INTRODUCTION
Between 26 to 27 April 2001, the Heads of State and Government of the Organization of African Unity (OAU), with the inclusion of Botswana, met in Abuja, Nigeria.[1] This was in the form of a Special Summit mandated to review and address the continental challenges which existed in relation to HIV/AIDS, Tuberculosis and other related infectious diseases as a means to develop better policies, strategies and effective mechanisms to control these diseases across Africa.[2] Recognizing the need to effect improvements within the health sector, the Heads of State pledged to set a target of allocating at least 15% of the annual national budget to the health sector.[3] Ten years after the Abuja Declaration was made, in 2011, a promising 27 African countries increased the proportion of their expenditure in relation to the health sector with only Rwanda and South Africa actually reaching the target.[4] Conversely, 7 African countries reduced their health sector budgets.[5] By 2016, this drastically declined with 19 African countries spending less in comparison to their over all public expenditure ‘than in the early 2000s.’[6]
Noting the above, one may ask: where does Botswana stand in this context with regard to its health budget? This is particular so against the backdrop of the nation’s 2022 Budget Speech which was delivered by Honourable Minister of Finance and Economic Development Ms. Peggy Serame on 7 February 2022.[7] With the fiscal strain placed on African countries with the onset of Covid-19, this brief article will look at Botswana’s track record in relation to its health budget in light of the Abuja Declaration and will look at where it currently stands, noting Botswana’s most recent budget allocations for 2022, from the context of the Covid-19 pandemic.
History of Botswana’s Compliance with the Abuja Declaration Pre-Covid-19
In relation to Botswana’s record in terms of its expenditure on health, several texts have confirmed that Botswana has reached the Abuja Declaration target of 15% for particular years between the period of 2001 to 2017. For instances, according to Bwalya, he notes that Botswana reached this target together with Malawi in 2003.[8] Additionally, in the discussion paper titled Progress towards the Abuja target for government spending on health care in East and Southern Africa, Botswana is also recorded as having reached the target in 2005.[9] This was similarly the case in 2007 where Botswana met the target together with Djibouti[10] as well as in 2013.[11]
Despite this vibrant track record, Bwalya noted that Botswana together with most Southern African Development Community (SADC) countries, have began to struggle to meet their 15% annual target.[12] In 2018, Botswana only used 6% of its annual budget on the health sector. According to Bwalya, as based on a 2019 World Health Organization (WHO) report on global spending on health, one of the main reasons for failing to meet the target in the SADC region was due to the countries’ reliance on ‘ external aid to cover their expenditure requirements in several sectors, including health.’[13] According to the Botswana Brief Budget on Health, the country’s allocation to the health sector was below the 15% target set by the Abuja Declaration, in 2019, sitting at a total of 12% of the annual budget being allocated to health.[14]
The Impact of Covid-19 and the Budget for Health
Noting this decline in terms of the total expenditure related to the health sector in Botswana, the onset of the Covid-19 pandemic should have served as a wake up call for an increase in its budget. In terms of Botswana’s health care system, though it was deemed to have improved under the Healthcare Access and Quality Index (HAQ) between 1990 to 2000,[15] now ranking 122 out of 195 countries, with an HAQ index of 52, rising from an index of 39.7 in 2000, there still remains a plethora of challenges. Firstly, though health facilities are predominately physically accessible, ‘a disaggregation by urban/rural area reveals inequitable distribution of health facilities.’[16] Additionally, there are a further 18 hospital beds per population of 10,000 and 12 intensive care beds countrywide.[17] As such Botswana is said to have a lower inpatient care capacity in comparison to other middle-income countries.[18] In terms of Botswana’s health workforce, the doctor to population ratio is flagged at 5.27 doctors to 10,000 people, this being half the recommended ratio by WHO. Conversely, nurses and midwifes are approximately 54 to 10,000 people.[19] This is further exacerbated by the fact that there are urban/rural disparities in the accessibility of health care professionals.[20] Moreover, Botswana has generally suffered challenges in relation to the availability health equipment and supplies as well as essential medicines.[21]
From this context, once the pandemic reached Botswana borders, though Botswana’s response was characterized by robust prevention, these preexisting issues already present within the country’s health sector hindered the most effective response to the pandemic. Despite this wake up call, in 2020, Botswana was urged to allocate more funds in relation to its health sector noting that the amount allocated to health for that year was only 9.1%, as recorded by the SADC Gender Protocol Barometre, once again, falling short of 15% target for the Abuja Declaration.[22]
In the 2022 budget speech delivered by Honourable Minister Peggy Serame on 7 February 2022, it was evident that the Covid-19 pandemic is still very much an issue that remains of grave concern. She duly acknowledged the deficits faced by the country as a result of the pandemic, stating as that ‘COVID-19 had a huge fiscal impact, resulting in large budget deficits. These are now forecast to total P26.6 billion over the 2020/2021 and 2021/2022 financial years, compared to a surplus of P7.9 billion originally projected in NDP.’[23]
Despite these deficits, she also expressed her hope for recovery over the next year and under this, also touched on the need to allocate the largest Ministerial total budget portion to the Ministry of Health and Wellness, showing the Government’s commitment in terms of its efforts made to save Batswana from the Covid-19 pandemic.[24] In terms of figures, the Ministry of Health and Wellness was allocated the sum of BWP 10.01 Billion, this amounting to 18.7 % of the proposed Ministerial Recurrent Budget. [25]This is a growth of 26.7 % over the approved budget for last year with the country making significant and positive strides in relation to the Abuja target.
In the current climate, while this is an encouraging move that has been made by the Government, this comes at a time when a nation wide shortage in medical drugs has been announced, with the country currently operating at a capacity of 40%.[26] This grounding reality serves as a reminder that while resources are important, there is need for an efficient and transparent use of these resources. These are issues that have constantly plagued Botswana’s healthcare system despite significant budgetary allocations in the past. Bearing this in mind, ultimately, ‘the important role of health system resources in service delivery needs to be appreciated and concerted efforts made to improve resource allocation and utilization.’[27] This will once again be strengthened by the establishment of vigorous accountability mechanisms that will ensure ameliorated quality and coordination in the delivery of health services in the country.
Conclusion
Noting the effects of the Covid-19 pandemic, it is therefore evident that Botswana has heeded the call to prioritize healthcare as evident from the 2022 Budget Speech, so as to effectively save life. While the Government should be applauded for such a stride, the real challenge lies in the utilization of these resources to see lasting impact and improvement within the national healthcare system complemented by stronger accountability mechanisms. The Government is therefore encouraged to breath life into the healthcare sector in this regard and to promote better quality in the delivery of health services across the country.
[1] Organization of African Unity (OAU) ‘African Summit on HIV/Aids, Tuberculosis and Other Related Infectious Diseases Abuja, Nigeria (Abuja Declaration)’ 24-27 April 2001 available at: https://au.int/sites/default/files/pages/32894-file-2001-abuja-declaration.pdf (Accessed 7 February 2022).
[2] OAU (n1) 1.
[3] OAU (n1) 5.
[4] J Biegon ’19 years ago today, African countries vowed to spend 15% on health’ African Arguments 27 April 2020 available at: https://africanarguments.org/2020/04/19-years-africa-15-health-abuja-declaration/ (Accessed 7 February 2022).
[5] Beigon (n4).
[6] Beigon (n4).
[7] Ministry of Finance and Economic Development ‘2022 Budget Speech (Botswana)’ available at: https://www.finance.gov.bw/images/DevelopmentandBudget/2022-23/2022_Budget_Speech-_07_02_22_Final.pdf (Accessed 7 February 2022).
[8] J Bwalya ‘Southern African Development Community (SADC) and the Abuja Declaration: Honouring the Pledge’ Policy Briefing 230 February 2021 available at: https://media.africaportal.org/documents/Policy-Briefing-230-bwalya.pdf (Accessed 7 February 2022).
[9] V Govender, D McIntyre et. al ‘Progress towards the Abuja target for government spending on health care in East and Southern Africa’ EQUINET Discussion Paper 60 April 2008 available at: https://equinetafrica.org/sites/default/files/uploads/documents/DIS60finABUJA.pdf (Accessed 7 February 2022) 8.
[10] D M Whande ‘Botswana urged to give more priority to Abuja Declaration target’ Sunday Standard 17 September 2020 available at: https://www.sundaystandard.info/botswana-urged-to-give-more-priority-to-abuja-declaration-target/ (Accessed 7 February 2022).
[11] Serge M Piabuo and J C Tieguhong ‘Health expenditure and economic growth- a review of the literature and an analysis between the economic community for central African states (CEMAC) and selected African countries’ Health Economics Review 7(23) (2017) 2.
[12] Bwalya (n8) 4.
[13] Bwalya (n8) 4.
[14] UNICEF ‘Botswana Budget Brief Health: Fiscal Year 2019/2020’ 3 available at: https://www.unicef.org/esa/media/5461/file/UNICEF-Botswana-2019-Health-Budget-Brief.pdf (Accessed 7 February 2022).
[15] S Betuel ‘8 facts about healthcare in Botswana’ The Borgen Project 3 August 2020 available at: https://borgenproject.org/healthcare-in-botswana/#:~:text=Botswana%20now%20ranks%20122%20out,percentage%20of%20GDP%20was%205.4%25. (Accessed 7 February 2022).
[16] United Nations ‘Socio-economic impact analysis of Covid-19 in Botswana’ Analysis Brief No. 1 (6 May 2020) available at: https://borgenproject.org/healthcare-in-botswana/#:~:text=Botswana%20now%20ranks%20122%20out,percentage%20of%20GDP%20was%205.4%25. (Accessed 7 February 2022).
[17] UN (n16) 9.
[18] UN (n16) 9.
[19] UN (n16) 9.
[20] UN (n16) 9.
[21] UN (n16) 9.
[22] Whande (n10).
[23] Ministry of Finance and Economic Development 2022 Budget Speech (n7) 4.
[24] Ministry of Finance and Economic Development 2022 Budget Speech (n7) 2.
[25] Ministry of Finance and Economic Development 2022 Budget Speech (n7) 24.
[26] L Molelo ‘Drug shortage cripples public health facilities’ Sunday Standard 9 November 2021 available at: https://www.sundaystandard.info/drug-shortage-cripples-public-health-facilities/ (Accessed 7 February 2022).
[27] O Seitio-Kgokgwe, RDC Gauld et. al ‘Assessing performance of Botswana’s public hospital system: the use of the World Health Organization (WHO) health system performance assessment framework’ International Journal of Health Policy and Management 3(4) (2014) 188.
