botswana is 80% desert contribute to poor household food security through constant crop 12
failure which necessitates food imports. At present, Botswana imports 70-80% of its food requirements from neighbouring countries and elsewhere. As a result of rapid urbanization, Batswana have changed their eating habits. Many people eat much of their food away from home; such food is often prepared by street vendors who may not have the knowledge and resources to provide safe and quality food. The main nutrition problems in Botswana include protein-energy malnutrition, micronutrient deficiencies (vitamin A, iodine and iron) and diet-related noncommunicable diseases. The causes of nutritional problems include inadequate food intake, inadequate maternal and child-caring practices, ignorance, poverty, food taboos, lifestyles and predisposing diseases such as TB and HIV/AIDS. On the other hand, heavy rainfall in recent years resulted in severe acute malnutrition due to water contamination and loss of lives of children under-two due to outbreaks of diarrhoea. A contributing factor to this could possibly be the fact that PMTCT efforts have resulted in a large number of non-breastfed children which has presented some challenges. Under normal circumstances, severe malnutrition has not been a major problem in Botswana. Facility-based malnutrition trends among children under-five have been declining since 1998. However, district-specific trends show significantly higher levels continuing to drop. Malnutrition levels continue to be affected by availability of supplementary feeds as shown for the years 1997 to 1998 when feeding of under-fives was stopped during non-drought years. Nutritional surveillance plays an important role in determining the nutritional status of children under-five, especially in a country where there are recurrent droughts. Thus, strengthening and maintaining the surveillance system cannot be over-emphasized.
2.4.7 Communicable diseases The good collaboration and coordination between the MoH and the WHO Country Office and support from the IST/ECA facilitated progress made in Integrated Disease Surveillance and Response as well as Epidemic Preparedness and Response. A five-year national IDSR plan was developed in 2001 and a strategy was adapted in 2003. Human resource capacity has been improved which has strengthened the coordination, planning, monitoring and evaluation of surveillance activities between the MoH and MLG. The Epidemiology Unit coordinates all outbreak response activities with support from structures such as the National Emergency Preparedness and Response Committee and the IDSR Coordination Committee. The WHO epidemic preparedness guidelines were adapted and staff at district level were trained in their use in 2005. Rapid Response Teams have been established. Routine data collection (weekly and monthly) is in place, and the quarterly IDSR bulletin is published to provide feedback on disease status as well as district disease reporting. The government funds all procurement of vaccines, cold chain and related logistics for the immunization programme. A 2002 review of the programme revealed low human resource and management capacities and weak surveillance systems. Assessments of the performance and quality of immunization services were conducted in 2003 and 2007, and the vaccine procurement process was assessed in 2007. These revealed that managerial gaps still pose a problem, especially in vaccine management and procurement processes. National vaccination coverage of 2007 revealed poor performance for TT vaccination in women. Access to tetanus toxoid vaccination as indicated by TT-1 coverage was poor (52%), despite the high proportion 13
of mothers that received antenatal care (95%). The risk of neonatal tetanus still exists in Botswana. Despite the above gaps there were some achievements. A national vaccination coverage survey in 2007 showed good access and utilization of childhood vaccination. About 90% of children 12–23 months surveyed received all the valid doses of the recommended vaccines. Improvement is seen in the status of indicators for both polio eradication and measles casebased surveillance. The national polio eradication documentation was submitted to the African Regional Certification Commission and accepted in 2005. This gives the country the status of having met the polio-free certification criteria. However, there is still need to guard against virus importation. Indicators for acute flaccid paralysis (AFP) improved since 2002 when the non-polio AFP rate was 1.5 per 100 000 children under 15 years (stool adequacy of 78%). In 2007, the non-polio AFP rate was 2.1 per 100 000 children under 15 years of age (stool adequacy of 94%). Indicators for case-based measles surveillance have similarly improved. For 2007 the reporting rate was 8.1 per 100 000 population; there were 138 suspected cases, and less than 1% were IgM positive for measles. All cases reported were investigated. The number of districts with at least one suspected case improved from less than 50% in 2002 to more than 80% in 2007. Human resource shortages remain a problem for IDSR in Botswana. The number of IDSR staff at the Ministry of Health is inadequate and there are no focal persons at district level. Other challenges include the absence of an IDSR taskforce, the weak laboratory component, and inadequate financial resources.
2.4.8 Healthy environments and sustainable development The Botswana government acknowledges that environmental quality is an important direct and indirect determinant of human health; it further recognizes that deteriorating environmental conditions hinder sustainable development and present hazards which are major contributory factors to poor health and poor quality of life. Efforts to diversify the economy with manufacturing, agriculture, tourism, mining and service businesses have resulted in other environmental health challenges. Population growth has led to self-settlements and overcrowding. Pollutants of all kinds and hazardous substances are on the increase. The existing infrastructure can no longer cope; where appropriate services are non-existent, potential environmental health problems loom. In Botswana, the major role players in occupational health and safety are the Department of Occupational Safety and Health in the Ministry of Labour and Home Affairs, the Occupational Health Unit in the Ministry of Health and the Mining Department of the Ministry of Mines, Energy and Water Affairs; the former two are service providers for other sectors. The MoH mandate is to provide essential occupational medically-oriented back-up to all sectors, that is, virtually to the entire working population of over 539 150. Back-up service ranges from workers’ well-being from the time of entry into the labour market to the time of exit through retirement, to medical concerns, incapacity, redundancy, retrenchment or death. Presently, the health professionals providing occupational health services in the abovementioned areas have limited knowledge in occupational health management, and the referral role at the Occupational Health Unit is severely limited because of the small number of trained cadres with occupational health expertise. Apart from limited financial support to occupational health activities, there have been serious constraints in coordinating occupational health among the role players. The magnitude of occupational health has not been comprehensively assessed to determine priorities.
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There has been very slow progress in meeting the increasing demands for occupational health from the public sector, private sector, ministries, parastatal organizations and educational institutions. The Ministry of Health was not able to respond to the majority of such requests because occupational health was not included in NDP 9 or in the WHO Country Office budget. To adequately respond to the various challenges, several activities have been initiated in collaboration with partners. The draft National Environmental Health Policy was submitted to Parliament for approval, and a national strategic plan is being developed to implement the policy. A chemical substances and products act has been drafted. Relevant environmental public health standards were initiated by the Department of Public Health and are being developed by the Bureau of Standards to facilitate the legislation. The Public Health Act of 1971 is being amended to suit present developmental and environmental challenges in the country. A national strategy and code of practice for better management of health-care facility waste is being updated to recognize HIV/AIDS issues. A national strategy on port health is being developed and will include a national port health programme. Botswana ratified the Framework Convention on Tobacco Control in 2005 and is updating current tobacco control legislation to harmonize it with the provisions of the Convention.
2.4.9 Noncommunicable diseases Botswana has been experiencing a steady increase in noncommunicable diseases and therefore utilization of health services related to NCDs has also increased. A recent countrywide survey of persons aged above 50 seeking health services revealed that 67% and 12.4% of respondents had hypertension and diabetes, respectively. The government in collaboration with the WHO Country Office conducted the STEPS survey in July 2007. The results of the survey will inform the national policy on noncommunicable diseases and the subsequent strategic plan to control and prevent NCDs. The Noncommunicable Disease Unit in the Ministry of Health is relatively new and needs to be strengthened. Road accidents in Africa have the highest fatality in the world, with about 190 000 people dying each year. Botswana continues to experience road traffic accidents, often involving young people, as the number of vehicles increases. Road accidents also lead to increased cases of disabilities. The government in collaboration with WHO has been implementing road campaigns, especially during holidays, to reduce mortality. The government will also contribute to the global road safety report and further strengthen programmes to reduce disabilities and mortality. The Cancer Registry was established in 2003 in the Epidemiology and Disease Control Unit of the Ministry of Health. The objectives of the Registry are to determine the disease burden attributable to cancer by quantifying the magnitude of cancer morbidity and mortality and their geographic trends in Botswana; identify high-risk subgroups which should be targeted for cancer prevention; identify potential risk factors; monitor and evaluate cancer treatment, control and prevention programmes; and stimulate and facilitate epidemiological research on cancer. Mental health has also been observed to be a problem in Botswana. The Alcohol and Substance Abuse Prevention Strategy was formulated in 2002, and the National Mental Health Policy was developed in 2003. However, there are gaps in implementation due to lack of resource capacity. 15
Investment in oral health care is low and the limited resources are primarily allocated to emergency oral care and relief of pain. Restorations are available to the few who can pay and are provided mainly by private dental practitioners. Outreach services, especially oral health programmes have been provided at primary schools (the current coverage being 55%). These services are expected to improve with the utilization of mobile dental clinics. A national survey carried out in 2000 indicated an increase in oral disease prevalence among the adult population aged 35-44 years. The same survey revealed low disease prevalence in the younger population, with over 88% of 12-year-olds and over 95% of 5year-olds being caries-free. The challenge therefore is to maintain the high percentage of caries-free persons through adulthood. Although oral manifestations of HIV/AIDS present at different clinical stages of the disease, comprehensive management involving oral health personnel is limited due to unclear referral channels between MoH units.
2.4.10 Health promotion Health promotion plays a pivotal role in addressing the key determinants of health. During the implementation of the ninth National Development Plan (NDP 9), health promotion provided individuals, families and communities with the requisite knowledge, information and skills to influence their own health and that of the nation. The Health Promotion and Education Unit (soon to be a division) developed an innovative, interactive community education campaign that addresses issues of youth and alcohol abuse. The campaign is broadbased and includes sexual and reproductive health, HIV and AIDS, and other issues that influence the health of young people. The campaign moves from one district to another and is informed by both the WHO/CDC Student-Based School Health Survey of 2005 and the ACHAP-funded Youth, Alcohol and HIV/AIDS Study of 2003. The Unit also continues to support programme-specific community education and mobilization as required by different programmes and situations. With support from WHO, the Ministry of Health has developed and is working to operationalize a health promotion policy along with other legislation to cover traditional health practices and tobacco use control. Further challenges remain and require continued WHO support. One challenge is the finalization and operationalization of the Health Promotion Policy, the Traditional Health Practice Bill and the Health Promotion Strategic Plan. It is also necessary to develop guidelines and materials for teachers to promote safe and healthy learning environments (Health Promoting Schools); such materials can also be used to develop capacity to influence other sectors to value and invest in health. Programmes are needed for re-emerging communicable diseases; emerging noncommunicable diseases; and behavioural and lifestyle-related problems, including early use of alcohol and drugs among youth. Additional challenges include development and utilization of key indicators for monitoring and evaluating programme outcomes; and documentation, dissemination and utilization of best practices and lessons learnt from planned activities.
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SECTION 3 DEVELOPMENT ASSISTANCE AND PARTNERSHIPS Most of the health budget in Botswana is financed by the government. In the 2007-2008 financial year, 6.8% of the development budget was allocated to the Ministry of Health (Budget Speech Feb 2007). However, this is an underestimate of the total government financial commitment to health because it does not include the HIV/AIDS funding that comes from the Ministry of State President and the health services provided by the ministries of local government and education. Overall it is estimated that approximately 17% of the national budget is allocated to health, and 9.8% of the development budget is allocated to the HIV/ AIDS Programme (Budget Speech Feb 2007). With its rating as an upper middle-income country, Botswana has experienced a reduction in the number of development partners. The few remaining partners have concentrated their support on HIV/AIDS. The major external donor in the health sector is the United States of America through PEPFAR and CDC (BOTUSA) followed by ACHAP, the European Commission, UN agencies and Japan (JICA). The partners are coordinated through the Ministry of Health and the National AIDS Coordinating Agency (NACA).
3.1 DEVELOPMENT PARTNERS Development partner support in health is concentrated on HIV/AIDS prevention, treatment, care and support. The development partners mostly provide financial support with some technical assistance. Because Botswana is classified as a middle-income country, external sources form a relatively small proportion of the total funding for HIV/AIDS, increasing from 10% in 2003 (approximately P74 million) to 19% in 2004 (P187 million) and 20% (P228 million) in 2005 (NACA Report 2007). The proportional increase in development partner funding was due to the large and increasing allocations made by the Government of Botswana to HIV/AIDS. The Ministry of Finance and Development Planning (MFDP) is the principal recipient of all donor funds, including those for the implementation of HIV/AIDS programmes in the public sector. NACA accesses all funds and disburses the money to implementers (mainly MoH and MLG) according to their budgets, workplans and other agreed procedures. In return, NACA on behalf of the government, reports to donors in the form of periodic financial and narrative progress reports on funds disbursed and programmes implemented. All donor-funded projects are implemented in accordance with the signed memoranda of agreement between the donor and the MFDP (on behalf of the government), the project document and the annual workplans (NACA Report 2007).
3.1.1 PEPFAR/BOTUSA BOTUSA has supported the implementation of the NSF with significant PEPFAR funding and technical assistance, including programme support in 15 different technical areas within 17
the overall areas of HIV/AIDS prevention, treatment, care, support, strategic information, capacity building and others. Some of these areas have included: capacity-building through funding of government positions (MOH, NACA, MLG, MOE, MLHA); development and implementation of a 10-year human resource development plan; national wellness programme for health workers; integrated health services plan for the health sector; strengthening institutes for health sciences; supporting in-service training in various HIV-related topics; strengthening civil society; strengthening laboratory infrastructure; and supporting surveillance, research, monitoring and evaluation. Since 2004, PEPFAR financial support to Botswana has increased rapidly, building on existing successful programmes, identifying new partners and building capacity for sustainable, effective and widespread HIV/AIDS responses. In addition, there has been implementation of strong strategic information systems that will contribute to continued learning and identification of best practices. This has been made possible by significant funding support to national and civil society actors. In 2007, funding amounted to US$ 73 million. However, PEPFAR is limited to supporting programmes on an annual basis according to US congressional support. This results in some uncertainty of future funding levels. PEPFAR through BOTUSA also supports the Botswana National Tuberculosis Control Programme by funding isoniazid prevention therapy. This intervention aims to provide HIV positive clients with prophylaxis so that they do not develop active tuberculosis.
3.1.2 African Comprehensive HIV/AIDS Partnership (ACHAP) ACHAP is the second largest donor to HIV/AIDS and thus to health in Botswana. ACHAP is a country-led public-private development partnership between the Government of Botswana, the Bill and Melinda Gates Foundation, and Merck & Co. The ACHAP programme has existed since January 2001. Both the Bill and Melinda Gates Foundation and Merck & Co. donated US$ 56.5 million each. The areas of focus for ACHAP are HIV prevention, including blood safety and STIs; HIV counseling and testing; improving access to ART by supporting the national ART programme; and advocacy and community mobilization. ACHAP supports central government programmes as well as programmes in seven partner districts. Between 2001 and 2002, ACHAP provided about US$ 96 million. ACHAP is also playing a crucial role in strengthening country response to the emerging challenges of drug-resistant tuberculosis through provision of equipment and infrastructure for the National TB Reference Laboratory and support for development of infrastructure to reduce the spread of TB infection within health-care settings. As a result, there has been improvement of human resource capacity vital for strengthening surveillance and monitoring of the TB Programme at national and district levels and in the National TB Reference Laboratory.
3.1.3 Swedish International Development Agency Sida, through Forum Syd, has become a key player providing funding to HIV/AIDS in the NGO sector. The total budget for 2007-2009 is Sek 42 million.
3.1.4 World Bank and European Union The Government of Botswana is planning to obtain a five-year US$ 50 million World Bank loan to support HIV/AIDS interventions in the public sector as well as through NGOs 18
and civil society. The processes of loan negotiation are currently ongoing. The Ministry of Finance and Development Planning has indicated preference for a buy-down that reduces the effective interest rate8 down to 0%. The European Commission has agreed to support the buy-down of this project and has already approved an additional euro 14 million (US$ 20 million9) in its next four-year Economic Development Framework (EDF10 for 2010-2014) to finance the HIV/AIDS loan.
3.1.5 Global Fund to Fight AIDS, Tuberculosis and Malaria The GFATM has supported Botswana with a Round 2 grant. Unfortunately this grant was discontinued due to capacity constraints for monitoring and report. In Round 5, GFATM supported TB control activities and these are on-going.
3.1.6 United Nations agencies The United Nations agencies in Botswana consist of UNDP, UNICEF, UNFPA, UNAIDS, UNHCR, FAO and WHO as resident agencies. The work of the UN in Botswana was guided by UNDAF (2003-2007). UNDAF identified three key thematic areas for UN focus: HIV/ AIDS, poverty and environment. Health was identified as one of the crosscutting issues in UNDAF and was further elaborated in the first CCS (2003-2007). An evaluation of UNDAF in 2006 indicated that apart from addressing HIV/AIDS, implementation was far below the expected performance rate. A number of reasons were identified that need to be addressed as the next UNDAF is prepared. A Common Country Assessment has been completed and this will be the basis of the next UNDAF. The UN Country Team has decided to align UNDAF with the National Development Plan (NDP). In this regard, the next UNDAF will be developed for the period 2010 to 2015. Meanwhile, the current UNDAF will be revised to bridge the period 20082009. The CCA has identified priority areas for the UNDAF where the UN could add value in supporting the national developmental agenda. With respect to health, it is recommended that the UN provide assistance with the following: z z z z z z z
prioritizing health spending, including developing cost-sharing strategies for longterm sustainability in the health sector; developing an integrated health policy and human resources for health; strengthening health information systems; ensuring policy formulation that reflects recent demographic changes; assisting in areas of particular health need such as reducing child and maternal mortality and dealing with TB; formulating policies to deal with communicable and noncommunicable diseases; intensifying support to HIV/AIDS interventions.
WHO’s work was guided by the first CCS (2003-2007) which addressed public health priorities as outlined in the National Health Development Plan and Vision 2016. The work of WHO focused on provision of technical support for strengthening health systems, HIV/AIDS
8 9
The estimated interest rate is based on the forward LIBOR rate. Based on the FX Forward rate euro/US$ (5-year).
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response, human resources for health, implementation of priority interventions for control of communicable diseases, and strengthening partnerships. MoH human resource constraints and a limited WHO budget were the major constraints in the implementation of the first CCS. Nevertheless, various achievements were made. Apart from WHO, which addresses all aspects of health, the other UN agencies mostly work on HIV/AIDS. UNICEF focuses on child health, including PMTCT, immunization and diarrhoea control; UNDP focuses on capacity-building, collaborating closely with WHO to develop a plan for human resources for health; UNFPA works mostly in sexual and reproductive health.
3.2 COORDINATION WITHIN THE UNITED NATIONS The work of the UN is coordinated by the Resident Coordinator who is also the Resident Representative for UNDP and head of the UN Country Team. Theme groups on HIV/AIDS, poverty and environment were formed in line with UNDAF areas of focus for 2003–2007. In 2007, the theme groups were revisited and new groups were created for HIV/AIDS, health, human rights and gender, and governance and civil society. The groups provide strategic guidance and oversight; membership is drawn from the UN agencies. WHO chairs the health group and is also represented in all the other groups. In addition to theme groups, a number of working groups were formed, including the Programme Coordination Group, the Joint UN Team on AIDS, MDG working group and the UN Learning Team. The Joint UN Team on AIDS operates through three key strategic areas: “3 ones”, HIV prevention, and HIV care and support. WHO chairs the working group on HIV care and support, while UNAIDS coordinates the whole Joint UN Team on AIDS. The small size of the UN team in Botswana has meant that most individual staff members belong to more than one working group or theme group. This situation together with requirements for supporting the government programme has affected the operations of both the theme groups and the technical working groups.
3.3 PARTNER COORDINATION International partners providing support to health are coordinated through the Ministry of Health. With support from WHO, a partnership forum was formed, bringing together all key stakeholders in health. However, the Forum did not work out well due to the large staff turnover in both the Ministry of Health and WHO. WHO is now working with MoH to revive this forum. Another mechanism of coordination is the GFATM Country Coordinating Mechanism (CCM) that oversees GFATM processes and funding. Because Botswana is not eligible for GFATM funding for malaria, the CCM looks mostly at TB and HIV/AIDS issues as they relate to GFATM. Recently, the CCM also deals with HIV/AIDS issues related to PEPFAR support to the country.
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An HIV/AIDS partnership forum has been revived to effectively galvanize and harmonize support to HIV/AIDS. Given the few partner organizations in Botswana, it is always a challenge to form and sustain such forums because inevitably it is the same few members that participate in the partnership meetings.
3.4 CHALLENGES IN UTILIZING DEVELOPMENT PARTNER FUNDING Challenges in utilizing development partner funding include cumbersome reporting requirements; poor financial management capacity, especially in NGOs; different financial years of government and partners; and low absorptive capacity.
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SECTION 4 WHO CORPORATE POLICY FRAMEWORK: GLOBAL AND REGIONAL DIRECTIONS WHO has been and is still undergoing significant changes in the way it operates, with the ultimate aim of performing better in supporting its Member States to address key health and development challenges, and the achievement of the health-related MDGs. This organizational change process has, as its broad frame, the WHO Corporate Strategy.10
4.1 GOAL AND MISSION The mission of WHO remains “the attainment by all peoples, of the highest possible level of health” (Article 1 of WHO Constitution). The corporate strategy, the Eleventh General Programme of Work 2006-201511 and the document Strategic orientations for WHO action in the African Region 2005-200912 outline key features through which WHO intends to make the greatest possible contributions to health. The Organization aims at strengthening its technical and policy leadership in health matters as well as its management capacity to address the needs of Member States, including the Millennium Development Goals (MDGs).
4.2 CORE FUNCTIONS The work of the WHO is guided by its core functions, which are based on its comparative advantage,13 these are: z z z z z z
Providing leadership in matters critical to health and engaging in partnership where joint action is needed; Shaping the research agenda and stimulating the generation, dissemination and application of valuable knowledge; Setting norms and standards, and promoting and monitoring their implementation; Articulating ethical and evidence-based policy options; Providing technical support, catalysing change, and building sustainable institutional capacity; Monitoring the health situation and assessing health trends.
10 11
12
13
WHO EB105/3, A Corporate Strategy for the WHO Secretariat. Eleventh General Programme of Work 2006-2015: A Global Agenda, Geneva, World Health Organization, 2006. Strategic Orientations for WHO Action in the African Region 2005-2009, Brazzaville, World Health Organization, Regional Office for Africa, 2005. Eleventh General Programme of Work 2006-2015: A Global Agenda, Geneva, World Health Organization, 2006.
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4.3 GLOBAL HEALTH AGENDA In order to address health related policy gaps in social justice, responsibility, implementation and knowledge, the global health agenda identifies seven priority areas; these include: z z z z z z z
Investing in health to reduce poverty; Building individual and global health security; Promoting universal coverage, gender equality and health-related human rights; Tackling the determinants of health; Strengthening health systems and equitable access; Harnessing knowledge, science and technology; Strengthening governance, leadership and accountability.
In addition, the Director-General of WHO has proposed a six-point agenda focusing on health development, health security, health systems, evidence for strategies, partnerships and improving the performance of WHO. In addition, the success of the Organization shall be measured in terms of results in women’s health and the health of African people.
4.4 GLOBAL PRIORITY AREAS Global priority areas have been outlined in the Eleventh General Programme of Work.14 They include: z z z z z
Providing support to countries in moving to universal coverage with effective public health interventions; Strengthening global health security; Generating and sustaining action across sectors to modify the behavioural, social, economic and environmental determinants of health; Increasing institutional capacities to deliver core public health functions under the strengthened governance of ministries of health; Strengthening WHO leadership at global and regional levels and supporting the work of governance at country level.
4.5 REGIONAL PRIORITY AREAS The regional priorities have taken into account the global documents and resolutions of WHO governing bodies, the health Millennium Development Goals and the NEPAD health strategy, resolutions on health adopted by heads of state of the African Union and the organizational strategic objectives which are outlined in the Medium Term Strategic Plan (MTSP) 2008-2013.15 These regional priorities have been expressed in Strategic orientations for WHO action in the Africa Region 2005-2009. They include prevention and control of communicable and noncommunicable diseases, child survival and maternal health, emergency and humanitarian action, health promotion, and policy-making for health in
14
15
Eleventh General Programme of Work 2006-2015: A Global Agenda, Geneva, World Health Organization, 2006. Medium Term Strategic Plan 2008-2013, Strategic Directions 2008-2013, p. 4, paragraph 28.
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development and other determinants of health. Other objectives cover health and environment, food safety and nutrition, health systems (policy, service delivery, financing, technologies and laboratories), governance and partnerships, and management and infrastructure. In addition to the priorities mentioned above, the Region is committed to supporting countries to attain the health MDGs, and assisting in tackling the human resource challenges. In collaboration with other agencies, assisting countries to source financing for their national goals will be done with the leadership of countries. To meet these added challenges, one of the important priorities of the Region is that of decentralization and the installation of Intercountry Support Teams to 15further support countries in their own decentralization process so that communities may benefit maximally from the technical support availed to them. To effectively address the priorities, the Region is guided by the following strategic orientations: z z z z z
Strengthening the WHO Country Offices; Improving and expanding partnerships for health; Supporting the planning and management of district health systems; Promoting the scaling up of essential health interventions related to priority health problems; Enhancing awareness and response to key determinants of health.
4.6 MAKING WHO MORE EFFECTIVE AT THE COUNTRY LEVEL The outcome of the WHO corporate strategy at country level will vary from country to country depending on country-specific contexts and health challenges. By building on the WHO mandate and its comparative advantage, the six core functions of the Organization, as outlined in Section 4.2, may be adjusted to suit individual country needs.
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SECTION 5 CURRENT WHO COOPERATION During the first CCS, the objectives of the WHO were to: z z z z z
provide technical support for the improvement of health systems; develop partnerships and broaden approaches to health; provide international leadership for health advocacy; support the development of appropriate human resources for health policies and plans; work with the ministries of health and local government as well as regional partners located in Botswana, such as SADC. advocacy for health, technical support for priority health programmes, health policy development, strategic partnerships, health promotion, planning, implementing, monitoring and evaluating WHO work, leadership and stewardship, WHO country presence, support for strengthening health systems, strengthening health sector response to HIV/AIDS, emergency preparedness and response.
WHO core functions were: z z z z z z z z z z z
5.1 MAIN CONTRIBUTIONS TO HEALTH, 2003-2007 During the implementation of the first CCS, 2003-2007, WHO was able to demonstrate leadership and partnership, particularly in advancing WHO priorities such as global health security. WHO led the development of the influenza pandemic preparedness plan and participated actively in the UN avian flu preparedness plan. WHO led in the application and promotion of norms, including the adaptation of international standards for national policies (e.g. identification of the essential drugs list, 2005). WHO provided support for health systems. WHO provided technical assistance to the MOH and its partners to develop, implement and sustain efficient, effective and responsive health systems for improved performance and outcomes. This technical assistance was for health sector reforms, health management information systems and national health accounts. WHO also supported stewardship and assisted the MoH to analyse pro-poor aspects of health policies and advocacy for continued equitable allocation of health resources. 25
WHO supported the Government of Botswana to implement health sector response to HIV/AIDS and manage opportunistic infections. The three main broad categories of support were provision of technical support, provision of catalytic funding for new interventions, and formulation of policies and guidelines. WHO supported the government to implement priority disease control interventions by contributing to the formulation of policies, strategies and guidelines; surveillance; and international reporting. Technical leadership was provided during the wild poliovirus importation in 2004, diarrhoea outbreak in 2006 and SARS threat in 2003. WHO also led the development of port health services, critical for implementation of the revised International Health Regulations. WHO supported operational research with the aim of influencing various disease intervention programmes. Research was transformed into useful knowledge for revising programmes and changing national policies; data were provided from a malaria drug resistance study in 2006, leprosy elimination in 2004 and tuberculosis control in 2006. Country experiences in monitoring and evaluating expanded antiretroviral therapy in 2006 were documented and will contribute to regional and global knowledge. WHO supported operational research on stigma reduction in HIV/AIDS. To promote ethical and evidence-based health policy options, WHO catalysed assessments leading to national programme and policy formulation. These included assessment of emergency obstetric care in selected health facilities in 2006, the EPI programme in 2002, the national cervical cytology screening programme in 2005, the national roadmap for reduction of maternal and newborn mortality in 2006, national health accounts in 2006 and a STEPS survey in 2007. To strengthen national capacity, WHO has provided fellowships for Batswana medical students studying in Ghana. It has conducted various local and international capacity-building workshops for various health programmes. Support from the Regional Office ad HQ was very critical to the implementation of the CCS. This was mainly due to shortages of staff resulting in lack of expertise in some areas of work at country level. All areas of work have been supported by the Regional Office or the IST and occasionally by HQ. The support has been in all the areas mentioned above. Furthermore, the Regional Office has provided training to WHO Country Office technical staff and to MoH counterparts in various regional training workshops. Working as one, WHO has facilitated close communication and support from all levels of the Organization in all the core functions of the Country Office. Health systems support and collaboration from the MoH have been critical in various areas of work. The Country Office has experienced financial crisis in the implementation of the current CCS; thus, the MoH contributed to the funding of activities.
5.2 RESOURCES Due to the medium-income status of Botswana mentioned above, the number of donors in the country has decreased. Therefore, there is no stakeholder or donor mapping available for any area of work. Likewise, the WHO Country Team does not have a strategy or structured approach to mobilize resources locally. In addition, WHO faced a shortage of staff, inadequate office space, financial constraints, cost-of-living increases and unfavourable exchange rates during the first CCS. The WHO 26
Country Office relocation to the UN common premises resulted in doubled rent which led to budgetary constraints from 2002 to 2004. The WHO Representative requested assistance from the WHO Regional Office for Africa which responded positively by providing funds for paying the rent for four months in 2004. Thus the Country Office was able to disburse the allocated funds for activities. The high rental situation was finally resolved in July 2005 when the government offered office space through a basic agreement with WHO. Two critical WHO positions were lost at country level: the epidemiologist in Disease Prevention and Control and the health systems development expert. However, the WCO staff levels gradually improved in 2004-2005 and in 2006-2007 (Figure 6). The final reprofiling realistically defines the positions necessary for the Country Office. Figure 6: Human resource status, 2002-2007
5.3 REPORTING AND INFORMATION-SHARING During the first CCS, not much information and experience of WHO work in Botswana was shared or published in journals. This was mainly due to financial and time constraints. The filing and archiving system does not facilitate an effective sharing of information among WCO staff. This will need to be improved. Since the move of the WCO to the MVA building in 2005 and with technical support provided from HQ and the Regional Office, the WCO is included in the GPN and there is good independent telephone, e-mail and internet communication with all levels of the Organization. With support from the Canadian International Development Agency (CIDA), funding was allocated to the Country Office in late 2006 to provide sufficient additional modern computer hardware so that all staff have desktop or laptop computers.
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The CIDA funding was also used to acquire an additional back-up server which was configured and installed in March 2007. There has been an upgrade to McAfee anti-virus software as per Regional Office guidelines. All user documents are backed up, and the weekly tapes are kept off-site at the administrative officer’s office. Tests of recovery procedures from the back-up tapes are done on a different computer. The financial budget evolved from US$ 93 000 in 2002-2003 to US$ 1 848 000 in 20042005 and to US$ 2 008 000 in 2006-2007 for the Regular budget. At the same time, Voluntary funds increased from US$ 20 000 in 2002-2003, to US$ 2 027 000 in 2004-2005, though the WCO received only US$ 4000 of the pledged amount. Voluntary funds were significantly lower during the 2006-2007 biennium (Figure 7). Figure 7: WHO Country Office budget allocations, 2002-2007
5.4 INFORMATION SECURITY Only the information and communications technology (ICT) officer (under temporary contract) has knowledge of administrator accounts and passwords required for the management of the WCO computer systems environment. The administrative password for the server has been confidentially kept in a safe place.
5.5 MINIMUM OPERATING SECURITY STANDARDS Currently there is no security phase in Botswana. Therefore, country-specific MOSS are prepared in view of “No Phase MOSS Requirement” as per guidelines issued by Headquarters.
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5.6 STRENGTHS, WEAKNESSES, OPPORTUNITIES AND THREATS There is an increase in the WCO team’s technical capacity since 2003. The available technical staff are skilled, committed and dedicated. Teamwork in the office has improved the efficiency of implementation. Adequate office space provided by the government since July 2005 has improved the working environment. There is a positive working relationship with the MoH which places great confidence in the WCO. Continuous support from the Regional Office and Headquarters strengthens the WCO. Lack of adequate funds for key staff, office and programme activities compromises WCO ability to support the MoH. There is an inability to fully implement staff development training. There is no strategy or structured approach to mobilize funds and resources locally. Financial resources come only from the Regional Office and Headquarters. Main opportunities are the political stability and commitment in the country as well as the trust of the MoH and other stakeholders in the WCO. Other opportunities are offered by the joint capacity-building activities for MoH staff and training with WCO team; new office space provided by the government which allowed Regular budget funds to be released for activities; additional funding from other sources (CIDA, etc) that could be used for emergencies; government funding for some unfunded activities in the workplan; good working relationship with UN partners; and good and harmonious relationships with MoH and other partners. Threats include the middle-income status of the country; loss of confidence in the WCO team to provide technical support in specialist areas for which there are no experts; uncertain funding in terms of amounts, timing and instability of contracts; high rents in 2004-2005; and the 2004 appreciation of the pula against the US dollar. There is uncertainty in receiving funds, especially Voluntary funds.
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SECTION 6 STRATEGIC AGENDA: PRIORITIES FOR WHO-COUNTRY COOPERATION The overall goal of WHO work in Botswana is to ensure that all necessary actions are undertaken for attainment of the highest possible level of health as reflected in aspirations set out in national strategic documents on health. The strategic agenda for meeting the goal is based on the analysis of the health situation in Botswana and on identified gaps and challenges. It focuses on what WHO, at all three levels, can effectively contribute to the national health agenda within the existing resource capacity constraints and recognizing the roles and contributions of other partners. The national strategic agenda is modeled after the overall WHO strategic objectives as set out in the organization-wide Medium Term Strategic Plan 2008–2013. WHO’s strategic approaches for attaining the set agenda will be through the provision of long-term and short-term technical assistance for policy development, planning, monitoring and evaluation of evidence-based interventions in the health sector; development and dissemination of technical guidelines, modules and training materials adapted to the local context; capacity-building for implementation, including training and exploration of innovative approaches such as public-private partnerships and task-shifting; documentation and sharing of best practices nationally and internationally; and strengthening partnerships to ensure building of synergies for optimal provision of good health care. WHO will play a leading role and collaborate with other partners in the provision of support to the government. In addition, WHO will ensure the availability of at least all the staff complement as reflected in the WCO Human Resources Plan 2008–2013. In delivering on the strategic agenda, WHO will work primarily through the Ministry of Health. The Organization will also work with the Ministry of Local Government and other government departments such as NACA as well as with partners: NGOs, civil society, UN agencies, CDC/BOTUSA, ACHAP and BHP.
6.1 COMMUNICABLE DISEASES Epidemic preparedness and response for major epidemic-prone diseases and emerging diseases is one of the priority areas for disease control identified by the MoH. This requires a sustained availability of timely data and information and vigorous monitoring and surveillance of targeted diseases. Maintenance of the polio eradication, measles elimination and neonatal tetanus elimination achievements remains an important issue. There is a need to strengthen vaccine and cold chain management within the existing weak health systems. The laboratory component of disease surveillance will need to be strengthened. The objectives of the Ministry of Health are to ensure rapid preparedness, response and containment of outbreaks; control communicable diseases, including vaccine-preventable diseases, through the Expanded Programme on Immunization; and maintain vaccine coverage above 90% for all antigens. 30
WHO will continue to support the MoH in: z z z z z z z
strengthening vaccine management at all levels and cold chain management; strengthening capacity for planning, organization and management of communicable disease interventions (EPI, IDSR, other communicable diseases); implementing and achieving vaccine-preventable disease control goals; introducing and initiating new strategies and technologies for disease control; strengthening data management and use of information for proper monitoring and evaluation of disease control activities; reviewing the national five-year IDSR strategic plan and supporting its implementation; providing technical support for the attainment of minimum core competencies required for the implementation of the International Health Regulations 2005.
6.2 HIV/AIDS The comprehensive programme approach used in the National Strategic Framework for HIV/AIDS in Botswana is already paying dividends as the prevalence of HIV in young women aged 15–19 attending ANCs has dropped from 24.7% in 2001 to 17.5 in 2006; and the coverage of essential HIV/AIDS treatment and care services such as ART have exceeded 80%. The approach created an opportunity for government to engage partners from a multidisciplinary and multisectoral perspective. However, the HIV/AIDS disease burden and its impact on health system development are still immense. The strategic agenda for WHO will continue to focus on strengthening national HIV response in the health sector in order to scale up evidence-based HIV services towards universal access. In particular, WHO will focus on: z
strengthening national policy and operational framework for a comprehensive health sector response to HIV/AIDS through development of relevant policies and plans, as well as design of appropriate service delivery, regulatory and monitoring systems; scaling up HIV prevention efforts to ensure that the country moves as close as possible to the national goal of no new infection by 2016; sustaining the large number of patients on ART, and ensuring continued quality ART and other HIV/AIDS treatment and care services; strengthening HIV/AIDS strategic information collection and use, including monitoring and addressing emergence of HIV drug resistance; strengthening the management of opportunistic infections, including malignancies and other complications, as well as the co-management of TB/HIV and minimizing the emergency of MDR-TB and XDR-TB.
z z z z
6.3 TUBERCULOSIS The re-emergence of TB from the late 1980s has been exacerbated by the HIV epidemic. Co-infection with TB and AIDS has greatly contributed to high mortality, particularly among AIDS patients. Drug-resistant TB is gradually gaining momentum and the occurrence of XDRTB is even a greater threat to the management and control of TB in Botswana. The programme experiences low performance indicators partly related to challenges of human capacity in the National TB Programme and laboratory support. 31
WHO has always supported the activities of the Botswana TB control programme since its inception in 1975. WHO will continue to provide support during the second generation CCS for: z z z z z z z
developing and reviewing policies, strategies, standards and guidelines for the BNTP; strengthening TB case management, including emerging issues such as TB/HIV coinfection, MDR-TB and XDR-TB; strengthening human resource capacities and staff management skills; strengthening surveillance and monitoring of TB/HIV co-infection, drug resistance and programme performance; strengthening involvement of patients, families and communities in TB interventions; increasing advocacy for greater partnerships, resource mobilization and collaboration between TB and HIV programmes; promoting both operational and academic research to inform policy and improve performance.
6.4 MALARIA Botswana’s aim is to move from malaria control to elimination as stipulated in the 20062011 Malaria Strategic Plan. This would contribute to reduction in childhood mortality rates and thus the attainment MDG 8 which aims at halving and halting by 2015 and begun to reverse the incidence of malaria and other major diseases. The unstable nature of malaria transmission and the occurrence of epidemics related to heavy rainfalls pose major threats to the country. The national malaria programme still has challenges in achieving the 2010 Abuja targets of 80% ITN coverage for pregnant women and children under-five and malaria elimination by 2015. WHO will continue to support the Ministry of Health in: z z z z z
developing policies and strategies for operational planning in malaria; improving programme delivery and outcomes using WHO recommended standards and guidelines on malaria; developing effective surveillance, monitoring and evaluation mechanisms to track programme performance; maintaining and creating malaria partnerships with UN agencies for greater participation at national, district and community levels; supporting the development and implementation of the national malaria elimination strategy.
6.5 NONCOMMUNICABLE DISEASES, MENTAL HEALTH, VIOLENCE, INJURIES AND DISABILITIES There is a steady increase of noncommunicable diseases in Botswana, namely, hypertension, cancers and diabetes. Mental health, injuries and disabilities are also problems. The major challenge for the Ministry of Health is to obtain baseline data to get a clear understanding of the magnitude of these diseases and conditions. Oral diseases and conditions are serious public health problems and include dental caries, oral manifestations of HIV/AIDS, orodental trauma, periodontal disease, tooth loss, 32
oropharyngeal cancers and necrotizing ulcerative stomatitis (noma). Their impact on individuals and communities is considerable in terms of pain, suffering, impairment of function and reduced quality of life. Despite the fact that these diseases have become a burden to the individual and often the disadvantaged and poor populations, provision of oral health services has not enjoyed sufficient attention at national and community level over the years. WHO will continue to support the Ministry of Health in: z z z z z z z z z z z z z z z
strengthening the policy and legislative framework around mental health, NCDs, injuries and disabilities; implementing the WHO STEP-wise approach for the surveillance of risk factors of NCDs; developing policies, strategies and guidelines for the prevention and control of NCDs; implementing the National Cervical Cancer Control Programme; advocating for collaboration in the management and control of violence, injuries and disabilities; promoting mental health through a stigma reduction strategy; surveillance of the magnitude of mental disorders and epilepsy and development of a prevention and management strategy; providing standard practices for community mental health; enhancing governance and regulation, control and monitoring of service standards, resource allocation and programming, monitoring and evaluation of mental health; formulating an oral health policy; integrating oral health in national and community health programmes; developing oral health information systems as an integral part of surveillance programmes for NCDs and their risk factors; strengthening oral disease prevention and health promotion programmes, including ART and fluoride-based prevention; participating in regional and international continuing education workshops; promoting research in oral health.
6.6 SEXUAL AND REPRODUCTIVE HEALTH Reproductive health is one of the priority programmes in health as its implementation contributes to the reduction of maternal, newborn and child mortality and thus improves the quality of life of Batswana. WHO will, therefore, continue to support the Ministry of Health in: z z
developing and revising SRH policies, guidelines and strategies to guide programme implementation; building and strengthening capacity for planning, organization, implementation and management to effectively deliver health services as well as improve the quality of health services for SRH, including cervical cancer screening; improving programme delivery and outcomes using WHO recommended materials in SRH; strengthening monitoring and evaluation mechanisms to track performance for all programmes; 33
z z
z z
strengthening the integration of family planning and HIV/AIDS programmes; supporting the programme for repositioning family planning.
6.7 MAKING PREGNANCY SAFER WHO will continue to support the Ministry of Health in: z z
developing and revising policies and strategies to guide programme implementation; building and strengthening capacity for planning, organization, implementation and management to effectively deliver health services as well as improve the quality of health services for making pregnancy safer and safe motherhood programmes; improving programme delivery and outcomes using WHO recommended materials in MPS; strengthening monitoring and evaluation mechanisms to track performance; establishing baseline data for perinatal and neonatal mortalities as well as programme strategies; implementing the national roadmap for the reduction of maternal and newborn mortality; improving quality of emergency obstetric care in order to reduce maternal and newborn mortalities.
z z z z z
6.8 CHILD AND ADOLESCENT HEALTH WHO will continue to support the Ministry of Health in: z z
developing and revising IMCI and adolescent health policies and strategies to guide programme implementation; building and strengthening capacity for planning, organization, implementation and management to effectively deliver health services as well as improve the quality of the health services for IMCI and adolescent health; improving programme delivery and outcomes using WHO recommended materials for IMCI and adolescent health; monitoring and evaluating programme implementation for youth-friendly services and IMCI.
z z
6.9 EMERGENCY PREPAREDNESS AND DISASTER MANAGEMENT Natural and man-made disasters continue to claim many lives and adversely affect lives of many people. Disaster prevention and mitigation through adequately formulated plans remain major challenges. The flood disasters in Botswana in 1999-2000, SARS and the threat of avian flu have shown the need for the country to have policies and guidelines in place to respond adequately to emergencies. It is necessary to put in place mechanisms that would ensure systematic response to emergencies or disasters. There is also a need to ensure that the health aspects of any emergency or disaster are adequately addressed. The World Health Organization will provide technical support to the Ministry of Health for: z
developing and implementing policies and strategies; 34
z
providing guidelines and training to adequately prepare for and address health aspects of any public emergencies or disasters.
6.10 HEALTH PROMOTION The success of health interventions and services is largely dependent on requisite capacity and supportive legislative framework. The next six years of WHO support to the Government of Botswana will include: z
strengthening the policy and legislative environment to further empower relevant structures, broaden their scope of operation and ensure that they provide for new and emerging issues related to healthy lifestyles and health-seeking behaviour; strengthening operational capacity and competencies to enable comprehensive programming and enhanced outcomes to address the broader determinants of health; strengthening the capacity of the Health Promotion and Education Division; reviewing the training curriculum for health promotion practitioners and advocating for its inclusion in the Faculty of Health Sciences of the University of Botswana; catalysing existing partnerships, facilitating new ones and promoting cross-sector collaboration and community involvement in addressing the broader determinants of health and healthy lifestyles; finalizing and operationalizing the draft Health Promotion Policy and the Traditional Health Practice Bill; strengthening evidence-based programming, monitoring and evaluation through development and utilization of clear and comprehensive indicators to ensure, document and demonstrate the effectiveness of health promotion.
z z z z
z z
6.11 SOCIAL DETERMINANTS OF HEALTH Attaining social justices is one of the objectives of national development in Botswana, in accordance with Vision 2016. Issues relating to quality and access to services are addressed in the National Development Plans. WHO will continue to support the country in: z
disseminating the CMH recommendations on social determinants of health and consensus-building among partners to identify key issues that affect the quality of, and equitable access to, essential health care and the other determinants of health; advocating for the formulation of appropriate policies and strategies to address health inequalities; strengthening coordination among multiple sectors for substantial progress towards reaching national health goals; strengthening health systems using the Primary Health Care approach to address equity and equality in health development and emphasizing district health systems; monitoring the implementation of the MDGs.
z z z z
6.12 ENVIRONMENTAL HEALTH Scientific approaches to address environmental health risks such as improved information systems, environmental risk mapping, updating policies and port health services are some of 35
the key challenges. It is necessary to improve the quality of environmental health services by developing policies and standards. In addition, there is need to reverse the very slow progress in the development of occupational health in the country. The World Health Organization will support the Ministry of Health in: z z z z z z z z z z z z
updating and implementing the national environmental health policy, including the monitoring of water quality; formulating a management plan that will map environmental health risks and establish information systems on environmental health risks; updating the code of practice for health-care waste management, including identifying appropriate technologies for the treatment of such waste; establishing port health as part of the requirements of the International Health Regulations; developing an action plan for the Framework Convention on Tobacco Control; finalizing and operationalizing revised tobacco control legislation. formulating strategies and standards for food safety, including hygiene for foods sold on streets and in commercial outlets; conducting a situation analysis of occupational health problems in the country to enable objective priority setting and programming; formulating the Health Sector National Workers’ Wellness Policy; assessing the magnitude of psychological and psychosocial ill-health, including stress, in occupational settings; implementing the WHO Global Strategy for Occupational Health for All and National Actions 1996-2005 and Beyond mobilizing support from various health partners for development of occupational health programmes.
6.13 FOOD SAFETY AND NUTRITION Food Safety and Nutrition is one of the most important programmes and is a priority for the country due to repeated droughts that result in malnutrition among vulnerable groups. WHO will continue to support this programme with more targeted interventions. The Ministry of Health will continue to be strengthened to address these challenges. WHO will continue to support the country in: z
developing, revising and finalizing nutrition policies, strategies, plans and guidelines to guide programme implementation as well as infuse nutrition policies and programmes into other relevant national programmes; developing comprehensive food safety policy, legislation, strategies, plans and guidelines based on recommended international Codex Alimentarius standards; building and strengthening capacity for planning, organization, implementation and management to effectively deliver and improve the quality of health services related to food safety and nutrition, including but not limited to revised CWC card, severe acute malnutrition, growth monitoring and promotion, nutrition and HIV/AIDS, nutrition surveillance, infant and young child feeding to improve coverage and the use of food safety management tools such as Hazard Analysis Critical Control Points to ensure safety throughout the food chain; 36
z z
z z z z
improving programme delivery and outcomes using WHO, FAO and Codex recommended materials in nutrition, food safety and drinking water quality; strengthening monitoring and evaluation mechanisms to track programme performance for all food safety and nutrition programmes; playing a leading role and collaborating with other partners in providing food safety and nutrition support to the government; participating in Codex work.
6.14 HEALTH SYSTEMS STRENGTHENING 6.14.1 Organization and management Strengthening the PHC approach with focus on district health systems is the emphasis in the WHO Medium Term Strategic Plan and the National Development Plans in Botswana. The formulation of health policies, norms, standards and guidelines is the responsibility of the MoH while implementation of the PHC approach is under the MLG. In addition, primary and district hospitals and major public health programmes are managed by the MoH, thus requiring direct interaction with MLG structures at community level. WHO will continue to support the Ministry of Health in: z z z z
formulating and revising the National Health Policy and Plans; revising policy to address the changing health environment, foster the stewardship role of the MoH and accommodate increasing partnerships in health development; formulating the comprehensive Integrated Health Service Plan; formulating programmes, policies, strategies and plans, as well as adapting norms, standards and guidelines.
Advocacy will continue for reforms and closer collaboration between the Ministry of Health and Ministry of Local Government. WHO will support the continuation of the restructuring of the Ministry of Health. Capacity-building and the functionality of the required divisions in the new Department of Policy, Planning, Monitoring and Evaluation and Department of Health Sector Relations and Partnership will be given particular attention.
6.14.2 Human resources Shortages in human resources for health are cross-cutting issues affecting all aspects of health development in Botswana. As a response, WHO supported the Ministry of Health in the formulation of a comprehensive long-term National Human Resource Plan. The plan has been finalized for adoption. WHO will continue to provide assistance in: z z z z z
disseminating the HRH plan and building consensus among all stakeholders; developing HRH implementation and retention strategies; supporting the medical students in Ghana until their programme completion; strengthening capacities of national health training institutions; providing short-term and in-service training for staff skills development in various health programmes and encouraging staff to benefit from best practices documented in other countries within the Region. 37
6.14.3 Health financing National Health Accounts have been developed. Data up to 2002 were collected, analysed and published in a report produced in 2006. WHO will continue to support the government in: z
compiling and analysing data to produce information on the adequacy and trends of allocation of funds for health development by government, development partners, private sector and communities; disaggregating financial data for measuring specific impacts by programmes and projects; costing health services in Botswana to determine the actual costs of healthcare provision and to inform cost-sharing initiatives; developing long-term sustainable means of health financing that ensure equitable distribution of resources so that all individuals have access to effective public health care.
z z z
6.14.4 Health management information systems The lack of available relevant health information necessary for planning, timely interventions, monitoring and evaluation remains a major challenge in the health sector. WHO will continue providing technical support for: z z z
improving capacities of the Health Information Management Division; developing an integrated health management information system; supporting a comprehensive system of monitoring and evaluating health challenges and interventions in an integrated approach and in collaboration with key stakeholders; using new opportunities to achieve national and international targets such as the MDGs.
z
6.14.5 Research Application of research to enhance policies and decision-making remains a critical area of concern. It is critical that ethical principles guide health-related research. WHO will support the country in: z z z z z z
developing legislative frameworks for human health research; developing policies, strategies and guidelines for conducting health research; strengthening the capacity of the Health Research Unit to identify research priorities and support the conduct of health research; strengthening capabilities in evidence synthesis and analysis of systematic reviews of evidence to identify gaps; strengthening the scientific and ethical skills of the Health Research and Development Committee; addressing the gaps identified during the country health research assessment.
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6.14.6 Health services delivery and use of medical products and technologies To strengthen health services delivery and use of medical products and technologies, WHO will continue to provide technical support to build capacities and improve the management of health facilities and programmes. Specifically, WHO will support the government in: z
strengthening human resource capacities and management skills of the District Health Teams and health facilities, and promoting the expansion of proven interventions to ensure universal access; revising and implementing the Drug Act; providing drug information and toxicology services, essential drug selection and rational drug use, district pharmaceutical services, a national drug quality control laboratory, and drug regulatory authority, including strengthening the procurement system and management of essential drugs; providing technical support for strengthening the capacities of clinical laboratories, revising the National Blood Policy, and formulating a medium term strategic plan.
z z
z
6.15 LEADERSHIP AND GOVERNANCE The ever-changing environment in the health sector requires proper leadership and coordination in order to attain good health. The Minister of Health launched a health sector coordination mechanism in the form of a health sector partnership forum in August 2003. This mechanism has remained dormant due to frequent changes in MoH leadership. WHO will support the Ministry of Health in: z z z
revitalizing the health sector partnership forum as a coordination mechanism for the health sector; adopting a broader approach to health within the context of human development and human rights, focusing on the links between health and poverty reduction; establishing wider national consensus on health policy, strategies, quality management systems and standards by managing the generation and application of research, knowledge and expertise; stimulating more effective action to improve health and decrease inequities in health outcomes by carefully negotiating partnerships and catalysing actions of others; Creating an organizational culture that encourages strategic thinking, prompt action, creative networking and innovation.
z z
In addition, WHO will continue to play an active role in the UN reforms and participate in the various UN theme groups.
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SECTION 7 IMPLEMENTATION OF THE STRATEGIC AGENDA This Country Cooperation Strategy sets out the strategic directions and medium term agenda of the work of the entire WHO secretariat in Botswana for the period 2008-2013. The Biennial Workplan 2008-2009, despite being prepared earlier, shares the issues, challenges and orientations as outlined in this document. In addition, the two subsequent biennial workplans will be based on the strategic agenda in this document. The implementation of the CCS will have certain implications for the Organization’s work at all three levels.
7.1 WHO COUNTRY OFFICE The WHO Country Office will continue to increase its role as a broker and advocate for health. It will maintain a balance of highly experienced national professional officers and international experts. The core competencies required to deliver on this CCS include expertise in health systems, disease surveillance and control, programme management, advocacy for health, health promotion, maternal and child health, and resource mobilization. WCO will assist the country by providing the services of technical experts where and when necessary and as required. Given the envisaged limitations in numbers of staff in the WCO, existing programme officers will be reoriented to become functional in new programmes contained in the CCS, including advocacy and resource mobilization. WCO will support the Ministry of Health in exploring the recruitment possibilities of UN volunteers and consultants in order to strengthen programme implementation. Technical assistance will be intensified in areas where there is a critical shortage of national expertise such as health planning, monitoring and evaluation; human resources for health management; health management information systems; emergency preparedness and response; essential medicines; laboratory services; midwifery training and practice; NCDs; and others. WCO will jointly review programmes with the Ministry of Health to identify areas where it can make the maximum impact through, among others, the holding of joint quarterly planning and review meetings. WCO will continue to play an active role in the formulation, implementation and review of UNDAF by participating in the UN thematic groups and meetings with other development partners, thereby strengthening collaboration with partners, minimizing possible overlap of efforts and opening new avenues for resource mobilization at the national level in Botswana. To ensure that national health priorities are adequately addressed, the Country Office will continue supporting the preparation of proposals for resource mobilization from GFATM, PEPFAR and other potential funding partners. Further, the WCO will assist in implementing, monitoring and evaluating various grants as required. The Country Office will document results, including best practices, and demonstrate that WHO as an organization is making a difference in the health of the people of Botswana. It will implement the strategy for the promotion of the WHO image through advocacy and support for 40
International Health Days; launching and disseminating annual world health reports; commemorating internationally-accepted days such as Africa Health Day, World Health Day, World AIDS Day, SADC Malaria Day, World TB Day, World Blood Donor Day; supporting health promotion initiatives; and disseminating information on major health events in the world.
7.2 WHO REGIONAL OFFICE The WHO Regional Office for Africa will create an enabling environment that will facilitate organizational change and institutional development issues arising from the CCS. As a starting point, the Regional Office will review its support to Botswana and identify the implications of the new CCS on that support. The Regional Office will disseminate the Botswana CCS document to divisional directors and regional advisers. This will create a better understanding among RO staff of the country’s health system and its problems as well as improve the scope and quality of technical support provided to the country team. Bearing in mind the need for additional resources to support the implementation of the agenda of the CCS, the Regional Office will use the document to mobilize financial and technical resources for the Country Office. For this purpose, the CCS document will be disseminated to key donors and stakeholders in health. The Regional Office will endeavour to provide adequate technical backstopping to the Country Office for implementing the agenda in a timely manner. In this regard the ICST/ECA, Harare, will provide the more immediate support and increase access to technical assistance. The Regional Office will seek to increase allocation of resources to the Country Office in line with the priority areas identified in the CCS document. Decentralization of financial responsibilities has facilitated the work of the Country Office and should thus be sustained.
7.3 WHO HEADQUARTERS In accordance with the principle of “One WHO”, WHO headquarters will work with the Regional Office to mobilize resources and provide technical support for the implementation of the Botswana CCS, and to document lessons arising from the approach and its impact on WHO work as a whole as well as in individual countries. Headquarters will continue to provide up-to-date technical information to countries, directly and through the Regional Office. It will provide sufficient packages of WHO publications and other technical materials. Finally, headquarters will review the CCS document and use it as a basis for resource mobilization and revisiting the WHO reform agenda.
7.4 MONITORING AND EVALUATION The monitoring of the implementation of the CCS will be through the semi-annual monitoring review, mid term review and biennial evaluation of the Programme Budget. Indicators to be used will be specified in the biennial workplans for 2008-2009, 2010-2011 and 2012-2013. The monitoring and evaluation reports of national health programmes supported by WHO and other partners will be used to complement the standard WHO reports as described above. The results of other national evaluation exercises such as censuses, surveys and research will also be used to evaluate the impact of the CCS. 41
SECTION 8 CONCLUSION This CCS will guide the annual plans and programmes of the WHO Country Office in Botswana for the next six years. It is hoped that it will guide and gain the support from all the three levels of the Organization and will lead to better coordination of the “One WHO” efforts. It is also hoped that this document will be used as an advocacy tool to guide all partners in their resource mobilization efforts to support Botswana in achieving its stated health development agenda. The priorities and technical orientations in the document should guide partners of Botswana to be more focused in their development assistance.
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