The effects of HIV on Botswana’s development progress

By Siddharth Krishnaswamy

Siddharth was a part of the Vulnerability & Mapping Unit (VAM) of the WFP. Prior to this he worked for an international NGO in Northern Uganda. He holds an MBA and a Master's in Development from Cornell University, USA. He is currently completing coursework towards his Ph.D.

This work is a condensed version of a working paper written for the WFP. The author wishes to thank Mr. Arif Hussein & Ms. Joyce Luma at the WFP. Without their insight, comments and input this paper would not have been possible. Needless to say, errors if any, belong solely to the author.

This paper attempts to study the impact of HIV on Botswana's development. This is followed by an evaluation of government policy. In order to gauge the impact of HIV, Botswana's development has been divided into two periods - 1970 to the early 1990s and from the early 1990s to 2002. Finally, based on the above data, the paper offers a hypothesis on the country's present HIV crisis.

Performance of Adult Health Indicators

Adult Mortality Rate

In 1970 in Botswana the adult mortality rate (per 1000) was 395 for women and 472 for men. By 1980, female and male adult mortality had fallen to 278 and 341 respectively - an improvement of approximately 29% in the space of one decade. By contrast, South Africa would take nearly twice as long (1997) to reduce the adult mortality rate by 20 %. However between 1980 and 1997, both male and female life expectancy declined in Botswana (61% and 51% respectively), with an even steeper decline for women between 1997 and 2002 (see table 1).

Life Expectancy at Birth

Mirroring the adult mortality trend, life expectancy at birth for females improved from an average of 57 years in 1970 to 67 years in 1992 and for males from 53 years to 62 years. However, between 1995 and 2002 total life expectancy fell by 36% (see figure 1). Thus, it can be seen that not only were all the gains of the 1970s and 80s nullified, but the life expectancy of a man or women in 2002 was roughly 20 years less than it had been in 1970.

A comparison of life expectancy rates (figure 2) of Botswana's neighbours (South Africa and Swaziland) proves that HIV had an adverse impact on these countries as well. However, the rate of decrease in life expectancy is markedly more pronounced in Botswana as compared to her neighbours.

Source: World Bank, 2002

Source: World Bank, 2002

Source: World Bank, 2002

Performance of Child Health / Nutrition Indicators

Although a similar decline in child health indicators in the period 1970 - 2002 is to be expected, this has not occurred.

Infant Mortality Rate and Under 5 Mortality Rate

Between 1970 and 1990, Botswana reduced infant mortality by more than 50% - from 99 deaths per every 1000 in 1970 to 45 per 1000 in 1990. There was a slight reversal in the next 5 years - reaching 50 deaths per 1000 in 1995. In the period between 1996 and 2000, there was a further and sharp increase, resulting in infant mortality being reported at 74 in 2002. The net effect of this was that, in 30 years, Botswana had reduced infant mortality by approximately 25% rather than the pre-1990 achievement of 50%. The Under-5 Mortality Rate had been reduced by 28% in 2002 compared to 1970 (see figure 3)

Other Indicators

There has been a 36% increase in diphtheria immunisations in the past two decades, from approximately 71% of 12-23 month old children in 1980 to 97% reported immunisation of this age-group in 2002. Similarly, immunisation rate against measles had increased from 60% to 90% of all children (between the ages of 12 - 23 months) by 2002 - an increase of 43%.

Botswana has made steady and constant progress in reducing child malnutrition. There has been a 21% reduction in prevalence of stunting (moderate and severe) amongst children under 5 years from 1996 to 2001, while prevalence of underweight (moderate) amongst children below the age of 5 has more than halved between 1984 and 2002.

HIV / AIDS

Botswana has the second highest HIV prevalence rate in the world at 37.3% (see table 2). Paradoxically, awareness of the disease and the use of condoms are widespread. More than 90% of the population aged between 15 - 24 years are aware of the importance of condoms. However, a low percentage of the population have comprehensive knowledge about HIV (see table 3).

Table 1: Percentage Change in Adult Mortality Rates (1970 - 2002)
	1970 - 1980	1980 - 1997	1997 - 2002	1970 - 2002
Adult mortality rate, female (per 1,000)	-29.6%	+ 51%	+ 88%	+ 100%
Adult mortality rate, male (per 1,000)	-27.7%	+ 61%	+ 50%	+ 74%
Adult mortality rate, male and female (per 1,000)				+ 88%

Source: World Bank, 2002

 

Table 2: Prevalence of HIV / AIDS in 2003
Botswana - HIV and AIDS estimates, end 2003
Adult (15-49y) HIV prevalence rate	37.3 % (range: 35.5%-39.1%)
Adults (15-49y) living with HIV	330,000 (range: 310,000-340,000)
Adults and children (0-49y) living with HIV	350,000 (range: 330,000-380,000)
Women (15-49y) living with HIV	190,000 (range: 180,000-190,000)
AIDS deaths (adults and children) in 2003	33,000 (range: 25,000-43,000)

Source: Report on the global AIDS epidemic (UNAIDS), 2004

 

Table 3: Awareness and knowledge of HIV / AIDS amongst adults in Botswana
	%
Men aged 15-24y who know that a healthy-looking person can transmit HIV	76%
Women aged 15-24y who know that a healthy-looking person can transmit HIV	81%
Men aged 15-24y who know that a person can protect himself from HIV infection by consistent condom use	89%
Women aged 15-24y who know that a person can protect himself from HIV infection by consistent condom use	93%
Men aged 15-24y with comprehensive correct knowledge of HIV/AIDS	33%
Women aged 15-24y with comprehensive correct knowledge of HIV/AIDS	40%

Source: UNICEF-UNAIDS-WHO, 2001

 

Table 4: Total and Public Health Expenditure in Botswana (1990 - 2000)
	1990	1995	2000
Total health expenditure (percentage of GDP)	3	5.4	6
Public health expenditure (percentage of GDP)	1.7	2.8	3.8
Total health expenditure per capita (current US$)	89	168	191

Source: World Bank, 2003

 

Government Policy and Health Expenditure

Government expenditure on health has increased substantially in the past decade, with a 63% increase in total per capita expenditure on health in the 4 years between 1998 and 2002, and programming has moved from a narrow focus on blood screening to a broader portfolio concerned with the prevention of transmission of the disease.

In 1990, total health expenditure in Botswana was 3% GDP, increasing to 6% of GDP in 2000 (see table 4). Similarly, public health spending also doubled from 1.7% to 3.8 % of GDP, similar to the mean for upper middle-income countries (3.3 per cent of GDP). In per capita terms, total expenditure on healthcare in Botswana was US$191 per capita in 2000. Compared with other African counties, Botswana's total public expenditure on health appears to be one of the highest in Southern Africa (figure 5) - about 30 times the level of expenditure in the other five countries.

As a percentage of GDP, the HIV/AIDS expenditure in Botswana is very high at one per cent of GDP¹. The median HIV/AIDS expenditure is US$0.9 per capita. If one considers only the infected population, then Botswana spends $51.42 per person living with HIV/AIDS (PLWHA) and the other countries spend below US$15.

Source: World Bank, 2002

Source: A Comparative Analysis of the financing of HIV / AIDS programmes, 2003. Published by the Human Sciences Research Council & funded by the Kellogg Foundation.

Source: World Bank, 2003

Source: Botswana Human Development Report 2000

Discussion

The data presented above appears confusing and contradictory.

• The country has one of the highest HIV prevalence rates in the world, yet the Government of Botswana is one of the biggest spenders on health and HIV prevention in Southern Africa.
• On most development indicators excluding adult health, Botswana has made progress and indicators of child health and nutrition are relatively sound.

Analysing the data in figure 5 one can argue that Botswana's HIV problem and its resulting impact on development is not because of lack of commitment or action on the government's part but results from crucial delays in government action.

Little change or increase in government spending (relative to later years) on HIV/AIDS was realised during the period 1990 - 97. Although expenditure increased by 162 percent from 1997 onwards, by this time, Botswana's development was already in steep decline (see figure 6). Arguably, if government expenditure and activity on AIDS had been initiated a few years earlier - 1995 instead of 1998/99 - then Botswana's HIV problem would probably have not been so dire.

It can also be hypothesised that the fact that overall child health and nutrition in Botswana is better than expected is a direct result of government spending/development programmes since 1997.

Indeed indicators that measure the nutritional status and wellbeing of children in 2003/04 use subjects born after 1997. By this period, the government was actively involved in addressing not just the HIV problem but also dedicated to increasing public expenditure on health. This manifested itself in the introduction of various programmes ('Education for young people', 'Condom distribution and education', 'Prevention of mother to child transmission of HIV (PMTCT)'. The Government of Botswana also initiated programmes specifically for women and girls, such as psychosocial support, especially for home based female caregivers, education on HIV/AIDS gender based violence, and training on HIV/AIDS and human rights. There are also government programmes for orphans and vulnerable children. Furthermore, the government has announced plans to provide free anti-retroviral therapy to any citizen tested positive for AIDS (UNICEF).

Many of the current programmes in place expressly target maternal and child health. It could be argued that under-5 and infant mortality rates are very high, primarily due to mother to child transmission² while other indicators such as stunting, wasting, and low birth weight have all shown steady improvement over the past 3 decades.

In conclusion, it appears that while Botswana's HIV problem is dire, the silver lining is that children's health status is markedly better. The government is clearly concentrating on improving and maintaining child nutrition. Programmes such as school feeding and support to orphans are evidence of this. More importantly, all the data underline the effectiveness of this commitment. Unfortunately adult health is a different story. With hindsight it could be argued that had the government commenced its present comprehensive programme in 1994/5 rather than 1997/8, the situation now would be far better. Present projections imply that mortality rates will continue to rise till 2007 before levelling off (figure 7). This slowing of mortality rates in 2008 would be a result of the present actions and initiatives of the government.

For further information, contact: Siddharth Krishnaswamy, email: sidkrish@gmail.com

---

¹A Comparative Analysis of the financing of HIV/AIDS programmes, 2003

²Infant feeding practices are also a key consideration when investigating infant mortality rates. See two research pieces in this issue that look at infant feeding strategies and morbidity and mortality outcomes in Botswana. (Eds)