Friday, December 1, 2023

Low health sector performance contradicts Botswana’s upper-middle-income country status

The process set up by the WHO Africa Regional Office with the subsequent adoption of a transformation agenda with the objective of ensuring support to countries built around achieving results based on shared values, smart technical focus country’s priority needs, responsive strategic operations and effective communication and partnership.

The State of Health in the WHO African Region 2018 Report presents a comprehensive picture of the state of health and its determinants in the WHO African Region and aims to act as a bench of progress as the region adopts a range of actions to move their populations towards the health and well-being ideals of the 2030 Agenda for Sustainable Development.

According to the report, the state of health system performance and the state of investments highlight the country index against the four dimensions of performance and the three input system investment areas.

The report acknowledges that “the Botswana health system is commensurate with that of a low-income country”, against that “the health status is on the low side for its classification, being a lower and upper-middle-income country”.

Overall, health life expectancy; morbidity and mortality rates are better than the regional average and the implications of the current status quo is that the health status is low and “below that needed to reach the SDGs”.

Botswana is advised by the report to “accelerate ongoing efforts to reduce communicable and non-communicable diseases burdens, targeting hard to reach populations” and also “explore lessons to be shared with keeping low the burden of disease due to injuries and violence”.

The report notes that the overall utilization of health and health-related services to achieve the SDGs in Botswana stands at 57 percent of what is feasible in the region, higher than the regional average of 48 percent.

It is further observed that the country does comparatively well as the country utilization is higher than the regional average for all outcome domains assessed compared with other upper-middle-income countries , the country utilization is marginally higher for financial risk protection, and lower for all other outcome areas assessed.

The report also laments that “tangible systems investments are good compared to the regional average, but are particularly low for health infrastructure” and “information is suggestive of some effective system processes (service delivery, financing, governance and information), with a high ratio of overall performance score to consolidate tangible investment scores”.

The 2018 report also encourages Botswana to “introduce innovative approaches to improve investment in infrastructure and equipment”, as well as to “improve on data availability, particularly on systems resilience” in addition “to acceleration of improved access, quality of care and service demand focused on hard to reach areas”. 

“While witnessing improvements in healthy life – seen in the relative improvements in healthy and reductions in morbidity/mortality – the region is coming from a very low base, with current levels still lower than the rest of the world.

“In addition, the high burden of risk factors prevents well-being from being assured, and the non-communicable diseases (NCD) burden will continue to rise to a level where the improvements in healthy life become eroded by losses in well-being”, bemoans the 2018 report.

It is explained that “the burden of risk factors to morbidity and mortality is not seeing commensurate reductions. A person in the region aged between 30 and 70 years has a 20.7 percent chance of dying from one of the major NCD.

All the four major risk factors identified in the Global Action Plan for the prevention and control of NCDs (2013 – 2020) are still high in the region. These include alcohol abuse, insufficient physical activities and unhealthy diets and substance abuse.

Six dimensions of outcomes has been devised by the WHO African Region and the comprise availability of essential services, coverage of essential interventions for SDG 3 targets, financial and risk protection, service satisfaction, health security, and coverage of non-SDG 3 health targets.

The region shows a mixed picture across the six health and health-related outcome domains of the framework. An overall index for health services based on the average for the indices of each of the six dimensions gives a level of 0.48 out of a possible 1.

This implies that the population of the region is only utilizing 48 percent of the possible health and health-related services needed for their health and well-being.

Countries score in the region range of 0.31 to 0.70 and only five countries have a score above 0.60, with the best country in the region (Algeria) only able to provide 70 percent of the possible health and health-related services that its population needs – a worrying situation indeed.

“All six dimensions of services outcomes under-perform, with the best only able to provide 57 percent of what is feasible. All member states therefore need to be reviewing what they have available for their populations, with the aim of identifying and improving the services needed to improve each dimension.

“The worst performing dimensions relative to others are service availability (36 percent of what is feasible), and financial risk protection (34 percent of what is feasible). Improving population outcomes in the region will accordingly require relatively more effort in further enhancing these two dimensions”, the report advises.  

The analysis of the health system performance is based on how well it is able to achieve across the four dimensions of access to essential services, quality of essential services, effective demand by communities for essential services, and the resilience of the system to shocks.

The consolidated average systems performance index in the region is 0.49, implying that “systems are only performing 49 percent of their possible levels of functionality. Country’s performance scores range from 0.26 to 0.70. All the indices for the performance dimensions are under-performing, with systems resilience and access to essential services doing worst”.

Countries are therefore advised invest across seven areas – through programmes or cross cutting system investments – to perform at the level needed to move towards Universal Health Coverage (UHC): health workforce, health infrastructure, medical products, service delivery, health governance, health financing and health information.

The report notes that countries are spending an average of 60 percent of their health expenditures on tangible investments (health workforce, health infrastructure and medical products) as compared to intangible ones.

Within the tangible investments, highest spending of government funds is on medical products (39 percent of government spending), followed by the health workforce (14 percent). Only seven percent of government expenditure is on infrastructure, which includes equipment, transport and information, communication and technology (ICT).

A country with a good performing health system puts more emphasis on health workforce (40 percent versus 14 percent) and infrastructure (33 percent versus seven percent) compared to countries with less performing systems. Finding a similar pattern in other countries with good performing systems would suggest that the investment focus should shift to health workforce and infrastructure investments.

The state of health and well-being is a function of the levels of attainment of the dimension related to outcomes – the health and health related services desired by the population. For sustainable development, these services must be broad enough to cover all populations, irrespective of their needs and locations. The six dimensions of health outcomes provide this breadth, irrespective of where a population is within the region.

There is recognition that UHC is an umbrella target within SDG 3. UHC is based on universality and sustainability and is underpinned by principles of efficiency, effectiveness and equity spanning health system inputs and processes (interactions across various building blocks) and health system performance outputs as measured by access, quality, demand and resilience of essential services.

It is achieved in concert with health security, service, satisfaction and other non-health interventions. Universality ensures that all persons are targeted without any discrimination – leaving no one behind. It denotes a shift of focus fro0m priority services to vulnerable populations to essential services for all, at all ages.

Sustainability, on the other hand, ensures that gains can be maintained at least over a strategic planning cycle (3-7 years). It denotes a shift from short-term project-driven results, to longer term development gains.

The country scores in the region range from a low of 0.31 to a high 0.70. Only five countries in the region have a score above 0.6. Namibia (0.62), Kenya (064), South Africa (0.66), Seychelles (0.68) and Algeria (0.70).

Algeria, the country with the best score in the African region, is only able 70 percent of the possible health and health-related services needed by its population.

The report further observes that there are significantly inequities in the utilization of health services in the Africa region as there is a clear dividend in terms of utilization of services by level of income, with the utilization score increasing with the country economic ranking.

The 11 percent higher utilization in high income countries is significant: this trend is only reserved for health promotion interventions, whose score is decreasing as the income level of the country grows. This may reflect the increasing medicalization of services in higher income countries.

Countries with the highest health expenditure have higher utilization of services – with the highest variation being with creative and rehabilitative services. Low country spending on health shows higher utilization of promotion services, an indication of a lower focus on health promotion as countries spend more on health.

Countries with lower populations have higher utilization of interventions, compared to those with higher populations. This may be associated with interventions in lower population countries, where identifying and assessing non-covered populations may be better achieved. The variation is most pronounced with SIDS countries, which have a more than 100 percent higher utilization score.

Inequities in the utilization of interventions are not only between countries; they can also be seen within countries. A review of population coverage with essential health interventions relating to reproductive, maternal, newborn and child health by wealth quintile across Africa countries shows an average of 22 percent reduction in coverage between the highest and lowest quintile in countries of the region.

Inequities are also based on the overall health expenditures. The countries with the health expenditures also have the highest financial risk protection index – more than double that for the countries with the lowest health expenditures.

This suggests health expenditures are increasingly spent in areas that provide better financial risk protection. Additionally, the smaller the country population, the higher the financial risk protection – though this pattern is reversed for social security funding, with higher population countries spending on social security.

This may be a result of preference for government funded and managed services in smaller countries, where social security mechanisms may not provide the economies of scale needed to run them.


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