R 070801Z OCT 08
FM AMEMBASSY GABORONE
TO SECSTATE WASHDC 5292
INFO SOUTHERN AF DEVELOPMENT COMMUNITY COLLECTIVE

UNCLAS GABORONE 000884 
 
 
DEPT FOR OES/PCI, OES/FO, OES/ENV, OES/IHA 
DEPT FOR AF/S, AF/EPS AND EB 
 
E.O. 12958: N/A 
TAGS: KHIV TBIO ECON EAID SOCI BC
SUBJECT: HEALTH CARE IN BOTSWANA IN THE ERA OF HIV/AIDS 
 
¶1. Summary: Botswana just celebrated its National Day on September 
30 and the country has made significant progress in the fight 
against hunger, poverty, injustice, illiteracy and unemployment over 
the last forty two years.  The rate of progress is, however, 
threatened by the HIV/AIDS epidemic, and could be reversed in the 
absence of a concerted national fight against the epidemic.  The 
HIV/AIDS epidemic has also imposed a considerable burden on the 
public health system.  Concerns have been expressed that HIV/AIDS 
programs, especially the, ART treatment program, have squeezed the 
resources available for other important health needs and programs. 
End Summary. 
 
Background 
---------- 
 
¶2. Botswana has made significant progress in the fight against 
hunger, poverty, injustice illiteracy and unemployment over the last 
forty two years.  The country rose from being one of the poorest in 
the world at the time of independence, to becoming a middle-income, 
developing nation.  Nonetheless, this progress is now threatened by 
the HIV/AIDS scourge, and could be reversed in the absence of a 
concerted national fight against the epidemic.  Botswana is one of 
the countries hardest hit by HIV/AIDS epidemic.  The Botswana AIDS 
Impact Survey of 2004 estimated HIV prevalence in the general 
population at 17.1 percent.  The prevalence rate among pregnant 
women aged 15- 49 years was 32.4 percent, with Chobe district having 
the highest rate (42 percent) and Kgalagadi the lowest (19.1 
percent).  The HIV/AIDS epidemic has also imposed a considerable 
burden on the public health system such as: a) an increase in the 
number of patients being treated for HIV/AIDS-related illnesses and 
their social impacts; b) a rise in the death rate; c) a reduction in 
the population growth rate and life expectancy; and d) a substantial 
increase in the number of orphans and vulnerable children (OVC). 
This is having adverse implications for the health and other 
development sectors.  Furthermore, Botswana's health infrastructure, 
despite efforts made by the government of Botswana (GOB) and 
development partners, continues to perform insufficiently in 
granting access, equity, quality, effectiveness, efficiency and 
sustainability in health care delivery.  The health system thus 
continues to bear the brunt of the impact of the HIV/AIDS pandemic. 
 
¶3. Significant, however, is the government's deep commitment to high 
levels of expenditure on meeting the basic needs of the population. 
Since the mid-1970s, 30-40 percent of the annual budget has been 
allocated to the social sector.  Government health facilities 
provide primary health care and top-level hospital treatment free, 
including anti-retroviral treatment (ART) for only a token payment. 
Providing communities with safe drinking water is another high 
priority for the GOB.  Much of this additional expenditure has been 
directed to HIV and AIDS, and there are concerns that this has 
caused a diversion of health resources away from other health needs. 
 This remains a major worry among some health practitioners, who 
have expressed fears that the focus on HIV/AIDS has allowed other 
equally dangerous diseases such as cancer, hypertension, diabetes 
and diarrhea to ravage populations unabated and unnoticed. (Note: A 
long article in the Botswana Gazette edition of 20-26 February 2008, 
titled "Health System Hobbled by Focus on HIV and AIDS" spelled out 
these concerns in sobering detail.  End Note). 
 
Health challenges 
----------------- 
 
¶4. Botswana still faces major health challenges in managing other 
diseases such as cancer, diabetes, diarrhea, high blood pressure and 
others as listed below.  A concerted effort by the GOB, development 
partners and civil society is needed in order to focus attention on 
these diseases and on the improvement of health care service 
delivery. 
 
¶5. Tuberculosis (TB): TB is often associated with HIV and AIDS as 
one of the main opportunistic infections in those who are HIV 
positive.  After many years of decline, TB notifications started 
rising in the early 1990s and increased from 200 per 100,000 people 
in 1990 to 620 per 100,000 in 2002; and by 2007, approximately 80 
percent of patients were co-infected with HIV.  TB prevalence in 
Botswana is thus now one of the highest globally.  Moreover, TB drug 
resistance is a challenge: there are multi-drug resistant TB 
(MDRTB), and extensively drug resistant TB (XDRTB) manifesting 
themselves in patients.  MDRTB refers to resistance against 
first-line drugs-isoniazid and rifampicin.  XDR indicates a 
resistance to almost all of the effective anti TB drugs.  One 
hundred cases of MDRTB have been identified and put on treatment in 
Botswana.  There were two cases of XDRTB that were recorded and the 
patients put on treatment, but one died.  According to a Ministry of 
Health (MOH) 2006 assessment, MOH 2005 data also reports significant 
progress in immunizing against TB, with BCG immunization coverage 
reaching 99 percent.  Additionally, health facility reports of March 
2007 indicate coverage of 88 percent, according to MOH statistics 
from the Child Health Unit. 
 
¶6. A number of initiatives have been put in place such as: i) 
isoniazid TB preventative therapy (IPT) for people living with HIV 
and AIDS; ii) the establishment of improved TB diagnostic capacity 
with the development of a TB reference laboratory with drug 
resistance capacity; and iii) the strengthening of TB surveillance 
capacity through the development and implementation of a national 
computerized TB transmission in health care facilities.  However, 
efforts still need to be intensified in order to reach 100 percent 
coverage.  Botswana has made commendable progress in making TB 
treatment accessible, attaining adequate case identification through 
an electronic TB register, keeping resistance below 1 percent and 
maintaining an effective DOT strategy and community mobilization. 
All of these efforts and results demonstrate positive progress 
towards reducing morbidity and mortality caused byTB. 
 
¶7. Malaria: The occurrence of malaria in Boswana is seasonal, and 
is related to rainfall peiods.  The number of cases thus varied 
between 202 and 2006.  Botswana recorded 3,453 confirmed cases in 
2004, but only 53 confirmed cases in 2005, a record low.  A Malaria 
Indicator Survey (MIS) conducted in March, 2007 rvealed that the 
current level of malaria control in Botswana needs to be pushed to a 
new frontier, with the current IRS coverage of 67.6 percent; this 
needs to rise to above 80 percent.  In addition, vector control 
through Insecticide Treated Nets (ITNs) was identified as an area 
that needs improvement.  The survey showed levels of 26 percent ITNs 
coverage at household level, with 15.4 percent for pregnant women 
and 12.9 percent for children under five.  In order to attain this 
target, an increased coverage of prevention measures over and above 
those currently used will be necessary.  The house-to-house 
community education initiatives, such as the one carried out last 
August by students and teachers of the Gaborone Senior Secondary 
school and Alexander Dawson School, Colorado, in collaboration with 
the U.S. Embassy, are commendable examples of this extra effort. 
 
¶8. Maternal and Reproductive Health: For a number of years, the 
percentage of women availing themselves of the antenatal services 
have been over 90 percent.  In addition, more than 90 percent of 
deliveries are conducted by skilled health practitioners.  The 
Sexual and Reproductive Health Program incorporates a strong 
component of IEC and Safe Motherhood Initiative (SMI) elements. 
Moreover, family planning was designed to improve maternal health in 
Botswana.  Data on maternal mortality is poor, with various 
estimates of the maternal mortality ratio (MMR) from different 
sources.  For instance, government health facilities data for 
2005/2006 indicates a rate of 150 per 100,000 live births, a marked 
improvement from the 330 rate in the 1991 census.  The establishment 
of a Maternal Mortality Audit System, which is focused on collecting 
facility based data on maternal deaths, is a development that will 
also indirectly address issues of quality of services and 
inefficiency. 
 
¶9. According to the joint March 2007 IATT draft report, existing 
opportunities to optimize access to HIV infected women to family 
planning have not been fully explored.  Data from surveys in 
Gaborone and Francistown revealed that 65 percent of pregnancies 
among HIV positive and negative women were unplanned and 35 percent 
unwanted.  Additionally, although CD4 testing is available to 
pregnant women, the proportion of HIV-infected pregnant women 
accessing ARV therapy for their own health is lower (16 percent) 
than the target of 25 percent.  Given the policies, frameworks and 
strategies towards maternal health that have been put in place, the 
GOB has made significant strides in improving this sector.  However, 
there are major gaps in the ability of health institutions to 
deliver, both in terms of the health systems, resources, supplies 
and equipment, as well as sufficient staff with the requisite 
knowledge and skills.  Family planning needs to be integrated with 
the Prevention of Mother To Child Transmission (PMTCT) program in 
order to ensure that they are not run as parallel programs. 
Moreover, PMTCT and ARV programs need a high-level coordination 
forum to ensure that implementation bottle necks are addressed and 
program planning and training are well coordinated. 
 
¶10. Child Health: Child health indicators showed steady improvements 
through the 1970's and 1980's; but since then, there has been a 
reversal in the trend.  Between the 1991 and 2001 census, infant 
mortality rose from 48 to 56 per 1000 live births, and under-five 
mortality increased from 63 to 74 per 1000.  Many believe this is 
mainly due to the HIV/AIDS pandemic, which accounts for nearly half 
of all under-five deaths.  The remainder is due to diarrhea, acute 
respiratory infections, pneumonia and neonatal causes.  Nonetheless, 
demographic projections indicate that the peak in infant and under 
five mortality rates should have declined to 28 and 58 per 1000 
respectively in 2007 due to the roll out of ART and PMTCT. 
 
¶11. Non-communicable Diseases: There are indications that 
non-communicable diseases are on the rise, notably cardiovascular 
diseases, hypertension, cancer, mental disorder and diabetes.  While 
the data may be partially a result of improved diagnostic methods, 
it may also be attributable to lifestyle changes that are 
encouraging the growth of such diseases.  The government needs to 
provide the population with health information on diet and exercise 
in order to encourage them to live healthy life styles.  There is 
also a need to do further situation analysis of communicable disease 
to facilitate and inform program planning and response and determine 
the true burden to the country.  The World Health Statistics 2008 
indicates that leading infectious diseases like tuberculosis, HIV, 
neonatal infections and malaria will become less important causes of 
death globally over the next 20 years. 
 
¶12. Death and injuries from car accidents also constitute a major 
problem for the health sector; they are largely due to driver error 
and alcohol abuse.  According to the Central Statistical Office 
(CSO) statistical brief No 3/May, 2008, the number of road accidents 
rose from 65 per 10,000 in 1995 to 108 per 10,000 in 2003.  It 
decreased to 106 per 10,000 2004, and further 98 per 10,000 
population in 2006.  Though there are signs of a drop in road 
accidents, they still need to fall them further. 
 
Challenges 
---------- 
 
¶13. Given the aforementioned disease burden and other health 
infrastructure issues in Botswana, the health sector will continue 
to face major challenges in the foreseeable future.  They include: 
a) the need to respond appropriately to the country's changing 
demographic profile.  For instance, there is a need to look at task 
shifting to respond to new health areas such as a) consider male 
circumcision; b) prioritize disease programs,  such as striking a 
balance between HIV and AIDS and other serious diseases; and c) 
ensure appropriate resource allocation between primary health 
care(PHC) and hospital-based services. There is clear need to place 
emphasis on PHC to avert the cost related to hospital care; d) 
harmonize the current range of health sector policies and strategies 
into an integrated health policy, and the development of a strategic 
plan to guide the implementation of health care in Botswana; d) 
improve the referral system and reduce distances and delays between 
primary, secondary and tertiary facilities; and e) develop a 
long-term, cost-sharing strategy. 
 
¶14. At the service delivery level, the health sector also faces a 
shortage of manpower, and slow implementation of policies, 
strategies and programs.  The availability and use of timely health 
information for policy and planning is equally weak across all 
health sectors and programs.  Consequently, the effective 
implementation of policies formulated for various health programs is 
low and lacks proper monitoring and evaluations of outcomes and 
impacts.  For instance, in a damning headline titled "Shortage of 
Medical Supplies Blights our Nation Reputation", the September 7 
edition of the Sunday Standard detailed the lamentable situation of 
patients unable to access medical supplies due to shortages at 
public health centers. The author urged the President to use his 
powers to "ensure that Botswana's health system is saved from ...a 
slide towards eventual crumble."  Nonetheless, the GOB and development 
partners are trying to respond to all these health challenges, with a 
special effort to strengthen Botswana's health infrastructure despite 
the difficulties posed by the HIV/AIDS epidemic and other development 
challenges. 
 
¶15. Final Comment:  Stronger linkages between the MOH and other line 
ministries, development partners and key stakeholders should seek to 
strengthen the health system response in order to achieve Botswana's 
Vision 2016 and the UN's Millennium Development Goals.  Some have 
voiced concerns that HIV/AIDS programs, especially the provision of 
ART, have squeezed the resources available for other important 
health programs.  This unease is not without foundation.  In a July 
23, 2008 health article on the Science and Development Network 
newsfeed (i.e., SciDEV.Net), the author asserts that "chronic 
diseases such as cancer, diabetes and heart disease are quickly 
overtaking infections as the biggest killers of the world's poor," 
and in fact kill a higher proportion of people than infectious 
diseases.  In short, the author concludes, under-resourced health 
systems in developing countries must now cope with the twin burden 
of infectious and non-communicable diseases.  However, most funding 
from donors is directed toward the former, with comparatively little 
going to the latter.  The GOB would do well do take cognizance of 
this emerging reality. 
 
 
GONZALES