Botswana's Healthcare from a Public, Private and International Perspective

Today we visited the Botswana-Baylor Children’s Clinical Centre of Excellence (COE), located in Gaborone adjacent to Princess Marina Hospital, which is the largest public hospital in the country. Established in 2003, Baylor is publicly and privately sponsored by the Government of Botswana, Princess Marina Hospital and Baylor’s International Pediatric AIDS Initiative. COE is a well-maintained and spacious facility housing ten exam rooms, a children’s play area and garden, conference facilities, a classroom, a telemedicine room and more. The centre is committed to providing holistic care to patients and families and their services include the following: HIV testing and counseling, health education and prevention for children and their families, psychosocial support, ARV therapy, Teen Club as well as medication adherence counseling and monitoring of side effects. This centre serves as the only HIV/AIDS clinic in the country of Botswana and provides care to 4,000 pediatric patients nationwide whose ages range from birth through 19 years old. This clinic additionally provides treatment for diagnoses secondary to HIV/AIDS such as tuberculosis.

We first met with one of the peer educators for the Teen Club, which provides psychosocial support for adolescents living with their HIV diagnosis. In the meeting we discussed two of COE’s services; the children’s play group and the Teen Club. The children’s play group is a way for the patients to interact and play while they are waiting for their scheduled appointments. Typically, patients come for a monthly check up to monitor their CD4 counts and viral loads, however appointments are tailored to the severity of each child’s illness and can include ARV therapy when necessary. In regards to patient population at this clinic, we learned that the program currently serves 1,000 adolescents but in the next three years will likely serve 3,000 adolescents due to increased identification of positive HIV status in children who were born before the prevention of maternal-child transmission program (PMCTC) began. PMCTC encourages HIV testing for women prior to pregnancy, and mandates HIV testing and treatment as part of prenatal care.

As a group, we felt very welcomed by the COE staff, however we struggled with the ethics of some of the information that was discussed. For instance, the disclosure patterns between parents and their children are similar to those in the United States. We learned that children are not told of their HIV status until they are 13 years old, and prior to that point, parents tend to tell their children that they attend COE for treatment of other conditions i.e. diabetes. As a group, we struggled with the ethics of this perspective. Not only are parents deceiving their children, which can ultimately impact the quality and strength of parent-child relationships, but we also wondered whether it was appropriate to wait until a child turned 13 before disclosing their diagnosis. We were saddened at the thought of these children having to watch their parents die due to HIV/AIDS, particularly when the children are aware that they live with the same condition.

This scenario can trigger a wide range of psychological responses and while COE has a growing psychosocial service team, the psychological component of treatment is not regularly addressed at these children’s appointments. Lastly, we were glad to hear that ARV therapy allows HIV positive patients to live longer more fulfilling lives, but it may also create a false sense of security and lead to high risk behaviors.

We spent the afternoon visiting Botswana’s Ministry of Health where we had the opportunity to discuss the healthcare infrastructure of this country. The Botswana Ministry of Health is the overseer of national health care in Botswana. The ministry is responsible for developing health policies and ensuring that they are implemented and interpreted accurately in public health facilities nationwide. These facilities include 27 hospitals and 101 clinics with 3,699 beds, as well as 171 clinics without beds, 338 health posts, and 844 mobile health stops. The ministry’s operating budget is 375 million dollars which provides all citizens with healthcare services. The only cost to Botswana citizens is $1 for the course of any illness ranging from the common cold to HIV/AIDS. The Ministry of Health (MOH) feels that it is their responsibility to provide services that focus on the consumer at a level comparable to standards set in other leading nations. The “key result areas” that the MOH is focusing on include reducing disease in all age groups, and controlling the prevalence of HIV and TB, lowering the risks of pregnancy and child birth, and providing adequate primary health care for all citizens.

During our visit, we spoke about a lot of interesting topics including the ministry’s transition from a centralized system to 27 individual district management teams, and the construction of one new teaching hospital for which adequate staff and supplies have yet to be allocated. Although the ministry supports the medical education of 35 physicians overseas, only one-fifth of these physicians actually return to work in Botswana. One year ago, Botswana opened its first medical school which has 30 students who are about to complete their first year. It will be interesting to see whether the country’s own medical school will help to retain a larger percentage of physicians within the country.

Posted by Grace Oppenheim, Bridget Sullivan, Randi O’Neill and Linden Spital

Old Naledi

When you drive through the hustle and bustle of downtown Gaborone, it's easy to forget the poverty that impacts the lives of thousands in the surrounding villages. One of the communities stricken by poverty is Old Naledi, a shanty town rife with high unemployment, alcohol abuse issues, and scarce resources such as food, running water, and electricity. In fact, many residents refer to this community as "zola", a Setswana word meaning "no rules." Tirisano, a local organization run through the Catholic church,, works with children of the Old Naledi community to provide life skills, food, and social support for children ages 1-18 - a support system that is crucial for the children.

Today, our group of eight traveled to a field across from Old Naledi, swarming with children and reverberating with songs. This field is the meeting place where Tirisano holds weekly meetings for children from the community. The majority of Gaborone's orphans and children of single parents reside in Old Naledi, which indicates a strong need for an organization like Tirisano. Along with dancing, singing, and games, Tirisano also provides food and education about sexual health, HIV, and other important topics. While the organization had been funded by UNICEF for the last three years, the funding has run out this year. The local Catholic church has stepped in to help keep the program afloat, but has recently faced a budget crisis of its own, and is no longer able to provide consistent funding for food and the workers' salaries. This lack of funding has placed the program in a precarious position - there is no guarantee that there will be food from week to week, or that the educators will receive any compensation for their work.

One way that Tirisano has attempted to close the gap is to train the older children in the art of traditional African dance - both an opportunity to raise needed funds and to build friendships. This form of fundraising is homegrown and sustainable, and is one of the ways that the organization is attempting to meet its own needs. However, there is currently a lack of traditional costumes for the dancers, and insufficient funds to purchase materials to make more.

Posted by Danielle Altares, Trudy Kao, Megan Rogers, and Erin Schelar

A Warm Welcome at Kamogelo

Today we had the chance to work at Kamogelo Orphans and Vulnerable Children’s Project in Mogoditshane and it turned out to be a very fulfilling experience. We arrived at the daycare center during breakfast and were greeted by over one hundred smiling children. Kamogelo is a safe haven for children aged 2-6 years old, and the daycare center strives to meet developmental needs of the children. Many of these children have been orphaned due to the HIV/AIDS epidemic and are currently living with extended family. Kamogelo works to relieve caregiver burden by offering nutritional, educational and psychosocial support as well as administering medications if needed.

After meeting the children at breakfast, Sister Margaret and other Kamogelo staff took us on a tour of their facility. It consists of a large dining hall and kitchen, administrative offices, four classrooms, a playground and a vegetable garden. Buses provided by Tirisanyo Catholic Commission, the Rotary Club of Gaborone and Unicef transport the children to the daycare center from neighboring towns on a daily basis. Kamogelo’s success and recognition as one of the leading centers of its kind in Botswana are a result of the generous funding by the Rotary Club of Gaborone and Tirisanyo, as well as its teachers’ passion and dedication to the project.

In the past two years, the UPenn nursing groups have spent time at Kamogelo assessing the children. Our purpose today was two-fold; we wanted to assess each child comprehensively while also tracking their progress from previous years. After each assessment, we updated existing charts and noted concerning findings requiring follow-up care. Our hope is that abnormal assessment findings will be communicated to these children’s families in a timely manner so that they can receive proper healthcare.

As a group, we all really enjoyed our time at Kamogelo and were touched by the sheer joy in these children despite the adversity so many of them have faced. There were times during the assessments when we struggled to communicate with the children, especially the younger ones who solely spoke Setswana. However, we quickly learned that some caring gestures are universally understood. We especially appreciated the input of Bridget and Danielle as they have just completed their advanced health assessment course. Overall, we received a warm welcome from the staff and children at Kamogelo, and enjoyed the opportunity to build upon the previous contributions of UPenn nursing students.

Posted by Linden Spital and Megan Rogers

Home based care and HIV

On Tuesday we met with the Flying Mission (FM) team to find out more about their outreach work in Botswana, as well as ways that we can become involved in their projects here. FM is committed to preventing the spread of HIV/AIDS by training local grassroots organizations to be effective and partnering with caregivers to provide home-based care (HBC). FM was founded to provide medical transport services and reach communities that are difficult to access via roads, but has since expanded its work to encompass care for orphans and vulnerable children, homebound individuals, and HIV outreach education. In order to help support their non-profit work and show their commitment to sustainability, FM also has a for-profit wing that uses their planes for private safaris and excursions.

Relationship-building is extremely important in Botswana, and as such, FM has spent much time and effort to cultivate their relationships with the community. Before meeting with villagers or doing any health assessments in the surrounding areas, it is expected that visitors meet with the village chief at the kgotla. Traditionally, the kgotla is the focal point of the village and a place where the chief (or kgosi) and villagers meet to discuss important issues. Today it remains an important place for visitors to pay their respects to the chief and receive his endorsement to be in the village. FM has established relationships with the villages in which they provide HBC, which will enable us to meet key leaders and bridge the cultural divide. We will be able to learn from their health care workers about providing medications and education in a rural area.

FM’s HBC program hires and trains volunteers to be caregivers in the communities. These caregivers visit client’s homes as frequently as they can, depending on the need of the residents. In some communities, the caregivers also help create home gardens to increase the residents’ access to fresh produce. Due to the nursing shortage in Botswana, the caregivers are the main providers of HBC.

Home care and feeding programs are vital in Botswana due to the country’s high HIV/AIDS prevalence. There is some controversy over the correct HIV prevalence rate in Botswana: UNICEF cites the HIV rate at 23.9% for 15-49 year olds (2007), WHO cited the HIV 35.5-39.1% (2003), and Botswana’s own data shows that the rate is 17.1% (2003). Despite the discrepancy between data sources, the impact of HIV without doubt reverberates throughout the community. During our meetings with FM and others we learned about the attitudes and behaviors surrounding the epidemic. A conversation with Dr. Sheila Shaibu from the University of Botswana leads us to believe that one reason for the discrepancy regarding prevalence is lack of testing and knowledge of one’s own HIV status due to stigma and fear. Botswana has tried to combat this by holding annual Mr. and Miss Stigma pageants and anecdotally it seems that younger generations have better understanding of the risks associated with unsafe sexual practices.

As we begin our journey into the community we have much to learn, and we are very grateful to FM for helping us to start the work!


Posted by Danielle Altares, Trudy Kao, & Erin Schelar

“Thuto Ke Thebe” (Education is a Shield)

University of Botswana's Version of Fagin Hall!

The title of our post is the University of Botswana's motto. This morning we attended a community nursing class at the main campus. The university has four campuses; two in Gaborone and one each in Maun and Francistown. This university was established in 1982 and provides education to approximately 15,000 undergraduate and 1,500 graduate students. Of the 15,000 undergraduates 8,500 are female and 6,500 male. The majority of students live on campus in residence halls similar to undergraduate housing at UPenn but many also live with their families in Gaborone. The students have access to a free medical clinic, counseling services, and are free to take advantage of the school’s swimming pool, athletic courts and fields, and extra-curricular activities similar to ones found at university and colleges in the United States. The University of Botswana or “UB” is a public university and the majority of students receive funding from the Botswana government to pursue the degree they desire. To be considered for admission students must meet program requirements and must have demonstrated high academic ability and achievement. Students wishing to pursue nursing at UB apply to the program when they apply to the university just as those who begin the nursing program at Penn as undergraduates. The program is four years in length and students graduate with a Bachelors of Science in Nursing, the same degree each of us will graduate with this December! UB also offers opportunities for students to pursue a master’s degree in nursing as well as programs for bachelor’s completion for those who already have a diploma in nursing. UB’s nursing students take their community nursing course in the first semester of their 3rd year as opposed to our curriculum which places the community nursing course in the first semester of our 4th year.

The nursing community within the University of Botswana had many similarities to our community at Penn. There was the typical buzz that occurs on the first day of class when students are greeting each other again after a semester break. As class began, the professor had everyone introduce themselves and we were given a warm welcome from the UB community. Other similarities we noted were the use of PowerPoint for lecture media, consequent IT troubles associated with the use of PowerPoint, and the gasps from the students when the price of the book was discussed.

One of the biggest differences was the presence of men in the class! Of the 80 students, 35 were men (38% of the class). Another significant difference was the lack of technology used in the classroom. Aside from the computer and projector for the PowerPoint, there were no laptops or electronics—students use notebooks and nothing else was out on the wooden desks. PowerPoint lectures are not put online and printing is limited. The professor prints the course outline and copies it for the students, but after that, notes and lecture materials are the student’s individual responsibility to maintain. Sources for papers are not expected to come from online resources, but mostly from texts and library journals.

Overall it was a great day getting to know the nursing students at UB! We felt comfortable participating in the class discussion, were warmly greeted by the students and look forward to working with them at their clinical sites in the coming weeks.

Posted by: Bridget and Randi

Clincal Sites: Kamogelo, Pabalelong, & Upenn-Botswana

Today was an extremely informative day!!! It was our first clinical/working day. We met a number a people and arranged various clinical sites. Things work in a more traditional manner here—before we can delve into clinical work we need to be introduced to the organization leaders and have the organizations determine we are a good fit for the site. We started out the morning by driving to a village called Mogoditshane which is about 30 minutes outside of Gaborone. We visited a daycare center, Kamogelo, which gives children that have been impacted by the HIV/AIDS epidemic, a second chance at life. The daycare accommodates 124 children ranging from 3-6 years of age; it provides the children with clothes, food, and education. It was decided that we would come back and perform growth and physical assessments on the children. Following our visit at the daycare center we went to a village called Metismotlhabe to visit a hospice called Pabalelong, a home of love and care. The hospice is run by the Catholic Church. The hospice opened in May and can accommodate ten patients: 4 double rooms and two private rooms. Many of us are interested in returning to the hospice to help in various capacities including home visits and assessments. After visiting the aforementioned sites we headed back into Gaborone and went to the Upenn-Botswana partnership office and met with Gill Jones, the coordinator of our experiences here. We made arrangements to meet with her and some of her fellow colleagues tomorrow to solidify more clinical opportunities and the possibility of taking part in a week long breast cancer awareness ride called the Journey of Hope. Tomorrow we are off to other clinical sites and are looking forward to embarking on new experiences.
-Grace Oppenheim

Hello From Kgale Hill!

We arrived safely yesterday and were met at the airport by Jody, our clinical instructor and David, our driver from the UPenn-Botswana partnership. After an afternoon getting acclimated to our new surroundings and a good nights sleep, we took a hike up Kgale Hill on the edge of Gabarone. Kgale is 1204 meters high, so we got a good view of the city and quarrys, as well as some much needed movement for our legs after 18 hours of flying. We also sat down today to map out our time here, and have lots of exciting plans to come.

Stay tuned!