Botswana Multi-Sectoral Strategy for the Prevention and Control of Non-Communicable Diseases, 2018–2023

Objectives

Botswana’s 2018–2023 National Non-Communicable Diseases (NCD) Strategy seeks a healthy lifestyle for all, free from preventable disease and premature death, by reducing the burden of NCDs and modifiable risk factors through evidence-based, cost-effective interventions and partnerships.[1]It provides a national, multi-sectoral roadmap aligned with Botswana’s National Development Plan 11, Vision 2036, the Sustainable Development Goals, and the World Health Organization Global Action Plan for the Prevention and Control of NCDs 2013–2020.[2][3][1]

• Focus on cancers, cardiovascular diseases, diabetes and chronic respiratory diseases, which account for 82% of NCD-related deaths, while addressing smoking, harmful alcohol use, unhealthy diet and physical inactivity as the principal modifiable risk factors.[4]
• Reduce risk factors through primordial prevention, health promotion, public awareness, community mobilisation, healthy lifestyles and legislative and policy environments that enable healthy living.[5][6]
• Improve access to healthy foods, physical activity, breastfeeding support, active urban design, safer workplaces and environmental-health measures, using regulation, taxation, subsidies and incentives where appropriate.[7][8]
• Prevent and detect disease early through integrated primary-care services, systematic screening, vaccination, adult health checks, timely referral and linkage to care.[9][10]
• Provide standardised, quality, people-centred treatment, palliative care, rehabilitation and psychosocial support, beginning at primary-care level and supported by a capable workforce, essential medicines, diagnostics and specialist services.[5][9][11]
• Strengthen monitoring, surveillance, information systems and policy-impacting research to understand disease burden, evaluate interventions and identify innovative solutions.[5][12]
• Strengthen national prioritisation, investment, governance, coordination and partnerships so that NCD action is integrated across sectors and development planning.[5][12][13]

The strategy sets measurable prevention targets, including by 2025 a 30% reduction in tobacco use, a 10% reduction in harmful alcohol use and physical inactivity, a 30% increase in fruit and vegetable consumption, and no increase in obesity.[6]It also targets, by 2023, 95% coverage of eligible people for human papillomavirus and hepatitis B vaccination, 80% cervical-cancer screening coverage, 60% early diagnosis of breast and cervical cancers, and a 25% increase in early hypertension diagnosis.[9]Further outcome ambitions include 80% of the population having NCD-prevention awareness and 80% of community structures supporting quality, cost-effective prevention interventions by 2023.[6]

Service priorities encompass diabetes and cardiovascular risk management, cancer prevention and care, chronic respiratory disease, eye health, mental health, substance-use support and palliative care.[14][15][16]The strategy recognises major health-system constraints, including late cancer diagnosis, centralised curative services, inadequate funding, insufficient coordination, weak use of research and limited NCD data.[17][16][18]

Implementation

Implementation follows a people-centred, equitable and rights-based model built on community participation, health-system strengthening, integrated primary care, evidence and innovation, and multi-sectoral collaboration.[1]It combines population-level policy action with community, school, workplace and health-facility interventions, spanning primordial prevention, primary prevention, early diagnosis, treatment, care and support.[7][8]

• Lead national coordination through the Ministry of Health and Wellness and its national NCD programme, which is the strategy’s coordinating unit and custodian.[19]
• Operate a three-level governance structure comprising the national NCD programme, a national coordinating committee and a high-level multi-sectoral steering council.[19]
• Convene the national coordinating committee quarterly, chaired by the Director of Public Health, to guide implementation, review monitoring and evaluation results, consider annual performance reports and exchange information.[19]
• Convene the steering council twice yearly under the Office of the President and chaired by the Vice President to provide high-level policy guidance, review national commitments and support resource allocation.[19]
• Integrate NCD activities into ministerial, district, parastatal and partner plans through a graduated minimum NCD response package, annual work plans, reporting mechanisms and sector budget lines.[20][21]
• Engage government ministries, local authorities, health programmes, private-sector and parastatal organisations, civil society, media, academic institutions, professional bodies, development partners and community structures.[20][22][23]

Operational delivery includes a comprehensive NCD communication plan; dissemination through radio, television, print and social media; training and deployment of community health workers for outreach and screening; and support for village health committees and other community structures.[6][20]Schools and workplaces are delivery platforms for health education, healthy food, physical activity, screening and wellness programmes.[14][7][24]Primary-care services are to use standardised guidelines, routine screening, adult well checks, strengthened referral pathways, multidisciplinary care, HIV integration, improved laboratory capacity, medicines supply monitoring and patient-support groups.[9][10][25]

Policy and regulatory measures include implementing the World Health Organization Framework Convention on Tobacco Control; smoke-free environments; tobacco packaging, advertising and sales restrictions; alcohol marketing and availability controls; drink-driving enforcement; and fiscal measures affecting tobacco, alcohol and unhealthy foods.[6][26][24]The strategy also envisages stronger health-promotion financing through alcohol and tobacco levy funds, potential future sin taxation, corporate social investment, partnership agreements and an essential primary-care insurance package.[20][27]It does not specify total budgets, monetary allocations or a quantified funding gap.[27][28]

Monitoring and accountability rest with the Ministry of Health and Wellness, supported by a comprehensive national framework that standardises indicators, definitions, data collection and information flows, while integrating NCD reporting with existing health information systems.[13][29]Data sources include risk-factor surveys, national statistics, cancer and diabetes registries, primary-care reporting tools, programme records, health accounts audits and palliative-care records.[30][31]Progress is to be tracked through indicators covering risk factors, disease burden, service coverage, treatment control, medicines, cancer diagnosis, vaccination, palliative care, awareness, coordination and funding.[29][28]Annual NCD reports, stakeholder dissemination, annual performance reviews, a third-year external mid-term review and a sixth-year end-of-term review provide the principal review mechanisms.[13][19]

Monitoring & Evaluation

The strategy establishes a national monitoring, evaluation and information-management system to track non-communicable disease (NCD) risk factors, disease burden, health-system performance, implementation and impact. The Ministry of Health and Wellness is the custodian of the monitoring and evaluation function, supported by a national NCD programme acting as secretariat to the coordinating structures.[13][29][19]

• Standardise indicators, definitions, data-collection methods and information flows through a comprehensive monitoring and evaluation framework integrated with existing health information systems.[13][29]
• Measure risk-factor outcomes including tobacco and alcohol use, unhealthy diet, physical inactivity, obesity, raised blood glucose and hypertension, as well as premature NCD mortality and incidence of diabetes, hypertension, asthma, breast cancer and cervical cancer.[29][28]
• Track health-response indicators covering prevention awareness, early cancer diagnosis, cervical screening, human papillomavirus and hepatitis B vaccination, diabetes treatment, palliative-care access, essential-medicine availability and national funding for NCD activities.[29][28]
• Use data from the WHO STEPwise approach to noncommunicable disease risk-factor surveillance survey, WHO country profiles, Statistics Botswana, cancer and diabetes registries, primary-care reporting tools, programme records, health accounts audits and palliative-care records.[30][31]
• Report most risk-factor indicators every three years from 2020, while reporting mortality, cancer, treatment-control, palliative-care, screening and vaccination indicators annually from 2018 or 2019.[30][31]

Time-bound targets include 80% complete and timely reporting of key data fields, a 25% increase in relevant NCD data fields, and 25% increases in NCD publications and publications led by Batswana by 2023.[12]Prevention and service targets include reductions in tobacco use, harmful alcohol use, physical inactivity, unhealthy diet, hypertension and premature NCD mortality, while maintaining obesity and diabetes prevalence without increase by financial year 2023.[30][31]

Monitoring is intended to inform quality improvement, financing, workforce and resource-management decisions, and national and global reporting.[29]Routine programme monitoring, audits, structured supervision and periodic facility-capacity assessments are to assess service uptake, disease outcomes, waiting times and patient satisfaction.[11]Risk-factor surveys are to be conducted every five years with comparability over time, alongside strengthened implementation research, research ethics, grants management, data sharing and evidence-to-policy processes.[12][32]

Accountability arrangements include annual NCD reports and information dissemination, quarterly meetings of the national coordinating committee to review monitoring results and annual performance reports, and twice-yearly high-level steering-council reviews of national commitments.[13][19]External implementation reviews are planned at the third-year mid-term and sixth-year end-of-term points.[19]Botswana’s Performance Management System is intended to support public-service accountability, alongside financial accountability for response resources.[21][33]

Important information-system gaps include limited routine NCD data use, infrastructure and connectivity constraints, weak data management, inadequate cross-sector information exchange, and incomplete data on morbidity, treatment, medicine toxicity, disease control and retention in care.[18]Indicators are to be expanded in phases as data systems, monitoring infrastructure and resources improve.[29]

Costing & Financing

The strategy promotes cost-effective NCD prevention and control, but the supplied material does not provide a consolidated budget, programme-level costing, quantified funding gap, economic assumptions or expenditure plan.[1][6][16]Financing is envisaged as a multi-sectoral responsibility involving government, private-sector organisations, parastatals, civil society, development partners and international partners.[22][33]

• Increase total funds spent on NCDs across sectors by 25% by 2023.[12]
• Increase national multi-sectoral per-capita NCD spending by 20% by financial year 2023, measured through a health accounts audit.[31]
• Establish sectoral budget lines for NCD programming as part of the graduated minimum response package, to be instituted by 2022.[21]
• Develop comprehensive national costing and a sustainable investment case for NCD action.[20]
• Use alcohol and tobacco levy revenues, potential future sin taxes, corporate social investment and partnership agreements to support health-promotion and NCD activities.[20][27]
• Support expanded preventive services through universal insurance coverage for an essential primary-care package.[27]

Government was the main NCD financing source in 2013-14, when NCD goods and services represented 14% of total health spending.[16]Spending was concentrated on inpatient curative services, followed by outpatient services and governance and coordination.[16]Resources for NCDs were reported to be increasing, but a significant funding gap remained, with greater participation by partners and sectors required because NCDs did not have a global funding mechanism comparable to HIV.[16]

Alcohol-control financing included an alcohol levy introduced at 30% in 2008 and subsequently reported at 55%, with the Levy on Alcoholic Beverages Fund generating USD 150 million in its first five years for prevention, rehabilitation, monitoring, law-enforcement support and community activities.[34]Tobacco products were subject to a 30% levy introduced in 2014, below the World Health Organization recommendation of at least 70% of retail price.[35]The Ministry of Finance and Economic Development is assigned responsibilities for mobilising, allocating and disbursing resources, coordinating development-partner contributions and ensuring financial accountability.[33]

Phased implementation is intended to begin with more efficient use of available resources and strengthened coordination and monitoring before progressing to activities requiring additional resources.[19]The high-level steering council is expected to identify relevant budgets and plans across participating institutions and support appropriate resource allocation.[19]