Assessment of unintended pregnancies, contraception, and abortion in Botswana.

Botswana has a policy of contraception for all that is delivered through a rights-based family planning program. The program combines a "rights-based family planning approach" with "supportive policies for contraception," and "a commitment to promote equitable access to modern contraception, and expand availability, method mix and uptake of modern contraceptive methods for all women and girls." However, abortion is legally restricted up to 16 weeks of pregnancy provided that provisions of Section 160-162 of the Botswana Penal Code Amendment Act 1991 are met, and that the termination of pregnancy is carried out by a registered medical practitioner in a health facility approved for the purpose. In 2020, the Ministry of Health and Wellness, Botswana, in collaboration with United Nations Population Fund and World Health Organization, conducted a strategic assessment of unintended pregnancies, contraception, unsafe abortion, and abortion services in Botswana. A consensus operational plan to address these issues was developed during a national stakeholder meeting in Gaborone, Botswana. The consensus reached was to avert unintended pregnancies, improve access to modern contraception, and open nationwide discussions around abortion in the community to enable positive change and decrease maternal morbidity and mortality from unsafe abortion. This article describes the findings of the assessment and outlines the foundation for new or modified services or practices to be developed and pilot tested.

A mixed method analysis of the Botswana schistosomiasis control policy and plans using the policy triangle framework.

BACKGROUND: The present goal of the World Health Organization (WHO) 2021-2030 roadmap for Neglected Tropical Diseases is to eliminate schistosomiasis as a public health problem, and reduce its prevalence of heavy infections to less than 1%. Given the evolution and impact of schistosomiasis in the Ngamiland district of Botswana, the aim of this study was to analyze the control policies for the district using the Policy Triangle Framework. METHODS: The study used a mixed method approaches of an analysis of policy documents and interviews with 12 informants who were purposively selected. Although the informants were recruited from all levels of the NTD sector, the analysis of the program was predominantly from the Ngamiland district. Data were analyzed using Braun and Clarke's approach to content analysis. RESULTS: The study highlights the presence of clear, objectives and targets for the Ngamiland control policy. Another theme was the success in morbidity control, which was realized primarily through cycles of MDA in schools. The contextual background for the policy was high morbidity and lack of programming data. The implementation process of the policy was centralized at the Ministry of Health (MOH) and WHO, and there was minimal involvement of the communities and other stakeholders. The policy implementation process was impeded by a lack of domestic resources and lack of comprehensive policy content on snail control and no expansion of the policy content beyond SAC. The actors were predominately MOH headquarters and WHO, with little representation of the district, local level settings, NGOs, and private sectors. CONCLUSIONS: The lack of resources and content in the control of environmental determinants and exclusion of other at-risk groups in the policy, impeded sustained elimination of the disease. There is a need to guide the treatment of preschool-aged children and develop national guidelines on treating foci of intense transmission. Moreover, the dynamic of the environmental transmissions and reorientation of the schistosomiasis policy to respond to the burden of schistosomiasis morbidity, local context, and health system context are required.

Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model.

BACKGROUND: Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. MAIN TEXT: Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. CONCLUSION: There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.

Feeding back of individual genetic results in Botswana: mapping opportunities and challenges.

PURPOSE: We explored the views of Botswana stakeholders involved in developing, implementing and applying ethical standards for return of individual study results from genomic research. This allowed for mapping opportunities and challenges regarding actionability requirements that determine whether individual genomic research results should be fed back. METHODS: Using in-depth interviews, this study explored the views of sixteen (16) stakeholders about the extent, nature and timing of feedback of individual genomic research findings, including incidental findings that arise in the context of African genomics research. Coded data was analyzed through an iterative process of analytic induction to document and interpret themes. RESULTS: Overall, respondents were of the view that feedback of actionable individual genomic results was an important outcome that could benefit participants. However, a number of themes surfaced that pointed to opportunities and challenges that exist in Botswana that could help in planning for feeding back of individual genomic results that were mapped. Some of the opportunities cited by the respondents included the existence of good governance; democracy and humanitarianism; universal healthcare system; national commitment to science; research and innovation to transform Botswana into a knowledge-based economy; and applicable standard of care which could promote actionability. On the other hand, contextual issues like the requirement for validation of genomic research results in accredited laboratories, high cost of validation of genomic results, and linkage to care, as well as lack of experts like genomic scientists and counselors were considered as challenges for return of individual results. CONCLUSION: We propose that decisions whether and which genomic results to return take into consideration contextual opportunities and challenges for actionability for return of results in a research setting. This is likely to avoid or minimize ethical issues of justice, equity and harm regarding actionability decisions.

Psychometric properties of a clinical assessment tool in the postgraduate midwifery programme, Botswana.

BACKGROUND:  The psychometric properties of a clinical assessment tool used in the postgraduate midwifery programme in Botswana have not been evaluated. A lack of reliable and valid clinical assessment tools contributes to inconsistencies in clinical assessment in midwifery programmes. OBJECTIVES:  This study aimed to evaluate the internal consistency and content validity of a clinical assessment tool used in the postgraduate midwifery programme in Botswana. METHOD:  For internal consistency, we calculated the total-item correlation and Cronbach's alpha coefficient. For content validity, subject matter experts completed a checklist to evaluate the relevance and clarity of each competency in the clinical assessment tool. The checklist included questions with Likert-scale responses, indicating the level of agreement. RESULTS:  The clinical assessment tool had a good reliability, with a Cronbach's alpha of 0.837. The corrected item total correlation values ranged from -0.043 to 0.880 and the Cronbach's alpha (if item deleted) ranged from 0.079 to 0.865. Overall content validity ratio was 0.95, and content validity index was 0.97. Item content validity indices ranged from 0.8 to 1.0. The overall scale content validity index was 0.97 and the scale content validity index using universal agreement was 0.75. CONCLUSION:  The clinical assessment tool used in the postgraduate midwifery programme in Botswana has acceptable reliability. Most of the competencies included in the clinical assessment tool were relevant and clear. Certain competencies need to be reviewed to improve the reliability and validity of the clinical assessment tool.Contribution: The clinical assessment tool currently used in the postgraduate midwifery programme in Botswana had acceptable internal consistency reliability and validity.

Association Between Household Food Insecurity (Access) Scores, Poverty Indicators and Child Malnutrition in Botswana.

In Botswana the Household Food Insecurity Access Scale (HFIAS) has been used in studying the urban-poor, but less in rural settings high in poverty, child malnutrition (CM), and social protection beneficiaries. This cross-sectional study compared HFIAS scores, household poverty (HP) and CM in two rural districts: Bobirwa with moderate and Mabutsane with high poverty. Households (n = 872) with children under-five years participated. Most children (87.6%) experienced food insecurity. Mean HFIAS for all households was 11.0 ± 8. HFIAS scores were higher in Mabutsane (p < .001). HFIAS scores were consistently associated with HP and CM in both districts. HFIAS can assist in targeting the rural-poor.

Services as a Determinant of Botswana's Economic Sustainability.

In 2015, the services sector contributed about 58 percent to the gross domestic product (GDP) in Sub-Saharan Africa (SSA), which was a significant increase from the 47.6 percent observed in 2005, and a shift from the mining, agriculture, and manufacturing sector. This increase calls to support services as the catalyst for sustained economic development as indicated by the structural transformation and modernization theories. The main objective of this paper was to examine the relationship between and the impact of services on the economic development in Botswana and make recommendations on how Botswana can apply well-directed policies to improve its services sector and diversify its impact on other sectors and GDP, making it less reliant on mining which is vulnerable to price volatilities. The paper applied econometric modeling and results of the Autoregressive-Distributed Lag (ARDL) Bounds test for cointegration indicate that services and other industries services, agriculture, industry, mining, and investment impact GDP over the short and long run. These variables impacted GDP and converged to equilibrium at the speed of 46.89 percent, with a percent change in services in the short and long run impacting GDP by 0.328 and 0.241 percentages, respectively, and the outcome of the Wald test indicated causality from services to GDP growth. The services sectors have contributed over 40 percent to the country's GDP from 1995 to the present, though the sectors have not gone without challenges with limitations such as limited infrastructure development; poverty and inequality; unemployment of over 20 percent; disease, which has dampened productivity; and lack of proper governance and accountability, which has created a habitat for an increase in cases of corruption in state and private entities. The findings of the study with the lessons learned from other studies with similar findings recommend that the government of Botswana should formulate suitable policies and strategies for services diversification. This is by expanding the market for the sector in areas such as tourism that were impacted by the COVID-19 pandemic, escalating investments by instituting strategies to attract and grow domestic and foreign investments, and improve on management of institutions and resources.

Assessment of awareness and knowledge of schistosomiasis among school-aged children (6-13 years) in the Okavango Delta, Botswana.

BACKGROUND: Schistosomiasis is a global health problem affecting 250 million people, with 90% in Sub-Saharan Africa. In Botswana, the burden is high in the Okavango delta because of the water channels. WHO recommends integrated measures, including access to clean water, sanitation, health education, and drugs to control and eliminate schistosomiasis. Gauging knowledge and awareness of schistosomiasis for School-Aged Children (SAC) is crucial. Our study aimed at assessing knowledge and awareness of schistosomiasis among SAC in the Okavango Delta. METHODS: A cross-sectional survey assessing awareness and knowledge of schistosomiasis in schools was conducted. 480 questionnaires were administered to gather demographic profiles, awareness, and knowledge of risky behaviors. Chi-square and descriptive analysis determined the differences in SAC`s awareness and knowledge levels based on localities, gender, age, and health education. RESULTS: The results showed a low awareness level, with only (42%) of respondents having heard about the disease and (52%) knowing its local name. Younger children from Sekondomboro (83%) and Samochima lacked awareness, while children from Mohembo (77%) and those who had health education (70%) demonstrated significant awareness levels (P ≤ 0.001). Seventy-two percent (72%) lacked knowledge of the cause and (95%) did not know the disease life-cycle. Children from Xakao (91%), (85%) Sepopa, and (75%) of younger children did not know haematuria is a symptom of the disease. Older and SAC with health education were more likely to know that swimming is a risk factor (P ≤ 0.001) and (P ≤ 0.05) respectively. CONCLUSIONS: Although respondents from four schools demonstrated some level of awareness of the disease, and knowledge of risky behaviors, the study showed a lack of in-depth knowledge on the life-cycle and cause of the diseases. We, therefore, recommend the implementation of an integrated approach to health education and improvement in access to clean water and sanitation in all study areas.

The Extent of Integration of Community Health Worker Programs Into National Health Systems: Case Study of Botswana.

BACKGROUND: The paucity of Human Resources for Health (HRH) is a major global health challenge. The World Health Organization (WHO) recognizes the potentials that Community Health Workers (CHWs) have in closing the gap of an inadequate supply of human resources for health (HRH). However, weak CHW integration into national health systems curtails effective implementation of CHW delivered high impact interventions in resource constrained settings. This study assessed the extent of integration of the CHW Recruitment, Education, and Certification (REC) component into the national health system's HRH building block, using Botswana's CHW program as a case study. METHODS: The study used mixed methods. Data collated from CHW training program documentary abstraction, five key informant interviews were analyzed thematically. Data collected through the survey with 123 CHWs were analyzed quantitatively. A recently developed Community Health Workers Program Integration Scorecard Metrics (CHWP-ISM) that comprises of the WHO building blocks and corresponding CHW integration metrics, with process, evidence, and status of integration parameters, was used to determine the extent of integration. RESULTS: An analysis of Botswana's CHW REC component using the CHWP-ISM scale showed that the component was 80% integrated into the national HS. Whereas the CHW training program was fully government sponsored and accredited, some aspects of the program's selection and recruitment criteria and training modalities were lacking integration. Although CHW training was exclusively offered at a local private training institute, findings from documentation reviews, interviewed KIIs and the survey show that the training accreditation, regulation and funding was the responsibility of the central government. CONCLUSION: The application of the CHWP-ISM scale to assess extent of CHW program integration into HS identified important CHW human resource integration gaps in CHW selection criteria and recruitment process as well non-inclusion of CHWs post-training accreditation by national accreditation board in government policy documents.

Protocol for an automated, pragmatic, embedded, adaptive randomised controlled trial: behavioural economics-informed mobile phone-based reminder messages to improve clinic attendance in a Botswanan school-based vision screening programme.

BACKGROUND: Clinic non-attendance rates are high across the African continent. Emerging evidence suggests that phone-based reminder messages could make a small but important contribution to reducing non-attendance. We will use behavioural economics principles to develop an SMS and voice reminder message to improve attendance rates in a school-based eye screening programme in Botswana. METHODS: We will test a new theory-informed SMS and voice reminder message in a national school-based eye screening programme in Botswana. The control will be the standard SMS message used to remind parents/guardians to bring their child for ophthalmic assessment. All messages will be sent twice. The primary outcome is attendance for ophthalmic assessment. We will use an automated adaptive approach, starting with a 1:1 allocation ratio. DISCUSSION: As far as we are aware, only one other study has used behavioural economics to inform the development of reminder messages to be deployed in an African healthcare setting. Our study will use an adaptive trial design, embedded in a national screening programme. Our approach can be used to trial other forms of reminder message in the future. TRIAL REGISTRATION: ISRCTN 96528723 . Registered on 5 January 2022.

Assessment of genetic diversity and relationship of the two Sanga type cattle of Botswana based on microsatellite markers.

The study was performed to evaluate genetic variation on two Sanga type cattle found in Botswana: Tswana and Tuli using twelve microsatellite markers. All amplified loci were polymorphic with 75 and 77 alleles genotyped in the Tswana and Tuli populations, respectively. The total number of alleles per locus ranged from 2 (BM1818) to 10 (TGLA227) with total mean of 6.25 for Tswana and 6.43 for Tuli population. Almost all the markers showed high polymorphic information content (PIC) apart from BM1818 (0.375) and INRA23 (0.393) which were moderately informative in Tswana population. Most of the markers were in Hardy-Weinberg equilibrium except for CSSRM60 and CSSM66 loci in Tswana population and ETH10, ETH225 and CSSM66 loci in Tuli population. A total of 103 unique alleles were genotyped across the two breeds with 49-shared, and 26 and 28 were unique to Tswana and Tuli populations, respectively. The expected heterozygosity (He) values were higher than the observed heterozygosity (Ho) in both populations: Tswana (He = 0.7895 ± 0.033 vs Ho = 0.631 ± 0.091) and Tuli (He = 0.8123 ± 0.033 vs Ho = 0.556 ± 0.021). The inbreeding coefficient was 0.200 ± 0.002 and 0.332 ± 0.001 in Tswana and Tuli populations, respectively. Analysis of molecular variance revealed 6.8% of the total genetic variation corresponding to differences between the two breeds and 93.2% within populations. The genetic identity between the two breeds was 56% and there were similar levels of multilocus heterozygosity and allelic diversity in the two breeds. The use of Tswana and Tuli breeds in a crossbreeding programme is likely to result in minimal heterosis and therefore not recommended.

The Acceptability and Feasibility of Routine Use of Validated Cancer Symptom Assessment Instruments Among Patients and Nurses in the Oncology Ward at Princess Marina Hospital, in Gaborone, Botswana.

This cross-sectional study evaluated the acceptability and feasibility of oncology nurses using validated cancer symptom assessment instruments to assess symptom burden. A consecutive sample of cancer patients and oncology ward nurses at a hospital in Gaborone, Botswana, was used. Patients' symptom burden was assessed using the Memorial Symptom Assessment Scale-Short Form and the Visual Analog Scale-Pain, and patient- and nurse-acceptability data were assessed using the Client Satisfaction Questionnaire and the Intervention Rating Profile. Rates of participation, assessment length of time, and rates of completed Memorial Symptom Assessment Scale-Short Form and Visual Analog Scale-Pain determined feasibility. The sample included 124 patients (female, 84) and 20 nurses (female, 14). The mean (SD) Client Satisfaction Questionnaire score was 30.1 (2.8; minimum-maximum, 19-32), and the mean (SD) Intervention Rating Profile score was 86.8 (4.3; minimum-maximum, 74-90). There was a significant difference in the scores of the Intervention Rating Profile between preassessment (mean [SD], 80.1 [6.0]) and postassessment (mean [SD], 86.8 [4.3]; t19 = -4.853, P < .001). All patient participants (100%) completed assessments. The routine nursing assessment was acceptable to and feasible among patients and nurses. Nurses can integrate validated instruments into routine nursing assessment to determine patients' symptom burden for quick referrals to palliative care.

Health Impact and Cost-Effectiveness of HIV Testing, Linkage, and Early Antiretroviral Treatment in the Botswana Combination Prevention Project.

BACKGROUND: The Botswana Combination Prevention Project tested the impact of combination prevention (CP) on HIV incidence in a community-randomized trial. Each trial arm had ∼55,000 people, 26% HIV prevalence, and 72% baseline ART coverage. Results showed intensive testing and linkage campaigns, expanded antiretroviral treatment (ART), and voluntary male medical circumcision referrals increased coverage and decreased incidence over ∼29 months of follow-up. We projected lifetime clinical impact and cost-effectiveness of CP in this population. SETTING: Rural and periurban communities in Botswana. METHODS: We used the Cost-Effectiveness of Preventing AIDS Complications model to estimate lifetime health impact and cost of (1) earlier ART initiation and (2) averting an HIV infection, which we applied to incremental ART initiations and averted infections calculated from trial data. We determined the incremental cost-effectiveness ratio [US$/quality-adjusted life-years (QALY)] for CP vs. standard of care. RESULTS: In CP, 1418 additional people with HIV initiated ART and an additional 304 infections were averted. For each additional person started on ART, life expectancy increased 0.90 QALYs and care costs increased by $869. For each infection averted, life expectancy increased 2.43 QALYs with $9200 in care costs saved. With CP, an additional $1.7 million were spent on prevention and $1.2 million on earlier treatment. These costs were mostly offset by decreased care costs from averted infections, resulting in an incremental cost-effectiveness ratio of $79 per QALY. CONCLUSIONS: Enhanced HIV testing, linkage, and early ART initiation improve life expectancy, reduce transmission, and can be cost-effective or cost-saving in settings like Botswana.

A community-based evaluation of disability resources and inclusion practices in rural Botswana.

BACKGROUND: Community-based approaches to enhance the inclusion of persons with disabilities have proven effective; however, not much is known about cultural and contextual factors that influence the capacity of policy implementation and inclusion practices in rural Botswana. OBJECTIVE: The study evaluated local disability education and health resources in rural Botswana to develop a deeper understanding of cultural and contextual factors impacting inclusion practices. METHOD: Researchers used socio-demographic and qualitative research methods to conduct a comprehensive community-based needs assessment. Sampling techniques included maximum variation and snowball sampling. Thirty-two individuals participated in the study. Data were collected between June and August of 2019 through participant observation, in-depth interviews, and focus group discussions. An inductive thematic analysis was conducted by examining participants' attitudes, perceptions, and experiences of community members with disabilities. RESULTS: Four primary themes emerged identifying factors that affect people living with disabilities in the rural community: (1) culture of vulnerability, (2) determinants of disability, (3) educational resources for persons with disabilities, and (4) effective systems integration. Findings suggested that while policies associated with disability at the government level are in place, disparities among rural communities' hindered local responses to managing the needs of persons with disabilities. CONCLUSIONS: Social, environmental, and physical barriers prevent the full implementation of policies that advocate for the rights of persons with disabilities in Botswana's rural settings. Increasing awareness of cultural and contextual factors may help community stakeholders facilitate inclusive practices in Botswana.

Acceptance rate and risk perception towards the COVID-19 vaccine in Botswana.

BACKGROUND: The COVID-19 disease burden continues to be high worldwide and vaccines continue to be developed to help combat the pandemic. Acceptance and risk perception for COVID-19 vaccines is unknown in Botswana despite the government's decision to roll out the vaccine nationally. OBJECTIVES: This study aims to assess the acceptance rate and risk perception of COVID-19 vaccines amongst the general population in Botswana. METHODS: We interviewed 5300 adults in Botswana from 1-28 February 2021 using self-administered questionnaires. The main outcomes of the study were vaccine acceptance and hesitancy rates. Demographic, experiential and socio-cultural factors were explored for their association with outcome variables. RESULTS: Two-thirds of the participants were females (3199), with those aged 24-54 making the highest proportion (61%). The acceptance rate of COVID-19 vaccine was 73.4% (95% CI: 72.2%-74.6%) with vaccine hesitancy at 31.3% (95% CI: 30.0%-32.6%). When the dependent variable was vaccine acceptance, males had higher odds of accepting the vaccine compared to females (OR = 1.2, 95% CI: 1.0, 1.4). Individuals aged 55-64 had high odds of accepting the vaccine compared to those aged 65 and above (OR = 1.2, 95% CI: 0.6, 2.5). The odds of accepting the vaccine for someone with primary school education were about 2.5 times that of an individual with post graduate level of education. Finally, individuals with comorbidities had higher odds (OR = 1.2, 95% CI: 1.0, 1.5) of accepting the vaccine compared to those without any underlying conditions. CONCLUSION: This study demonstrated a high acceptance rate for the COVID-19 vaccine and a low risk perception in Botswana. In order to achieve a high vaccine coverage and ensure a successful vaccination process, there is need to target populations with high vaccine hesitancy rates. A qualitative study to assess the factors associated with vaccine acceptance and hesitancy is recommended to provide an in-depth analysis of the findings.

The Prevalence, Intensity, Assessment, and Management of Acute Pain in Hospitalized Children in Botswana.

BACKGROUND: There is very limited clinical and observational data on acute pain experienced by children in sub-Saharan Africa. AIMS: To report the prevalence and intensity of acute pain, pain management practices, and describe associations between acute pain outcomes, children's and parents or guardian's demographics in hospitalized children aged 2 months to 13 years in Botswana. DESIGN: A descriptive correlational prospective observational study using five repeated cross-sectional samples. SETTINGS: Two referral hospitals in Botswana. PARTICIPANTS: The sample size included 308 children and 226 parents or guardians. Data were collected between November 2018 and February 2019 from children, their parents or guardians (<7 years child), and the health record for pain documentation and treatment. MEASURES: Pain was measured using Faces Pain Scale-Revised for children ≥7 years, revised Face, Legs, Activity, Cry, Consolability scale for children <7 years and numeric rating scale for parents or guardians. RESULTS: There are 1,290 data points for children of which 1,000 were children <7 years and 999 data points for parents or guardians of children <7 years were used in analysis. Fifty percent of children <7 years were in pain using the revised Face, Legs, Activity, Cry, Consolability scale, whereas parents indicated 46% to be in pain. The pain prevalence for children ≥7 years was estimated at 54%. Pain was documentated at a rate of 54 % on the health records. Acetaminophen was most common analgesic across all age groups. Univariate associations of child <7 years pain intensity was statistically significant (p ≤ .05) for weight, diagnosis, residence, and parent relationship. Parents reported pain intensity was statistically significant (p ≤ .05) for child sex, weight, diagnosis, residence, surgery, parent or guardian age and education. Only age and surgery were significant for children ≥7 years. CONCLUSIONS: Acute pain prevalence and intensity among hospitalized children in Botswana is low.

A Review of the User Fees Policy for Primary Healthcare Consultations in Botswana: Problems With Effective Planning, Implementation and Evaluation.

BACKGROUND: The Government of Botswana introduced user-fees for primary healthcare consultations in 1975. The policy has remained in place since then, although the fee has remained largely unaltered despite rising inflation. Early reviews of the policy pointed to problems in its implementation, but there has been no evaluation in the past 20 years. The aim of this study was to review the policy to assess whether documented issues with its implementation have been addressed. METHODS: This qualitative study involved interviews with 32 key informants: 18 policy-makers and 14 front-line revenue collectors. Data were analysed thematically using a template approach with constructs from an established organizational capacity assessment framework used as predetermined categories to guide data collection and analysis. RESULTS: Limited administrative and management capacity has been a major hindrance to effective implementation of the policy. The lack of infrastructure for effective revenue collection led to misappropriation of funds. Lack of clear guidelines for health facilities on how to implement the policy generated interdepartmental conflicts. Study participants believed the current policy was unlikely to be cost-effective since the cost of collecting fees probably exceeded the revenue it generated. CONCLUSION: If the Botswana Government persists with the policy then it needs to improve organizational capacity to collect and manage revenues efficiently. However, policy thinking since the turn of the century has turned away from user-charges in healthcare as they impede the move towards universal access. It is timely therefore to consider alternative financing approaches that are more effective and a more equitable means of paying for healthcare.

Improving child health care in Botswana: what can be done?

Access to appropriate healthcare for children remains a challenge in Botswana, as evidenced by the under five mortality rate and integrated management of childhood illness indicators. Successful implementation of the integrated management of childhood illnesses strategy can drastically reduce child mortality through innovation, national health care worker training coverage, enhanced supervision and use of guidelines.

Cigarette prices in eight sub-Saharan African countries in 2018: a cross-sectional analysis.

OBJECTIVE: While the trend in smoking prevalence is decreasing worldwide, the number of male tobacco smokers is growing in Africa. This study compares the cigarette market in eight sub-Saharan African countries. This includes examining cigarette prices, pricing differentials, pack sizes and affordability at national and subnational levels. DESIGN AND SETTING: A cross-sectional data analysis using data from the Data on Alcohol and Tobacco in Africa (DATA) Project. The DATA Project was centrally coordinated by project supervisors following a standardised protocol. University students were recruited to conduct data collection and a total of 22 347 retail cigarette price data points collected between June and August 2018 were analysed (including Botswana, Ethiopia, Lesotho, Namibia, Nigeria, South Africa, Zambia and Zimbabwe). Prices were converted to US$ and standardised to the price of a 20-cigarette pack. RESULTS: This research found large price differentials within provinces/states, with the gap between medium and minimum prices per 20-cigarette pack exceeding 50% of the medium price in 18 out of 24 provinces/states. Single cigarettes were widely available, especially in Lesotho and Ethiopia. Results of multivariable regression suggest prices (per 20-cigarette pack) were lower for cigarettes sold in packs than single sticks (-US$0.27, 95% CI: -US$0.39 to -US$0.23) and lower in less populated areas (-US$0.28 in rural compared with urban settings, 95% CI: -US$0.41 to -US$0.15). Availability of cheaper single cigarettes (lower per unit price than packed cigarettes) were identified for Lesotho and South Africa. CONCLUSIONS: These findings identify a varied picture in cigarette pricing in studied countries and suggest measures to tackle pricing differentials and availability of single sticks are warranted. These measures should counteract the potential health consequences of the increasing penetration of tobacco industry in these sub-Saharan African countries.

Factors associated with and socioeconomic inequalities in breast and cervical cancer screening among women aged 15-64 years in Botswana.

BACKGROUND: The most commonly diagnosed cancers among women are breast and cervical cancers, with cervical cancer being a relatively bigger problem in low and middle income countries (LMICs) than breast cancer. METHODS: The main aim of this study was to asses factors associated with and socioeconomic inequalities in breast and cervical cancer screening among women aged 15-64 years in Botswana. This study is part of the broad study on Chronic Non-Communicable Diseases in Botswana conducted (NCD survey) in 2016. The NCD survey was conducted across 3 cities and towns, 15 urban villages and 15 rural areas of Botswana. The survey collected information on several NCDs and risk factors including cervical and breast cancer screening. The survey adopted a multistage sampling design and a sample of 1178 participants (males and females) aged 15 years and above was selected in both urban and rural areas of Botswana. For this study, a sub-sample of 813 women aged 15-64 years was selected and included in the analysis. The inequality analysis was conducted using decomposition analysis using ADePT software version 6. Logistic regression models were used to show the association between socioeconomic variables and cervical and breast cancer screening using SPSS version 25. All comparisons were considered statistically significant at 5%. RESULTS: Overall, 6% and 62% of women reported that they were screened for breast and cervical cancer, respectively. Women in the poorest (AOR = 0.16, 95% CI = 0.06-0.45) and poorer (AOR = 0.37, 95% CI = 0.14-0.96) wealth quintiles were less likely to report cervical cancer screening compared to women in the richest wealth quintile. Similarly, for breast cancer, the odds of screening were found to be low among women in the poorest (AOR = 0.39, 95% CI = 0.06-0.68) and the poorer (AOR = 0.45, 95% CI = 0.13-0.81)) wealth quintiles. Concentration indices (CI) showed that cervical (CI = 0.2443) and breast cancer (CI = 0.3975) screening were more concentrated among women with high SES than women with low SES. Wealth status was observed to be the leading contributor to socioeconomic inequality observed for both cervical and breast cancer screening. CONCLUSIONS: Findings in this study indicate the need for concerted efforts to address the health care needs of the poor in order to reduce cervical and breast cancer screening inequalities.