Integrating social determinants of health in all public policies: The case of health development in

Integrating social determinants of health in all public policies: The case of health development in Botswana

Botswana WHO/AFRO Library Cataloguing – in – Publication

Integrating social determinants of health in all public policies: The case of health development in Botswana

1. Social determinants of health 2. Socioeconomic factors 3. Public policy 4. Health Planning 5. Health resources – supply and distribution – utilization 6. Cooperation behavior

I. World Health Organization. Regional Office for

ISBN: 978-929023266-7 (NLM Classification: WA 525)

© WHO Regional Office for Africa, 2013

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Disclaimer: This report contains the collective views of the drafting team and does not necessarily represent the decisions or the stated policy of the World Health Organization. 7. 6. Discussion 5. 4. Methodology. Background...... 3. 2. Hypothesis...... 1. Introduction...... Abstract Acknowledgments...... Contents ...... Conclusions andrecommendations policies andstrategies Findings: SocialdeterminantsofhealthinBotswana’s ...... 15 14 iv 6 5 2 2 1 v

iii Integrating social determinants of health in all public policies: The case of health development in Botswana iv Integrating social determinants of health in all public policies: The case of health development in Botswana An of prioritypublichealthconditions. experiences social andeconomicdeterminantsofhealth.It supports documentationofcountrylevel role ofMinistryHealthtoaddressing SDH istostrengthenleadershipandstewardship of theWorld HealthOrganization.TheoverallaimofSpanishCoreContributionGrantfor of Health(SDH) was madeavailablethroughtheSpanishCoreContributionGrantforSocialDeterminants Office (Kenya).WHO Regional to theprojectfrom inputs technical Theoverallguidanceand Moagi (WHO,Germano Mwabu,UniversityofNairobi and Professor Botswana) However,T.Dr Edward team included the drafting Mr (Botswana); Consultant Maganu, of Determinants the Social Health and prepared jointlybytheMinistryof case studywas This Acknowledgments on which waswidelydisseminatedduringtheWorldactions on intersectoral Conference through theMinistryofHealthtoconductthisactivity. not least,weexpressgreatappreciationforthesupportreceived from theGovernment but who cannotbementionedbyname.Last valuable inputsthroughouttheprocess SDH CoordinatorinWHOHQ, Geneva.We areindebtedtothemanypeoplewhomade Promotion The address socialdeterminantsofhealth. and level, stakeholder Health earlier Social final Risk the for product draft Africa Unit, Factors; review Determinants Cluster; in policy using of World receivedbytheDepartmentofEthicsandSocialDeterminantsHealth are this process is Dr Dr and gratefully intersectoral a case Health Davison Chandralall result strategy of leading study Health of Organization, acknowledged, Munodawafa, collective was discussions actions to held Sookram included the in aimed finalization efforts Rio Regional Programme and in on namely: de at a of Mr special addressing Janeiro, implementing many of Office Peter Dr the Area collection Tigest individuals Brazil Phori; case for the Coordinator, Africa. Ketsela, intersectoral in key study and of 2011. social and global Dr Financial generated Director Eugenio At organizations. Determinants determinants experiences the actions support country Health multi- Villar, to frameworks and regulatory strategies paper examinestheextenttowhichgovernmentpolicies, This Abstract for government the which the extentto regarding available information systematic no There is population. which formulation andimplementation.Thisisanimportantissuebecausethe conditions in development policiesintheAfricanRegion. national health into of determinants social of the incorporation hinder facilitate or that studies canprovideevidence in otherMemberStates.Suchcross-countryonfactors To determinants toimprovehealthandwell-being. implementation of health.Thereis,however, aneedto developmechanismsforstrengtheningthe determinants the conceptofsocial accepts to healthdevelopmentand approach has embracedthemultisectoral There isevidencethattheGovernmentofBotswana departments arenotwellunderstood. of thesectoralmandatescurrentlybeingimplementedbygovernmentministriesand health. Furthermore,purpose ofimproving thereviewfoundthathealthconsequences sectors inthecountryarecarryingouttheirrespectivemandatesbutnotwithexplicit but inadequately.in Botswana are coveredingovernmentdocuments Moreover, different health andprimarycare.Thereview revealed that socialdeterminantsofhealth determinants of available literatureandfromrelevantgovernmentdocumentsonsocial address Africa people (AFRO) the in in are Botswana of Botswana above born, and the new other issue, live

or approaches. incorporate and elsewhere partners a work desk determine should review in It social is Africa recommended support was determinants the has done level used studies to and existing that obtain distribution similar of the health WHO information knowledge to the Regional (SDH) of health present on from in Office social in their one the the

v Integrating social determinants of health in all public policies: The case of health development in Botswana vi Integrating social determinants of health in all public policies: The case of health development in Botswana other sectors. health. Thisresultsinthehealthsectorhaving todealwithhealthproblemscreatedby social determinantsofhealth,and,therefore, missoutonthe opportunity toimpacton the 15-49-year-old antenatalpopulation 17.8% of the labour force by the Botswana Core Welfareforce bytheBotswana of thelabour 17.8% Survey of2009/10 Indicators 8 7 6 5 4 3 2 1 health The The problem examination and empowerment.Thisautomaticallyledtothe systems; andcommunityparticipation information health alliances; and partnerships of the building general; in sector the health in governance the policies; all equity in health Health; of the Ministry in roles stewardship examine ifany,the application, ofintersectoralapproachesintheareasleadershipor This Purpose ofthereview Botswana Country profile 1. 81.8% compared tomalesat80.4% 81.8% with ahigherliteracyrateforfemalesat was 81.2%, The nationalliteracyratein2003/4 GDP per capita in 2009 was estimatedatUS$5959.5 GDP percapitain2009 HIV/AIDS Both themorbidityandmortalityforallagesarestilldominatedbyinfectiousdiseaseswith for malesand60females). The lifeexpectancyyears(48.8 atbirthisestimated54.4 Females havehigherunemploymentalthoughtheyliteracy. for femalesandmalesrespectively and 5.1% age of65yearswasestimatedat6.8% over the was under15yearsofage,whilethepopulation ofthepopulation 32.9% in 2010, It isestimatedthat was 1.9%. The annualpopulationgrowthratebetweenand2011 2001 has financing, especiallytheallocationofresources. actions wealth, 28%ofthepopulationlivesonlessthanadollarperday BotswanaGovernment (2011).2011BotswanaSecond GenerationHIV/AIDSAntenatal SentinelSurveillanceTechnical Report. GovernmentofBotswana(2012). CentralStatisticsOffice.BriefingKey IndicatorsJanuary2012. Ibid UnitedNationsStatisticsDivisionEconomicindicators2010(http://unstats.un.org/unsd/pocketbook/PDF/Botswana.pdf) Government ofBotswana2012.StatisticsBotswana.Preliminaryfigures 2011NationalPopulation and HousingCensus. Gaborone. Health Policy;National Government ofBotswana, TowardsGovernment Printer,Ministry ofHealth2011, a HealthierBotswana. 2003.quoted fromtheNationalHealthPolicyReport oftheSecondNationalSurvey onLiteracyInBotswana.CSO 2009. Gaborone (quotingUNDP2007). Health Policy;National Government ofBotswana, TowardsGovernment Printer,Ministry ofHealth2011, a HealthierBotswana. bulk an exercise sector. Introduction established into of and is the government of a Current was other landlocked health equity undertaken generalized communicable problems development in policies, relation country to that HIV to regulatory assess in policy 5 the diseases the . Unemploymenthighandwasestimatedat remains epidemic southern 8 Ministry utilization . frameworks the frameworks causing level with Africa of of Health an of the 3 with . in estimated about integration Due different health and deals a to population half strategies. the with 4 workforce . prevalence sectors the of skewed originate select deaths of The do 2.038 distribution and intersectoral 7 not of . Botswana outside aim to 30.4% address million was health 2 . The the to of in 6 1 . .

1 Integrating social determinants of health in all public policies: The case of health development in Botswana 2 Integrating social determinants of health in all public policies: The case of health development in Botswana component. Asaresult,healthimpactgenerallygetspassingmentioninEIAreports. impact for majordevelopmentprojectsbutsubsumeshealthimpactunderthesocial (EHIA). Impact some developmentdetailedpartoftheEnvironmental activities, possiblyasastand-alone Rural the qualifying criteria,especially populationandremoteness. implementation frameworks. different The healthconsequencesofdevelopmentarenotwell-understoodbythe programmes the lifecourse;andv)universalhealthcare. education; policies butatalowlevel. These categoriesare:i)early childhood development and to health need of determinants on social statements Clear policy integration. understand needs from themwouldbeenhanced.Hence,consideration the healthoutcomesemanating of theactivities, the healthimpact assessing If therewasacomprehensivemechanismfor the activities. improving health.Ifthey were understood therewouldbebetterhealthoutcomesfrom elements There key. on healthofthe various policiesarenotwell-understood.Thatiswhy integration isthe well-articulated schools, and tohealthcareand toservicesthatimpactedonhealthstatus whole populationaccess 9 Botswana 3. for happening butatavery low level.Theevidenceofthehypothesis; available isnotinsupport development Thishypothesisis,however,Botswana’s policies. rejected. Integration is The hypothesisofthispaperisthatsocialdeterminantshealtharenotintegratedinto 2. All Printer. (1972) Republic ofBotswana be sectors example, poor. well-being. incorporated Development is to Background Hypothesis Assessment The a sectors roads be The of need has have ii) Environmental given social all places Basic a to in the and an long Hence, and identify sectoral to impact determinants into five Programme other (EIA), where Health conducting history Rural Development in Botswana,GovernmentPaperRural Development Government Gaborone: No.1,March1972. therefore categories all the ways services on sectoral Impact resulting policies people of Services ARDP health. making of activities an (ARDP) of working Assessment of live; policies. and included in health in Health However, determinants (BHS) villages an policies iii) implementation 9 thatwaslaunchedin1972aimedtogive the Environmental in across work in Impact Specific these approach the its all frameworks in is environment; work. already construction the sectors. over Assessment sectors of health actions health This the that frameworks. and a Every requirement country for are sector can was are can Health iv) intersectoral of not (HIA) sector only covered social part clinics, then that according specifically Impact work The before of be aimed needs protection by the in water consequences included law, when action development Assessment Accelerated undertaking at to to especially supplies, aimed targeting integrate workers specific are across in not the at and age,the systems putinplacetodealwithillness(the health systems) determinants According historical backgroundismeanttoputthingsinperspective. and communityinvolvement.This collaboration of intersectoral PHC orthetwoconcepts past decadeaswell as healthsectorstrategicplans,butmostofthemhardlymention of reforms health sector The the PHCapproach. eclipsed new initiativesthat in resulted example, of PHC,i.e.intersectoralactionandcommunityinvolvement, fell bythe wayside. For emphasized The declining againafterthegeneralapplicationofantiretroviraltherapy(ART). reached pre-independencelevelsbefore and again PHC strategiesstartedrising and maternal) with thesocialgoalofHealthforAllbyYear 2000(HFA 2000) and communityinvolvement. collaboration ThePHCwasstronglyassociated approach of theMinistryHealthalwaysattemptedtoincludestrongelementsintersectoral and communityinvolvement and action.Subsequent policy andplanningdocuments collaboration intersectoral Health Servicesapproach; elements thatexpandedtheBasic 13 12 11 10 Health into thePrimary transformed in Botswana The BasicHealthServices(BHS)approach that AIDS However, articulated the conceptofprimaryhealthcaremoreclearly articulated who and disease.Certainly,of healthcare–notdeliveringtothose poordistribution Traditionally, politics. are shapedbyawidersetofforces:economics,socialpoliciesand circumstances must embraceallthekeysectorsofsocietyand notjustthehealthsector. Policiesand internationalagencies. fora, global business, communities, and programmes determinants ofhealthmustinvolvethewhole ofgovernment,civilsocietyandlocal but continent forvariousreasons.Inmanycountriesitwasbecauseofeconomiccollapse, The As DeclarationofAlma-Ata.InternationalConferenceonPrimaryHealthCare,Alma-Ata,6-12September1978. governments, (PHC) lead totheachievementofHealth for AllbytheYear 2000. Commission onSocial DeterminantsofHealth.Geneva, World HealthOrganization. determinants ofhealth.Final Report ofthe thegap inageneration:healthequitythroughactiononthesocial (2008).Closing CSDH of self-reliance andself-determination.” at every to maintainstageoftheirdevelopmentinthespirit that thecommunityandcountrycanafford and ata cost participation acceptable methodsandtechnologymadeuniversallyaccessibleto individualsandfamiliesinthe community through theirfull the stated in economic the 30th most pandemic. as Botswana 1990s Care the at World country Alma-Ata the which many key need international to

society Health health (PHC) shifted strategy social of problems the had Conference: countries In had and health it Assembly the – WHO for financing goal organizations has approach declined emphasis achieved is some implementation case one are looked and “Primary in of Commission in 1977 of other HFA the of the the and very and Botswana, agreed health in following to the to by conditions HIV 2000 communities. African countries, the economic the efficiency, all quickly care social on countries pandemic, field health the was is on essential the vision Region the and of determinants The of not Social in HFA sector fundamentals, pandemic the cost-effectiveness health; Declaration of Alma-Ata drastically health which achieved world Health and 2000 have care to Determinants in

the for Conference mortality order people deal based failed All developed reversed consequent of in with to by 11 of with improve on . The PHC approach had two . ThePHCapproach most the and health. practical, largely Alma-Ata in the are rates Year its 1978 and the the 12 the countries implementation 2000 born, concerns . of health endorsed health scientifically Action two (crude, major because other failure Health, as in status a grow, important major policies achievements Primary 1978 elements on in of sound about infant, of the of HFA social the the the live, 10 13 Health the and people , which . These of African health pillars social social in target 2000, child, socially work BHS HIV/ that Care the and of

3 Integrating social determinants of health in all public policies: The case of health development in Botswana 4 Integrating social determinants of health in all public policies: The case of health development in Botswana 14 The on SocialDeterminantsofHealth–FinalReport2008) from theWHOCommission (adapted of health categories ofsocialdeterminants Main up mineral mainly (NDPs).Plans NDPs,the various therefore, betracedthrough Itsevolutioncan, starting Development National its largely in out spelt many years for was Botswana in policy Health The evolutionoftheBotswanahealthcaresystem 5. 4. 1. to analysethesituationinBotswana. in variousgovernmentpoliciesandstrategies.Theyareusedthispaper approached and howtheyarebeing determinants ofhealthhavebeenaconsideration the social The analysis whereapplicable. and strategiesoutsidetheNDPs.policies produced These havebeenincludedinthe that 3. 2. Water, laidoutintheNDPsimpacts onhealthstatushavealsobeenhistorically (e.g.Education, 1995 principles Rural Development”. Thephilosophyofthe policy isalsostatedasbeingbasedonthe development, as hasbeensoclearlystated in GovernmentPaperon No.2of1973 underlay thepolicy. involvement also community and collaboration intersectoral decentralization, themes of Government ofBotswana.National HealthPolicy, MinistryofHealth1995,GovernmentPrinter, Gaborone. to categories Health-care systemsareavitaldeterminantofhealth. betweenhealthcareandequity.Universal :Therelationship health inequity. and health.Povertyare powerfuldeterminantsofill-healthand andlivingstandards protection Social betweensocial protection acrossthelifecourse:Therelationship powerful effectsonhealthandequity. lifelong equalizers. Education,preschoolandbeyond,fundamentallyshapeschildren’s are powerful education development and from thestart:Earlychildhood Equity Fair employmentanddecentwork: live affectstheirhealthandchancesofleadingflourishinglives. health equity?Wherepeople for matters Healthy places-healthypeople:Whyplace and livingconditions. employment income, adult on effect its through partly outcomes, health improved “Health first 14 that . The policy summarized the policies as they had been articulated in the NDPsin been articulated they had as summarized thepolicies . Thepolicy Agriculture, from revenues. such of date trajectories care the primary policy below and early has In etc.) addition, also health for form been 1970s and However, the had a care taken opportunities good health when the influence as policies by framework in the contained sector recent Government government in and for subsequent was Employment years, health. strategies from in produced the which to some started Educational Alma-Ata be policies. of part to and the individual by examine financing of other working the Declaration The overall attainment Ministry sectors 1995 the sectors health conditions socioeconomic extent policy of of whose is 1978. have care Health linked to stated which have work from also The to in between fluctuating, morbidity.dominate inpatient also been (MMR) has ratio mortality maternal of Estimation other infections,cancersandanaemias(notnecessarilyinthatorder).Theseconditions septicaemia, international standards. are mortality rates still causemostmortalityinbothchildrenandadults.Infantchildhood 16 15 This 4. Healthier Botswana) (National HealthPolicy:The currentpolicydocumentwasproducedin2011 Towards a of influential The diseasepatternofBotswanaindicatesthatsocialdeterminantshealtharevery with thehealthsectortoachievedesiredlevelsofstatus. Health onSocialDeterminantsofHealth(WHOTheNational and theCommission 2008). 2008, Health Systemsof on PrimaryHealthCareand Declaration the Ouagadougou (UN 2000), health These documentswereexaminedfromthe by theGovernmentofBotswana. produced were frameworks has anoverallaimofuniversalcoveragewithhealthcare.Thepolicyusesinternational it explicitly,stating determinants. Whilenot of thesocial part reality are in which the policy the taken. Commission purposely were papers authoritative selected? International How weretherevieweddocuments for theanalysis.Thestudydrawsheavilyonthatreport. Social and Care. Thesedocumentsarethemostrelevant andauthoritativeonthesubjectsofSDH regulatory undertaken care system, is also treated extensively as well as recent developments of the policies recent developments of well as treated extensivelyas also care system,is of thehealth the historicaldevelopments. PHC,whichhasforalongtimeformedthe basis treated extensively,is system in Botswana the healthcare The evolutionof with starting statutes andregulationsfromthehealthother sectors. NDP 10,were used extensively, aswellthenationalhealthpolicies, variouslegal Government ofBotswana,NationalHealth Service SituationAnalysisReport ,MinistryofHealth2009.Gaborone. Gaborone. Health Policy;National Government ofBotswana, TowardsGovernment Printer,Ministry ofHealth2011, a HealthierBotswana. health National dominated paper PHC taken The Determinants point Policy Methodology 150 and in respectively. frameworks selected. is policy into in mainly relation as Health of

a on and also in the their product view by account points Social that report. also 200 recognizes , because Service influence 15 to to The of order. . Thepolicyrecognizestheimportanceofsocialdeterminants per recognizes which of were Determinants of The determine Health in A main a reference, 100 large formulating desk former Situation Adult also diseases of on and 000 of other ones number the review health reviewed 2008 mortality separately if emphasizes live was the methodologies notably Analysis respiratory of were the births, cause and also of Health social of equities/inequities the policy country the or is the used the the among most literature used Report dominated determinants of final the Alma-Ata diseases, documents. Millennium socioeconomic 2008 largely documents need morbidity as report used the of references. and was 2009 for lower as Declaration by to of retroviral and of other used a Development of 16 The and HIV-related measure the policy framework on , communicable diseases , communicable ones health that determinants policies, as sectors final mortality. WHO The and infections in the action on report were Africa NDPs, it. Commission main strategy for Primary to infections, strategies It Goals According needs work influential the of is but framework especially (HIV) of the probably analysis high papers closely health, Health (4,5,6) to WHO and and TB, be on by or to

5 Integrating social determinants of health in all public policies: The case of health development in Botswana 6 Integrating social determinants of health in all public policies: The case of health development in Botswana relate tohealthequityinBotswana. relevance to health.Themajorareasaretreatedinturn,examiningparticularlyhowthey adequate mentioned 17 The tenthNationalDevelopment Plan(NDP 10) outcomes, partlythroughitseffectonadultincome,employmentandlivingconditions. and Education, preschoolandbeyond,fundamentallyshapeschildren’slifelongtrajectories 1) In 5. activities indifferentsectorsthatimpactonhealthformsthemainthrustofpaper. of thehealthsector. actionandintegrationofpolicies Theapproachtointersectoral that March The Health, Youth, LabourandFinance. “arising as directly listed not Health is opportunities. training and education of the provision through Goal • health evenifitisnotsostatedintheplan.ThegoalsofsectorNDP10are: Goal • have also shown, for example, that there is an inverse relationship between have alsoshown,forexample, thatthereisaninverserelationship infantand There aremanywaysin whicheducationcontributestohealthoutcomes. Manystudies equity. Childrenwhohaveattendedpreschoolestablishmentsperform betterinschool. health attaining for basis to provideagood education formal into (ECD), whichbuilds social needs).Theplandoesnotindicatecommitment toearlychildhooddevelopment and childrenwithother in remoteareas, children (childrenwithspecialneeds, vulnerable and disadvantaged to be paid will more attention that indicates The plan this articleasNDP 10). National Development (2010). Plan 10.Government Printer.Government ofBotswana Gaborone.(Thedocumentwillbereferredin dealing a mandate Indicators and tertiarylevels. system atprimary,education to ahigh-quality having fullaccess Batswana secondary expenditure asapercentageofGDP. development productivity index,thecompetitiveindexand thehumanresources sectors product. opportunities 2016, Botswana’s policiesandstrategies Findings: Socialdeterminantsofhealthin Early childhooddevelopmentandeducation from 2: supply 1: with in To contributing To in the of However, a that provide Chapter the this provide policy of Vision Education will qualified, for subject, be globally 2016 or health. 7 activities accessible, directly (An used strategy, productive it pillar Educated sector is competitive for Educational to of important of tracking this but is the equitable, An stated and and goal sector Educated the human this to competitive Informed field as attainment are note are quality being goal 17 Education, and

and that known resources that include Nation), to education. areas Informed covers produce human the is to linked Public unemployment word be covered to states the resources”. drive a Nation, skilled This major “health” period to Service, that economic may improved goal human is determinant the to April It may be rate, Agriculture, focuses plan’s also provide resource of 2009 growth. not labour health states great goal be on an to of lifestyles healthy of therefore theadoption and messages health of the internalization promoting noncommunicable of determinants to healthequitythroughvarioussocial is agreatequalizerandcontributor to genderequity,also includesthegirlchildandcontributes advocated intheplan, which employment and income,contributesdirectlytohealthequity. Universaleducation,as AIDS. 18 the the DestituteShelterProgramme, as schemes such shelter through the qualityofbasic states thatinordertorestorethedignity ofthepoor,NDP 10 will belaidonimproving focus ideal. to payis ability of regardless households all electricity andpavedstreetsfor sanitation, urbanization, whichmayresultinslumconditions. Prioritizationofprovisionwaterand especially inthecontextofrapid important, Shelter andhousingareparticularly Housing andshelter Where 2) mother’s and educationofthe mother; thesemortalitiesdecline with the higher the as oneofthemajorproblems facingthemajorityofpeopleinBotswana. vulnerable children. These regulations aremeant 2005”. toprovideforthe care andprotectionofparticularly levels ofhealthequity, with adiscussionofthecurrentstateaffairsinBotswana. the of thenaturalenvironmentareessentialforhealthequity. Thefollowingisanoverview of well-being, andthatareprotective designed topromotegoodphysicalandpsychological are that cohesive, socially are that goods, basic to that ensureaccess neighbourhoods and The enforced. the wayitistobe is elaboratedupon,including and exploitation.Eachoftheserights sexual abuse and (8)therighttoprotectionagainst practices; harmful labour against right toeducation;(6)the right toleisure,playandrecreation;(7)the right toprotection The directly mentionedasanoutcomeintheEducationsectorsectionofNDP10. know 17 rightslisted.Themostrelevantonestohealthare:(1)therightlife;(2) There are of ChildRights. an extensiveBill It has of thechild. of therights and protection low-income families toconstructtheirownhouses. SHHA health. Self areas implementation Children’s and is So, people Healthy places-healthypeople an Help education. and acronym that education be Formal Housing cared live have positive Act for affects “Self education (Cap diseases of for to Also, is Agency Help the be by a health-seeking their 28:04) major Housing taken Act as parents; health as stated also is (SHHA) Agency”, social covers supported well into facilitates and (3) above, account as 18 a determinant the andcivilsocietyschemes. Shelter is recognized many chances scheme behaviours. some right by education, the by to important the communicable the to make of acquisition “Children government health; leading of This health, living by areas (4) is flourishing where improving in areas of crucial the even Need diseases, relating loans health right healthy though are of lives. for chances provided to Care to knowledge, especially shelter; the the Communities and health Regulations at promotion control low of improve interest (5) better is thus HIV/ not the of to

7 Integrating social determinants of health in all public policies: The case of health development in Botswana 8 Integrating social determinants of health in all public policies: The case of health development in Botswana aimed but home development.Therearemanyschemesaimedatprovidinghousingtocitizens, with theprivatesectorandallmajoremployersin and tofosterapartnership alleviation; empowerment andpoverty as aninstrumentforeconomic promote housing housing; quality The to allrecognizedsettlementsandvillages. component ofruraldevelopmentThe governmentprovidespotablewater inBotswana. major responsibilityofthe government. Provision ofwaterhasalwaysbeen a major Wateris a of health.So,thesupplywaterto population isamajordeterminant Water in to water-bornee.g. changefrompitlatrines relating tolatrines, programmes systems of humanwaste,thegovernmenthas regardtodisposal With and pollutioncontrol. them are usually directlyassociatedwithhealth,andthese include wastemanagement on health.However,and allhaveabearing are verybroad Environmental issues someof Environment with in partnership home provision to facilitate is the policy of The thrust 2000. of Housing from theelements.ProvisionofshelterinBotswanaisguidedbyNationalPolicy on them protects their dignityand that maintains every humanbeingneedstohavehousing Decent shelter isabasichumanneed, and animportantdeterminantofhealth.Therefore, comprehensive policyonclimatechangeforthecountryhasbeenelaboratedyet. The some pit latrinesinruralareastoavoidpollutionofundergroundwaterashasoccurred always amajorissueinhousing,bothurbanandruralareas. for UN body onthe mitigation ofthe effects ofclimate change, andthere are programmes be plannedfor. Toto therelevant thatendthegovernmenthaspresented itsproposals According for waterresourcemanagementandcameup withanumberofmajorrecommendations. National Water MasterPlan(NWMP)Theplanprovided guidance was completedin1991. and development. Regularwater qualitymonitoring and infrastructure exception ofinstitutional has beenmade ontheimplementationofrecommendations, withthe progress The of health. are very important subjectsforlivelihoodsandthereforearesocialdeterminants management ofnaturalresourcesandpreventionenvironmentaldegradation.These on sustainable focused which has awareness and environmental education for programme urban the public NDP likely stakeholders; testing Environmental localities. at for SHHA 10 the areas, impact different to education for goal poor. is the chemical, Solid the or for of National channel This purposes promoting the Impact major climate waste and water should physical scheme more Water Assessment awareness change disposal sector (domestic, more have government and Master aimed is on an environmentally is “to microbiological also the impact undertaken agriculture, supply legislation at Plan environment the progressively resources on Review adequate low-income health is mine, by friendly in constituents to of and various and place water low better trade 2006 groups. therefore VIP and well-being. efficiently since and managed sectors. (NWMPR), (ventilated lower-middle were Other industry)”. 2005. on undertaken of Affordability health However, schemes with the substantial There improved) required landfills. The income should is first are no by is a fields. crime in reduction to contribute also could outlets, alcohol of positioning and the numbers of controls including controls, regulatory and design environmental Good to food. access healthy eatingbyfacilitating encourage could systems areputinplace.Retailplanning activity,physical to caterfor areas urban and designing especiallybythewaytransport Urbanization isproceedingatafastpaceinBotswana.Itimportantwhenplanning Urbanization/human settlements/ruraldevelopment Specifications the development in rural development addressing various causes of rural poverty.of rural various causes development addressing development inrural Botswana sustained through be promoted can areas urban and equity between rural Health largely accessibletoresidents butwithlimitedsecurityoftenure. tribal, usually is land usually freeholdorlong-term lease,whilerural is the two.Urbanland land administrationinbothurbanandruralareas becausetherearedifferencesbetween For 43:07) andOtherChargesAct(Cap Control ofGoods,Prices • Pollution Atmospheric Act(Prevention) (Cap65:03) • 65:04) Control ofSmokingAct(Cap. • Liquor Regulations,2008 • Road Traffic Act(Cap.69:01) • IndustrialDevelopment Act,2006 • Waste ManagementAct(Cap.65:06) • BuildingControlAct • Town Act(Cap.32:09) andRegionalPlanning • (District40:1) LocalGovernment Councils)Act(Cap. • list isbynomeansexhaustive. - the is asamplelistofsuchlawsandregulations settlements ingeneral.Thefollowing human cater for also to and by urbanization, about that arebrought demands varying transmission African The countryhaslowerincidenceofwater-bornedisguise. than mostother diseases water-borneof In terms in blessing been a weather has arid the Botswana diseases, to remedythesituation. Plans areinplace support. a regularbasisduetoshortageofmanpowerandlogistical of been treated.Theproblem boreholes orondamwaterthathas water providedthrough depends oneitherdeepunderground water inthecountryandmostofpopulation virtually disappearedinrecentyears.Thisisduetothefactthattherelittlesurface all imported.Theoccurrenceoftyphoidhasalwaysbeen sporadic andthe disease has living conditions. which isusuallyaresultofpovertyandpoor households morethantowatersources, recurrent sector rural and However, countries. areas, to violence. outbreaks of ensure (BOS cholera land the For quality There compliance 32:2000), rights example, constituting of (Cap. 65:02) are monitoring are diarrhoea many and particularly it with is included an probably laws the for in outbreak. children the Botswana and crucial rural water the regulations The villages only for may quality Standard few livelihoods. African be cases water in monitoring related place for country that supply Drinking Various to to have take of contamination that was dams occurred laws Water care has not deal and done of not Quality these were with had well on in

9 Integrating social determinants of health in all public policies: The case of health development in Botswana 10 Integrating social determinants of health in all public policies: The case of health development in Botswana greater consequences hazards –eachimportantforhealth.In psychosocial additiontothe direct health self-esteem,and relations development, social and physical from protection and When distribution NDP middle-income countries,Botswanafeaturesamongtheoneswithhighinequality. The income inequalitiesremainconsiderablyhighinBotswana,andthatcomparedtoother 11, Employment CreationismentionedasamajorstrategyinNDP10Goal3,Chapter inequities. including health postsormobilestops,dependingonpopulationsize. initiatives forremote areas have strong healthcomponents,usuallyinthe form ofclinics, dimension. These are contained in the National Strategy for PovertyStrategy for the National in contained These are dimension. include and Reduction some strategiesinNDP 10toaddressthisincomeinequity, whichalsohasagender Income inequityisamajor determinantofhealthinequity.put forward Thegovernmenthas laws inthecurrentplanperiod.TheLabourAct wasnotreviewedbytheauthors. vulnerable minimum wageintheagriculturalanddomestic servicesectorsinordertofurtherprotect The values aresimilartothoseofSouthAfricaandNamibia. unemployment ispartlyorevenforthishighincomeinequity.mainly responsible These and, 2002/03 The valueswerefrom 0.503. was The valueinthecities income. disposable based on being lowerthanurbanvillages(0.523), with ruralinequalityat0.515 0.573, Revised The convention. labour of child forms of theworst to employment,andtheelimination on theminimumageforadmission obligations ensure compliancewithinternational emerging and government is tobeestablishedaddress issuesofcommonconcernandresolve dialogue in 19 Employment 3) poor the country,of western parts into translates also This disadvantaged. the most being especially thoseinthe with theremoteareas, areas, inequities betweenurbanandrural considerable show still rates, mortality poverty and as levelsof development, such of and development generally,rural for and strategies developed manypolicies historically has development coefficient more unequaldistribution, with1correspondingto complete inequality. The NDP for which Decent Gini for health 10 these specific Fair employmentanddecentwork coefficient due the 10 quotes indicates National and allocating issues workers is involves national is Work indicators. to and employment entitled are in Goal measures populations of work’s a general CSO more amicably. working tackling Country good Policy from more figure, equal 2 safeguarding “A the as potential of There financial inequality and distribution, they Compassionate, estimating on financial work-related the conditions creation. Programme such showed An Incomes, in is same can action among role as health obviously exploitation. with the resources workers’ provide a Effective 0 values in the chapter. have deterioration corresponding programme Remote that inequities, reducing in Employment, value of particular. a Just powerful a the frequency financial rights, need social The to Area The of government and to poor gender, the government complete the to from on dialogue Development background distribution promoting effects All Caring keep Gini communities health security, child Prices 1993/94, rural equality, ethnic, coefficient revisiting (for on labour espouses among equity Nation”. development and example plans while health social social narrative racial Programme. which higher Profits will impacts to workers, to levels 19 rural Equitable and promote protection, in Botswana as inBotswana and review be status, and Gini was of development, developed coefficients health introduced income). explains policies is other will 0.537. employers described the Indicators personal equity be income A equity. labour social social low indicate even High and that Gini to in a opportunities, and strategiesdesignedtoreducepoverty and vulnerabilitybypromotingemployment

selection are The twochallengesthat facethegovernmentinimplementingthese programmes home-based carepatients,needychildrenand remoteareadwellers. to destitutepersons,the elderly (old-age pension), World War llveterans,community 20 l l l of income and economichazardsinterruptionorloss protect themselvesagainstpsychosocial Social Poverty arepowerfuldeterminantsofill-healthandhealthinequity. andlivingstandards 4) Botswana supporting informalsectorenterprisestograduatetheformalsector. sector development informal asasourceofentrepreneurialactivity,spread, assisting and geographical and with extensivesectoral employment growth broad-based of promotion Some areasofactivityandinitiativesinclude:

dependency syndrome that theprogrammesseemtoencourage.Ipelegeng, the labour- producing abagofgrainshouldnotbemorethantheretailpricesamebag. of cost The climate. the arid view of in play can farmers subsistence small the rolethat government spellsouttheconceptofhouseholdfoodsecuritymoreclearly, including agriculture asamajorsourceofemployment.Itis,however,support importantthatthe agriculture andtosupportfarmersgointocommercialfarming.Thisisalsomeant A The feeding isuniversal,allfundedbythegovernment. to carryhome,especiallytheonesthatareunderweight,andschool- with foodinclinics to enabled thecountry has This foods. to access safety netsthatenablehouseholds social well as as poverty alleviation of schemes has also and production food for gives subsidies schemes, foodsecurityatthe household level is atareasonablelevel. The government such asmaize and sorghum.However, becauseofvariousgovernment-supported country doesnotproduceenoughbasicfoodstofeed itself. Thisincludesgrainstaples Adequatesocialprotection Government ofBotswana (2010).NationalDevelopment Plan10.GovernmentPrinter. Gaborone. Revised keep o Equitable incomedistribution poverty ofabsolute Eradication o government protection social protectionandhealth Social protection acrossthelifecourse: therelationshipbetween Social assistanceandwelfareservicestrategies forthemostvulnerablegroups Enrolment onsocialsafetynets. 20 of National is . a beneficiaries food-deficit diminishing is has Policy covered levels plans on country.

and people’s low in Destitute and NDP sustainability. by strategies Although 10, African exposure Persons and standards. is most to defined These of to promote 2002 risks, people are as is Under-five and referred the are more exacerbated enhancing set employed efficient of to children policies, which in by their technologies covers agriculture, the are programmes capacity apparent provided support the to in

11 Integrating social determinants of health in all public policies: The case of health development in Botswana 12 Integrating social determinants of health in all public policies: The case of health development in Botswana The currentNationalHealthPolicy to actonthesocialdeterminantsofhealth. capabilities therefore have to bebuiltandstrengthened, as well as expanded to be able followed 22 21 offer systems care Health disease. just thetreatmentof more than system is The healthcare large geographicallyandthepopulationisunevenlydistributed. is where thecountry in Botswana, so and itisparticularly challenge inmanycountries, of healthcareisamajor policies andhealthsectorstrategicplans.Inequitabledistribution Development such astheNationalPlans,health the relevantdocumentsinBotswana, in been wellrecognized has This health. of determinant vital a are systems care Health 5) to continuouslylookformoresustainablesolutionstheseproblems. government needs The problems. structural size and small its with Botswana economy of creation ofpermanentwell-payingjobs.Thequestionishowtocreate such jobsinthe and inhibitinginitiative.Somecriticizeitbecausetheyoptionisthe feel thesustainable dependency causing it as because someregard iscontroversial programme, based The insurance ratherthanfeesatthepointofservice. this equitytobebasedonpre-payment,suchassocialhealth is forusercontribution contribute 68.1%, private sources 20.6% and donors 11.6% of the total healthexpenditure and donors11.6% contribute 68.1%,private sources20.6% Regarding of allhealthservicesthroughpublicfacilitiesand programmes. about 80% sector isalsostatedtobethemainproviderof healthcareservices,providing protect integrated withotherservices,suchasearlychildhooddevelopment (ECD). They can and Coordinationofthe is of equity,of theprinciples built onthebasis It diseasepreventionandhealthpromotion. and preferences,regardlessofabilitytopay. Healthcaresystems,therefore,havetobe extending the toneeds same scopeofqualityservicestothewholepopulation,according and servicesareorganizedaroundtheprincipleofuniversalcoverage,i.e. institutions health equitywhere the to improvinghealthand contribute most systems Health care disadvantaged andmarginalizedgroups. equity throughattentiontotheneedsofsocially Medicines, Services (ServiceDelivery), (5) (3) HumanResources forHealth,(4)HealthFinancing, population the policydocument notesthat,nationally,In relationtouniversalaccess, 95%ofthetotal

Gaborone. Health Policy;National Government ofBotswana, TowardsGovernment Printer,Ministry ofHealth2011, a HealthierBotswana. country. the of the westernparts especially in the population, of nature the veryscattered of recognition in is This population. the rural for 8 crucial km health benefits has health equity Universal HealthCare:Therelationship betweenhealthcareand against been the therefore and Vaccines health workforce used WHO that 89% since sickness, care go framework that the of and beyond beginning the is health Health Sector(Governance), financing, Other a rural generating very of on care just population health Health important health the system treating 21 planning hasattempted to addressthese issues. It has a Technologies, Botswana sense systems in live financing Botswana component illness; within of and life

government as this 8 (2) AccessandUtilizationofHealth the and be security, has km maximum is equitable. of (6) of sections especially the a Health health distance and has health One can on Information from been facility so care (1) way a promote when health Management estimated 22 . Thepublic of system. facility ensuring they System. health to attain are Its to cross-cutting issues.Thefollowingissuesarehighlighted: is to hightechnologycareintheprivatesector,The membersareabletohaveaccess which and canonlybeaccessedbymiddle-high-incomegroups. based onaffordability schemes promotehealthinequitiesbecausetheyare that theseinsurance be argued NDP approach. Theplanstatesthat80%ofthepopulationiswithin5kmahealthfacility. with varioussectorsandpartnersindifferentcapacitiestoensurethemultisectoral care provisionby, inaddition tostrengtheninghealthcareprovision,alsocollaborating through successiveNDPs,of health createdasolidfoundation has successfully Botswana Health Policyit needstobeemphasizedintheNational well. TheNDPreiteratesthat as PHC the on anchored is Botswana delivery in the healthcare reiterates that Health of Ministry In good incomesinthepublicservicetoaccesselitemedicalcare. those whoearn health servicestendtobeneglected.Thegovernmentisalsosubsidizing to medicalaidandhaveaccessprivatecare,public civil servantsgenerallysubscribe citizen (BPOMAS) earning is availableforthose of thesubscriptions, by theemployerpayingaproportion in theformofmedicalaid,usuallysubsidized Private insurance to gointhatdirection. steps concrete propose not does be exploredbut are yetto health insurance social as payment such of alternative methods that indicates The policy not beenassessed. has and the aged mothers, pregnant (children, system, withexemptionforvulnerablepopulations A by thegovernment. Individual costofhealthcareinthepublicsectorisheavilysubsidised 2009/10. Gaborone,Botswana.) 2012. of Botswana. Republic Health, needs. (Ministryof services across of distribution and inequity infunding curative services,indicating on is spending this of Most in 2009/10. support Information andcommunication technology:telemedicine,IT Human capitaldevelopment: humanresourcesdevelopment HIV/AIDS mitigation:treatment andsupportstrategies legislation Governance: reviewanddevelopmentofpolicies and Gender anddevelopment:equitableprovision ofservices Environmental sustainability:wastemanagement response, disastermitigation Disaster preparedness:epidemicpreparedness and Cross-cutting issues nominal also NDP specified strategy 10 Botswana more is 10, appropriate lists entitled cost and Goal efficient. the as communicable recovery a articulated to National areas few 4 “Affordable of income. It societies can Chapter where system Health also in diseases). There the and cross-linkages for be 11 through Alma-Ata Accounts the argued Quality (A is private Compassionate, a The a large fee Health that Declaration extent for sector at occur because Medical the Financial Care to point (BOMAID with which Services”. of Just Aid the other of 1978. Years these middle service Society and being programmes If Coordinating Agency 2007/08, Here, indeed charges Caring level applies MFDP/MESD for the the NDMO MEWT MCST MLHA NACA and public biggest). MSP this Nation), affect 2008/09 government/ in senior is as the the servants access well public It every case level and can as

13 Integrating social determinants of health in all public policies: The case of health development in Botswana 14 Integrating social determinants of health in all public policies: The case of health development in Botswana would bigger impact.Iftheyweretounderstandthe impactoftheiractivitiesonhealth,they it However, implementation isweakand The for development.Healthypeoplearemoreproductive. health sectorisnotaconsumingbutproductiveone.Goodessential that the It isnowgenerallyaccepted,evenbymanyeconomists, equitably distributed. and/or are favourable means thattheincomes usually It also health arefavourable. People development. health arenotwell-understood.Thosewhohealthy do notenjoy the fruits of When Health isaproductofdevelopment but healthisalsoastronginputintodevelopment. the governmentindicatethatithasnowfallento27%. releases by latest although 30.3%, estimated at line was below thepovertydatum living Analysis strategies thatareconducive to andpromote positivesocialdeterminantsofhealth. and policies has manygood shown thatthegovernment ofBotswana review has This other sectors. Ministry ofHealthisthere to mop-upanyincidental ornegative health outcomesfrom to beageneral perceptionandexpectationthatthe are notawareofit.Thereappears do highly Botswana of Poverty 6. quite considerableinBotswana. improving thehealthstatusofpeopleandinreducinginequities,whichare the social determinantsofhealth because itrecognizestheirimportanceingenerally committed toaddressing is that thehealthsector the tableshows above and The summary Partnerships/PSP: strategicnetworks/linkages clinics andotherfacilities) Rural development:infrastructuredevelopment(hospitals, outsourcing ofselectedservices Employment creation:publicsectorprivatizationand quality servicespromoteproductivity Poverty eradication/Pro-poorinterventions: accessibleand Cross-cutting issues difficult poverty not consequences a act skewed Discussion know who is society of to a even has in the major achieve undertake that the low health distribution better. is country. determinant they “developed”, levels of health policies are development their Some of According contributing equity. of own poverty, carry of income. and health. activities what These strategies out policies, official to there arestructural it The to work Although various really generally health. in situation statistics their which has strategies, means government international own If generally relate they has makes show sectors is a knew, regulatory that to negative attributes showed that high it documents, the literature carrying their difficult there Coordinating Agency levels social impact activities frameworks, a of societythatmake favourable are MFDP/MLG out to tends of determinants MFDP MFDP MFDP achieve still the poverty their on would to high population health state mandate etc., picture. and health levels have that but on to of well-being inmostofthem, intersectoral consideration more needs to be done toaddresshealthand some that whilethereis shown and strategies has ofgovernmentpolicies The analysis and whatcanbedonetostrengthenintersectoral actionforhealth. various examined in from earlychildhooddevelopment to tertiaryeducation.Thesameappliesconditions applies What needstobeexploredisbetterandfastermethodsofachievingthis.Thesame as possible. Government policiesaimatextendingthesetoasmuchofthepopulation good balanceddiets,electricityandcommunications. access towaterandsanitation, referred 23 and addresspowerimbalances problem-solving which valuecross-sector processes governments needinstitutionalized that reason, Fortheir activities. of well-being dimensions address thehealthand other sectorsto government and challenges, thehealthsectorneedstoengagesystematicallyacross Since healthisafundamentalenablerandpoorbarriertomeetingpolicy 7. sustainability. examining their whilecontinuously needs tobedoneisstrengthentheseprogrammes What development policies. governanceand sound its safety nets,andfor social and protection social including welfare programmes, is renownedforitssocial Botswana time toachieveascloseasituationfullemploymentpossible. positive equity aid, that canpaythehighfeesdemandedbyprivatesector,those onmedical including currently prevalentwheretheelite that is the situation to avoid a socialhealthinsurance financially sustainable. technologies examined. Forbe continuously needs to examine whetherthe to necessary example, itis of someaspectsthepoliciesandstrategies are strong.Thequestionofsustainability Policiesbeen extensivelydiscussed. has sector The health and are inplace strategies and maintain health. needed torestoreand provide themwithservices and they targetthepoor being as determinants are alsogenerallysupportiveofpositivesocial The policiesandstrategiesinothersectors the alreadywelloff. Social healthinsurancewouldpromoteequity. on health percapita spending moreon actually the governmentis servants, the public for healthandwell-being. WHO; which have Government and Conclusions andrecommendations government to impact to people access employment the in needs as sectors employed of Many the extent of of live South health. to to “Health education - policies more be of Australia the other to the and tackled. However, and which importance efficient in (2010). than programmes decent and All on the social Policies” health Adelaide The health regulatory size hardly services. work. government for and determinants Statement is to health well-known have approach. Policies any address mix and By on of of of large contributing implementation Health them aspects also the and

23 this . This approach is nowcommonly . Thisapproach of It in and influence health needs strategies All is specifically health dimension. Policies in is such this discussed to workforce to - are a moving on as consider spirit frameworks medical have good the taken mentions Action towards that to population’s in as dignified be the into the aid this a to proposed shared revised in feasibility document be health. scheme account paper Botswana taken governance shelter, from well- The has are for to of in -

15 Integrating social determinants of health in all public policies: The case of health development in Botswana 16 Integrating social determinants of health in all public policies: The case of health development in Botswana policies andstrategies. to alldevelopment in fact,isapplicable development andeducation.This, childhood poverty reductionandthosedealingwithearly and strategies,suchasthoseaddressing health outcomesinallgovernmentpolicies includes incorporating the situation address

ISBN 978-929023266-7

978- 929023266- 7