63074 Fertility Decline in Botswana 1980–2006 A Case Study The World Bank May 2010 Fertility Decline in Botswana 1980–2006 A Case Study May 2010 iii Contents Acknowledgements v List of Acronyms vii Executive Summary viii Introduction 1 Botswana’s Health Care System 3 HIV/AIDS Has Slowed Progress on Some Health Indicators 4 Total Fertility Rate Has Declined 5 National Family Planning Program Is Integrated with Primary Health Care 6 Family Planning Services in Public Health Facilities 6 Botswana Population Sector Assistance Project, 1988–1996 7 Condom social marketing program 7 Information, education, and communication 9 Workplace education 9 Training for reproductive health 9 NGO programs in reproductive health 9 Contraceptive logistics system 10 Monitoring and Evaluation of the Family Planning Program 10 Knowledge of family planning and contraceptive method mix 10 Availability and Quality of Family Planning 12 Increased Age at First Birth and Prolonged Breastfeeding Are Important Determinants of Declining Fertility 14 Age at First Birth Versus Age at Marriage 14 Cohabitation 14 Child fostering 15 Prolonged Breastfeeding and Postpartum Abstinence 15 Effect of HIV on Fertility 16 Induced Abortion 16 iv Socioeconomic and Cultural Factors Have Contributed to the Fertility Decline 17 Female Education 17 Women’s Labor Force Participation 18 Urbanization 18 Improved Survival of Children 18 Lessons and Implications for Other Sub-Saharan African Countries 19 The Way Forward: How to Strengthen the Botswana Family Planning Program 21 References 23 Appendix Fertility Reduction 1980–2006 in Countries with a Total Fertility Rate of more than 6.0 in 1980, by Region 26 End Notes 28 Tables Table 1. Botswana at a Glance, 2009 2 Table 2. Public Health Facilities in Botswana, 2004 3 Table 3. Current Use of Modern Contraceptive Methods (1984–2007), Percent of all Women Aged 15–49 Years 11 Table 4. Contraceptives Supplied to Public Health Facilities by inistry of Health Central Medical Store by Year, 1993 and 2005–2008 12 Table 5. Contraceptive Method by Family Planning Attendances, 1998–2003 12 Table 6. Enrollment at the University of Botswana by Sex, 1996–2006 17 Figures Figure 1. Map of Botswana x Figure 2. Total and HIV-Specific Maternal Mortality Ratio in Botswana, 2005–2007 4 Figure 3. Total Fertility Rate in Botswana, 1981–2007 (selected years) 5 Figure 4. Service Providers Trained for Youth-Friendly Services, 2003–2008 9 Figure 5. Percentage of Women Ages 15 Years and Above Who are Married, 1971–2001 15 Figure 6. Literacy Rate (percent) by Sex, Ages 10–70, 1981–2003 17 Boxes Box 1. Timeline of Important Events in the Botswana Family Planning Program 8 Fertility Decline in Botswana, 1980–2006 | A Case Study v Acknowledgements T his report was prepared by Samuel Mills with the literature search. Mukesh Chawla, of the Health, Nutrition, and Popula- Sector Manager (HDNHE) and Julian Sch- tion unit of the Human Development weitzer, Sector Director (HDNHE) provided Network (HDNHE), Veronica Leburu of the overall guidance and support. Thanks to Vic- Botswana Ministry of Health (BMOH), She- toriano Arias (HDNHE) for providing ad- naaz El-Halabi (BMOH), Lesego Mokganya ministrative support. (BMOH), and Sadia Chowdhury (HDNHE). This case study was part of a larger World The commitment, support, and partici- Bank Economic Sector Work entitled Ad- pation of many individuals from the Bo- dressing the Neglected MDG: World Bank Re- tswana Ministry of Health are gratefully view of Population and High Fertility with an acknowledged. The staff of the Sexual and Re- external advisory group comprising: Stan Ber- productive Health Division in the BMOH nstein (United Nations Population Fund), contributed immensely to the development John Bongaarts (Population Council), John of this document. Special thanks go to Tshe- Casterline (Ohio State University), Bar- gofatso Maotwe, Family Planning Program bara Crane (IPAS), Adrienne Germain (In- Officer. Tshiamo Keakabetse and Mrs. Sinah ternational Women’s Health Coalition), Jean Phiri are also commended for ensuring con- Pierre Guengant (L’Institut de recherché pour tinued availability of pertinent data. The le développement), Jose Guzman (United support of the Ministry of Finance and Devel- Nations Population Fund), Karen Hardee opment Planning (Central Statistics Office), (Population Action International), Daniel Ministry of Education and Skills Develop- Kraushaar (Bill and Melinda Gates Founda- ment, Ministry of Local Government (Pri- tion), Gilda Sedgh (Guttmacher Institute), mary Health Care), Botswana Family Welfare Amy Tsui (Johns Hopkins University, Bloom- Association, and Population Services Interna- berg School of Public Health), and Wasim tional are also appreciated. Special thanks go Zaman (International Council on Manage- to Diemo Motlapele (Health Statistics Unit) ment of Population Programmes). The World for ensuring that relevant statistical data were Bank advisory group comprised: Martha Ain- available to the District Health Teams’ man- sworth (IEGWB), Peter Berman (HDNHE), agement in Gaborone, Kweneng East, and Eduard Bos (HDNHE), Rodolfo Bulatao Kgatleng and for allowing the research team to (HDNHE), Hugo Diaz Etchevere (HDNVP), use some health facilities for assessment. Rama Lakshminarayanan (HDNHE), John The authors are grateful to the World May (AFTHE), Elizabeth Lule (AFTQK), and Bank Library Research Services for assisting Thomas Merrick (WBIHS). vi The authors would like to thank the gov- Correspondence Details: ernment of the Netherlands, which provided financial support through the World Bank- Æ Sadia Chowdhury (HDNHE), World Netherlands Partnership Program (BNPP) for Bank, Mail Stop G7–701, 1818 H Street presentation of the report at the International N.W., Washington, DC 20433, USA, Conference on Family Planning: Research and Tel: 202-458-1984, Best Practices, Kampala, Uganda, November email: schowdhury3@worldbank.org 2009 and for the publication of the report. Æ This report is available on the following website: http://www.worldbank.org/hnppublica- tions. Fertility Decline in Botswana, 1980–2006 | A Case Study vii List of Acronyms AFTHE Health, Nutrition, and IEC Information, Education, and Population unit of the Africa Communication region IEGWB Independent Evaluation Group, AFTQK Africa Operational Quality and World Bank Knowledge Services MCH/FP Maternal and Child Health/ BOTSPA Botswana Population Sector Family Planning Assistance Project STI Sexually Transmitted Infection CSO Central Statistics Office UNFPA United Nations Population HDNHE Human Development Network, Fund Health, Nutrition, and UNICEF United Nations Children’s Fund Population unit USAID United States Agency for HDNVP Office of the Senior Vice International Development President and Head of Human WBIHS World Bank Institute Health Development Network Systems HIV/AIDS Human Immunodeficiency WHO World Health Organization Virus/Acquired Immune Deficiency Syndrome viii Executive Summary B otswana has had a stable democratic immunizations, and STI), they are also of- government and good governance since fered family planning services. With the ad- independence in 1966. With a sustained vent of the HIV epidemic in the 1990s, high average economic growth (about 9 per- HIV/AIDS services were also integrated cent) fueled by the diamond mining industry, into MCH/FP. These integrated services— it is the only country in Africa listed among offered daily in a vast network of primary the 13 “economic miracles” of the world for health care facilities in both rural and urban 1960–2005. areas—made family planning widely avail- The total fertility rate remains high able in Botswana. MCH/FP services are free in Sub-Saharan Africa, with 25 countries and accessible—every citizen is within 8–15 showing a rate greater than 5.0. In contrast, kilometers of the nearest health facility. And Botswana experienced the greatest fertility de- outreach services at mobile stops and home cline in the region during 1980–2006, with visits reach out to those who do not use the the total fertility rate decreasing from 7.1 in service facilities. 1981 to 3.2 in 2006. The Botswana national Other components that strengthened family planning program, judged the stron- the family planning program included: pre- gest in Africa, contributed to this decline. service and in-service training of service pro- Other factors contributing to the fertility de- viders; a condom social marketing program cline include: (a multimedia campaign); information, ed- ucation, and communication (IEC) that Æ Increased age at first birth. focused on training service providers and de- Æ Prolonged breastfeeding. veloping IEC materials; training of nongov- Æ Increased female education. ernmental organizations to improve outreach Æ Women’s participation in the labor force. services to youth and collaborate with private Æ Improved survival of children. providers of family planning; improvement of the contraceptive logistics system; and The government strongly committed to strengthening of the monitoring and evalua- meeting family planning needs, integrated tion system. maternal and child health/family planning Knowledge of at least one family plan- (MCH/FP) and sexually transmitted infec- ning method increased from 75 percent to tion (STI) services in 1973. When women 98 percent between 1984 and 2007. Use of visit health facilities for maternal and child modern contraceptives increased steadily health services (antenatal care, postnatal care, among all women ages 15 to 49, from 16 Fertility Decline in Botswana, 1980–2006 | A Case Study ix percent in 1984 to 29 percent in 1988, 40 Some of the lessons learned by Botswana percent in 1996, 42 percent in 2000, and might be applicable to high-fertility countries: 51 percent in 2007. Oral contraceptives were the most popular contraceptive during Æ Integrate maternal and child health, 1984–1996, but use of male condoms in- family planning, and HIV/AIDS services creased dramatically from 1 percent in 1984 at all levels of the health care delivery to 42 percent in 2007. Use of injectables also system. increased, from 1.1 percent in 1984 to 6.8 Æ Generate demand for family planning ser- percent in 2007. Data on contraceptives sup- vices. plied by the Central Medical Store to health Æ Strengthen program management through facilities (1993–2005) and family planning regular supervision and monitoring. attendance records show that the increasing Æ Promote and invest in the education of use of male condoms is attributable to the ef- girls. fective multimedia HIV campaign for dual Æ Promote policies that favor female partici- protection. pation in the labor force. Æ Promote prolonged breastfeeding. x Figure 1 | Map of Botswana Source: World Bank Map Design Unit. Fertility Decline in Botswana, 1980–2006 | A Case Study 1 Introduction O ne of the few upper-middle-income 2001, 72 percent of Batswana were Christian, countries in Sub-Saharan Africa, Bo- 21 percent professed no religion, and less than tswana is a landlocked country bor- 1 percent were Muslim. dered on the west by Namibia, on the south Botswana has had a stable democratic and southeast by South Africa, on the north- government and good governance since inde- east by Zimbabwe, and on the north by pendence from the United Kingdom in Sep- Zambia and Angola (figure 1). The popula- tember 1966. Over the past four decades, the tion has nearly tripled since 1971, growing nation has experienced a sustained high av- from 649,083 to 1,841,263 in 2008. There erage economic growth of about 9 percent, fu- are more females than males, with a sex ratio eled by the diamond mining industry. It is the of 92 males per 100 females (table 1).1 More only country in Africa listed among the 13 than four-fifths of the population lives in the “economic miracles” of the world for 1960– eastern part of the country, while the vast 2005.3 Poverty has reportedly declined from areas of the Kalahari Desert—about 84 per- about 59 percent in 1985–86 to about 30 per- cent of the total land area—in the west are cent in 2002–03.4 The government spends sparsely populated.2 Nearly 60 percent of the about 18 percent of its total budget on health, population is urban. Setswana is the national a higher proportion than the Abuja Declara- language and English the official language. In tion’s target of 15 percent.5 2 Table 1 | Botswana at a Glance, 2009 Population, total (million)a 1,841,263 Population growth (annual percent) 1.9 Population ages 0–14 (% of total) 35.4 Population ages 15–64 (% of total) 59.5 Population ages 65 and above (% of total) 5.2 Dependency ratio 68.1 Sex ratio (males per 100 females) at birth 92.4 Urban population (% of total) 59.6 GNI per capita, PPP (current international $) 11,850 Population living below US$ 1 per day 23.4 Health expenditure, total (% of GDP) 8.3 Health expenditure, public (% of GDP) 4.5 Health expenditure per capita (current US$) 431.1 Average number of children per household 1.46 Total fertility rate (births per woman) 2.9 Adolescent fertility rate (births per 1,000 women ages 15–19) 118 Contraceptive prevalence (% of women ages 15–49) 51 Life expectancy at birth, female (years) 60 Infant mortality rate (per 1,000 live births) 48 Maternal mortality ratio (maternal deaths per 100,000 live births) 193 Prevalence of HIV (% of population ages 15–49) 17.6 Births attended by skilled health staff (% of total) 95 Antenatal care with health personnel (%) 94 DPT immunization coverage (% by age one) 95 Nurses and midwives (per 1,000 people) 1.31 Physicians (per 1,000 people) 0.184 Literacy rate, adult female (% of females ages 15 and above) 81.8 Source: Several including Botswana Government report and the 2009 World Development Indicators. a Estimate, based on the 2006 Botswana Demographic Survey population of 1,773,240 and a 1.9 percent growth rate. Fertility Decline in Botswana, 1980–2006 | A Case Study 3 Botswana’s Health Care System B oth the Ministry of Health and the cilities in 24 health districts. Health services are Ministry of Local Government are re- accessible in both urban and rural areas, with sponsible for providing health care—at 84 percent of the population living within five different levels of the health system. Botswana kilometers of a primary health care facility.8 As has a six-tiered health care delivery system: health facilities are readily accessible in rural mobile stops, health posts, clinics, primary areas, differentials in health indicators between hospitals, district hospitals, and referral hos- rural and urban areas are not wide.9 Hospitals pitals (table 2).6 The Ministry of Health runs are open 24 hours a day and clinics from 7:30 the primary, district, and referral hospitals, a.m. to 4:30 p.m., with someone on call after sets national polices, and is responsible for closing hours to attend to emergencies.10 health personnel training; the Ministry of Health services are virtually free at the Local Government manages the clinics, health public facilities, requiring only a nominal posts, and mobile stops.7 A joint Primary charge of 5 Botswana pula (US$ 0.70 at the ex- Health Care Coordinating Committee has co- change rate of 1 US$ = 7.2 pula). Maternal and ordinated the two ministries’ activities since child health and family planning services are 1976. In most towns private hospitals and exempted from the nominal fee. Paved roads clinics also provide family planning services. connect most villages, making referrals rela- Three mining hospitals also serve as district tively easy even in the rural areas. Ambulances hospitals and provide services to the public in are available at the lower-level health facilities the mining communities. for transfers to hospitals. The government also Primary health care is provided through an has a contract with Netcare 911 to provide air extensive, decentralized network of health fa- ambulance services in emergencies. Table 2 | Public Health Facilities in Botswana, 2004 Level Number Characteristics Mobile stops 528 Outreach services by registered nurses/midwives and health education assistants; two-way radio communication system or telephones Health posts 341 Registered nurse and midwives, family welfare educators; telephones; ambulance available for referral Clinics 259 Registered nurses and midwives; sometimes doctors; telephones; some provide normal delivery services; ambulance or transport for referral available Primary hospitals 17 Nurses, midwives, and medical officers; basic emergency obstetric care; telephones District hospitals 14 Comprehensive emergency obstetric care; telephones Referral hospitals 3 Comprehensive emergency obstetric care; specialized care; telephones Source: Central Statistics Office, Botswana Ministry of Health 2007. 4 HIV/AIDS Has Slowed Progress on Some Health Indicators B otswana was experiencing remark- the infant mortality rate dropped from a high able improvements in health indicators of 97.1 deaths per 1,000 live births in 1971 to until the advent of the HIV/AIDS epi- a low of 37 deaths in 1996 but increased to 56 demic in the 1990s. Despite significant prog- deaths in 2001. By 2006 infant mortality had ress since then, HIV/AIDS remains a major decreased to 48 deaths per 1,000 live births, health issue, with a prevalence rate of 17.6 perhaps because of the coordinated national percent,11 the second highest in the world. response to the HIV/AIDS epidemic.15 Co-infection of HIV/AIDS and tuberculosis Accurate data for maternal mortality is dramatically increased the number of deaths only available for 2005–2007 because the during the 1990s.12 For example, life expec- World Health Organization’s International tancy rose from 55.5 years in 1971 to 65.3 Statistical Classification of Diseases was only years in 1991 but had fallen to 54.4 years by recently applied to maternal deaths in the 2006.13 Without HIV, life expectancy would country’s health information system. The data have been about 70 years by 2000.14 Similarly, suggest that HIV/AIDS as a major cause of maternal mortality might be on the decline (figure 2).16 If the 2005–2007 maternal | Figure 2 Total and HIV-Specific mortality ratios from the recently instituted Maternal Mortality Ratio in Botswana Maternal Mortality Monitoring Botswana, 2005–2007 System are accurate, Botswana is among the countries in Sub-Saharan Africa with 250 the lowest maternal mortality.17 200 193 The National AIDS Control Pro- 158 150 140 gram, established in 1989, has coordinated a strong national response (including both 100 prevention and treatment) to the epidemic. 47 50 43 Routine HIV testing has been carried out 19 0 in all public hospitals since October 2003, 2005 2006 2007 and the provision of free antiretroviral drugs MMR HIV MMR began in January 2002. Fertility Decline in Botswana, 1980–2006 | A Case Study 5 Total Fertility Rate Has Declined T he total fertility rate has fallen remark- Analysis of the 1988 Botswana Family ably since 1981, from 7.1 to 2.9 in 2007 Health Survey indicated that factors that (figure 3)—the steepest decline in fer- could account for this reduction in fertility tility in Sub-Saharan Africa during that period include higher age at first birth, lower in- (see appendix)18. Teenage fertility has declined fant mortality, prolonged breastfeeding, from 23.7 percent of all births in 1988 to 11.8 higher education, use of contraceptives, and percent in 2006.19 By 1988 all socioeconomic child fostering.22 The 1996 Botswana Family groups had declining fertility,20 but dispari- Health Survey attributed the decline to ur- ties persist. For example, the total fertility rate banization, women’s participation in the is 4.6 for rural dwellers, 2.4 for city and town labor force, education, and increased contra- dwellers, and 3.2 in the urban villages.21 Edu- ceptive use. Still other authors have suggested cation also creates disparities: the total fertility that the strong national family planning pro- rate for women with a university education gram contributed immensely to the decline is 2.6, in stark contrast to the rate of 5.8 for in fertility.23 Indeed, in 1991 the Botswana women with no education and 3.3 for women national family planning program was judged with a secondary education. the strongest in Africa.24 Figure 3 | Total Fertility Rate in Botswana, 1981–2007 (selected years) 8 7.1 7 7.1 6 5.0 5 4.2 4 3.4 3.3 3.2 2.9 3 2 1 0 1981 1984 1988 1991 1998 2001 2006 2007 Note: Adjusted total fertility rate for 1981 and 1984 is according to the 1988 Botswana Family Health Survey. 6 National Family Planning Program is Integrated with Primary Health Care B otswana’s readily accessible and strong During 1988–1996, the Ministry of national family planning program Health implemented the Botswana Popula- and the increased use of modern con- tion Sector Assistance Project to strengthen traceptives it inspired have contributed to family planning and STI services, including the declining total fertility rate. Although HIV/AIDS. This integrated program was the government did not articulate a na- funded by the United States Agency for In- tional population policy until 1997, from ternational Development and the Govern- the outset it showed strong commitment ment of Botswana.27 Although the decline in to meeting the family planning needs of the total fertility rate began in the 1980s be- Batswana by establishing the Maternal and fore the project was implemented.28 Currently, Child Health/Family Planning (MCH/FP) the family planning program receives funding Unit under the Primary Health Care de- from the national government and the United partment in 1973.25 This unit integrated the Nations Population Fund, and technical sup- family planning program into primary health port from the World Health Organization. care, using the vast network of health facili- The United Nations Children’s Fund supports ties in both rural and urban areas. This ap- the Maternal and Neonatal Care program. proach was key to making family planning services readily available.26 Family Planning Services in Public In 1979, the MCH/FP unit, along with Health Facilities the nutrition and health education units, be- Public health facilities have been providing came the Family Health Division under the family planning and maternal and child health Department of Public Health. In 2002 the services (including immunization, antenatal MCH/FP unit became a division on its own care, delivery, and postnatal care) since 1973, under the Department of Public Health and and the quality of services at rural and urban was renamed the Sexual and Reproductive facilities is comparable.29 Before MCH/FP ser- Health Division, with four subunits: Adoles- vices were fully integrated in 1984, each of cent Sexual and Reproductive Health, Family the services—such as antenatal care, postnatal Planning, Maternal and Newborn Care, and care, and immunizations—was offered on a Monitoring and Evaluation. Child Health different day of the week. Since then, family became a separate division. (See box 1 for planning services have been available daily at milestones in the Botswana family planning the network of health facilities, particularly program.) at the lower level health facilities where most Fertility Decline in Botswana, 1980–2006 | A Case Study 7 family planning visits occur. Clinics in the injectable (Depo-Provera), intrauterine de- capital city’s Gaborone district have the most vice (Copper T), male sterilization, and fe- annual family planning visits in the country, male sterilization. The last two are only offered 99.8 percent of all family planning visits in at the hospitals. Implants have not been ap- 2004.30 Fixed facilities that offer MCH/FP proved for use; after a pilot study initiated in services increased from 50 in 1973 to more 1996, the National Standing Committee on than 441 in 1989.31 Drugs declined to approve Norplant for use. To improve the quality of services, the Ministry of Health embarked on an intensive Botswana Population Sector training program for health personnel, nursing Assistance Project, 1988–1996 students, and tutors, with a target of training The Botswana Population Sector Assistance 60 family welfare educators per year. Topics Project was established in 1988 to strengthen included the integration of MCH/FP services, the existing family planning program and was family planning clinical skills, contraceptive evaluated by Trayfors and colleagues in 1996.33 logistics, family life education, and nutrition. Although the findings of that evaluation were Several family welfare educators were also mixed, the project’s key achievements included: trained for home visits and community out- reach activities at mobile stops. The program Æ Among modern contraceptives, condom trained approximately 600 between 1973 and sales increased dramatically as a result of 1989.32 Family Planning Policy Guidelines the Condom Social Marketing Program. and Service Standards were developed in Oc- Æ Reporting on the family planning pro- tober 1987 and reviewed in September 1994. gram improved considerably. In 1989 a family planning logistics manual on Æ The Ministry of Health Central Medical contraceptive commodities and drugs was de- Store ensured fewer stock-outs of contra- veloped to ensure that contraceptives were al- ceptive commodities and STI drugs. ways available at the health facilities. At the health facilities, the midwife or Key components of the Botswana Popu- health education assistant gives health educa- lation Sector Assistance Project—with recent tion talks in the waiting room prior to indi- updates where applicable—included: vidual consultation. Women who visit most MCH/FP clinics are routinely screened for Condom social marketing program cervical cancer (Pap smear). HIV counseling Established in November 1992 and imple- and treatment are integrated into MCH/FP mented by Botswana Population Services In- services: typically, MCH/FP clients first go for ternational, this program targeted youth and initial counseling and testing for HIV before men—who typically do not use public family they are attended by a midwife to choose a planning services—to prevent both HIV in- contraceptive method choice. fection and pregnancies. A branded product, The contraceptive methods currently Lovers-Plus condoms, was created and dis- available at the health facilities are oral con- tributed either free of charge or at an afford- traceptives, male condom, female condom, able price of 0.50 Botswana pula per condom 8 Box 1 | Timeline of Important Events in the Botswana Family Planning Program 1973 The Maternal and Child Health/Family Planning (MCH/FP) Unit (under Primary Health care) is established. Family planning is integrated into maternal and child health from the outset. 1979 The MCH/FP Unit, along with the nutrition and health education units, becomes the Family Health Division. 1984 MCH/FP services begin to be offered daily at most health facilities. 1987 Family Planning Policy Guidelines and Service Standards are developed. 1988 Botswana Population Sector Assistance Project begins (runs through 1996). 1998 Family life education is introduced into the school curriculum. 1989 Family planning logistics manual (contraceptive commodities and drugs) is developed. 1989 National AIDS Control Program is established. 1991 Abortion is made legal through the Penal Code (Amendment) Act of 1991 in any of these three cir- cumstances: rape or incest; to save a woman’s life; or fetal impairment. Two doctors must consent, and the procedure must be done in the first 16 weeks of pregnancy. 1994 The Family Planning General Policy Guidelines and Service Standards are reviewed. 1997 National Population Policy is developed, with a goal to decrease the total fertility rate from 4.0 (in 1996) to 3.4 by 2011. (This goal was achieved by 2009.) 1996 Family Planning Procedures Manual is developed. 2000 Adolescent Sexual & Reproductive Health: A Trainers Manual is developed for service providers. 2002 Department of Public Health is reorganized. MCH/FP Unit becomes the Sexual and Reproductive Health Division. 2003 Adolescent Sexual and Reproductive Health Implementation Strategy is developed. 2001 Marriage Act 2001 is enacted, raising the legal age for marriage from 14 to 18 with parental con- sent and to 21 if there is no parental consent. 2006 Maternal death is classified as a notifiable event (recommendation submitted for Public Health Act). 2008 Family planning manual and family planning trainers manual (Adolescent Sexual & Reproductive Health) are revised. 2008 A strategy for reproductive health commodity security is finalized. (US$ 0.07 at the exchange rate of 1 US$ = print media, and T-shirts. The campaign 7.2 pula) per pack. These male condoms were further stimulated the demand for the free made widely available in bars, gas stations, ho- condoms distributed by government health tels, markets, pharmacies, private clinics, and facilities. salons. Key distributors, wholesalers, and re- The three-year target of 2 million condom tailers with national reach were identified and sales was exceeded, with sales reaching 2 mil- trained to distribute the products. lion in 1995. This highly subsidized program A successful multimedia campaign called cost US$ 1,242,000 between November 1992 It’s my Life was implemented in 1994–95 and March 1996, with actual sales revenue of with call-in radio shows, peer education, only $115,000. Fertility Decline in Botswana, 1980–2006 | A Case Study 9 Information, education, and tries. A handbook, posters, and brochures communication were also developed and distributed. The information, education, and communica- tion (IEC) component of family planning and Training for reproductive health STI prevention was implemented by the Health This project component included both pre- Education Unit of the Department of Public service and in-service training. The nursing Health (now the Health Promotion and Edu- and midwifery pre-service curricula were re- cation Division). Unlike the Condom Social vised. Midwifery training included both Marketing Program, IEC focuses on improving family planning and HIV/STI, making pos- clinical services. Nurse-midwives and health sible the integration of the two services from education assistants receive IEC training based the outset. General nurses took courses on on materials developed at the national level and family planning and contraceptive methods. distributed to health facilities. But materials Practicing nurse-midwives received on-the- such as posters and flip charts are sometimes in- job training. Adolescent Sexual & Reproductive adequately supplied at the facility level. Health: A Trainers Manual for Service Pro- viders was developed in 2000, and the Min- Workplace education istry of Health trained 16 national “trainers of The Ministry of Health’s Occupational Health trainers” as part of the African Youth Alliance Unit, in collaboration with the National AIDS in 2002. An average of 146 service providers Control Program, implemented the Botswana annually were trained in youth-friendly ser- HIV/AIDS Prevention in the Workplace out- vices during 2003–2007 (figure 4). reach program to reach men at their work- places because they rarely frequent the regular NGO programs in reproductive health public reproductive health facilities. Approxi- To complement the strong government pro- mately 800 peer educators were trained, and grams, the Population Council was contracted condoms were distributed to over 100 indus- to strengthen the capacity of NGOs to improve Figure 4 | Service Providers Trained for Youth-Friendly Services, 2003–2008 300 267 250 200 144 150 131 129 108 100 100 50 0 2003 2004 2005 2006 2007 2008 Source: Pan Arab Project for Child Development Survey 1992. 10 outreach services to youth. A number of NGOs ences with managers of the district health team, participated, including the Botswana Family annual reports, supervision visits to the health Welfare Association, the Young Women’s Chris- facilities, and during seminars and workshops. tian Association, which provided counseling The main sources of data for monitoring and services for adolescents, and the Botswana Pop- evaluating the family planning program are the ulation Services International, which made Botswana Family Health Surveys (1984, 1988, condoms available to youth through social 1996, and 2007) and the health information marketing and peer education. system via annual health statistics reports. The Health Statistics Unit of the Central Statistics Contraceptive logistics system Office oversees the health information system A single huge national Central Medical Store in the Ministry of Health. The health facili- located in Gaborone procures medicines and ties under the Ministry of Local Government supplies—including contraceptives—for the send their monthly summary sheets to the dis- whole country and distributes them directly to trict health team, which collates health services health facilities using Ministry of Health trucks statistics—including family planning—and in scheduled deliveries. There are no regional forwards them to the Health Statistics Unit warehouses to facilitate this process. During the and the Sexual and Reproductive Health Divi- Botswana Population Sector Assistance Project sion. Hospitals administered by the Ministry of the Central Medical Store and the distribution Health send their monthly summary sheets di- system were strengthened to reduce stock-outs rectly to the Health Statistics Unit. The Health at health facilities, resulting in fewer stock-outs Statistics Unit analyzes the data from all health of family planning commodities and STI drugs facilities and produces annual reports on all in 1995 than in 1991. But the Central Med- services and programs, including family plan- ical Store currently has limited storage capacity ning. The monitoring and evaluation unit of because of the increased number of health fa- the Sexual and Reproductive Health Division cilities and the large quantities of antiretroviral liaises with the Health Statistics Unit to ensure drugs procured for the HIV epidemic. Diffi- the accuracy of data on family planning, but culties in procuring and distributing antiretro- the annual reports are not timely and now are a viral drugs seem not to have affected the supply few years behind schedule. and distribution of contraceptives. May 2009 stock-outs of Depo-Provera and Norinyl (com- Knowledge of family planning and bined pill) at some clinics were attributed to contraceptive method mix the failure of health facilities to communicate Knowledge of at least one family planning information on stock balances of contraceptives method increased from 75 percent in 1984 to the Central Medical Store. to 98 percent in 2007.34,35 In 1996, knowl- edge about the source of contraceptives was Monitoring and Evaluation of the 96 percent and this did not vary much by age, Family Planning Program marital status, or education, indicating that The national family planning program provides family planning services were widely available feedback during scheduled biannual confer- throughout the country. Fertility Decline in Botswana, 1980–2006 | A Case Study 11 Because of the strong family planning of female condoms has also been dismally low. program, use of modern contraceptives in- Use of intrauterine devices decreased from 4.1 creased in the last three decades. The modern percent in 1984 to 0.8 percent in 2007. contraceptive prevalence rate among all Data from the Central Medical Store and women ages 15–49 rose steadily, from 16 per- health information system corroborate this cent in 1984 to 29 percent in 1988, 40 per- change in the contraceptive mix. Data on cent in 1996, 42 percent in 2000, and 51 contraceptives supplied by the Central Med- percent in 2007 (table 3).36 Use of traditional ical Store to the health facilities (1993–2005) methods of contraception decreased from 7.5 indicate that condoms have become about percent in 1984 to 2.6 percent in 2007. three-and-a-half times more popular while in- Family planning clients rely on three main trauterine device use has waned considerably methods of contraception: male condom, oral (table 4). During 2005–2008, the uptake of contraceptives, and Depo-Provera. Oral con- female condoms was also very low compared traceptives were the most popular contracep- to male condoms. Increased use of male con- tive during 1984–1996, but the use of male doms is attributed to the effective multimedia condoms increased steadily from 1.0 percent HIV campaign for dual protection.37 Data in 1984 to 41.6 percent in 2007. Use of inject- from the health information system also show ables also increased, from 1.1 percent in 1984 that the condom has become the most pop- to 8.1 percent in 2000, and decreased slightly ular contraceptive (table 5). to 6.8 in 2007. Neither male nor female ster- A 2001 study38 indicated that teenagers ilizations have ever been popular. The uptake considered condoms to be not easily accessible, Table 3 | Current UseAgedModern Contraceptive Methods (1984–2007), Percent of all Women of 15–49 Years 1984a 1988b 1996c 2000d 2007e Oral contraceptives 8.5 17.7 17.7 14.3 6.1 Intrauterine device 4.1 4.5 3.1 1.7 0.8 Injectables 1.1 3.2 5.7 8.1 6.8 Diaphragm/foam/jelly 0.1 0.0 0.0 0.1 0.6 Female condoms 0.0 0.0 0.0 0.5 — Male condoms 1.0 1.3 11.3 15.5 41.6 Female sterilization 1.2 2.2 2.4 1.2 2.1 Male sterilization 0.0 0.1 0.0 0.2 0.1 Implants 0.0 0.0 0.0 0.4 — Total 16.0 29.0 40.2 42.0 51.2 a Botswana Family Health Survey 1984. b Botswana Family Health Survey 1988. c Botswana Family Health Survey 1996. d Central Statistics Office, Botswana Ministry of Health, and United Nations Children’s Fund 2001. e Botswana Family Health Survey 2007. Age group is 12–49 years. 12 Table 4 | Contraceptives Supplied to Public Health2005–2008by Ministry of Health Central Medical Store by Year, 1993 and Facilities Contraceptives 1993a 2005 2006 2007 2008 Male Condoms (in 100s) 68,684 246,605 271,899 150,978 222,246 Female condoms (in 100s) 0 2,572 8,014 5,380 6,454 Intrauterine device (IUD) 19,200 1,917 2,683 1,921 Depo-Provera 57,000 110,113 142,797 167,251 102,161 Oral contraceptives Combined low dose, 100 cycles 5,700 2,622 3,788 1,647 6,352 Progesterone-only low dose, 100 cycles 1,900 163 1,267 1,197 3,025 Combined high dose, 100 cycles 0 197 2,895 4,173 7,278 Oral contraceptives 7,600 2,982 7,950 7,017 16,655 Source: Central Medical Store. These data assume that all the contraceptives procured or distributed per year were eventu- ally used by clients. a. 1993 data is for numbers procured. Data on numbers supplied was not obtained. especially at public health facilities where they child (15.5 percent), partner disapproval (6.7 said their sexuality was questioned when they percent), method failure (5.5 percent), and in- asked for free condoms.39 In response, con- convenience (3.3 percent). Notably, the cost doms have been made more readily available and availability of contraceptives were only in condom dispensers, and security personnel mentioned by 0.1 percent and 0.9 percent re- at health facilities can distribute condoms at spectively, indicating that family planning night after closing. services were accessible. But unmet need for Some women discontinue contracep- family planning was not estimated in the 1996 tives. Using the 1988 Botswana Family Health Botswana Family Health Survey. Survey, Ngom and Zulu estimated the contra- ceptive discontinuation rate to be 12 percent Availability and Quality of Family within a year of initiation of the contracep- Planning tive.40 According to the 1996 survey, reasons Although no formal assessment of the quality for discontinuing contraceptives included of the family planning program has been un- health problems (49.5 percent), wanting a dertaken in recent years, the quality of the Table 5 | Contraceptive Method by Family Planning Attendances, 1998–2003 Contraceptives 1998 1999 2000 2001 2002 2003 Oral contraceptives 154,178 145,225 118,244 119,016 104,721 137,959 IUD 8,253 7,700 5,808 5,719 4,228 6,355 Injection 99,503 106,481 103,327 119,189 124,516 182,336 Condom 491,434 617,030 482,412 536,197 559,523 860,969 Source: Central Statistics Office, Botswana Ministry of Health 2007. Fertility Decline in Botswana, 1980–2006 | A Case Study 13 family planning services might not have been terviewed reported using modern contra- adversely affected by the HIV epidemic. STI/ ceptives themselves. A majority of the staff HIV/AIDS services were integrated into had received training in MCH/FP and STI/ MCH/FP from the outset. Indeed, dual pro- HIV/AIDS services. Record-keeping was very tection is on the rise, with a dramatic increase good, with monthly reports submitted to the in the numbers of condoms distributed.41 next administrative level. District medical of- A 1996 situational analysis by Baakile ficers had conducted supervisory visits in the and colleagues provided some information on prior six months to 92 percent of the selected the quality of family planning and STI/HIV health facilities. services hitherto unavailable from the health Some drawbacks were noted. For ex- information system or national household ample, although a majority of clients were surveys.42 Most health facilities had basic in- satisfied with the services, some would have frastructure and equipment for the provision preferred longer consultation time with service of MCH/FP and STI/HIV/AIDS services. providers. Some clients indicated that they Three selected contraceptives—oral contra- were not offered information on the full range ceptives, condoms, and injectables (Depo- of contraceptives. IEC materials, particularly Provera)—were available in over 90 percent flipcharts, were lacking in most facilities. Su- of the facilities, although some lacked the pervisory visits in May 2009 noted that IEC full range of modern contraceptive methods. materials were still not on display in selected Over 70 percent of the service providers in- health facilities. 14 Increased Age at First Birth and Prolonged Breastfeeding are Important Determinants of Declining Fertility F ertility decline can be influenced by of fertility in Botswana than age at mar- proximate determinants such as age at riage.44 first birth, breastfeeding and postpartum The median age at first birth was nearly abstinence, infertility, and abortion. Increased 20 years in 1988. Secondary analysis of the age at first birth and prolonged breastfeeding 1988 Botswana Family Health Survey showed appear to be have contributed to declining fer- that an increase in age at first birth of one year tility in Botswana. was associated with a 27 percent reduction in fertility.45 But there is no other data available Age at First Birth Versus Age at from censuses or surveys on median (or mean) Marriage age at first birth to enable a trend analysis. The proportion of married reproductive- Births to teens did decrease by half between age women is considered one of the proxi- 1988 and 2006, indicating that age at first mate determinants of fertility, assuming that birth has increased in recent decades—possibly the higher the age at marriage, the less likely contributing to the decline in fertility. women are to be exposed to sex, leading to fewer births and lower fertility. But in Bo- Cohabitation tswana premarital childbearing is common, Although studies have shown that nearly all with some young women making the deci- women will want to have children, cohabiting sion to marry only after giving birth. Indeed, unions have been on the rise, with Botswana the proportion of women age 15 and above among countries with the highest prevalence of who are married declined from 42.9 percent such unions in Sub-Saharan Africa.46 Reasons in 1971 to 17.9 percent in 2001 (figure 5).43 for cohabitation include labor migration, de- In the same period, the proportion of never- cline in polygyny, better educated women, and married women increased from 37.0 percent enhanced legal rights of unmarried women. to 46.5 percent. According to the 1988 Bo- During 1940–1970 about a third of Botswa- tswana Family Health Survey, the median na’s adult males were migrant laborers working age at first birth was five years younger than at mines in South Africa.47 The long absence the median age at marriage. Because child- of fathers took a toll on families, with female- bearing is not restricted to married women, headed single-parent families or delayed mar- the age at first birth is a better determinant riages becoming more common. Some analysts Fertility Decline in Botswana, 1980–2006 | A Case Study 15 Figure 5 | Percentage of Women Ages 15 Years and Above Who are Married, 1971–2001 50 45 42.9 41.5 40 35 30 27.2 25 20.3 20 17.1 15 10 5 0 1971 1981 1991 1998 2001 Source: 1971–2001 Botswana censuses. suggest that the relative shortage of young (the act of giving one’s child to another to males increased the proportion of unmarried raise) was associated with lower fertility.51 women, as polygyny had become rare in Bo- The reason could be that young women give tswana.48 And the 2001 Marriage Act gave un- their children to family members to take married women land and business rights not care of them while they further their edu- available to married women, making marriage cation or advance their careers. This con- less attractive. trasts with West Africa, where fostering out Mokomane suggests that premarital child- to the extended family makes room for more bearing is a prelude rather than an alternative births. However, Pennington’s study of the to marriage.49 He argues that labor migration Herero—the ethnic group with the highest to South Africa cannot account for increasing fertility in Botswana—indicated that the re- cohabitation because external labor migration lationship between fertility and fostering is has declined since the 1980s as a result of the not clear-cut.52 development of the mining industry in Bo- tswana. Instead, internal migration to mining Prolonged Breastfeeding and towns or urban centers encourages cohabita- Postpartum Abstinence tion rather than marriage,50 as most people Cultural norms, such as prolonged breast- have multiple residences, with homes in the vil- feeding and postpartum abstinence, might lage, cattle post, farming land, or urban center. have also contributed to the fertility de- Public service employees also are frequently cline.53 In 1984, 73 percent of women transferred from one district to another. breastfed for more than a year.54 The 1988 Botswana Family Health Survey indicated Child fostering that the mean duration of breastfeeding Analysis of the 1988 Botswana Family was 19 months, half of women abstained Health Survey indicated that child fostering from sex in the first year after delivery, and 16 nearly half of women had not resumed their are reduced frequency of sex, use of contra- menses one year postpartum. The 2000 ceptives to prevent giving birth to an infected Multiple Indicator Survey also reported that baby, amenorrhea due to weight loss, spon- 53 percent of children ages 12–15 months taneous or induced abortion, and tubal oc- were still being breastfed. Prolonged breast- clusion due to pelvic inflammatory disease feeding, which delays the resumption of secondary to STI co-infection.60 Although menses after delivery, coupled with post- no such studies have been conducted in Bo- partum abstinence contributed to longer tswana, it is possible that the HIV epidemic birth intervals.55 might have contributed to the fertility de- cline for similar reasons. On the other hand, Effect of HIV on Fertility the fertility decline was well underway in the Given the high HIV prevalence among repro- 1980s, prior to the epidemic. And the wide- ductive-aged women, the question is whether spread use of antiretrovirals may have blunted this contributed to the fertility decline in Bo- the effect of HIV on fertility, because women tswana. Available evidence is inconclusive. could take the risk of having a baby knowing Using cross-sectional data in three rural dis- that mother-to-child transmission could be tricts in neighboring Zimbabwe (also ex- reduced with antiretrovirals. periencing an HIV epidemic), Terceira and colleagues reported that HIV might have ac- Induced Abortion counted for about a quarter of the total fer- Women in some countries consider induced tility rate decline.56 Controlling for age, abortion as a means of menstrual or fertility marital status, contraceptive use, and birth regulation. High levels of induced abortion history, the study found that the odds of preg- could lead to lowered fertility. In Botswana it nancy at the time of the survey among HIV- is uncertain whether induced abortion con- positive women were 38 percent lower than tributed to the fertility decline because there is among HIV-negative women. The major no accurate data on abortion rates.61 Abortion drawback of this study was that it was not a was illegal—with no exceptions—until the cohort study with accurate information on law was changed in 1991 to grant three excep- the duration of the HIV infection or the time tions: in cases of rape or incest, if childbearing when women became HIV positive.57 Other poses a risk to the physical or mental health of studies in Sub-Saharan Africa, including the woman, or if there is (or is a risk of ) fetal Uganda and Cameroon, have also reported impairment.62 A medical doctor must conduct lower fertility among HIV-positive women.58 the abortion in a health facility during the first Using data on the duration of infection 16 weeks of pregnancy with the written con- in the U.S. state of Maryland, Lee and col- sent of another doctor. When abortion was il- leagues have shown that the longer the du- legal, unsafe abortions were one of the major ration of HIV infection, the lower the total causes of maternal mortality, and septic abor- fertility rate.59 Some of the reasons for low- tion still caused 16 percent of all maternal ered fertility among women with HIV/AIDS deaths in 2007.63 Fertility Decline in Botswana, 1980–2006 | A Case Study 17 Socioeconomic and Cultural Factors Have Contributed to the Fertility Decline S | Literacy Rate (percent) by ocioeconomic factors typically do not Figure 6 directly affect fertility, but they can in- Sex, Ages 10–70, 1981–2003 fluence fertility decline through the 90 proximate determinants described earlier. In 80 77.6 75.3 69.8 Botswana, increased female education, wom- 70 65.0 60 en’s participation in the labor force, urbaniza- 50 tion, and improved survival of children may 40 36.0 32.0 have contributed to the fertility decline.64 30 20 10 Female Education 0 2001 2003 Better female education is associated with 1981 Females Males lower fertility because educated women are more likely to delay age at first birth, use con- Source: 2003 Literacy Survey report. traceptives, and have lower ideal family size. The 1994 Botswana Revised National Policy on Education established access to basic ed- ucation as a fundamental right.65 Education was free until 2006, when school fees were in- stituted for secondary schools.66 As a result, Table 6 | Enrollmentby Sex,University of Botswana at the 1996–2006 Percent Botswana is one of the few countries where Year Male Female Total female more females are educated than males. Ac- 1996 3,812 3,485 7,297 47.8 cording to the 2003 Literacy Survey report, 1997 4,128 3,879 8,007 48.4 the female literacy rate increased from 36.0 1998 4,525 4,073 8,598 47.4 percent of females ages 10–70 in 1981 to 1999 5,011 4,584 9,595 47.8 77.6 percent in 2003 and has been consis- 2000 5,738 5,483 11,221 48.9 tently higher than male literacy rates (figure 2001 6,318 5,968 12,286 48.6 6).67 Female enrollment is also higher than 2002 6,573 6,648 13,221 50.7 male enrollment at the University of Bo- 2003 7,757 7,871 15,628 50.4 tswana (table 6).68 As noted earlier, TFR 2004 7,537 8,187 15,724 52.1 markedly declined among women with higher 2005 7,416 8,294 15,710 53.0 education. Clearly, female education contrib- 2006 7,601 8,638 16,239 53.2 uted to the fertility decline.69 Source: Education Statistics Unit 2006. 18 Women’s Labor Force Participation cause the urban percentage of the population Women are economically active, but not to an has increased dramatically, from 9.1 percent extent commensurate with the sex differen- in 1971 to 59.6 percent in 2006, urban- tials in education.70 According to the 2002–03 ization might have also played a role in de- Household Income and Expenditure Survey, clining fertility. 48.5 percent of the economically active per- sons ages 12 and above were female and 51.5 Improved Survival of Children percent male. Among women ages 15–49, According to the demographic transition 73.7 percent were employed, the majority in theory, improved survival of children as a result paid cash employment. Increased women’s of improved public health explains the transi- participation in the labor force might have tion from high fertility to low fertility.72 Be- also contributed to the fertility decline. cause the infant mortality decreased drastically during 1970–2000—from 97.1 deaths per Urbanization 1,000 live births in 1971 to 37.4 in 1998—the In 2006 urban women had a lower total fer- increased survival of children might have been tility rate (2.4) than rural women (4.6).71 Be- a factor in decisions to have fewer children. Fertility Decline in Botswana, 1980–2006 | A Case Study 19 Lessons and Implications for Other Sub-Saharan African Countries B otswana’s national family planning pro- has increased the availability of family gram has been one of the strongest in planning services. And the quality of ser- Sub-Saharan Africa. While fertility has vices provided in rural areas was similar to declined remarkably in Botswana, about 25 those offered in urban areas. countries in Sub-Saharan Africa still have total fertility rates higher than 5.0 births per 2. Generate demand for family planning woman. Some of the lessons learned from Bo- services. tswana’s family planning program might be Outreach services via mobile stops and applicable to those countries. home visits by family welfare educators have brought services to the doorsteps of women 1. Ensure access to and quality of family who do not visit the clinics. A strong be- planning services. havior-changing communications campaign Improve access to and quality of family using multimedia also generates demand for planning with the following main compo- family planning. nents: 3. Strengthen program management. Æ Integrate MCH/FP/HIV/AIDS services Regular interaction among the national at all health facilities. Fully integrated family program staff, district health teams, services have made it easier for clients who and health facilities through scheduled bi- visit primary health facilities for antenatal annual conferences, supervision visits to the care, postnatal care, immunization, and health facilities, seminars, and workshops has HIV counseling to be offered family plan- allowed two-way feedback to improve the pro- ning services as well, increasing the uptake gram. The monitoring and evaluation unit at of family planning. Integrating MCH/ the Sexual and Reproductive Health Division FP services was also an integral part of the also follows up on health facilities that do not pre-service midwifery training curriculum, submit routine monthly summary sheets. family welfare educators’ curriculum, and regular in-service training. 4. Promote and invest in the education of Æ Provide family planning services at all girls. levels of the health care delivery system. The government’s investment in the ed- The vast network of family planning ucation of girls was also instrumental in re- clinics within reach of villages and towns ducing fertility, as evidenced by low fertility 20 among educated women. Educated women are 5. Promote policies that favor female par- able to make informed choices, and school at- ticipation in the labor force. tendance itself also delays the age at first birth. 6. Promote prolonged breastfeeding. Several studies have shown that female educa- tion has positive effects on most health indica- tors, including infant mortality and maternal mortality. Fertility Decline in Botswana, 1980–2006 | A Case Study 21 The Way Forward: How to Strengthen the Botswana Family Planning Program T he Botswana family planning program condoms, oral contraceptives, and Depo- has already achieved the 2011 National Provera, all of them short-term. Long-term Population Policy target of a total fer- contraceptive methods, such as sterilization tility rate of 3.4. But it has not yet reached and intrauterine devices, are less popular, the contraceptive prevalence rate target of 65 and implants are nonexistent. The National percent.73 Fertility is still a high 4.6 percent Standing Committee on Drugs could review among rural women, and the national con- new methods—such as Ortho Evra Patch, traceptive prevalence rate is below 50 percent. NuvaRing, and Implanon—to ascertain their The following suggestions might address some appropriateness for Batswana women. Sem- of the current shortcomings of the family inars, workshops, and in-service training planning program. programs should encourage nurses and mid- wives to counsel clients on the full range of 1. Strengthen the contraceptive logistics contraceptives, allowing better informed de- management information system. cisions. Condoms should continue to be pro- The Central Medical Store does not have moted for dual protection (pregnancy and accurate information on stock balances of HIV prevention), but clients must be made contraceptives at the health facilities, which aware of condoms’ relatively low contracep- makes forecasting difficult. For example, there tive efficacy. were stock-outs of Depo-Provera and Norinyl During 2007–2008 Norinyl, a high-dose in some clinics in May 2009. Stocking prob- oral contraceptive, was more available than lems can be resolved by accurate and timely Nordette, a low-dose pill. Because high-dose monthly reporting of stock levels at the health oral contraceptives generally have more side facilities to the Central Medical Store, by effects than low-dose pills, the use of Norinyl training pharmacy technicians and pharma- should be evaluated. Certain drugs, such cists on logistics management information as rifampicin for tuberculosis, are known systems, and by building capacity in supply- to make oral contraceptives less effective, chain management. so other contraceptive methods besides the high-dose pill should be offered to clients in 2. Offer the full range of contraceptives. such circumstances. Currently, family planning clients use three main contraceptive methods, male 22 3. Make information, education, and Monitoring and Evaluation Unit should con- communications materials more available at tinue to work closely with the Health Statistics MCH/FP clinics. Unit to ensure accuracy and completeness of The Health Promotion and Education Di- data on sexual and reproductive health. vision should coordinate with the Sexual and Reproductive Health Division to make IEC 5. Strengthen the integration of sexual materials more available at the clinics. The and reproductive health and HIV/AIDS Health Promotion and Education division must services. be proactive in sending adequate quantities of Although the health facilities provide new and existing educational materials to dis- both family planning and HIV/AIDS services, trict health teams for distribution to the health sexual and reproductive health (including facilities. Private health facilities should also be family planning) and HIV/AIDS programs provided with training and IEC materials. are coordinated by different departments within the Ministry of Health (Public Health 4. Strengthen the Sexual and Reproductive and HIV/AIDS Prevention and Care respec- Health Division’s Monitoring and tively). 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Geneva. 26 APPENDIX: Fertility Reduction 1980–2006 in Countries with a Total Fertility Rate of more than 6.0 in 1980, by Region Total Total Fertility reduction fertility rate fertility rate (difference between Country Region 1980 2006 1980 and 2006) Botswana Sub-Saharan Africa 7.1 3.2 3.9 Namibia Sub-Saharan Africa 6.5 3.3 3.2 Comoros Sub-Saharan Africa 7.2 4.0 3.2 Zimbabwe Sub-Saharan Africa 7.0 3.8 3.2 Cape Verde Sub-Saharan Africa 6.6 3.5 3.1 Cote d’Ivoire Sub-Saharan Africa 7.4 4.6 2.8 Swaziland Sub-Saharan Africa 6.2 3.5 2.7 Ghana Sub-Saharan Africa 6.6 4.0 2.6 Rwanda Sub-Saharan Africa 8.5 5.9 2.6 Kenya Sub-Saharan Africa 7.4 5.0 2.4 Sao Tome and Principe Sub-Saharan Africa 6.3 4.0 2.4 Togo Sub-Saharan Africa 7.0 4.9 2.1 Sudan Sub-Saharan Africa 6.4 4.4 2.1 Cameroon Sub-Saharan Africa 6.4 4.4 2.0 Malawi Sub-Saharan Africa 7.5 5.7 1.9 Zambia Sub-Saharan Africa 7.1 5.3 1.9 Mauritania Sub-Saharan Africa 6.3 4.5 1.8 Gambia, The Sub-Saharan Africa 6.5 4.8 1.7 Senegal Sub-Saharan Africa 7.0 5.3 1.7 Burkina Faso Sub-Saharan Africa 7.7 6.1 1.6 Benin Sub-Saharan Africa 7.1 5.5 1.6 Madagascar Sub-Saharan Africa 6.5 4.9 1.6 Congo, Republic Sub-Saharan Africa 6.1 4.6 1.6 Ethiopia Sub-Saharan Africa 6.8 5.3 1.5 Guinea Sub-Saharan Africa 7.0 5.5 1.5 Nigeria Sub-Saharan Africa 6.9 5.4 1.5 (continued on next page) Fertility Decline in Botswana, 1980–2006 | A Case Study 27 (continued) Total Total Fertility reduction fertility rate fertility rate (difference between Country Region 1980 2006 1980 and 2006) Eritrea Sub-Saharan Africa 6.5 5.1 1.4 Tanzania Sub-Saharan Africa 6.6 5.3 1.4 Mozambique Sub-Saharan Africa 6.5 5.2 1.3 Niger Sub-Saharan Africa 8.1 7.0 1.1 Somalia Sub-Saharan Africa 7.2 6.1 1.1 Mali Sub-Saharan Africa 7.6 6.6 1.0 Angola Sub-Saharan Africa 7.2 6.5 0.7 Chad Sub-Saharan Africa 6.8 6.3 0.5 Uganda Sub-Saharan Africa 7.1 6.7 0.4 Congo, Dem. Rep. Sub-Saharan Africa 6.7 6.3 0.4 Liberia Sub-Saharan Africa 6.9 6.8 0.1 Guinea-Bissau Sub-Saharan Africa 7.1 7.1 0.0 Sierra Leone Sub-Saharan Africa 6.5 6.5 0.0 Burundi Sub-Saharan Africa 6.8 6.8 0.0 Bhutan East Asia and Pacific 6.5 2.3 4.2 Lao PDR East Asia and Pacific 6.4 3.3 3.1 Solomon Islands East Asia and Pacific 6.7 4.0 2.7 Micronesia, Fed. Sts. East Asia and Pacific 6.2 3.8 2.4 Nicaragua Latin America and Caribbean 6.1 2.8 3.3 Honduras Latin America and Caribbean 6.2 3.4 2.9 Haiti Latin America and Caribbean 6.1 3.6 2.4 Guatemala Latin America and Caribbean 6.1 4.2 1.9 Iran, Islamic Republic Middle East and North Africa 6.6 2.1 4.5 Libya Middle East and North Africa 7.3 2.8 4.5 Algeria Middle East and North Africa 6.8 2.4 4.4 Syrian Arab Republic Middle East and North Africa 7.3 3.2 4.1 Oman Middle East and North Africa 7.2 3.1 4.1 Jordan Middle East and North Africa 7.0 3.2 3.8 Saudi Arabia Middle East and North Africa 7.1 3.4 3.7 Yemen, Republic Middle East and North Africa 8.7 5.6 3.1 Djibouti Middle East and North Africa 6.7 4.1 2.6 Iraqa Middle East and North Africa 6.5 — — Afghanistan a South Asia 7.8 — — Maldives South Asia 6.9 2.7 4.2 Pakistan South Asia 7.0 3.9 3.1 Source: World Development Indicators (World Bank) for all countries except Botswana, for which data for year 2006 was obtained from the Central Statistics Office. a Data not available for year 2006. Note: Total fertility rate is number of births a woman will have at the end of her reproductive period based on the current age- specific fertility rates. 28 End Notes 1 Central Statistics Office, Botswana Ministry 20 Lesetedi and others 1989; Langeni-Mnde- of Health 2009. bele 1997. 2 Central Statistics Office, Botswana Ministry 21 Central Statistics Office, Botswana Ministry of Health 2009. of Health 2009. 3 Commission on Growth and Development 22 That was the finding of a multivariate re- 2008; World Bank 2009. gression analysis conducted using the 1988 4 Central Statistics Office, Botswana Ministry Botswana Family Health Survey, which of Health 2009. treated the total number of children ever 5 Abuja Declaration 2001. born to women ages 15–49 as the depen- 6 Mogobe, Tshiamo, and Motsholathebe dent variable. Langeni-Mndebele 1997. 2007; Lesetedi and others 1989; Cen- 23 Thomas and Muvandi 1994; Ngom and tral Statistics Office, Botswana Ministry of Zulu 1994; Letamo and Oucho 2002; Health 2007. CSO, FHD MOH 2009. 7 Mogobe, Tshiamo, and Motsholathebe 24 Ross and others 1992. 2007. 25 Letamo and Letamo 2002; Letamo and 8 Central Statistics Office, Botswana Ministry Oucho 2002; Lesetedi and others 1989. of Health 2007. 26 Baakile and others 1996. 9 Langeni-Mndebele 1997. 27 Trayfors and others 1996. 10 Mogobe, Tshiamo, and Motsholathebe 2007. 28 Baakile and others 1996. 11 Central Statistics Office 2008. 29 Lesetedi and others 1989. 12 Central Statistics Office, Botswana Ministry 30 Central Statistics Office, Botswana Ministry of Health 2009. of Health 2007. 13 Central Statistics Office, Botswana Ministry 31 Lesetedi and others 1989. of Health 2009. 32 Lesetedi and others 1989. 14 World Bank 2009. 33 Trayfors and others 1996. 15 Central Statistics Office, Botswana Ministry 34 CSO, FHD MOH 2009. of Health 2009. 35 Central Statistics Office, 2009. 16 Central Statistics Office, Botswana Ministry 36 Lesetedi and others 1989; CSO, FHD of Health 2008. MOH 2009; Manyeneng and others 1985; 17 World Health Organization 2007. Central Statistics Office, Botswana Ministry 18 Central Statistics Office, 2009. of Health, and UNICEF 2001. 19 Central Statistics Office, Botswana Ministry 37 Letamo and Oucho 2002. of Health 2009. 38 Meekers, Ahmed, and Molatlhegi 2001. Fertility Decline in Botswana, 1980–2006 | A Case Study 29 39 Meekers, Ahmed, and Molatlhegi 2001. 61 Letamo and Letamo 2002; Mogobe 2007. 40 Ngom and Zulu 1994. 62 United Nations Secretariat 1999. 41 Baakile and others 1996. 63 Central Statistics Office, Botswana Ministry 42 Baakile and others 1996. This analysis en- of Health 2008. tailed 451 service provider interviews in 186 64 This study could find no pertinent informa- health facilities (20 hospitals, 121 clinics, tion on the role of religion in fertility. and 45 health posts), observation of 406 65 Education Statistics Unit, Central Statistics service provider-client interactions in con- Office 2006. sulting rooms, and exit interviews with 386 66 Primary education is still free; junior sec- family planning clients and 724 maternal ondary tuition, 300 pula per year; senior and child health clients. secondary, 450 pula per year, and technical 43 Langeni-Mndebele 1997. colleges, 750 pula per year. Bursary and so- 44 Kwesi Gaisie 1995; Letamo and Letamo cial welfare services are available for those 2002; Langeni-Mndebele 1997. who cannot afford tuition. 45 Langeni-Mndebele 1997. 67 Central Statistics Office, Botswana Ministry 46 Pitso and Carmichael 2003; Mokomane of Health, and Department of Non-Formal 2005, 2006. Education 2005. 47 Kwesi Gaisie 1995. 68 Education Statistics Unit, Central Statistics 48 Kwesi Gaisie 1995. Office 2006. The University of Botswana is 49 Mokomane 2006. the only university in the country. 50 Pitso and Carmichael 2003. 69 Blanc and Rutstein 1994; Central Statistics 51 Langeni-Mndebele 1997. Office, Botswana Ministry of Health 2009; 52 Pennington 1991. Lesetedi and others 1989 ; Langeni-Mnde- 53 Langeni-Mndebele 1997. bele 1997. 54 Manyeneng and others 1985. 70 Labour Statistics Unit, Central Statistics 55 Letamo and Letamo 2002. Office 2008; Central Statistics Office, Bo- 56 Terceira and others 2003. tswana Ministry of Health 2004. 57 Lee and others 2000. 71 Central Statistics Office, Botswana Ministry 58 Gray and others 1998; Fabiani and others of Health 2009. 2006; Kongnyuy and Wiysonge 2008. 72 McCarthy 2001; Bloom, Canning, and Se- 59 Lee and others 2000. villa 2003; Gelbard, Haub, and Kent 1999. 60 Gray and others 1998; Fabiani and others 73 Letamo and Oucho 2002. 2006. THE WORLD BANK 1818 H Street, N.W. Washington, DC 20433