Published on Investing in Health

Closing health gaps for women: The Botswana story

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Menstrual Hygiene Education
HPV vaccine being administered in Botswana. Photo: Ministry of Health of Botswana

​The World Bank Group’s new Gender Equality Strategy for 2016-2023, launched last week, addresses gender inclusion not just as a goal in and of itself, but one critical to development effectiveness.  

Closing health gaps for women and girls by expanding access to essential services is one of the strategy’s main objectives. It represents a critical call for supporting major innovations to strengthen health care organization and service delivery platforms, along with adequate funding allocations, to make health systems more fully responsive to the needs of women and girls, offering high-quality, comprehensive and readily accessible services.
Botswana’s recent effort to integrate service delivery for HIV and cervical cancer offers a good example of a promising approach to improve women’s health and reduce preventable deaths.  Let us explain why.
Botswana is located in Southern Africa, which is widely regarded as the 'epicenter' of the global HIV epidemic. Girls and women of reproductive age have been severely affected by HIV, with a prevalence of 29.4%. Southern Africa also has the highest incidence of cervical cancer in the world, with rates exceeding 50 per 100,000 population and mortality higher than 40 per 100,000 population.
HIV-positive women are four-to-five times more likely to develop cervical cancer, a preventable condition that usually results from a viral infection by the human papillomavirus (HPV), which is generally sexually transmitted, and one of the leading causes of premature death and ill health among women in sub-Saharan Africa. The high mortality from cervical cancer reflects limited access to cervical cancer screening and timely treatment.
The government of Botswana’s comprehensive response to the HIV epidemic, particularly its commitment to the national anti-retroviral (ARV) treatment program, using mostly domestic funding, has made the country a leader in Africa’s HIV response.  However, the long-term demands of Botswana’s HIV/AIDS epidemic have overstretched the capacity of the health workforce and created fragmentation in health system planning and service delivery. 
In response to these challenges, the Botswana Ministry of Health (MOH) has embarked on an ambitious agenda to harmonize and align health planning, financing, service delivery, and monitoring and evaluation across the health system. The Ministry is also implementing a 10-year Integrated Health Sector Plan to address current and future health needs and explicitly shift away from a vertical approach to program planning and implementation.
As part of this more integrated approach, with initial assistance from the World Bank-funded National HIV/AIDS Prevention Support Project, the Pink Ribbon Red Ribbon Initiative of the G.W. Bush Institute, PEPFAR, and other partners, the MOH is supporting expansion of the national Cervical Cancer Control Program.  Under this strategy, the HIV diagnostic and treatment platforms established across Botswana since the early 2000s are being leveraged  to expand upon, integrate and scale up the “see and treat” cervical cancer screening approach, using a visual inspection acetic acid procedure and enhanced digital imaging, as well as cryotherapy, to destroy abnormal tissue in the cervix by freezing it.
Given resource limitations hindering the expansion of cytology-lab based screening, the “see and treat” approach has proven to be a cost-effective intervention to prevent cancer deaths in different countries, such as India and Thailand.  As of June 2015, the program in Botswana had achieved 60% of its target coverage and had been expanded to eight sites, with two additional sites and two mobile clinics planned for the near future. 
Building upon a pilot program in Gaborone, HPV vaccination for school-age girls was rolled out nationwide in 2015 as part of the Expanded Program for Immunizations under a joint MOH and Ministry of Education Skills and Development initiative. The vaccine was administered in all schools and health facilities.
As of June 2015, more than 90% of girls aged 9-13 years had been vaccinated against HPV. The HPV vaccine can prevent infection from HPV types that are responsible for 70% of cervical cancer worldwide and also protects against types that cause anal and genital warts.  
Sustainability of the integration strategy requires that regular MOH budgetary allocations be maintained and improved to ensure continuity of Botswana’s relatively high cervical cancer coverage screening and HPV vaccination rates, along with diagnosis and treatment of HIV and other sexual transmitted infections.  Support is also needed to facilitate geographical expansion of service coverage in rural districts with low population density, using mobile health units already employed to support the safe male circumcision outreach program.
Cervical cancer data collection in health facilities also needs improvement, through using revised data collection forms and integration within the new national electronic health information system.
Proposed incorporation of HPV DNA testing into the mobile health program would streamline cervical cancer screening. Essentially, this new technology would be used to screen out the 80-85% of women who would test negative for HPV DNA and consequently enable greater focus on the 15-20% who are at risk.
The Botswana experience of integrating cervical cancer control into HIV service delivery platforms has the potential to have a transformational impact in closing a major health gap for women and girls by maximizing the use of available resources. It also shows the power of leveraging and expanding partnerships with different actors to improve health outcomes.
Based on the government’s high level of commitment to this effort, we are confident that the health services delivery integration strategy will go a long way to save women's lives and improve gender equality. 
Follow the World Bank health team on Twitter: @WBG_Health 
World Bank Group Gender Strategy (FY16-23) : Gender equality, poverty reduction and inclusive growth
HIV/AIDS in Botswana
Botswana HPV Roll-Out Campaign
Pink Ribbon Red Ribbon:  Botswana Cervical & Breast Cancer Overview
Cervical Cancer Undermines Gender Equality in Africa
The challenge of non-communicable diseases and road traffic injuries in Sub-Saharan Africa : An overview


Patricio V. Marquez

Former World Bank Group (WBG) Lead Public Health Specialist

Sheila Dutta

Senior Health Specialist

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