**3. Botswana health care system**

Two healthcare systems run concurrently in Botswana: Western and traditional healthcare. Every Motswana (a person living in Botswana) has access to traditional health, and only some have access to Western health care. People's beliefs, customs and values influence the selection of which healthcare system to access. The common practice is that people exhaust the traditional healthcare services before consulting Western healthcare, especially if one suffers from an illness that needs to be clearly understood. Therefore, healthcare providers must take into cognisance the operations of these systems and fully comprehend the belief system of the people they serve to strike a balance between the two health systems.

#### **3.1 Western health care**

At independence in 1966, Botswana inherited a largely curative, hospital-based health care delivery system from the British, with most of the population without access to services [3]. Therefore, hospital-based health care challenged the government to provide health care for most people, thus necessitating the building of basic health facilities throughout the country. The main objectives were to strengthen the primary health care services, equitably distribute them to all people with more emphasis in the rural areas and improve hospitals to ensure adequate referral services [3]. The emphasis of the health policy N0.1 of 1970 was directed towards preventing more life-threatening health problems such as maternal and child health and combating communicable diseases such as childhood conditions, tuberculosis, and malaria. The policy trend has not changed significantly since its inception, but it has also infused the prevention of non-communicable diseases [4].

The health delivery philosophy in Botswana is to provide quality and affordable health services to Batswana. It is based on a decentralised model, with primary health care being the cornerstone in delivering health services. This system comprises a network of health facilities organised at different levels of sophistication and coverage [1]. Initially, the population and distance guided the infrastructure development [3]. Therefore, a 15-kilometre radius and a population of 500 people were prerequisite criteria [5]. Currently, the population of Botswana is about 2.346,179 million [5]. Health facilities are distributed according to the population and catchment areas they are to serve. It is currently estimated that most of the population lives within 5 km of a health facility [6].

Botswana has 27 health districts comprising the lowest and the highest referral services [7]. The mobile stops or outreach (921) are at the lowest level, where services are generally provided under a tree or at a school. Then follows health posts (351), clinics without beds (206), Clinics with beds (101), 17 primary health hospitals, 15 districts and three referral hospitals at the top [8, 9]. Finally, a teaching hospital at the University of Botswana, a quaternary public health facility providing highly specialised services, has recently been opened. However, the operations of the latter are still at very rudimentary stages.

Botswana provides universal health care to all citizens through the public health care system by operating 98% of the health facilities. However, privately run health care is also available and accessed by a privileged few with their resources [10].

The primary care model is the foundation of Botswana's healthcare system. Primary healthcare is the most economical way of achieving universal health coverage. Comprehensive care is offered throughout the lifespan and should include preventive, curative, and promotional health services [11].

The clinics primarily provide outpatient services within reach of communities, including general consultations, health prevention, and promotion services. Health posts offer limited services, whereas mobile stops need a permanent structure and are serviced by clinics and health posts within their catchment area. In the lowest-level facilities are health posts run by at least two general nurses and a health care assistant or a health education officer.

This extensive network of health facilities is well integrated to complement preventive, promotive, and rehabilitative health services and treatment and care of common health problems for citizens [11]. Primary health care services include immunisations, maternity care, children's health, prevention of communicable diseases, environmental health, nutrition, school health services, first aid, drug education, accident prevention, emergency services, and assistance with family life education [9]. In addition, health Education Assistants conduct health promotion activities by providing basic healthcare advice and health education materials to families and communities [12].

Botswana's healthcare system advocates for community participation in health promotion and prevention. Community involvement through community leaders and support groups to improve health promotion and prevention. The support groups' mission is to work with expectant mothers before and after pregnancy, expectant mothers who are HIV-positive pregnant, teenagers, and underage children engaging in sexual activity. There are discussion groups known as "Botsogo Pitso", a different approach aiming to promote interaction with patients and the communities, inform them of the services provided, and solicit their feedback.

These different health strategies and approaches have greatly influenced the improvement of health indicators and access. However, all the country's health concerns have not been alleviated because, like many countries in Sub-Saharan Africa, Botswana is still battling high rates of HIV and AIDS, other infectious diseases and currently with an upsurge of non-communicable diseases.

#### **3.2 Traditional health care**

The traditional healthcare system operates on beliefs, values and cultural doctrines. According to traditional Tswana philosophy, illness, death and misfortunes are never accepted as natural occurrences. Instead, they are attributed to the supernatural intervention of external agents such as ancestral spirits, supreme God powers, and sorcerers [13]. Ancestral spirits are regarded as the guardians of familial and tribal morality. They can sanction punishment for deviation from or violating familial and tribal norms with illness and misfortune [13]. Further, the supreme God, the creator of the universe and controller of everything, can inflict punishment on people by sending famine, diseases and death [13]. Lastly, the sorcerers cause illnesses and misfortune through witchcraft and manipulation of roots and herbs so that illness, death and misfortune would befall an individual [13].

Therefore, treatment interventions for people who hold these beliefs will depend on what is believed to have caused it. For example, if the illness is believed to be caused by ancestral spirits, certain rituals, such as prayers or offerings, are held to appease the spirits. If the illness is believed to be caused by sorcerers, traditional healers will be consulted to counteract the sorcery. Various traditional healers use different treatment modalities and approaches to counteract acts of sorcery. The beliefs also determine the health prevention modalities and interventions that will be instituted.

The Botswana health care system has utilised the Primary Health Care (PHC) approach to undergird its health programmes, strategies and interventions. This approach was the most feasible, realistic and relevant for an emerging nation with meagre resources and health infrastructure.

### **4. Primary health care strategy**

PHC is viewed as an essential function in driving the country's development. As early as the 1980s, PHC was given priority in terms of funds allocation in the national development budgets, indicating the country's commitment to health care for all citizens [14].

Central to PHC are the concepts such as community participation, universal coverage and accessibility, appropriate technologies, inter-sectoral collaboration, appropriate, timely referrals and the use of community-based healthcare providers. While all concepts are essential, community participation is deemed a very critical strategy in PHC, where individuals and members of the communities assume the responsibility of improving and maintaining their health [14].

Primary Health Care is considered essential healthcare at the operational level. It includes education on current health issues and related preventive and control strategies, promotion of supply of food and appropriate nutrition, provision of safe water and basic sanitation, maternal and child healthcare, immunisations against major communicable diseases, prevention, and control of locally endemic diseases, appropriate treatment of common diseases, and provision of essential drugs.

Primary Health Care service delivery has changed due to the recent increase in non-communicable diseases in Botswana. These services are now part of the entire hospital and healthcare services range. These organisations offer treatment services for common illnesses as well as preventive, promotional, and rehabilitative health services [15].

The Ministry of Health in Botswana further adopted the World Health Organisation's package of essential non-communicable diseases (WHO PEN) recommended for low-resource settings to integrate non-communicable diseases (NCDs) into PHC [16]. The recommendations guided the development of the Botswana Primary Care Guidelines (BPCG), which the country implemented in 2017 to strengthen health promotion initiatives. The guidelines seek to aid healthcare professionals in identifying signs and symptoms of common illnesses and their management. In addition to evidence-based treatment decision support for healthcare providers, the guidelines emphasise the promotion of patient self-management through individual counselling by a nurse and a dietitian, as well as group health education, defaulter tracing and strengthening coordination of care [16].

Like other African countries, Botswana has endured increasing demands on the health care system. There have been great success stories in some areas, especially the battle against HIV and AIDS. However, despite the country's high middle-income status, Botswana has not been as successful in other areas, such as childhood malnutrition and infant and maternal mortality [17].

#### **4.1 Health promotion processes and strategies**

Botswana as a member of the World Health Organisation (WHO), was part of the Ottawa Chatter Conference (1986) agreement whose primary purpose was to enhance the health and well-being of the public [18]. The Ottawa Chatter Conference demanded that the WHO member states orchestrate five main strategies: build public policy; create supportive environments; Strengthen community action; develop personal skills and reorient health services.

Since the inception and adoption of the Ottawa Chatter agreements, Botswana has put processes and strategies in place that are geared towards attaining its vision. At the top of the strategy is the Ministry of Health MOH), whose function oversees the country's health needs, mainly through public health [19]. The mission of MOH is to "provide integrated, holistic, and sustainable preventative, curative

and rehabilitative quality services in the country." MOH has eight departments: Cooperate services, clinical services, public health, HIV and AIDS prevention and care regulatory services, Health policy development monitoring and evaluation and Health hub.

The Department of Public Health provides health prevention and promotion initiatives in Botswana under Child Health, Health Promotion and Education, Sexual and Reproductive Health, Disease and Control, Environmental and Occupational Health, Nutrition and Food Control, Rehabilitation and Mental Health, Oral Health, Alcohol and Substance Abuse and Prevention of Blindness Units.

To promote health and achieve the Ottawa Chatter mandate, Botswana, through the lead of the MOH, has adopted international strategic goals such as Millennium Development Goals and the United Nations Sustainable Development Goals (SDGs) (2015). In 2000 Botswana government signed the United Nations Millennium Development Goals (MDGs), which mandated the UN member states to commit to eight goals: to combat poverty, hunger, disease, illiteracy, environmental degradation, and discrimination against women by 2015. However, the MDGs have been superseded by The United Nations Sustainable Development Goals (SDGs), which envisioned a world free of poverty, hunger, and disease. The main emphasis is on SDG3, which prompts countries to promote member states' health by 2030. In addition, health promotion initiatives recognise that social determinants of health go beyond the health sector.

In response to these strategies in 2010, the Botswana government, through the help of the American Centre for Disease, developed the "The Essential Health Service Package for Botswana, [20]. The EHSP is a set of health interventions that are promotive, preventive and curative, and rehabilitative that should be available to the entire population of the country." The essence of EHSP is that essential health care should be cost-effective, accessible and readily available to people. Furthermore, the provision of care through the EHSP is based on the ethical principles of need, cost-effectiveness and human dignity. Therefore, it is integral that health care is provided within an integrated area where public members can access care within one area rather than through a fragmented piecemeal.

The goals of the EHSP in Botswana were to ensure that all Botswana people have universal coverage of essential health care services. Accordingly, a revised National Health Policy was launched in 2011 [21] to guide the implementation. The policy strives to provide an environment where everyone in Botswana can achieve and maintain the highest health and well-being. The policy operates through the guidance of guiding principles as per **Table 1**.

#### **4.2 Health promotion strategies in Botswana**

Throughout the years, the Ministry of Health, through the Public Health Department, has made a concerted effort to develop and implement health promotion activities across the lifespan and to respond to the SDGs. These efforts incorporated strategies that promote health and well-being from childbirth across a life span. They include:
