Botswana's Health Care Policy: Is it Alma Ata or Post-Alma Ata?

KENEETSWE B. SETLHARE, M.D. | Friday February 8, 2008 00:00

In as much as I am grateful for his late welcome to the public forum) he needs to know that I have been debating on the national scene for the last four years.

The purpose of the last article I wrote was to continue a healthy debate on health care policy because it is policy that determines how health care is delivered even the facilities and manpower required. One must admit that Dr. Maganu's 2006 article entitled 'Rights without responsibilities?' was unacceptable to the young because simply put one can argue that education is a right society has to bestow on its young people. As citizen doctors, we were born Batswana and that entitles us to education as determined by the Botswana education policy.

It has been said that I don't know Botswana's health care policy, yet knowledge consists of theory and practice. You don't have to be a policymaker to know policy; to suggest that a 27-year-old who has not worked for decades cannot have an understanding of policy is a continuation of the old idea of demanding too much experience from the young, and the same idea denies the youth meaningful participation in our economy.

The practice part of the policy affects the nation at large, in other words, even someone who cannot read and write has some understanding of our health care policy at an experiential or practical level. If there is any written document called health care policy of Botswana, it is not wise to assume those who can read cannot understand it. Dr. Maganu seems to have a tendency of defending the status quo even when he knows that 'the establishment' he used to work for is wrong.

Dr. Maganu subconsciously admits exactly the point I was making when he writes, 'I am aware that, following the short policy document produced in the early 1990s, Botswana has not produced a more detailed articulated Health Policy and Health Sector Strategic Plan as is now the practice in international health. I have advocated for some time that Botswana takes this path.' Maybe we should put it in his words that the current policy which was developed in the 1990s is behind time and international trends. For the learned and experienced doctor's information, the title of my article in the word document I sent to Mmegi was,

A CALL FOR CONSULTATIVE LEADERSHIP ON HEALTH CARE POLICY. In other words, I was calling on the ministry of health to take the initiative and make dialogue with health professionals an urgent part of the current policy. Dialogue is not a want but an urgent necessity if we really care about improving results.

It is wrong for Dr. Maganu to insinuate that I said primary health care model is not respected and even to assume I am not familiar with health economics. Dr. Maganu should not assume when he speaks we will take his word as a word of a god. Human experts make mistakes and everyone knows that. One also wonders how far Dr. Maganu can part company with his employer (WHO) which recommends the model in question. It will be interesting to know what his economic figures are; can we afford one dialysis centre? How many transplantation centre can we afford? The learned doctor talks about dynamics and reforms of the primary care model - that's exactly what I was trying to argue. The sovereignty of Botswana demands that we move beyond recommendations and guidelines towards establishing what is right, specific, and affordable for our country.

In practice, how does the Botswana model differ from the Alma Ata declaration? My argument is that we are still stuck with the basics of the model without significant reforms we can show for the last 30 years since Alma Ata. Even the HIV/AIDS epidemic found us unprepared, and we only got better in our response with time. The recent diarrhoea which left many young lives lost was a national embarrassment even to those who claim we have advanced beyond Alma Ata. Primary care in developed and progressive developing countries is led by specialists, for example, primary care internists and family physicians. Can the same be said about Botswana?

Rights always come with responsibilities and the young people of Botswana have learnt that even the hard way. If we may ask, does the one year spent on national service count towards the five-year post-qualification service required from those educated on grant scheme? In other words, what's the difference between those who served and those who did not when it comes to giving back in terms of public service? The government always seems to be on the receiving end of payments, and we ask where justice is? Does education sponsorship release government from responsibilities toward its citizens? Those who argue the government case seem to suggest that sponsorship earns government five years of cheap labour (poor salaries, 70+ hours' work a week, no dialogue, and so on). The Botswana public should resolve whether sponsorship equals a price for this form of slavery.

Beyond political expediency, Dr. Maganu agrees with me that the public is denied service by their children, and we don't know if it is because of the push or pull factors; only dialogue can establish the real cause of health professionals' emigration. We also agree that it is citizen health professionals who can change the direction of our health care system, and health care policymakers have to engage stakeholders including health professionals in a dialogue.

Beyond marking ourselves present in the public books even beyond putting ourselves up for political appointment, we have to find ways of making investment in training our personnel count.

We cannot spend then deny the public the benefits of their investment by failing to retain the trained professionals. To this far, I remain convinced that the policy (in practice) of the ministry of health denies Batswana the benefit of the public's investment. It is like the minister of health and her ministry are doing everything possible to keep the citizen doctor's out of public service. I am convinced that a middle-income country like Botswana can enter into talks with her citizen health professionals and come out with a win-win solution.