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Informação sanitária, investigação, evidências e conhecimentos

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O conteúdo em Portugês estará disponível em breve.

Data are crucial in improving health.[1] The ultimate objective of collecting data is to inform health programme planning as well as policy-making and, ultimately, global health outcomes and equity. A well-functioning health information system empowers decision-makers to manage and lead more effectively by providing useful evidence at the lowest possible cost.

A health information system has been aptly described as "an integrated effort to collect, process, report and use health information and knowledge to influence policy-making, programme action and research". It consists of:

  • inputs (resources)
  • processes (selection of indicators and data sources; data collection and management)
  • outputs (information products and information dissemination and use).

The role of a health information system is to generate, analyse and disseminate sound data for public health decision-making in a timely manner. Data have no value in themselves. The ultimate objective of a health information system is to inform action in the health sector. Performance of such a system should therefore be measured not only on the basis of the quality of the data produced, but also on evidence of the continued use of these data for improving health systems' operations and health status.

The health information system[2]

The availability and use of information enables:

  • improved definition of a population
  • recognition of problems
  • setting of priorities in the research agenda
  • identification of effective and efficient interventions
  • determination of potential impact (prediction)
  • planning and resource allocation
  • monitoring of performance or progress
  • evaluation of outcomes after interventions
  • continuity in medical and health care
  • healthy behaviour in individuals and groups.

It also empowers citizens by enabling their participation in health care, policy and decision processes; and empowers countries and international partners by enabling better transparency and accountability through use of objective and verifiable processes.

Health knowledge gaps are where essential answers on how to improve the health of the people in Lesotho are missing. This is an issue related to the acquisition or generation of health information and research evidence. The “know-do gap” is the failure to apply all existing knowledge to improve people’s health. This is related to the issue of sharing and translation of health information, research evidence, or knowledge. Although there are major structural constraints, the key to narrowing the knowledge gap and sustaining health and development gains is a long-term commitment to strengthen national health information systems.

Esta seção do perfil do sistema de saúde está estruturado da seguinte forma:

Contents

Analytical summary

O conteúdo em Portugês estará disponível em breve.

Botswana has an enabling environment to support information and communication technology (ICT). Public and private funding for ICT has been in place since 1997. Health professionals have access to international electronic journals. In 2005, the Botswana National ICT policy was developed to guide, integrate and coordinate all ICT initiatives.

The major areas addressed by the policy include community access and development, government, learning, health, economic development and growth of the ICT sector, infrastructure, security, legislation and policy. The policy stipulates, as one of its objectives, an enhanced disease control and health care programme.

Over the past few years, there have been several initiatives to expand ICT services in Botswana. The Connecting Communities Programme connects rural, urban and remote areas with affordable computer and Internet services. Kitsong Centres (knowledge centres), which target rural areas, are part of the Government of Botswana's obligation to involve the nation in the social and economic development of the country. Thuto (education) Net links all secondary schools to the Internet and is aimed at reducing the literacy gap between students in rural and urban schools.

The Botswana Information Hub provides a forum for researchers, industry, higher education and business to interact. In the health sector, Local Area Network and Wide Area Network link health facilities within localities, or across localities, respectively, for easy communication, coordination and sharing of resources. The Patient Information Management System computerizes patients’ records to allow interaction of providers and to ease patients’ movement across health facilities. ICT systems are used to manage:

  • commodity procurement and distribution
  • blood inventory and distribution
  • antiretroviral therapy patient information
  • health facility communication in the districts.

Health information is generated through quarterly and annual reports in public and private health facilities and in nongovernmental organizations that provide health services. The information ultimately goes to the Central Statistics Office where it is published and disseminated. Other sources of health information include:

  • reports from various Government-funded and donor-funded programmes
  • policy documents
  • strategic frameworks/plans
  • programme guidelines and procedure manuals
  • programme and project evaluation reports generated by Government and strategic partners.

Population census publications provide information about demographic changes. Reports and publications on surveys, disease surveillance and studies conducted by Government, strategic partners and research institutions provide information on health status trends and sociocultural health status determinants.

The major challenge in securing the right health information at the right time is resource constraint, particularly human resource shortage. There have been reports about inadequate resourcing of the Central Statistics Office and the health facilities where the data should be captured. The problem is compounded by staff movements/transfers that create a need for continuing training. Standardization of reporting also needs improvement to reduce instances of conflicting information in published sources. The country is yet to make health information available in local languages.

Context

Enabling environment

National Information and Communication Policy
The Government of Botswana has provided an enabling environment through commitment to the adoption of information and communication technology (ICT) as a key driver in achieving social, economic, political and cultural transformation within the country. In light of this, a National ICT Policy was developed in 2005 to build upon other Government initiatives and to assist in achieving Botswana’s national vision 2016. Among other things, the national vision expresses that by 2016 “Botswana will be abreast of other nations in information technology and will have become a regional powerhouse in the field”. This would be achieved thorough up-scaling citizenry ICT skills and expanding technical infrastructure.

National eHealth Policy
Botswana recognizes the capability of ICT to transform health care delivery and service to all. A health e-readiness assessment was conducted prior to the development of the National ICT Policy to inform the process. e-Health, as outlined in appendix D of the Policy, outlines the objectives, recommended programmes, desired outcomes, specific targets, provisional cost estimates and other enabling factors to drive the activity.

National Procurement Policy
Through the Public Procurement and Asset Disposal Board, the country has set out to encourage local businesses by establishing tender evaluation processes that are more favourable to companies that manufacture goods locally and those that are citizen owned. There is a National Procurement Policy specific to ICT procurement. This Policy has come into effect to allow for standardization and uniformity in software and hardware in order to have a well-coordinated system in place.

Availability of public funding
For the 2012–2013 financial year, the e-Government strategy has been allocated a total of BWP 100 million. However, these funds are not inclusive of other finances that are specific to various programmes.

Public–private partnership
Botswana has invested in the Eastern African Submarine Cable System, which is a multicountry, multipartner fibre optic cable project that endeavours to bring about substantial bandwidth cost reduction to its partners. This investment will ensure that connectivity, as a key factor that enables access to well-functioning ICT, is upgraded.

Capacity development
The Ministry of Health has engaged in a 3-year tripartite partnership with Centers for Disease Control and Prevention Botswana and Botho College, a local IT training institution, to increase capacity of information systems and ICT support personnel at district level.

eHealth standards
The Government recognizes international standards that guide system selection, development and deployment. In light of this, the National ICT Policy places a strong emphasis on the need for the eHealth infrastructure to comply to international and national data standards that seek to protect patient confidentiality. Additionally, a national eHealth council is expected to assume a standard setting role to oversee the process of identifying and implementing these standards.

Citizen protection
Prior to the National ICT Policy development, the Botswana ICT legislative framework had to be reviewed to identify key areas that needed to addressed or amended to ensure that the Policy would be implemented effectively. To date, the Telecommunication and Cyber Crime Act has been enacted. As the country up-scales the implementation of e-governance and e-health, there is a greater need to enable legislation on data protection and electronic transactions.

Equity
A digital divide exists in the country for various reasons, the most significant being:

  • rural vs urban facilities
  • young health providers vs older health providers
  • characteristics specific to service users (literate vs illiterate, affluent vs poor)
  • level of importance placed on specific health programmes.

The Government has worked to address these challenges from various angles. The urban vs rural divide is being addressed by electrification and rural telephone programmes that are being rolled out nationwide targeting the most disadvantaged areas. One such programme is the NTELETSA (Call me) rural telephone programme, which is being rolled out in partnership with the mobile telecommunication companies working in-country. However, the pace of roll out of both initiatives is not adequate to satisfy demand, let alone the aggressive requirements of the national ICT project.

The 2001 census and the 2004 World Economic Forum Global IT Report both indicate computer ownership and Internet usage levels to be low (between 3% and 5%) and major initiatives have been taken to address this. For those employed in the Government sector, a computer ownership initiative has been rolled out that affords employees an opportunity to purchase computers and pay them off without having to pay interest on the borrowed amount. To make for greater access for the general public, community centres have and continue to be established.

One such initiative is the Kitsong project, which began in 2006–2007. Through this project, 35 community centres have been established and are functioning, while an additional 25 are at various stages of completion. Another project that strives to address the invariable technology divide is the Sesigo project, which is a global development project funded by the Bill & Melinda Gates Foundation in partnership with the Government of Botswana through the Botswana National Library Services. This project strives to avail “a platform where all can access, at no cost, ICT services at the public libraries and thus extends the reach of the e-government portal by providing the access points”. The target of this project is to equip at least 78 public libraries with the relevant ICT and to train their staff to train would-be users and carry out basic troubleshooting.

While such activities are seen as important and are welcomed by the majority of Batswana, basic needs such as food, electricity, roads and access to health care are prioritized as much more pressing.

Promotion of multilingualism and cultural diversity
In an endeavour to promote health information sharing and dissemination, the Government intends through the Maitlamo document to develop a health portal. The content of the interactive portal is to be kept current, relevant and particularly adapted to the language and cultural needs of the population.

Infrastructure

A 2004 information and communication technology (ICT) survey conducted to support the National e-Readiness Assessment indicated that close to 1 billion pula was spent on ICT annually, with the greater proportion going to foreign companies. This flight of capital was rationalized on the premise that there was little by way of expertise and capacity in-country to carry out much of what needed to be done.

Botswana recognizes the importance of developing local solutions that are both affordable and sustainable. This has, in part, come about as a result of realizing the great extent to which the country has been reliant on adopting wholesale solution developed for other countries as alluded to in the expenditure on ICT.

To this end, the Ministry of Infrastructure, Science and Technology through its Department of Research Science and Technology has set out to encourage and nurture innovators and inventors. A national innovators/inventors register has been set up which, beyond compiling a list of all inventive activities in-country, seeks to:

  • create awareness about intellectual property and its management
  • facilitate national advocacy
  • network and collaborate
  • fund raise.

Cultural and linguistic diversity and cultural identity

The Botswana population is made up of people with different cultures and a diversity of languages and dialects. As a member state of the United Nations Educational, Scientific and Cultural Organization (UNESCO), Botswana has signed the UNESCO Universal Declaration on Cultural Diversity. To facilitate the free expression and preservation of these diverse cultures and languages, the National Policy on Culture was passed by Cabinet in 2002. This Policy sets out many objectives, including to:

  • create a conducive environment for cultural preservation and participation by all the people of Botswana, in the form of infrastructure, programmes and services;
  • preserve and protect the cultural heritage by caring for, and expanding, historical monuments and sites, museums, archives and library collections, artistic and intellectual property;
  • recognize and strengthen the interrelationship between culture, science and technology, education, health etc., to ensure that all educational programmes are strongly founded on Botswana cultural ideals;
  • assert cultural values, publicize and popularize cultural products, both nationally and internationally, through vigorous and varied programmes of artistic performance and marketing.

While various structures are involved with ensuring that these objectives are met, the Division of Culture within the Ministry of Youth, Sports and Culture has an overarching role as it is mandated with coordinating and facilitating programmes and projects geared towards the preservation, presentation and development of culture in its different facets across the country.

Through a commitment to the objectives of the World Summit on the Information Society, Botswana continues to make strides in this area of diversity. The Ministry of Health, with developmental partners and nongovernmental organizations, has supported some communities to develop language and culturally sensitive and specific information, education and communication materials, especially in the area of tuberculosis care.

Existence of multilingual projects, translation and cultural adaptation

Most Government of Botswana ministries, including the Ministry of Health, now have websites and some have dedicated websites for the different departments within the ministry. Some of the ministry websites, though not fully translated, have an option to browse the site in the local language (Setswana).

There is also a Government of Botswana portal where citizens have access to information about government processes. However, more work needs to go into upgrading and automating various government processes. Owing to the slow uptake of online services, Botswana has been reported to drop rankings in the e-Government, as reported by the United Nations.

Content

The e-health Maitlamo study in Botswana recommends, among others things, the setting up of a programme termed “Enabling Clinicians to Deliver Excellent Patient Care”. A number of specific projects are to be carried out as part of the programme to give clinicians access to the tools and current knowledge so that they are better enabled to deliver excellent patient care. Some of the projects include e-continuing education, building e-libraries and telemedicine.

Capacity

Botswana recognizes that, while it is important to develop information and communication technology infrastructure in a bid to be more efficient, that such an exercise is futile if it is not preceded or accompanied by an investment in capacitating its population to be able to make use of the same.

There is a present drive to have Internet and computers in all primary and secondary schools. As things currently stand, all secondary schools have computer laboratories with some also having Internet. With computer studies being an optional subject and the high student to computer ratio, the quality and reach of this capacity-building initiative remains limited.

Local health training institutions have introduced a module on computer literacy in a bid to ensure that those entering the job market have the basic requisite skills to function in this technologically driven age. However, there remains a need to train those who entered the workforce prior to the introduction of information and communication technology preservice and those who require further development beyond basic introductory classes. To this end, the Government of Botswana has set out an ambitious goal of training as articulated in the National Development Plan 10.

Outside health practitioners, there is the much-needed development of graduates who will be able to develop and service much of the requisite hardware. A move towards the attainment of this goal has been the establishment of the Botswana International University of Science and Technology, which strives to be a regional hub of scientific educational excellence.

Structural organization of health information

Organization and management

In Botswana, the Ministry of Health is the custodian of health in the country. It generates most of the health information and hence plays a leadership role on matters pertaining to health information. However, this role is not at the exclusion of other ministries; one key agency of note is the Central Statistics Office.

Within the Ministry of Health, the Department of Policy, Planning, Monitoring and Evaluation, set up in July 2005, is the lead department. Its goal is “to provide strategic direction and support on issues pertaining to health policy, planning, research and information management in order to ensure that policies are well formulated, plans, programmes and projects are coordinated, integrated, monitored and evaluated so as to achieve the national health goals and objectives”.

To strengthen organizational efficiency and effectiveness, the Ministry of Health is currently undergoing reorganization. This exercise seeks to harmonize plans and financing, and to appropriately resource departments and programmes with human resources.

Overview of the flows of information

There are, broadly speaking, two major organizations for health-related data: one for HIV/AIDS and one for general health indicators.

The Botswana HIV and AIDS Response Information Management System

The Botswana HIV and AIDS Response Information Management System (see figure) has been set up to:

Botswana HIV and AIDS Response Information Management System (BHRIMS). Source: About BHRIMS, Monitoring and Evaluation
  • facilitate the flow of information about HIV/AIDS
  • provide linkages between stakeholders
  • institute a national database across the national response.

It was developed out of the need, as stated by the National Strategic Framework, to gain a better understanding of the HIV interventions in the country. It is a tool through which harmonized HIV/AIDS response information can be collated and managed for utilization in programme planning, policy formulation and appropriate allocation of available resources.

District Health Information System

Prior to the introduction of the District Health Information System (see figure), health information management in Botswana faced several challenges, including:

  • manual transcription of data in districts
  • demand for data by different stakeholders
  • data quality and fragmented datasets
  • vertical information systems.
District Health Information System structure. Source: Botswana District Health Information System

The Botswana Health Information System Programme implemented the District Health Information System as a central database at the district level. Data from all health information programmes are integrated and entered into one database. The District Health Information System is open source software, which is available at no cost and is used at national level in many countries.

Despite this having been a well laid out plan with the necessary funding support from the European Union and later by the United States President's Emergency Plan for AIDS Relief, the initiative has not had the level of success that had been envisaged. This less than optimal success has been attributed to three major issues:

Specific regulatory framework

Information and communication technology regulatory framework

The Botswana Communications Regulatory Authority was established in 1996 to monitor and regulate telecommunications services in Botswana. As a regulatory authority, it is expected to:

  • promote competition
  • ensure operator compliance with regulatory instruments
  • enhance availability of a wider range of services
  • ensure customer's interest are protected and upheld.

Telecommunication legal advice is provided through the office of the Botswana Communications Regulatory Authority Legal Advisor.

Data sources and generation

Censuses

The Central Statistics Office was established in 1971 with a statutory mandate to “produce and provide the Government of Botswana, the private sector, parastatal organizations, international organizations, civil society and the general public with statistics”. To deliver on the above, strategic financial and technical partnerships have been forged and maintained over the years.

This agency has carried out decennial censuses from 1971 to 2011. Thanks to the political stability in Botswana, these have had few limitations and have served as an authentic record for the country to use when making national development plans. In 1991, the country carried out its first population and housing censuses within the United Nations framework and this tool has undergone several editions to capture recent perspectives.

In a bid to improve on the delivery of the Central Statistics Office, the Government has taken a decision for the agency to become more autonomous by becoming parastatal.

Civil registration and vital statistics systems

Recognizing the importance of having a system through which meaningful data could be collected at national level and on a continuous basis, in 2003 legislature was passed in Botswana mandating the registration of all births and deaths, as well as having a national registration number at the age of 16 years. This exercise, led by the Department of Civil and National Registration, a department of the Ministry of Labour and Home Affairs, has had great success.

Birth registrations by the Department of Civil and National Registration have been a success, as a great majority of mothers deliver in health care facilities.

With respect to registration of deaths, the uptake has been encouraged by the prevailing situation where insurance companies, burial societies, governmental departments and other relevant bodies insist of seeing an authentic death certificate or letter from local authorities for them to assist in matters involving the estate of the deceased or other related matters. However, it is apparent that International Classification of Diseases coding is not being adequately followed by health care providers when stating cause of death.

As it is mandatory for all people over the age of 16 years to show their national registration card where identification is required, be it in government establishments or the private sector, the public response in requesting registration has been phenomenal.

Health surveys

Botswana AIDS Impact Survey
The Botswana AIDS Impact Survey is a population-based survey jointly implemented by the Central Statistics Office and the National AIDS Coordinating Agency together with development partners. It has been conducted every 4 years since 2001. The survey aims to assist in monitoring HIV trends in Botswana.

Botswana Family Health Surveys
The Botswana Family Health Surveys (BFHS) were first conducted in 1984 and to date four surveys have been completed, albeit an irregular timing. The latest survey (BFHS IV) was conducted between United Nations Children's Fund. The BFHS is conducted to provide information on:

  • family planning awareness, approval and use
  • basic indicators of maternal and child health
  • other topics related to family health.

In addition, the BFHS IV complemented the data collected in the 2006 Botswana Demographic Survey, by obtaining information needed to:

  • explore trends in fertility and mortality
  • examine factors that influence these basic demographic indicators.

Surveillance systems

The Government of Botswana, through its e-Health Policy, recognizes that surveillance of health, demographic and social indicators is essential to its ability to manage and improve the health system and the health of the population. Surveillance systematically identifies emerging issues and monitors the effectiveness of intervention strategies. Across Botswana, there are several high-quality yet independent health surveillance systems used to track public health, chronic and reportable diseases, including those supporting HIV/AIDS and tuberculosis reporting.

These systems are operated by different governance entities across several government ministries, each with their own data access protocol, and this complicates the integration challenge.

Some examples of surveillance projects are detailed below.

Positive Innovation for the Next Generation’s Disease Surveillance and Mapping Project pilot

Positive Innovation for the Next Generation surveillance. Source: Disease Surveillance and Mapping Project, PING Technical Projects

Health care workers at 16 facilities in the Chobe District of northern Botswana use Hewlett-Packard Palm Pre 2 smart phones to reports back real-time disease outbreak data, tag the data with global positioning system coordinates to the Ministry of Health and sms disease outbreak alerts to all other health care workers in the district. Data are aggregated in real time on the back end and graphs and reports are generated simultaneously. Currently, the pilot is focusing on malaria. However, Positive Innovation for the Next Generation, Hewlett-Packard and the Ministry of Health intend to expand the project sites and number diseases reported.

Ministry of Health HIV sentinel surveillance
Surveillance of HIV/AIDS is vital in establishing the prevalence and trends in HIV as well as in providing useful information to inform programmes, policy-making and decision-making, Botswana conducts yearly HIV/AIDS surveillance among pregnant women aged 15─49 years. The surveillance was first instituted in 1992 and focused on the collection of data to determine the magnitude and trends of the epidemic for resource mobilization and for policy development. To date, the surveillance has become necessary to review the strategies to include additional behavioural data in order to understand the dynamics of the epidemic.

Systematic documentation of contextual and qualitative data

In Botswana, the Central Statistics Office has a health-specific unit, the Health Statistics Unit, which is housed in the Ministry of Health and has the core mandate of producing and “disseminating quality health information that would facilitate evidence-based planning and monitoring in the health care system". This Unit works primarily on data on:

  • health facilities
  • personnel
  • causes of outpatient morbidity
  • causes of inpatient morbidity and mortality.

However, there are challenges in carrying out this mandate as the Unit has a shortage of appropriately trained manpower and associated financial resources. The loose relationship that it has with the Ministry of Health further compromises execution of its mandate as it depends on Ministry facilities to avail the data to be analysed.

Outside the Health Statistics Unit, individual programmes produce annual reports, which are a means of systematic documentation of data and a means of comparison of past and future years. Realizing that such a vertical reporting approach has its limitations, the Ministry of Health has in the past year established a working team that analyses various reports and seeks to establish gaps and interprogramme synergy.

Health research

The use of research as a means of generating data is important in the Botswana context. For this reason, a health research agenda had been developed as it serves to prioritize areas that require answers.

In-country research takes on various forms with much of it being operation-level research. More recently, there has been a move towards implementation research.

For clinical research, the Botswana–Harvard AIDS Institute Partnership, established in 1996, has been a key driver. The research and training initiatives of this Partnership focus on questions of epidemiology, virology, molecular biology, immunology, genetics, clinical treatment, and social and behavioural medicine issues relevant to the AIDS epidemic in Botswana and southern Africa.

Data management

Data collection

The use of relevant, timely data is of great importance for the advancement of any country's health care system. Botswana has over the years put in place various data collection methods.

At the lowest level, there are the facility-based data collection tools. This data source has served well in giving a glimpse as to what takes place within the reporting health facilities and makes up the larger part of programme reports once compiled.

With health care being accessed from different sources (i.e. public sector, private sector and traditional practitioners) the reliance on public health facility reports as an indication of the health of the nation has its limitations. Realizing this, the Government of Botswana has engaged with licensed private health care facilities so as to have them submit statistics on indicators of public health importance.

Within the public health system, there is a challenge in that there is an inordinate number of reporting tools requiring completion by facility staff. This data collection burden has resulted in a situation where submitted reports are incomplete or inaccurate and, in some instances, no submissions are made. To address this challenge, the Ministry of Health has set out to review programme-reporting tools to identify key indicators and harmonize reporting.

Data compilation, storage, management

Data compilation
Facilities compile data per request from the national level. These reports are then further compiled at district level and sent to the national programme coordinators at Ministry of Health headquarters. Such data are then shared with the relevant stakeholders.

The Health Statistics Unit of the Central Statistics Office plays a pivotal role in ensuring that such data are analysed and compiled into annual reports. Recent developments within the Ministry of Health have been such that the Department of Policy, Planning, Monitoring and Evaluation is being strengthened to fulfil its mandate of coordinating all monitoring activities of the various Ministry of Health programmes.

Data storage
At facility level, as at national level, there is no structured data storage system for both electronic and paper-based records. Without having standardized guidelines spelling out the duration of record-keeping, the nature of records to be kept, or the manner in which records are to be kept, things have largely been left at the discretion of individuals that unfortunately have no training in records management. As such, facilities have tended to pile up paper registers and other medical records, never to return to them in either the medium or the long term. The Ministry is currently engaged in an exercise to develop the relevant guidelines for handling medical records.

The present system of patients keeping their outpatient cards has proven to be of great value in that the responsibility of record-keeping is shared between the facility and the client. This system is also necessary as the system allows for free movement of patients between public health facilities.

A few of the programmes have electronic databases and registers and an electronic data storage system. The more mature electronically based programmes are the National ART Programme and the National Tuberculosis Treatment Programme. There is currently no integrated data repository.

Data management
There is currently no specific legislature on data management. As such, the de facto position taken is that of the professional ethics governing the individuals. With the development of computer-based records, the country has come to acknowledge that there is a need to develop a data management policy or guidelines to set in motion a standardized way of doing things.

From the perspective of protection again computer crimes through the Botswana Communications Regulatory Authority, measures have been taken to advocate for an amendment of the law to encompass such complex matters.

Data sharing and access

Where computer systems exist in Botswana, there is a system in place whereby individual users access data using their personal names and private codes. This is intended to ensure that individuals access only that which their access code permits. However, in practice, individuals share their computer codes and systems are left logged on and shared.

Data quality and analysis

The Government of Botswana has employed monitoring and evaluation officers in all districts. While these officers worked exclusively on HIV/AIDS programmes when first introduced, their role has been expanded to support all other programmes. Under the supervision of a medical public health specialist in the districts, this cadre works to ensure that established standards of data quality are employed. The Government, with support of development partners, has invested in ensuring that this cadre is adequately equipped with the necessary skills to carry out the data assurance role.

In addition to the district-level efforts, the respective programme coordinators and the monitoring and evaluation teams within the Ministry of Health headquarters conduct periodic support visits to verify the quality of data they receive.

Estimation methods

Working with relevant stakeholders such as United Nations partners and training institutions, the Government of Botswana is able to adapt and apply modelling tools for estimating disease-specific indicators.

Statistics

The Ministry of Health, together with the Central Statistics Office, has a team of experts who are trained in statistics. This team provides the necessary checks and balances to ensure that data generated from the various programmes are of the highest quality possible.

In addition to the above teams, relevant stakeholders such as United Nations partners and training institutions contribute to the compilation, analysis and dissemination of data as per the expressed needs of programmes.

Access to existing global health information, evidence and knowledge

Availability and use of indexes of local, non-English, and unpublished

In Botswana, the Ministry of Health headquarters operates a library whose mission is “collection, maintenance and facilitating the use of information resources to support projects and programmes of the Ministry of Health as the primary function of the library”. This library does not operate in isolation to existing library services. This is well articulated in its vision of “existing to support the Botswana National Library Services in promoting literacy, education, research and acquiring legal deposit publications from the Ministry of Health for preservation by the National Reference Library for posterity".

Despite such noble intentions and the aspirations to carry out its mandate in keeping with best international practice, the staff shortage and inadequacy of resources has impeded efforts to train stakeholders on best practice issues. As such, while the library receives some unpublished works from various ministry departments, the research division and outside stakeholders, these are in formats decided upon by those submitting and do not necessarily meet the appropriate standard.

The national Ministry of Health headquarters library is not adequately resourced, in respect to both manpower and finances; hence much of what is planned remains elusive.

Availability and use of search engines, networking platforms

Botswana enjoys an open environment for accessing Internet sites with little restrictions. As such, many of the search engines and networking platforms are available and used. Data on the extent of utilization of search engines and networking platforms by persons in the health sector are not available.

Availability and use of open access journals

The use of open access journals is not well established within the Ministry of Health in Botswana. There is currently no repository or system in place for authors to archive their published articles for public consumption. The Ministry does not subscribe to any open-access publishers.

With Internet access being available in many of the facilities, there exists an opportunity for individuals to use open-access journals. However, the extent of use is not documented.

Access to copyrighted publications

The Ministry of Health headquarters library subscribes to a limited number of paper-based journals and is unable to procure all relevant reference books needed. With many competing priorities, staff development has unfortunately fallen low on the list and hence receives little funding. Where free or low-cost access to journals exists, such as the HINARI Access to Research in Health Programme and its associated e-trainings, the Government of Botswana has been slow to take full advantage of this.

The Ministry of Health runs a number of specialized libraries within the referral hospital and the training institutes. These libraries function independently of each other and hence do not benefit from collective bargaining.

Regulatory frameworks on intellectual property

As contracting part to the World Intellectual Property Organization (WIPO) Botswana has adopted a framework law on trademarks and patents that is in keeping with international best practice. At an international and regional level, the country has signed a number of treaties related to intellectual property:

Its international treaties are:

  • Hague Agreement Concerning the International Deposit of Industrial Designs (5 December 2006)
  • Protocol Relating to the Madrid Agreement Concerning the International Registration of Marks (5 December 2006)
  • WIPO Copyright Treaty (27 January 2005)
  • WIPO Performances and Phonograms Treaty (27 January 2005)
  • Patent Cooperation Treaty (30 October 2003)
  • Berne Convention for the Protection of Literary and Artistic Works (15 April 1998)
  • Convention Establishing the World Intellectual Property Organization (15 April 1998)
  • Paris Convention for the Protection of Industrial Property (15 April 1998).

Its regional treaties are:

  • Swakopmund Protocol on the Protection of Traditional Knowledge and Expressions of Folklore within the Framework of the African Regional Intellectual Property Organization (ARIPO)
  • Banjul Protocol on Marks Within the Framework of the African Regional Industrial Property Organization (ARIPO) (29 October 2003)
  • Harare Protocol on Patents and Industrial Designs Within the Framework of the African Regional Industrial Property Organization (ARIPO) (6 May 1985)
  • Lusaka Agreement on the Creation of the African Regional Intellectual Property Organization (ARIPO) (6 February 1985).

There are a number of intellectual property laws within the country which address matters including, but not limited to, copy rights/patents, indigenous knowledge and technology transfer. Some of these laws are:

  • Copyright, Act, 15/05/2000, No. 8 - Copyright and Neighbouring Rights Act, Act No. 8 of 2000
  • Industrial Property, Act, 21/08/1996, No. 14 - Industrial Property Act, Act Nº 14 of 1996
  • Industrial Property, Act (Amendment), 04/11/1997, No. 19 - Industrial Property (Amendment) Act, Act Nº 19 of 1997
  • Industrial Property, Regulations, 25/08/1997, No. 78 - Industrial Property Regulations, Statutory Instrument Nº 78 of 1997.

Storage and diffusion of information, evidence and knowledge

Availability and use of health libraries and information centres

There is currently no comprehensive structure for health information and knowledge management in Botswana. As such, activities are somewhat opportunistic. The Botswana National Libraries Service with its countrywide coverage of libraries, reading rooms and mobile services, helps to facilitate the availability of all information, including that of health, to the public.

However, there is little by way of health libraries and information centres, outside the health training institutions and the referral hospitals.

Availability and use of publications in appropriate formats and languages

In Botswana, publications are available in the two official languages (English and Setswana), with most being in appropriate formats.

The Botswana National Library Service has various players that acquire documents from various organizations, regions and countries. These organizations have their own institutional document collection policies. Despite the absence of a policy guiding publication collection, the majority of publications collected by the Ministry of Health are in the appropriate languages and formats.

Consolidating and publishing existing evidence for policy and decision

In Botswana, the existing evidence derived from operation research, programme reviews and monitoring of programmes is consolidated at the Ministry of Health's headquarter in various forms. Where it is deemed relevant, such information is published and distributed to policy-makers and decision-makers.

While this exercise is carried out across the entire breadth of programmes, it is more pronounced in programmes where there are multiple stakeholders and some come from outside the health sector. An example of this is the National AIDS Council, which relies on programme evidence to make key decisions on policy and legislature.

There is currently no publication that consolidates information from the various programmes and information is to be found in multiple places.

Mapping and sharing experiential knowledge, including best practices

Through the Ministry of Health and its partners, opportunities are availed for practitioners in Botswana to meet and share knowledge and best practice.

An annual HIV/AIDS conference brings together local, regional and international practitioners to share and discuss developments within their respective fields. At country level, there is an annual tuberculosis/HIV conference that brings together district health practitioners for the purpose of knowledge sharing.

The Ministry of Health, Ministry of Local Government and National AIDS Coordinating Agency work very closely to support districts in their preparation of submission to these conferences. This is seen as an important exercise, as it helps districts develop and implement operational and implementation research projects around their health priority areas while maintaining the scientific rigour required.

Indexing of local publications in international indexes

Botswana is an International Organization for Standardization (ISO) member country and as such subscribes to the ISO 2108 standard on International Standard Book Number (ISBN).

Some, but not all, local publication are indexed in international indexes. The shortfall from the ideal of having all local publication being appropriately indexed comes about as a result of inadequate knowledge of the expectations and process to be followed by those who develop and produce materials. Realizing this, the Ministry of Health headquarters library has been engaging with various health departments to help bridge this knowledge gap.

Research

Stewardship

In Botswana, the Division of Health Research in the Ministry of Health's Department of Policy, Planning, Monitoring and Evaluation is responsible for the stewardship of health research in the country.

This Division is currently staffed by six people, who by virtue of both numbers and skill mix are unable to effectively deliver on its twofold mandates of:

  • regulatory oversight of all health research activities taking place in country (reviewing studies, approving studies and ensuring compliance of researchers with good ethical standards and adherence to research scope as specified in the approval);
  • conducting health research to guide the Ministry of Health in its quest to develop programmes that are evidence based.

To address the identified handicaps, members from other departments, the community and teaching institutions are brought in to make up the national Health Research and Development Committee. It is through this structure that much of the due diligence needed before approval of studies and study audits once the studies are underway is carried out. While this assists in the operations of health research in-country, the Ministry of Health recognizes this to be less than ideal and hence desires to establish an autonomous body for health research.

Regulations
The Health Research Development Committee serves as the primary regulatory body for all research involving human subjects in Botswana. Several other regulatory bodies, such as the University of Botswana Institutional Review Board, the Botswana Network on Ethics, Law and HIV/AIDS (BONELA) and Princess Marina Hospital Research & Ethics Committee exist as institutional review boards.

However, the system is challenged in that there is currently no specific national legislature guiding research. As such, there is an overreliance on applying “international best practice”, which is not always clear and is also not always binding in the Botswana jurisdiction. The Ministry of Health has moved to plug this gap and the necessary steps for getting legislature passed are in the advanced stages. .

Research agenda
As a way of guiding research efforts in-country, a national health research agenda (2010─2016) was developed and approved through a consultative process that brought together Ministry of Health departments, district health management teams, nongovernment organizations, training and research institutions, multilateral organizations and international cooperation partners. The foreword to this document by the Minister of Health points out that this tool “will provide policy-makers, programme managers, researchers and students in the health field with clear indications of issues and problems to be research on” as to expedite “efforts in addressing the identified problems and enhance formulation of more comprehensive, meaningful and well-informed plans and policies".

Financing

Beyond the contribution of the Government of Botswana in terms of salaries for staff employed by the Health Research Division and the percentage contribution of government employees involved in collaborative research activities, along with whatever commodities are used, the overall health research budget of Botswana is hard to determine.

This situation comes about for various reasons, most notable being that a large proportion of the health research undertaken in Botswana is currently externally funded from sources such as the Centers for Disease Control and Prevention, through BOTUSA (Botswana─USA) (now CDC Botswana), Botswana Harvard AIDS Institute Partnership, Bill & Melinda Gates Foundation and the Global Fund to Fight AIDS, Tuberculosis and Malaria. While the major part of the work done by these institutions is centred on HIV/AIDS and tuberculosis clinical studies, the WHO Regional Office for Africa supports some research and surveys at country level through the WHO Country Office. In addition, WHO provides technical support for research design and implementation as necessary.

In addition, the various donors work directly with programmes at the exclusion of the Division of Health. Research and budgets are not disclosed.

The absence of guidelines and a code of conduct for receiving private sector funding means that this remains an untapped potential source of research funding.

Creating and sustaining resources

At present, research capacity in-country is weak as a result of the brain drain and the financial squeeze after the main donor, the Norwegian Agency for Development Cooperation, pulled out at the end of the Norway─Botswana Health Sector Agreement. This situation has been compounded by reforms within the training institutions, most notable the University of Botswana, where staff who had focused on health and nutrition research, as part of the National Institute of Development Research and Documentation, University of Botswana, have now been integrated into the teaching staff, hence diluting their function.

However, effort has been put in place to encourage district-level research by creating a platform for results dissemination and scientific discussion at the annual national HIV/AIDS research conferences. The requisite finance and capacity-building is not clearly articulated nor supported.

A glance into the past will show that Botswana has benefited from research capacity-building programmes sponsored by different institutions and programmes, among which have been:

  • Research and Training in Tropical Diseases;
  • The joint Dutch /WHO Regional Office for Africa Health Systems Research Project for Eastern Central and Southern Africa;
  • Development and Research Training in Human Reproduction;
  • Norwegian Agency for Development Cooperation;
  • National Institute of Development Research and Documentation Centre.

Research output

Through the various health sector players in Botswana, much is done in the area of research.

The Ministry of Health, through its various departments, engages extensively in policy and operational research. Many of these research projects are carried out in collaboration with international partners who often bring a complementary skill and expertise not readily found among Ministry of Health staff.

Collaborating partners carry out an extensive array of research based on their areas of expertise and interest. All these are guided by the Ministry of Health as the overall custodian of health.

Use of information, evidence and knowledge

Formatting and packaging of evidence for policy and decision making

Through monthly and quarterly reports, data generated at facility level in Botswana is systematically collected and analysed by the district health management teams, led by the public health specialist, before being forwarded to the programme coordinators at the Ministry of Health headquarters.

Depending on which indicators are being tracked by the Permanent Secretary and reported to the Office of the President, consolidated national reports are then compiled in a manner that assists in broader based policy-making and decision-making process, which may often cut across various sectors.

Despite all good intentions, this process is not always followed through, due in large part to a shortage of appropriately trained human resources.

Sharing and reapplying information and experiential knowledge

With evidence-based planning being the preferred approach of the Ministry of Health and its major stakeholders, opportunities are constantly being created in Botswana for information and experience sharing in the form of:

  • workshops to discuss progress, implementation constraints along with success stories;
  • an annual senior management meeting that serves as a forum for developing harmonized and goal-oriented annual work plans.

Policy and decision makers' articulation of their need for evidence

Botswana has adopted results-based planning in much of what it does. The system of performance-based reporting and the continuing efforts to establish evidence-based planning means that justifiers are required to be backed-up by substantive evidence.

Policy and decision makers' participation in the research agenda setting process

The national health research agenda was developed in Botswana with great participation from programme managers and senior management within the Ministry of Health and stakeholder organizations. As such, this document, which will guide activities from 2011 to 2016, is a product that clearly articulates the expressed needs of policy-makers and decision-makers.

Policy and decision makers' capacity to access and apply evidence

Through the adoption of performance-based management as a means of government appraisal, the effective use of evidence for decision-making has been encouraged in Botswana. This has been further enhanced by the establishment of the project management team within the Ministry of Health. The role of this team is to help guide the various programmes such that principles of project management are centred around strategic decisions, resource allocation and accounting based on the presenting evidence.

The move has been one whereby programmes are run as projects to allow a more indicator-driven service delivery.

Availability and use of networks and CoPs for better use of evidence for policy and decision

The terms "networks" and "communities of practice" are rarely used in the Botswana health context. However, forums exist that fulfil the criterion of networks and communities of practice as they provide practitioners with opportunities for exchanging best practice information, encouraging each other and trouble shooting.

The Ministry of Health has various organizational groupings that benefit from such.forums, including:

  • tuberculosis coordinators
  • public health specialists working at district level
  • antiretroviral therapy nurse prescribers
  • antiretroviral therapy nurse dispensers
  • district health team managers.

Leverage information and communication technologies

Level of access to IT infrastructure

While the national information and communication technology infrastructure has been greatly improved, utilization of its various components is at different levels.

Indicator
Telephone main line 137 400 (2010)

7/100 persons

Mobile phones 2363 million

>100/100 persons

Internet users 120 000 (2009)
Internet hosts 2739 (2009)

The low uptake of Internet services has been attributed to what is considered as the prohibitive cost of computers and the high costs of using Internet services.

Availability of IT solutions

There are various information technology solutions deployed within the health sector in Botswana, such as the integrated patient management system. This system is interoperable and scalable in settings where there is well-established Internet connectivity. Administrative solutions have also been deployed that are themselves interoperable and scalable. However, these systems are not developed locally, hence the question of long-term sustainability arises.

Local information technology solutions have also been developed to respond to the present country needs and priorities. While not all these systems are interoperable, they are scalable and sustainable in both the short term and long term.

A key finding of the e-readiness study was that websites being introduced were not developed around the needs of the end user, and that there were no common standards in the quality of the work done.

Global Observatory for e-Health

e-Health for Women’s and Children’s Health 2013 Survey

National e-health policy or strategy

The 2004 e-Health Policy is part of e-governance. Its implementation has been partial and in the area of patient information management systems. The Policy addresses all areas of women’s and children’s health. No comment was made on whether there is special funding for e-health.

e-Health systems

Recording of deaths and births is done partially using electronic methods. District health information systems are in place under the Ministry of Health. Electronic financial resource tracking is carried out at national level, partially using the government accounting and budgeting system under the Ministry of Finance and Development Planning. There is no dedicated tracking for reproductive, maternal, newborn and child health expenditure per capita.

Women’s and children’s health policy or strategy

The National Health Policy covers maternal and child health although they are not sure if it refers to e-health.

Monitoring the status of women’s and children’s health

The Commission on Information and Accountability for Women’s and Children’s Health monitors 10 indicators of women’s and children’s health. The exception is exclusive breast feeding for 6 months.

National overview of e-health initiatives for women’s and children’s health

The e-health initiatives are supported by public and donor funding.

Health services delivery
  • Pilot on use of information and communication technology (ICT) to provide health advice and triage services for new and expectant mothers by trained health professionals.
  • Pilot on sending antiretroviral therapy reminder messages using ICT provided by health services to new and expectant mothers, aimed at achieving medication compliance for themselves or their infants or children.
  • Pilot messages using ICT to new and expectant mothers to make or attend an existing appointment such as antenatal care (sexual health reminders).
  • Pilot m-health project consultation between health practitioners about patients using ICT.
  • Remote monitoring of pregnant women, new mothers and newborns (the m-health Kgonafalo project).
Health monitoring and surveillance
  • Registration of hospital-based births, infant and maternal deaths, and causes of death (pilot).
Access to information for health professionals
  • An integrated patient management system is already established.
Other e-health programmes
  • Pilot tuberculosis programme registers.
Possible barriers to implementing e-health services

Legal, infrastructure and financial barriers were mentioned. Infrastructure and legal barriers are being addressed.

Knowledge base – e-health for women’s and children’s health

Not sure whether they would be willing to share their information.

ICT training for health sciences students

Yes but no explanation is given.

Continuing education in ICT for health professionals

Yes but no details given.

Internet health information quality

There are government interventions in terms of educational programmes, laws and regulations, and technology filters and controls although there is no regular publication of data on women’s and children’s health.

Online safety for children

The country provides information and education about Internet safety to citizens but this is not specifically focused on children.

Privacy of personal and health-related data

link provides information about this legislation but not specifically of health-related data.

Social media and women’s and children’s health

No specific health programmes use social media.

Extent of integration of the HIS

Computerization is at different levels across the health system in Botswana. Within the clinical area, computers are available for all HIV treatment services without the necessary linkages to other relevant programmes. Through the deployment of the integrated patient management system, which is the Government of Botswana's chosen electronic health record system, it is envisaged that data will be readily available at all levels for decision-making. However, the present situation is one whereby there are many vertical electronic health records that are not able to communicate. Data from these are periodically transferred to respective data warehouses at headquarters.

The use of mobile data capturing applications at community level has not yet been implemented by the Government, although there are nongovernmental organizations who are using such technologies in a bid to improve their monitoring and evaluation.

Endnotes: sources, methods, abbreviations, etc.

References

  1. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. Framework and standards for country health information systems, 2nd ed. (pdf 1.87Mb). Geneva, World Health Organization, 2008