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Botswana public health care system in crisis

Kesitegile Gobotswang

“THINGS FALL APART”. These prophetic words of Chinua Achebe the Nigerian celebrated novelist and poet are fitting to describe the health care system in Botswana today. To describe the health care systems as a sector in a state of chaos is obviously a serious underestimation.

Let us acknowledge from the onset that while in other African countries diamonds were used to fight endless wars in Botswana money from the diamonds were mainly used in the development of the health, social and physical infrastructure.

Morden and state of the art hospitals were constructed in towns and major villages. Primary health facilities were established in villages across the length and breadth of the country. However, an omission of monumental proportions was in factoring in the maintenance cost of the infrastructure.

Consequently most health facilities are in a terrible state. The quality of health care has deteriorated to the extent that Ministers, senior public servants and their close relatives shun it in favour of South African ones. For the majority of Batswana they have no choice but to face appalling conditions and a staff whose morale is at its all-time low due to neglected working conditions. 

In many hospitals the emergency services have virtually collapsed as patients die after spending hours waiting for medical attention. The waiting time at public health facilities is unbearable. On average one has to budget eight (8) hours to get medical attention – a situation that affects productivity at the work place.

Over crowing is prevalent in the majority of public hospitals in Botswana. One of the local medical doctors recently revealed that with a bed capacity of 567 Princess Marina Hospital admits 750 patients. Patients sleeping on floors are not uncommon at public hospitals due to overcrowding.

This has the potential to increase preventable mortality at public health facilities. The situation at some primary hospitals is so bad that mixed sex medical wards have been reported. Under such circumstances sexual abuses or even rape cases cannot be ruled out.

Patients are not safe at public health facilities. The less we talk about the poor quality of meals at the hospitals the better. The basic rule is that if the Minister cannot enjoy it, it is not good for the patients.

In the rural areas the situation is worsened by the botched reversal of decentralization of the health care system as clinics are without ambulances and drivers spend most of the time playing cards under trees, idling.

The poverty stricken local Councillors are frequently forced to use their private open vans to transport the critically sick and pregnant women to health facilities. Yet government so it fit to increase salaries of Members of Parliament, the President and his Cabinet Ministers at the exclusion of Councillors who carry the burden of a collapsed health care system. 

X-ray and laundry machines are dysfunctional in most Hospitals. Where equipment is operational it is often not calibrated and tested resulting in misdiagnosis and possible loss of life. In this regard information collected from health facilities is highly questionable.

It is not surprising that in respect to nutrition information government reports single digits levels of under-nutrition (about 5%) while representative community-based surveys and United Nations agencies record double digits rates (about 13%) of poor nutrition among under-fives. Simple put it means 8% of children classified as normal are in fact undernourished.

Of late the biggest scaring development of the public health care system is the frequent reports of blood contamination. In March 2016 there was a health scare when the Ministry of Health confirmed that blood with bacteria that causes syphilis was detected. It was further revealed that the contaminated blood had already been used on some unsuspecting patients at Scottish Livingstone and Princess Marina Hospitals.

At the time of the reports system failure (whatever that is) was blamed for the problem. A service that deals with issues of life and death cannot afford to experience system failures. Recently yet another health scare was reported.

As it was the case in the previous report bacteria that causes syphilis was detected in the blood that was delivered at PMH and Scottish Livingstone. These incidents were widely reported in the regional and international press with the potential to tarnish the already worsening image of the country.

This time around the Ministry of Health blames human error for the disaster. Subsequently three clinical officers from the National Blood Transfusion Service (NBTS) were suspended to safe the face of the person who must account – the Minister of Health. It is unclear why these two hospitals and why syphilis.

The Ministry has a lot to explain to calm the worried general public. This is because if a referral hospital like PMH and a state of the art hospital like Scottish Livingstone can experience such incidents district as well as primary hospitals might be at greater risks across the country. The blood contamination crisis is a tip of the ice bag. It is just a reflection of a health system in an intensive care unit (ICU).

The poor state of the health care system in Botswana is well documented in the regular assessment reports conducted by the Council for Health Service Accreditation of Southern Africa (COHSASA).

According to the latest report all public health facilities except Scottish Livingstone, Mahalapye Hospital, Airstrip Clinic (Mahalapye), Xhosa Clinic (Mahalapye), and Phuthadikobo Clinic (Molepolole) failed to the accreditation exercise because of poor quality of service. Among the private hospitals only Orapa and Jwaneng Hospitals are accredited.

Most of the problems facing the country today can be attributable to three things only – corruption, corruption, and officially sanctioned corruption. Tenders and public procurements are corruptly awarded to briefcase companies owned by individuals with close connections to the powers that be through special awards procedures.

As a result shoddy maintenance work is carried out on the infrastructure and sensitive medical equipment. There is no indication that the corrupt ridden Economic Stimulus Program (ESP) will address problems of infrastructural decay at health facilities.  

In addressing corruption the Botswana Congress Party (BCP) advocates for the enactment of a laws on Declaration of Assets and Liabilities, Freedom of Information, Prohibition of Insider Trading, and the amendment of the recently passed law on the Protection of Whistle Blowers to be aligned to international best practice. The amended law should allow Members of Parliament and the media to receive such reports.

Concerning the maintenance of the physical infrastructure, BCP advocates for the introduction of massive public works program similar but not identical to post World War Marshall Plan. The envisaged program will replace the wasteful Ipelegeng program. It will also succeed in engaging Batswana in gainful employment as well as imparting basic maintenance skills.

Crowded hospitals are also a reflection of the failure of the preventive measures espoused by the well-acclaimed primary health care (PHC). Hence the BCP advocates for a robust reinvigoration of the PHC to address lifestyle diseases caused by poor diets, lack of physical exercise, smoking, alcohol and drug abuse.

Kesitegile Gobotswang (PhD) is the Deputy Leader, BCP

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Chronic Joblessness: How to Help Curtail it

30th November 2020
Motswana woman

The past week or two has been a mixed grill of briefs in so far as the national employment picture is concerned. BDC just injected a further P64 million in Kromberg & Schubert, the automotive cable manufacturer and exporter, to help keep it afloat in the face of the COVID-19-engendered global economic apocalypse. The financial lifeline, which follows an earlier P36 million way back in 2017, hopefully guarantees the jobs of 2500, maybe for another year or two.

It was also reported that a bulb manufacturing company, which is two years old and is youth-led, is making waves in Selibe Phikwe. Called Bulb Word, it is the only bulb manufacturing operation in Botswana and employs 60 people. The figure is not insignificant in a town that had 5000 jobs offloaded in one fell swoop when BCL closed shop in 2016 under seemingly contrived circumstances, so that as I write, two or three buyers have submitted bids to acquire and exhume it from its stage-managed grave.

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The Era of “The Diplomat”

30th November 2020

Youngest Maccabees scion Jonathan takes over after Judas and leads for 18 years

Going hand-in-glove with the politics at play in Judea in the countdown to the AD era, General Atiku, was the contention for the priesthood. You will be aware, General, that politics and religion among the Jews interlocked. If there wasn’t a formal and sovereign Jewish King, there of necessity had to be a High Priest at any given point in time.

Initially, every High Priest was from the tribe of Levi as per the stipulation of the Torah. At some stage, however, colonisers of Judah imposed their own hand-picked High Priests who were not ethnic Levites. One such High Priest was Menelaus of the tribe of Benjamin.

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Land Board appointments of party activists is political corruption

30th November 2020

Parliament has rejected a motion by Leader of Opposition (LOO) calling for the reversing of the recent appointments of ruling party activists to various Land Boards across the country. The motion also called for the appointment of young and qualified Batswana with tertiary education qualifications.

The ruling party could not allow that motion to be adopted for many reasons discussed below. Why did the LOO table this motion? Why was it negated? Why are Land Boards so important that a ruling party felt compelled to deploy its functionaries to the leadership and membership positions?

Prior to the motion, there was a LOO parliamentary question on these appointments. The Speaker threw a spanner in the works by ruling that availing a list of applicants to determine who qualified and who didn’t would violate the rights of those citizens. This has completely obliterated oversight attempts by Parliament on the matter.

How can parliament ascertain the veracity of the claim without the names of applicants? The opposition seeks to challenge this decision in court.  It would also be difficult in the future for Ministers and government officials to obey instructions by investigative Parliamentary Committees to summon evidence which include list of persons. It would be a bad precedent if the decision is not reviewed and set aside by the Business Advisory Committee or a Court of law.

Prior to independence, Dikgosi allocated land for residential and agricultural purposes. At independence, land tenures in Botswana became freehold, state land and tribal land. Before 1968, tribal land, which is land belonging to different tribes, dating back to pre-independence, was allocated and administered by Dikgosi under Customary Law. Dikgosi are currently merely ‘land overseers’, a responsibility that can be delegated. Land overseers assist the Land Boards by confirming the vacancy or availability for occupation of land applied for.

Post-independence, the country was managed through modern law and customary law, a system developed during colonialism. Land was allocated for agricultural purposes such as ploughing and grazing and most importantly for residential use. Over time some land was allocated for commercial purpose. In terms of the law, sinking of boreholes and development of wells was permitted and farmers had some rights over such developed water resources.

Land Boards were established under Section 3 of the Tribal Land Act of 1968 with the intention to improve tribal land administration. Whilst the law was enacted in 1968, Land Boards started operating around 1970 under the Ministry of Local Government and Lands which was renamed Ministry of Lands and Housing (MLH) in 1999. These statutory bodies were a mechanism to also prune the powers of Dikgosi over tribal land. Currently, land issues fall under the Ministry of Land Management, Water and Sanitation Services.

There are 12 Main Land Boards, namely Ngwato, Kgatleng, Tlokweng, Tati, Chobe, Tawana, Malete, Rolong, Ghanzi, Kgalagadi, Kweneng and Ngwaketse Land Boards.  The Tribal Land Act of 1968 as amended in 1994 provides that the Land Boards have the powers to rescind the grant of any rights to use any land, impose restrictions on land usage and facilitate any transfer or change of use of land.

Some land administration powers have been decentralized to sub land boards. The devolved powers include inter alia common law and customary law water rights and land applications, mining, evictions and dispute resolution. However, decisions can be appealed to the land board or to the Minister who is at the apex.

So, land boards are very powerful entities in the country’s local government system. Membership to these institutions is important not only because of monetary benefits of allowances but also the power of these bodies. in terms of the law, candidates for appointment to Land Boards or Subs should be residents of the tribal areas where appointments are sought, be holders of at least Junior Certificate and not actively involved in politics.  The LOO contended that ruling party activists have been appointed in the recent appointments.

He argued that worse, some had no minimum qualifications required by the law and that some are not inhabitants of the tribal or sub tribal areas where they have been appointed. It was also pointed that some people appointed are septuagenarians and that younger qualified Batswana with degrees have been rejected.

Other arguments raised by the opposition in general were that the development was not unusual. That the ruling party is used to politically motivated appointments in parastatals, civil service, diplomatic missions, specially elected councilors and Members of Parliament (MPs), Bogosi and Land Boards. Usually these positions are distributed as patronage to activists in return for their support and loyalty to the political leadership and the party.

The ruling party contended that when the Minister or the Ministry intervened and ultimately appointed the Land Boards Chairpersons, Deputies and members , he didn’t have information, as this was not information required in the application, on who was politically active and for that reason he could not have known who to not appoint on that basis. They also argued that opposition activists have been appointed to positions in the government.

The counter argument was that there was a reason for the legal requirement of exclusion of political activists and that the government ought to have mechanisms to detect those. The whole argument of “‘we didn’t know who was politically active” was frivolous. The fact is that ruling party activists have been appointed. The opposition also argued that erstwhile activists from their ranks have been recruited through positions and that a few who are serving in public offices have either been bought or hold insignificant positions which they qualified for anyway.

Whilst people should not be excluded from public positions because of their political activism, the ruling party cannot hide the fact that they have used public positions to reward activists. Exclusion of political activists may be a violation of fundamental human or constitutional rights. But, the packing of Land Boards with the ruling party activists is clear political corruption. It seeks to sow divisions in communities and administer land in a politically biased manner.

It should be expected that the ruling party officials applying for land or change of land usage etcetera will be greatly assisted. Since land is wealth, the ruling party seeks to secure resources for its members and leaders. The appointments served to reward 2019 election primary and general elections losers and other activists who have shown loyalty to the leadership and the party.

Running a country like this has divided it in a way that may be difficult to undo. The next government may decide to reset the whole system by replacing many of government agencies leadership and management in a way that is political. In fact, it would be compelled to do so to cleanse the system.

The opposition is also pondering on approaching the courts for review of the decision to appoint party functionaries and the general violation of clearly stated terms of reference. If this can be established with evidence, the courts can set aside the decision on the basis that unqualified people have been appointed.

The political activism aspect may also not be difficult to prove as some of these people are known activists who are in party structures, at least at the time of appointment, and some were recently candidates. There is a needed for civil society organizations such as trade unions and political parties to fight some of these decisions through peaceful protests and courts.

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