Botswana Voices Inspiring Change: Part 1
Goitsemang Rampa – Bomaid
Goitsemang Rampa is the Claims Manager for the Botswana Medical Aid Society (Bomaid), a private medical aid that provides services to over 90,000 Botswanans. ACS met with Goitsemang to discuss Bomaid’s responsibility in supporting Botswana’s movement toward universal health coverage (UHC).
What inspired you to work in the health sector?
From a young age, I wanted to work in health. My training was in nursing and midwifery. In my first job, I worked for the government for over 8 years, mostly in rural areas. As I grew in my career, I wanted to diversify my experience and eventually made my way to Bomaid. Even though I was no longer working as a nurse or in a clinical setting, I knew that I would still be able to use my skills towards improving the health sector.
Given your experience in rural and urban settings, how have you seen Botswana’s health system evolve?
Primary health care has always been in the forefront, even in the rural areas. The Ministry of Health and Wellness (MoHW) has ensured that our country’s disease burden, particularly non-communicable diseases (NCDs), are being addressed and that solutions are aligned with the Sustainable Development Goals. The MoHW’s approach is to focus on preventive care to ensure our nation is healthy and to reduce medical expenses.
When I joined Bomaid, there was only one private hospital in the capital and now we have four, inclusive of a day clinic. This growth comes with its own set of challenges but also speaks to the availability of healthcare access and the ability to choose from the private sector or government-run facilities.
GAs improvements have been made in the health system, the MoHW has involved different stakeholders in the process, like the private sector. Partnering with Bomaid helps the government to see that we have a role to play in health care delivery. Recently, the government has been looking at how to finance health care in the country. Bomaid has been involved because, as a medical aid, we can’t pay for everything. We assist as much as possible but members still have an out-of-pocket cost, which is a concern of the government. They want to better understand how much people are paying for health services.
What is Bomaid’s relationship with the government?
I think we have a good relationship but there are challenges within our health system. We want medical aid schemes, service providers and private practitioners to be regulated and to adhere to governmental guidelines when establishing new clinics and charging for health services.
Bomaid is working to create pricing for health services (tariffs), which we believe is a move in the right direction. Ultimately, we want there to be a national reference price for services. However, Bomaid is only looking at a small segment of the population that can afford to pay for health insurance. One challenge we’re addressing is the issue of people accessing government facilities and being treated as a private patient. There should be pricing guidelines for those services, and the government should recover money from these patients.
“Universal health coverage, for me, means access to health care by all citizens at a reasonable cost . It means having defined health care service packages administered at a national level.”
This is a good opportunity to discuss UHC. What does UHC mean to you and do you think it’s well understood in Botswana?
For me, it means access to health care by all citizens at a reasonable cost. It means having a defined health care services package that’s administered at the national level.
I don’t think UHC is well understood. The MoHW is trying to educate people on UHC, but the conversation doesn’t progress because policies and systems must be in place before you can actually move towards UHC. I think this is why the government is focused on looking at health financing and resource tracking as a base for UHC, so they can understand what needs to be recovered from medical aids.
What actions or interventions are critical to supporting Botswana’s movement to UHC?
We must raise public awareness because no one is talking about UHC. We must have private/public partners involved in UHC conversations, to hear what we’re doing and to also be part of the solution. There’s also a need for stringent regulations of medical aids, whose benefit plans should include a basic health care package that’s available to all members at no extra cost.
We must ensure our UHC package includes the HIV/AIDS basic package to sustain gains made. Finally, vulnerable populations should be covered 100% regardless of where they receive health services.
To move the conversation forward, the broader population must be sensitized on UHC through simple messaging from the government that communicates the cost of delivering health care to the population. Whether costs rest with the government or private sector, there will always be a cost for health care.
What has been the impact of COVID-19 on Botswana’s healthcare system? Has the virus affected the country’s commitment to UHC?
Because we are in the early stages of UHC, I do not believe COVID-19 has negatively affected the conversation. I think Botswana has been in the forefront in managing COVID-19 in terms of testing, treatment and reducing cases through quarantine measures. From my perspective, I don’t think services were interrupted because we were guided by government protocols and everyone complied. People were encouraged to delay elective procedures and only visit clinics and hospitals if absolutely necessary. As a medical aid, we extended prescriptions from one to three months for members who are in our NCD programs to minimize the number of trips to clinics and pharmacies. These measures were enacted for the benefit of all citizens to ensure people were not unnecessarily exposed to the virus.
Nana Gleeson – BONELA
Ms. Nana is the Finance, Operations and Resource Mobilization Manager at the Botswana Network on Ethics, Law and HIV/ AIDS Agency (BONELA), where she supports multiple portfolios and health financing advocacy.
What is the mission of BONELA and why is the agency committed to integrating an ethical, legal and human rights-based approach to its work?
BONELA’s vision is making the right to health a reality in Botswana. We work to ensure the protection, promotion and fulfillment of the right to health because we feel that without these three things, people cannot live their best lives. A lot of work is premised on the 7 principles of the right to health on the issues of availability, accessibility, acceptability, good quality, accountability, meaningful participation of the people who receive services, and the underlying determinants of health. This guides our programming and how we aim to achieve our vision of making the right to health a reality in Botswana. We strive to create agency in individuals to claim their right to health.
What have been the largest barriers that BONELA has encountered in relation to ensuring that the rights and voices of people living with HIV/AIDS (PLHIV) are heard and addressed?
There are many groups that are vulnerable because of their age, socio-economic status, sexual orientation or geographic location, and PLHIV/AIDS fall into this vulnerable population. All of these elements play a role in how people access health services. BONELA is constantly looking at these issues to see how we can play a role in creating an enabling environment such that people can achieve their health outcomes.
When BONELA first began, for PLHIV, the largest challenges were around stigma and discrimination because people didn’t understand HIV/AIDS. We’ve fought for policies to ensure that people are not fired from their positions because of their HIV status or sexual orientation. It’s important that this has been written into national policy.
Despite tremendous progress due to advocacy, we still experience resistance from people who don’t necessarily agree with what we’re doing. We’re constantly thinking about our engagement strategy depending on our audience and how to align our goals with various stakeholder groups, such as policymakers, technocrats and beneficiaries.
How effective has the Government of Botswana (GoB) been in supporting an enabling environment for a human rights-based approach to the HIV/AIDS epidemic in Botswana?
Over the past 3-5 years, there has been a shift in our relationship and I attribute it to advocacy. During this time, the GoB has created and supported an enabling environment through policy shifts. The country had its first LGBTQI organization recognized, registered and free to provide services. BONELA also won a court case which enabled access to antiretrovirals for foreign prisoners.
The GoB has also been leading a legislative review of all laws and policies that impact access to HIV, TB and malaria services. This shows country ownership. Together with the GoB, and through the support of the Global Fund, we have developed a 4-year human rights plan that has been costed and a commitment to fund the plan has been pledged by the government.
As the GoB works to achieve and maintain epidemic control of HIV/AIDS, what partnership(s) do you think will be most critical?
There’s a real opportunity for the GoB to leverage or capitalize on the relationships that civil society organizations (CSOs) have at the community level. Progress on achieving epidemic control has confirmed the value of civil society organizations in reaching the most vulnerable. COVID-19 has reinforced the need for CSOs to be innovative and flexible in their approaches, to build strong partnerships and coordinate their efforts with the government. BONELA, and similar organizations, work with the community every day. The government should utilize this benefit, to help them extend their messaging to the people, especially since CSOs have the skill set to engage different community groups, some of which the government may not necessarily reach.
What does universal health coverage (UHC) mean to you?
Assuring all people can use all health services they need, which are provided at the highest quality. When people receive services, they should never experience financial hardship.
How can the GoB ensure that the most vulnerable populations are protected under UHC? What do you think has to be done in order to ensure these protections?
There needs to be some level of UHC accountability. Ultimately, you need to be able to agree who should be covered, what proportion of costs should be covered, and what service should be covered. Then, it’s easier to hold the relevant stakeholders accountable. There has to be a minimum package of services that are being offered to Botswana as a whole, regardless of the cohort a person belongs to. This package of services also needs to be costed and ensure that it’s included in the country’s UHC package of services.
“COVID-19 has been the great leveler. It demonstrated that there is a lot left to do to make our health system resilient.”
From your perspective, what has been the effect of COVID-19 on Botswana’s health system, and do you think it has impacted the country’s commitment to UHC or how it funds vertical programs like HIV/AIDS?
COVID-19 has been the great leveler. People have talked about resilient, sustainable systems for health but COVID-19 has shown people that our health system is not resilient or sustainable. It has revealed the weakness of the health system; we have no choice but to acknowledge what isn’t working. We must become more adaptive.
During the pandemic, people didn’t want to go to health facilities due to movement restrictions and fear of contracting the virus. We have to make changes to the way in which we provide health services so that people can access services and their medication, especially if truly needed. Policies around multi-month dispensing need to be institutionalized coupled with improvements in drug supply chain management for essential medicines and commodities, which includes HIV, TB and non-communicable disease medicines.
COVID-19 demonstrated that there’s a lot left to do to make our health systems truly resilient.
Photo Credit: Goitsemang Rampa, and Nana Gleeson