INVESTING IN HUMAN CAPITAL IN BOTSWANA A Framework for a Coordinated Multi-Sectoral Approach May 15, 2024 Authors: Victoria Monchuk, Elizabeth Ninan Dulvy, Saima Malik, Jutta Franz, Faith Makhosazana Phelakwakhe Mamba, Kenneth Munge Kabubei and Usama Zafar 1 2 INVESTING IN HUMAN CAPITAL IN BOTSWANA A Framework for a Coordinated Multi-Sectoral Approach 3 4 Acknowledgements This human capital note aims to consolidate a view to human development as a core driver of Botswana’s economic growth and development agenda and to present a harmonized approach for investing in priority areas for human capital formation. The ultimate objective is for the note to serve as a guide for the Government of Botswana and its partners for prioritizing policies and actions to support human capital formation in the country. The note builds on the body of literature available in Botswana on education, skills, health and nutrition, and social protection and jobs. The note was prepared under the guidance and support of the Marie- Françoise Marie-Nelly (Country Director for Southern Africa, World Bank); Daniel Dulitzky (Regional Director for Human Development, Eastern and Southern Africa Region, World Bank); Liang Wang (Resident Representative, Botswana, World Bank); Muna Salih Meky (Practice Manager for Education, Eastern and Southern Africa, World Bank); Paolo Belli (former Practice Manager for Social Protection and Jobs, Eastern and Southern Africa, World Bank); Suleiman Namara (Practice Manager for Social Protection and Jobs, Eastern and Southern Africa, World Bank); and Francisca Ayodeji Akala (Practice Manager for Health, Nutrition and Population, Eastern and Southern Africa, World Bank). The team is grateful to Ian Forde (World Bank), Pedro Cerdan-Infantes (World Bank), and Rebekka Grun (World Bank) for peer-reviewing and providing invaluable feedback on a draft note. Carolina Diaz-Bonilla (World Bank) also provided significant contribution including updated poverty, growth, and employment statistics data and Dhushyanth Raju (World Bank) and Mpumelelo Nxumalo (World Bank) reviewed the section on labor market outcomes. The authors of the note are Victoria Monchuk (Senior Economist, World Bank), Elizabeth Ninan Dulvy (Program Leader for Human Development, Southern Africa, World Bank), Saima Malik (Senior Education Specialist, World Bank), Jutta Franz (Skills Consultant, World Bank), Faith Makhosazana Phelakwakhe Mamba (Senior Economist, Health, World Bank), Kenneth Munge Kabubei (Economist, Health, World Bank), and Usama Zafar (Social Protection Consultant, World Bank). The layout and design was prepared by Lyska Walters. The findings, interpretations, and conclusions expressed in this note are those of the authors and do not necessarily reflect the views of The World Bank or its Board of Executive Directors. During the preparation of this note, the World Bank team held a number of consultations with government and development partner officials. In June 2023 the team presented the life cycle framework for and preliminary data analysis of HD outcomes and policy responses to a group of government participants representing relevant line ministries, and the Ministry of Finance. In August and October 2023, the team also discussed selected parts of the review with the Ministry of Finance as well as development partners. Through the consultations counterparts provided the team with reflections on the data analysis and helped prioritize policy recommendations and cross-sectoral interventions. The World Bank team is grateful for the inputs provided by the government and development partners that helped shape the narrative of the note. The final note was launched jointly with the government in 2024. 5 Table of Contents Acknowledgements ...................................................................................................................... 5 Figures ............................................................................................................................................ 7 Tables.............................................................................................................................................. 8 Boxes............................................................................................................................................... 8 Acronyms........................................................................................................................................ 9 Executive Summary...................................................................................................................... 11 I. The Botswana Context......................................................................................................... 23 II. Assessment of Human Capital Outcomes Across the Lifecycle........................................ 33 A. Early Childhood (From Pregnancy to Age 5).............................................................34 B. School Age Children (Age 6-17)................................................................................42 C. Youth to Adulthood (Ages 18 and older)..................................................................50 III. Discussion – Implications of Botswana’s Human Capital Investments on Growth and Transformation................................................................................................. 61 A. The contribution of human capital to growth and poverty reduction.....................62 B. Improving the efficiency of current spending and spending more on early years to maximize human capital outcomes..................................................65 IV. A Multisectoral Framework to Accelerate Human Capital Development......................... 71 A. Policy priorities for early childhood.............................................................................72 B. Policy priorities for children of school going age .....................................................73 C. Policy priorities for youth to adulthood.......................................................................74 D. System level issues cutting across the lifecycle.........................................................75 References.................................................................................................................................... 79 Annexes........................................................................................................................................ 85 6 Figures Figure 1. A Lifecycle framework to examine inequalities in human capital development............................................................................................................ 12 Figure 2. Economic growth trend since 1990’s...................................................................... 23 Figure 3. Standards of living increases over time.................................................................. 24 Figure 4. Botswana’s economic growth is losing steam (average growth by period in percent)................................................................. 25 Figure 5. The poverty rate is high........................................................................................... 25 Figure 6. Poverty reduction is slowing.................................................................................... 26 Figure 7. The level of inequality is very high.......................................................................... 26 Figure 8. Human Capital Index Scores in Sub-Saharan Africa............................................. 28 Figure 9. Percentage of the population with post-school education by age group for selected districts, 2011............................................................... 30 Figure 10. A Lifecycle framework to examine inequalities in human capital development........................................................................................................... 34 Figure 11. Botswana’s Framework for ECCD............................................................................ 35 Figure 12. Under-Five Mortality Rate per 1,000 Live Births, Botswana and Peer Countries ... 36 Figure 13. Neonatal Mortality Rate per 1,000 Live Births, Botswana and Peer Countries..... 36 Figure 14. Reviewing social assistance support for infants and young children.................. 41 Figure 15. Enrolment by Grade, 2007 and 2017...................................................................... 43 Figure 16. Grade Repetition Rates in Primary Grades by Gender, 2012-2017....................... 44 Figure 17. Botswana Performance in TIMSS Grade 8/9 Mathematics, 2015......................... 45 Figure 18. UNESCO’s Global Monitoring of School................................................................. 46 Figure 19. Reviewing social assistance support for school age children.............................. 48 Figure 20. Population by Labor Market Status and Economic Activity, Q4 2022................... 50 Figure 21. Labor market characteristics of employed, unemployed, discouraged workers 2015/16................................................................................ 51 Figure 22. Employment rate by categorical groups, 2015/16................................................ 52 Figure 23. Distribution of Social Assistance Beneficiaries by Programs and Quintiles of Pretransfer Welfare, 2015/16................................................................ 54 Figure 24. The relationship between HCI and income level across the globe, 2020............ 64 Figure 25. Factors contributing to inequality in Botswana, 2010 and 2015........................... 64 7 Tables Table 1. Botswana’s Human Capital Index, Benchmarked Against Comparators............ 28 Table 2. Resource differentials across various dimensions, percent, TIMSS 2015............... 29 Table 3. Average spending per student by level of schooling and location, 2015-16 (in BWP per year)..................................................................................................... 29 Table 4. Still birth rate per 1,000 total births by district of usual residence......................... 37 Table 5. GER and NER at different education levels............................................................ 43 Table 6. Post-school Education and Training Overview, 2021............................................. 53 Table 7. Recommended short term actions (1-2 years)..................................................... 77 Table 8. Recommended medium term actions (3-5 years)............................................... 78 Boxes Box 1: Reasons for Botswana’s HIV/AIDS Successes......................................................... 31 Box 2: Social protection programs and their impact on human capital – evidence from South Africa.................................................................................. 39 Box 3: Madagascar: Promoting the Early Years through a Cash Transfer Program........ 42 Box 4: Dar-es-Salam Declaration: Commitment to invest in Human Capital.................. 63 8 Acronyms AIDS Acquired Immunodeficiency Syndrome ALMP Active Labor Market Policy ARV Antiretroviral drugs BWP Botswana Pula COVID-19 Coronavirus Disease 2019 CSG Child Support Grant DPP Destitute Persons Program ECCD Early Childhood Care and Development FY Fiscal Year GDP Gross Domestic Product GNI Gross National Income GPI Gender Parity Index HCI Human Capital Index HDI Human Development Index HIC High Income Country HIV Human Immunodeficiency Virus ICT Information Communication Technology ILO International Labor Organization JCE Junior Certification Exam LMIC Lower-Middle Income Country MLGRD Ministry of Local Government and Rural Development MoESD Ministry of Education and Skills Development MoH Ministry of Health MPDSR Maternal and perinatal death surveillance and response NAHPA National AIDS and Health Promotion Agency NCD Non-Communicable Disease NGO Non-Government Organization NMR Neonatal mortality rate NSHP National School Health Policy NSPF National Social Protection Framework OAP Old Age Pension OECD Organization for Economic Cooperation and Development PIRLS Progress in International Reading Literacy Study PLWHA People Living with HIV/AIDS PPP Purchasing Power Parity PSLE Primary School Leaving Exam TFP Total Factor Productivity TIMSS Trends in International Mathematics and Science Study 9 TVET Technical and Vocational Education and Training U5MR Under-Five Mortality Rate UN United Nations UNESCO United Nations Educational, Scientific and Cultural Organization UNDP United Nations Development Program UNICEF United Nations Children’s Fund UMIC Upper-Middle Income Country VGFP Vulnerable Groups Feeding Program VTC Vocational Training Center WHO World Health Organization 10 Executive Summary Context and problem statement Botswana has sprinted to become an upper-middle income (UMIC) economy largely thanks to strong institutions and mineral resource revenue. Living conditions have steadily improved since independence as the wealth from diamond discoveries has helped lay the foundations for growth and development together with investments in infrastructure and human development and the building of strong government institutions. Social public service delivery has expanded to provide large parts of the vast country with clean water, electricity, and sanitation; and basic education and health outcomes have steadily improved thereby strengthening the wellbeing of most Batswana. But this extractives-driven growth model is reaching its limits to further sustain poverty reduction and inclusive growth. The average economic growth has been declining since 2010 and has further decelerated and turned more volatile since 2016. Poverty and inequality rates also remain inordinately high for a country of its income level. Botswana’s projected extreme poverty rate for 2019 (13.5 percent) is more than four times higher than comparators of similar Gross Domestic Product (GDP) levels and is further expected to stagnate. Inequality is amongst the highest in the world. With decelerating growth, an undiversified economy, low human capital outcomes, and higher-than-expected poverty, Botswana’s high-income country (HIC) goal appears distant. The government has demonstrated a strong commitment to human capital development with high levels of investments in education, health and social protection Botswana spends significant government resources as a share of GDP on health (4.8 percent), education (7.1 percent) and social protection (2.6 percent) compared to many of its UMIC neighbors in the region that also have high levels of poverty, and inequality and high burdens of disease.1 Human Development is also centrally placed in the most recent National Development Plan (number 11, 2017-2023). Nevertheless, human capital outcomes are not commensurate with spending levels and will limit future growth prospects. Botswana currently has a score of only 0.41 on the World Bank’s Human Capital Index (HCI). This implies that a child born in in 2020 will only be 41 percent as productive when she grows up as she could be if she enjoyed complete education and full health. Botswana’s HCI score is slightly higher than the average for Sub-Saharan Africa (0.40), and far below the average for UMICs (0.56) stressing the need to improve the efficiency of investments in people to enhance the productivity of its next generation. Critical indicators such as stunting, child mortality rates, learning outcomes, and adolescent fertility rates are below what is expected of a HIC-aspiring nation with Botswana’s potential. Botswana’s low human capital outcomes will limit future growth and transformation as the labor market does not get the skills that it is needed to deliver productive outputs. 1 World Bank, 2023. The World Bank in Botswana: Overview: https://wwwworldbank.org/en/country/botswana/overview; World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://openknowledge.worldbank.org/server/api/core/bitstreams/16edcf93-7384-5de9-8c9c-b491c04d81bc/content; World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 11 Human capital investment across the lifecycle Improving human capital outcomes in Botswana requires holistic investments in nutrition, health, education, skills development, employment, and social protection to meet the needs of individuals at different stages of life. An important first step is assessing the state of human capital development in the country to identify deficiencies and disparities and to understand the determinants of the observed gaps. The findings of such an assessment can then form the basis for identifying priority challenges and for informing the design of the country’s policy and programmatic responses to address them. In line with this approach, this Policy Note presents an in-depth assessment of the status of human capital development in Botswana and identifies the priority challenges across the key social sectors involved in human capital development. This Policy Note uses a lifecycle framework to undertake an in-depth diagnostic of human capital development in the country. The lifecycle approach places a strong emphasis on investing in human capital development holistically, involving all relevant sectors, and as a continuum - following the trajectory of an individual’s life. It focuses on three critical stages of an individual’s life— (i) Early Childhood; (ii) School Age; and (iii) Youth to Adulthood (see Figure 1). This approach recognizes that early childhood, starting with the prenatal stage, forms the foundation for lifelong health, all future learning, and overall wellbeing, while investments during the school years and beyond reinforce developments in the early years, leading to further human capital accumulation. Moreover, the approach considers the complementarity of investments made across human capital development sectors and during the different stages of the lifecycle for synergistic effects. Figure 1. A Lifecycle framework to examine inequalities in human Figure 1: A Life capital development. cycle framework to examine inequalities in human capital development Early School Age Youth to childhood Children Adulthood (Pregnancy to Age 5) (Age 6-17) (Age 18 and older) Source: Adapted from Human Development Project, World Bank, 2021 12 Assessment of human capital across the lifecycle model A. Early Childhood (from pregnancy to age 5) Improving early childhood care and development (ECCD) outcomes forms the foundation for citizens to reach their full human capital potential. Global evidence shows that healthy development in the early years, specifically, the time from pregnancy to age 5, provides the basis for all future health, educational achievement, and thereby economic productivity in adulthood. There are several important and interlinked domains for ECCD, including physical, cognitive, socio-emotional, and linguistic development areas. Whether a child is healthy and well-nourished and receives early stimulation to support her learning strongly correlates with progress in several of these developmental domains and can thereby serve as good proxies for success on key ECCD outcomes. Botswana has developed a framework for ECCD which cuts across the core human capital sectors. Early year health outcomes in Botswana are below most of its income group peers which raises concerns regarding the quality of antenatal, perinatal, and post-natal care services. Although both infant- and under-five mortality rates have declined over the years, the improvement is slowing down, and rates remain comparable with the global average and are significantly higher than in other UMICs. Antenatal care visits (73 percent of women with four visits)2 are well below the World Health Organization (WHO) target of 90 percent. Data on post-natal care visits are unavailable. However, available data suggest that there are variations in health utilization by health district and the Ministry of Health (MoH) is in the process of strengthening its maternal and perinatal death surveillance and response (MPDSR) capacity.3 Botswana’s relatively high adolescent fertility rate (49.1 per 1,000 women ages 15-19) is also an important driver of poor early childhood outcomes as well as poor maternal health outcomes.4 Undernutrition among children aged 6-59 months remains a challenge in Botswana as evidenced by high levels of stunting and micronutrient deficiency. Estimates suggest that stunting remains largely unchanged from 25.9 percent in 2010 to 22.8 per cent in 2020 as was the prevalence of underweight and wasting.5 Other estimates suggest that the share of children under five that are not stunted (68 percent) is significantly less than in both Lower-Middle Income Countries (LMICs) (75 percent) and UMICs (87 percent).6 An estimated 43.3 percent of children aged 6-59 months had anemia in 2019. 7 Vitamin A supplementation coverage was estimated at 69 percent in 2019,8 While rates of exclusive breastfeeding for the first six months were equally low in boys (31.9 percent) and girls (28.1 percent) in 2017.9 Meeting the objectives of universal access, equity, inclusivity, and quality in early stimulation and pre- primary education remains a challenge in Botswana. Although a majority (81.6 percent) of government primary schools in Botswana had implemented the national pre-primary program (provision of one year of pre-primary or reception classes) by 2021, the pre-primary gross enrolment rate remains low.10 Outside of government pre-schools, some young children attend community based Early Childhood Care and Development (ECCD) centers but data on enrolment, attendance and quality of services offered in the community centers is lacking. Botswana also does not measure early learning and development of young children. Regularly collecting these data on young children can inform policies and interventions related to nutrition, stimulation, and early childhood education. In addition, any gaps in development can be identified early and children and families can be provided with timely support to optimize development and learning outcomes. 2 Statistics Botswana, 2009. Botswana Family Health Survey 2007-2008 3 UNPFA ESARO, 2023. Maternal and Perinatal Death Surveillance and Response. Status Report 2021: Assessment of Countries in East and Southern Africa https://esaro. unfpa.org/sites/default/files/pub-pdf/esaro_mpdsr_status_report_final.pdf 4 United Nations Population Division, World Population Prospects 5 UNICEF/WHO/World Bank Joint Malnutrition Estimates - Country Level Stunting Estimates https://data.unicef.org/topic/nutrition/malnutrition/ 6 See HCI outcomes in main text. 7 World Bank, 2023. World Development Indicators. https://databank.worldbank.org/source/world-development-indicators 8 Ibid. 9 https://data.unicef.org/country/bwa/ 10 Pillar, L.J. and Haricharan, S.J., 2023. “Early Childhood Care and Education in Botswana: Implications for access and quality”, South African Journal of Childhood Education 13(1), a1268. https://doi.org/ 10.4102/sajce.v13i1.1268 13 Despite the global evidence showing that targeted grants for children living in poor households, contribute to human capital, Botswana does not have a dedicated infant and child grant for poor households with children. Nevertheless, Botswana does have programs providing in-kind benefits for vulnerable children, including orphans, and the government is making inroads to devise a strategy to reorganize its main social assistance programs along the lifecycle stages - including the early years. This may involve considering a cash-based infant and child grant targeted to children in poor households by building on the Vulnerable Groups Feeding Program (VGFP), the Destitute Persons Program (DPP) and Orphan Care Program.11 In addition to providing income support to poor households with young children, social protection programs could contribute to ECCD outcomes by strengthening their links with ECCD programs. The importance of early childhood development is well recognized in Botswana and is fully articulated in the Policy Framework for Holistic Early Childhood Care and Development. At the same time, the Botswana Nutrition Strategy is an important document in moving the nutrition agenda forward. However, social protection programming has not yet implemented any direct links to ECCD center enrolment and nutrition programs on any scale. B. School Age Children (ages 6-17) Substantial investments are needed to ensure that children enroll in school on time, stay and complete their education, and learn and acquire the wide range of knowledge and skills they need to transition into adulthood. Continued investments in nutrition and health are also needed to ensure their physical, mental, and social development. Botswana commits a significant amount of its GDP (7.1 percent in 2019) to education12 - a testimony of the value placed on education in the country. While this amount is high compared to other countries, about one-third went towards tertiary education. Botswana has reached near universal completion rates in primary and junior secondary school thanks to important actions by the government. This is largely due to the removal of the high-stakes Primary School Leaving Exam (PSLE) prior to entering Junior Secondary School in 1987, which led to increased transition from primary to junior secondary education. However, a large number of students start to drop out of the education system after Form 3 (Junior Secondary). While the reasons for dropping out of school need to be investigated further, the available information points to several factors affecting drop out including: (i) high repetition rates in primary and secondary schools that discourages students from continuing their education; and (ii) insufficient supply of spaces for students to progress in senior secondary education, technical and vocational education and training (TVET) or other education and training pathways. Performance on learning assessments reflects low learning outcomes in Botswana. Botswana has participated in international learning assessments and was one of few African countries that participated in assessments such as the Progress in International Reading Literacy Study (PIRLS) till 2011 and the Trends in International Mathematics and Science Study till 2015. In both assessments, Botswana was amongst the poor performing countries and was far below levels that are commonly seen even in most middle-income countries. Analysis of the performance in the international assessment indicates that key determinants of learning in Botswana were the socio-economic status of school, region, and student gender (girls outperforming boys). While participation in international learning assessments will help benchmark Botswana’s learning performance against other middle income countries, Botswana should also consider implementing regular national learning assessments across different levels of education (starting with reading and mathematics assessments in early grades; language, science and mathematics assessments in junior secondary) to support the government to track performance and to set targets for enhancing learning outcomes. 11 Government of Botswana, 2020. National Social Protection Framework Implementation Plan. 12 World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://openknowledge.worldbank.org/server/api/core/bitstreams/16edcf93- 7384-5de9-8c9c-b491c04d81bc/content; More recent data from UNESCO Institute for Statistics, 2020 suggests a higher percentage at 8.74 percent of GDP: https://data. worldbank.org/indicator/SE.XPD.TOTL.GD.ZS?locations=ZG-BW 14 Strengthening teacher recruitment, training and support, as well as monitoring and performance management offers an avenue for improving the quality of teaching and learning. Although student teacher ratios are favorable in Botswana (25.7 for primary and 11.9 for secondary schools), there is an oversupply of teachers in certain subjects such as English, Setswana, History and Geography and a shortage of teachers for subjects such as Mathematics and Science. Teacher salaries constitute the largest share of the recurrent budget in education (63 percent of the recurrent budget is spent on teacher salaries and 9 percent on regional Ministry officials and support staff in schools), yet very little is known about teaching practice in the classroom. Teacher preparation, which is the responsibility of the regional education offices, is constrained by lack of funds and subject specialists. Decentralization of the teacher training function has not proven successful and subsequently there is insufficient teacher training and continuous professional development provided to teachers. Pre-and in-service teacher training should focus on strengthening the quality of teaching at the classroom level to support strengthening of learning outcomes in the country. It is vital to strengthen coordination between the Ministry of Education and Skills Development (MoESD), the Ministry of Local Government and Rural Development (MLGRD), and the Ministry of Infrastructure to improve allocation of funds, planning and budgeting for school infrastructure and other items. MoESD is generally responsible for education. However, at the primary school level, the MLGRD is responsible for infrastructure development, learning resources (except textbooks) and school feeding programs, and at the secondary education level, the Ministry of Infrastructure is responsible for managing senior secondary education school maintenance, and building of classrooms and schools with funding provided by MoESD. This fragmentation of both functions and budgets contributes to inefficiencies in the education administration. For instance, allocation of resources to building classrooms is not linked to decisions regarding the enrolment or appointment of teachers.13 The main social protection program for school age children is school feeding. More analysis of the cost-benefits and impacts of the school feeding program on schooling outcomes and learning is needed to assess the value for this high per student investment. In addition, two other smaller programs target school-age children: the Needy Students/Needy Children Allowances provide educational support to poor students attending school. The programs have not been evaluated, particularly with respect to their impact on human capital outcomes. As noted above, there is no comprehensive national cash-based social assistance programs in Botswana which supports poor households with school age children. However, there is scope to consolidate existing programs and implement a comprehensive safety net for children from poor households. Improving school health services forms part of the solution to improving the well-being of school- aged children. New HIV infections among adolescents are a concern in the face of other successes in Botswana’s HIV/AIDS response. Adolescents and young people, particularly women, are thought to account for more than a third of new infections. 14 Adolescent mental health is also an emerging area of concern that is insufficiently addressed in the country’s health policy and program. About 9.1 percent of girls and 3.5 percent of boys aged 5-19 years were estimated to be obese15 and experts have expressed concerns that only about one-third of Botswana’s 5-17-year-olds are meeting global recommendations for overall physical activity.16 The draft updated National School Health Policy seeks to address policy and implementation gaps in Botswana’s school health program including building a holistic learning environment and school health services. Implementing this strategy will require close coordination across the ministries, especially MoH and MoESD. 13 World Bank, 2019. Public Expenditure Review of the Basic Education Sector: https://documents.worldbank.org/pt/publication/documents-reports/ documentdetail/925981586798022916/public-expenditure-review-of-the-basic-education-sector-in-botswana 14 National AIDS and Health Promotion Agency, 2019. The 3rd National Multi-Sectoral HIV and AIDS Response Strategic Framework, NSF III 2019-2023 15 Global Nutrition Report, 2023. https://globalnutritionreport.org/resources/nutrition-profiles/africa/southern-africa/botswana/ Last Accessed Feb 28, 2023 16 Aubert S, Barnes JD, and Demchenko I, et al., 2022. Global Matrix 4.0 Physical Activity Report Card Grades for Children and Adolescents: Results and Analyses From 57 Countries. J Phys Act Health. 2022 Oct 22;19(11):700-728. doi: 10.1123/jpah.2022-0456. PMID: 36280233. 15 C. Youth to Adulthood (ages 18 and over) Youth to adulthood covers the transition from school to post-school education and training, to the labor market, to family formation, and gradually, to old age. Continued education and training, access to gainful employment, quality health care, and social protection for those who are vulnerable, all remain imperative to ensure that individuals reach their human capital potential and live full, productive, and healthy lives. During the transition between school age into adulthood, many youths struggle to acquire relevant high-level skills and to find employment. Often these challenges persist with many facing lifelong poverty and deprivation. Batswana also faces poor health outcomes in youth and adulthood, resulting in a short life expectancy that is much lower than what can be expected for UMICs. Despite a period of solid economic growth, unemployment remains persistently high in Botswana and women’s employment is lower than for men. The overall unemployment rate in 2022 is estimated at 23.4 percent.17 Nearly two thirds of the unemployed are under the age of 34. More men are employed than women and women have a higher probability of being discouraged in the labor market. Women’s overall employment rate stands at 49 percent, 9 percentage points lower than for men. Unemployed workers are disproportionately youth, poor, and reside outside of Gaborone.18 They are also less educated than the working-age population in general. A range of opportunities are available to assist young Batswana transiting from school to the labor market, in particular the formal post-school education and training sector comprised of higher education, Technical and Vocational Education and Training (TVET), and programs to support employability and entrepreneurship development. Overall, the landscape of opportunities is complex. The post-school education and training sector consists of 84 registered and accredited institutions, of which 44 are higher education institutions, and 40 are TVET institutions. Tertiary scholarships are given to all higher education students in both public and private institutions, but most beneficiaries are from better-off households since they are most likely to continue to higher education. In addition to formal TVET, the government currently aims to build a widely accessible pre-vocational stream in secondary education. Overall, the post-school education and training system is struggling to offer educational services at high quality and relevance. By the end of 2022, one third (33.5 percent) of youth aged 15 to 35 were unemployed and 40 percent were considered not in employment, education, or training.19 For students, the majority opt for occupational fields of study, which are expected to lead into white-collar jobs. But young people’s study preferences do not match labor market needs. Despite the shortage of technicians and engineers in the country, only 21 percent of all students in the post-school education and training system have chosen engineering, manufacturing, and construction fields.20 Programs with low labor market absorption capacities, such as teacher training, accommodate high student numbers, while TVET-level technical trade programs with considerable unmet market demand remain undersubscribed. To improve the coordination of the post-school education and training system and strengthen the labor market relevance of skills and employability programs, the recent reshuffling of ministerial responsibilities in the education sector has now brought all higher and TVET institutions under the auspices of the MoESD. Similarly, coordination is needed in the employability and entrepreneurship promotion eco- system. Botswana has a number of Active Labor Market Programs (ALMP) including the Ipelegeng public employment program and a number of government and non-government youth employment programs. Overall, the landscape of non-governmental initiatives is not well-documented, and information about performance and outcomes are hardly available. 17 Statistics Botswana, 2022. Quarterly Multi Topic Survey Quarter 4, 2022. 18 Raju, D. and Nxumalo, M., 2020. “Botswana National Employment Policy Development - Input Note”. World Bank. 19 Statistics Botswana, 2022. Quarterly Multi-Topic Survey Quarter 4, 2022. 20 Human Resource Development Council, 2022. Tertiary Education Statistics 2021. 16 Throughout youth and adulthood, a number of risks which affect human capital occur: loss of income from the labor market; childbirth and childcare responsibilities (mainly for women); illness and disability; shocks due to climate change and other events such as floods or fires; and old age and death. Social protection and health systems need to provide support to these age groups, both when risks occur but also to build the resilience and prevent major loss of productive human capital. Botswana’s population are benefiting from social protection programs including those aimed at addressing poverty and supporting youth to engage in productive activities. Nearly 56 percent of the total population benefit from at least one social protection program21 but 21 percent of the poor are not covered by any type of social protection program. Botswana’s social protection system has documented significant impacts on poverty and inequality reduction. However, there are multiple opportunities for improving efficiency of the social protection system, including implementation of the Single Social Registry, improving targeting and data management, more efficient benefit delivery systems, strengthening case management, and reallocating spending to programs that have the greatest impact on reducing poverty. The government has embarked on an agenda to strengthen the social assistance system, but the reform program could be broadened and deepened, and progress is slow. Life expectancy has improved in Botswana over the last decade, but maternal mortality rates are stubbornly high and non-communicable diseases (NCDs) add to the health burden of adults. Women enjoy a longer life expectancy at birth than men in Botswana largely thanks to the reduction in HIV/AIDS but even though maternal mortality has declined since 201422 it remains high relative to other UMICs. The increased risk of morbidity and mortality from NCDs is driven in part by increased risk of high body-mass index, cancers, and blood related health conditions. Health system challenges have been identified and include failure to implement protocols, poor organizational management, delays in ordering medical tests or performing interventions, delays in consulting or availability of senior clinical staff, and stock outs of essential supplies, coupled with delayed health seeking including during the antenatal care have been cited to impede good clinical outcomes.23 The system for routinely monitoring availability of essential medicines and the status of the supply chain is weak which is further exacerbated by challenges such as poor forecasting and quantification and insufficient operational autonomy for health facilities.24 Botswana has introduced strategies to enhance the health and care of older persons. The Health and Active Ageing Program launched in 2022 aims to, among others, improve access to and quality of health services for older persons aged 60+. The initiative would help meet the needs of older persons - a majority of whom have bad self-perceived health status and are living with chronic disease conditions.25 Moreover, the Old-Age Pension (OAP) is a universal social pension payable to citizens 65 years and older but private sector social insurance are largely unavailable. A World Bank review also identified gaps in the provision of social care services for the elderly, including home-based care, day care, and residential care, and this will become more acute as the elderly population grows.26 21 Government of Botswana, 2016. Botswana Multi-Topic Household Survey (BMTHS) 2015/16. 22 Statistics Botswana, 2020. Botswana Maternal Mortality Ratio 2020 23 Madzimbamuto, F.D., Ray, S.C., Mogobe, K.D. et al. 2014. A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement. BMC Pregnancy Childbirth 14, 231 (2014). https://doi.org/10.1186/1471-2393-14-231 24 National Strategy Office, 2019. Making Essential Medicine Available to Citizens in Botswana: Results of the Rapid Evaluation on Medicine Supply Chain (MSC) in Botswana https://vision2036.org.bw/sites/default/files/resources/Rapid%20Evaluation%20of%20Medicines%20Supply%20Chain.pdf 25 Mhaka-Mutepfa, M. and Wright, T. C. 2022. Quality of Life of Older People in Botswana. The International Journal of Community and Social Development, 4(1), 104–126. https://doi.org/10.1177/25166026211064693 26 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 17 The contribution of human capital to growth and poverty reduction There is plenty of international evidence that human capital is one of the main drivers of economic growth globally. Having a healthy and well-educated work force is positively linked to increased productivity and economic growth.27 Investments in education bring positive public returns since educated citizens are likely to earn more, pay higher taxes over their lives, and cost the government less in terms of social entitlements and welfare. Negative impacts on human capital can also have negative impacts on economic growth28 and social protection has also been shown to have significant impacts on reducing poverty and inequality levels across the globe and so is the case in Botswana.29 Especially in Africa, due to its young population, sustained investments in health, education, and social protection have been lauded as especially important for growth. The Africa Human Capital Heads of State Summit held in Dar-es-Salam in July-August, 2023 highlighted that robust economic growth development are a combination of a) smart physical infrastructure investments, b) appropriate economic policies, and c) timely and sustained human capital investments.30 In fact, lessons from the East Asian tiger countries like South Korea, Malaysia, and Singapore demonstrate that sustained strategic investment in human capital have contributed to between one third and a half of all their rapid economic growth.31 However, Botswana’s low human capital outcomes will limit future economic growth and poverty reduction. According to the World Bank’s forthcoming study of the drivers of growth in Botswana32, the low human capital accumulation, compared to countries with similar income levels, will limit future growth prospects. The study simulates Botswana total factor productivity (TFP) at the level of Chile’s, Mauritius’ and Malaysia’s TFP growth by year 2036 and shows that its GDP per capita falls short to meet the HIC threshold. Compared to other countries with similar GDP per capita, Botswana’s HCI is 30-40 percent less. A more skilled and productive labor force is needed which requires addressing both the stock (people already in the labor market) and the flow constraints of human capital development. Furthermore, analysis conducted as part of the World Bank’s Poverty Assessment33 shows that labor income was the main driver of poverty reduction in urban areas 2009-16 and the downward trend in the share of employed adults in rural households contributed to higher rural poverty. Improving the efficiency of spending to maximize human capital outcomes For Botswana’s labor market to deliver the outputs needed to sustain and further transform the economy from UMIC status to HIC status a more productive, skilled and healthy labor force is needed. This would require addressing both the stock and the flow constraints of skilled workers. In the short term, short skills programs and support to reorient existing labor supply towards growth-oriented sectors is important. In the longer term, more efficient delivery of human development services is needed including early investments to prepare children to grow and learn at school; ensuring that the education and skills system delivers quality learning and experiences that are fit for the demands of the labor market; ensuring workers are supported with better access to quality health care so they are more productive, and using social protection mechanisms to support the poorest households to access equitable and quality services, and cushioning them in case of temporary income loss and to reenter the labor market after shocks hit. 27 https://gpseducation.oecd.org/revieweducationpolicies/#!node=41761&filter=all 28 I. A. Mobosi, P.O. Okonta, and C.E. Nwan Kwo, 2022. Health burdens and labor productivity in Africa’s middle- and low-income economies: Implication for the COVID-19 pandemic, Journal of Knowledge Economics, October 17 (2022), 1-19. doi: 10.1007/s13132-022-01058-y. 29 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. 30 World Bank, 2023. Africa Human Capital Heads of State Summit. https://www.worldbank.org/en/events/2023/07/25/africa-human-capital-heads-of-state-summit 31 Ibid. 32 World Bank, 2023. Drivers of Growth Botswana, forthcoming. 33 World Bank, 2023. Botswana Poverty Assessment, forthcoming. 18 Nevertheless, current investment strategies in human capital could be better targeted to achieve the right outcomes. This Note points out that while Botswana spends significant resources on health, education, and social protection (over 14 percent of GDP in total) there are inefficiencies in the process of transforming these inputs and outputs into better human capital outcomes. Understanding where the inefficiencies in the delivery system occur and addressing them are of importance in Botswana. In addition to better efficiency of current spending, more funding is required to support the youngest individuals in Botswana. Early childhood care and development (ECCD) of children ages 0-5 has been underfunded in the country with few programs being directed to this segment of the population where global evidence suggests countries get the biggest return on investment. More funding is required to support a comprehensive social grant for infants and toddlers, to expand the provision of quality services in ECCD centers and pre-schools, and to support better nutrition programs for children. There is room for better coordination between different Ministries these services for children in a holistic way. Five areas that require attention for enhancing the value-for-money in the human development delivery systems are identified in this Note: 1. Ensuring funds are better targeted towards the poorest segments of the population and more funding goes to programs that support children from poor households • In all three sectors – health, education and social protection - there is scope to reorient some of the spending that does not benefit the poorest and focusing more on primary care services especially for children. • Providing human capital services in rural and remote areas is more expensive and careful consideration is needed with regards to how to most effectively and efficiently provide services in these areas to ensure that children receive the same opportunities to thrive and later contribute to the labor market as adults compared to children growing up in urban areas. 2. Measuring outcomes that matters and generating information to guide real time policy action • There is a need to strengthen results measurement and monitoring of core human development indicators to focus attention more strongly on advancing final human development outcomes. • Measurement needs to be undertaken frequently and organized in a way that it feeds into decision making to adjust programming based on the results. Botswana should continue to participate in international learning assessments. 3. Strengthening cross-sector coordination for programming for young children and youth • Keeping the focus on outcomes through the generation of data will allow attention to be paid to specific results areas across the life cycle that requires cross sectoral/cross ministerial coordination to maximize results across all life cycle stages including ECCD, schooling years, and youth and adulthood. • Both functions and budgets are split across MoESD, MLGRD, and the Ministry of Infrastructure for primary and secondary education which limits teacher and classroom allocations and challenges student learning. MoH also plays a role for school health. • Especially in the post-school and skills development sector there is significant institutional fragmentation and insufficient coordination and collaboration among the different actors. 4. Reviewing service delivery chains to incentivize performance and course correct early • The biggest budget items in the health and education budget relate to health workers and teachers as well as essential medicines and textbooks. Tracking the performance of staff and procurement of goods is a good place to start when trying to address inefficiencies. • For social protection there are multiple opportunities for improved efficiencies and efficacy in the administration and delivery of benefits, including implementation of the Single Social Registry. 19 5. Benefitting from private sector collaboration and expertise • Rather than taking on all aspects of financing and delivery of services, the public sector may take on the role of financing and regulating service delivery by inviting private actors into the sector. The competition from, and among private actors, in the education space may trigger an improvement in the quality of service delivery, allowing more and better services to be delivered across the sector. • Botswana’s private sector has been a key contributor to its health system gains, including in its response to HIV/AIDS and COVID-19 pandemics. Botswana should build on this by formalizing public-private collaborations through the development of specific guidance for health sector collaborations. Policy priorities It is time for Botswana to review its policies and priorities to ensure better impacts for its human capital investments. With the commitment of decision makers and solid investments there is potential to accelerate progress. More attention should be paid to supporting early childhood programs, measurement of young children’s development, learning outcomes throughout the school years, quality of and utilization of health services, and the efficiency of social protection spending. By focusing the attention on final outcomes Botswana can get back on the path towards HIC status. Smart human capital investments will also be critical in an ever-fluctuating world. In August 2023, Botswana signed the Dar-es- Salam Declaration, committing to focus efforts towards growth of Human Capital in the country. The below highlights priority policy recommendations for the three age lifecycle stages: early childhood, children of school going age, and youth to adulthood as well as needed cross-cutting actions. A. Policy priorities for early childhood • Strengthen the utilization and quality of maternal, neonatal and child health services: • Explore strategies to increase participation of children in pre-primary school and early childhood stimulation programs. • Consolidate safety nets for young children and link poor households to programs providing early stimulation and health and nutrition services. B. Policy priorities for children of school going age • Develop and regularly administer standardized, national learning assessments to follow progress in learning across primary and secondary levels. • Undertake analytical work to identify key causes of secondary school dropout and repetition and propose practical solutions to address these challenges. • Consolidate safety nets for school age children; assess the impacts of food and in-kind support; and target social protection to encourage poorer students to continue through secondary school. • Leverage existing school-based health interventions to enhance effective coverage of key services. C. Policy priorities for youth to adulthood • Improve coordination among skills development and ALMP programs and conduct systematic outcome monitoring of existing interventions. • Focus new investment in post-school education and training on skill areas with a high growth potential, notably digital skills and green skills. • Strengthen quality of adult care to address premature mortality and quality of life. 20 D. System level issues cutting across the lifecycle • Strategic investments in key health inputs delivered through a primary health care approach. • Accelerating reforms to health service purchasing to deliver effective coverage. • Building social protection delivery system for better targeting and identifying poor and vulnerable households to focus human capital investment. • Invest in the shock responsiveness and pandemic preparedness of human development delivery systems. 21 22 I. The Botswana Context Botswana’s has advanced to a stable UMIC economy thanks to its mineral resources and its prudent policies. The World Bank’s 2023 Systematic Country Diagnostic Update for Botswana34 notes that the discovery of large diamond deposits, and strong institutions and policies for growth have moved Botswana into one of the world’s fastest growing economies. GNI per capita growth reached above 7 percent since independence until the late 1990s – five times faster than the global trend (Figure 2). Figure 2. Economic growth trend since 1990’s GNI per capita (US$), Atlas method 14000 14000 12000 12000 High income 10000 10000 8000 Botswana 8000 Upper middle income 6000 6000 4000 4000 Lower middle income 2000 2000 Low income 0 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2015 2016 2017 2018 2019 2020 2021 2022 Source: World Bank, 2023. Botswana - Systematic Country Diagnostic Update: At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C. : World Bank Group. https:// documents.worldbank.org/en/publication/documents-reports/documentdetail/099112023112034378/ bosib056106b900660a7d8068fe9cad99f2 The resource wealth coupled with governance and investments in public infrastructure and human development contributed to a stable base for growth and development. While providing public services in a vast and sparsely populated country like Botswana was not simple, the access to electricity, drinking water and sanitation, is now benefiting a large share of the population (Figure 3). Universal enrolment in primary education was also reached much earlier than most African countries and investments in the health sector drove advancements in wellbeing outcomes such as mortality (Figure 3). 34 World Bank, 2023. Botswana - Systematic Country Diagnostic Update: At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C.: World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/ documentdetail/099112023112034378/bosib056106b900660a7d8068fe9cad99f2 23 Nevertheless, the reliance on extractives and a large public sector will not continue to sustain robust and inclusive growth.35 Growth rates have declined since 2010 and fluctuated in recent years. From a growth rate of 5.1 percent in 2002-08, and 3.2 percent in 2009-2014, GDP growth has slowed down to 2.4 percent in the period 2015-2021 (Figure 4). The weaker recent performance is somewhat influenced by several external shocks outside the control of authorities (economic recession in 2015, droughts in 2015 and 2019, floods in 2017, the 2020 Covid pandemic, and higher food and energy prices in 2022). A large public sector footprint and limited economic diversification beyond natural resources coupled with increasing vulnerability to climate shocks, has heightened both external and fiscal vulnerabilities and slowed down growth.36 Figure 3. Standards of living increases over time 100 1991 2000 2010 2020 100 1980s 1990s 2000s Latest 80 80 Coverage (percentage) 60 60 40 40 20 20 0 0 Access to People using at least People using Life exepectancy Adult literacy rate Infant mortality rate electricity basic drinking water at least basic at birth (years) (percent) (per 1,000 live births) services sanitation services Source: World Development Indicators, 2023. https://databank.worldbank.org/source/world-development-indicators. Using the WB Global Electrification Database, WHO/UNICEF Joint Monitoring Program for Water Supply, Sanitation and Hygiene (washdata. org), UN Population Division, UNESCO, and UN Group for Child Mortality Estimation. Drawn from World Bank, 2023. Botswana - Systematic Country Diagnostic Update : At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C. : World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099112023112034378/ bosib056106b900660a7d8068fe9cad99f2 In addition to slowing growth, inordinately high poverty and inequality rates cripple the distribution of growth. Rapid growth since independence supported many Batswana households to move out of poverty and to progress. But for an extended period, the share of the population living in poverty has remained high (albeit declining slowly) and well above what is expected for a country of Botswana’s income level. The World Bank’s 2023 Systematic Country Diagnostic Update notes that at 13.5 percent, Botswana’s projected extreme poverty rate for 2019 (as per the international poverty line of US$2.15 PPP) is over four times higher than what is predicted by its GDP per capita (Figure 5).37 Moreover, the rate of poverty reduction slowed between 2010 and 2016, and projections suggest further stagnation in recent years (Figure 6). Inequality is amongst the highest in the world, with a Gini coefficient of 0.53 (Figure 7). However, inequality has decreased over the last decade and education and health transfers contributed two-thirds of the reduction.38 Taken together, the decelerating growth, undiversified economy, and the higher-than- expected poverty and inequality makes the goal of becoming a high-income country far away. 35 Ibid. 36 Botswana is considered highly vulnerable to climate variability and change due to its high dependence on rain-fed agriculture and natural resources, high poverty levels – particularly in rural areas, and a low adaptive capacity to deal with these expected changes. 37 World Bank, 2023. Botswana - Systematic Country Diagnostic Update: At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C.: World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099112023112034378/bosib056106b900660a7d8068fe9cad99f2 38 World Bank, 2023. Botswana Poverty Assessment, forthcoming. 24 Figure 4. Botswana’s economic growth is losing steam (average growth by period in percent) Average annual GDP and GDP per capita growth by period (percent) 6 5.1% 5 4 3.2% 3.1% SCD update period 3 2.3% 2 1.2% 1 0.4% 0 2020 2021 2002 2012 2007 2017 2009 2019 2008 2018 2003 2013 2005 2006 2015 2016 2010 2011 2004 2014 GDP GDP per capita Source: World Bank, 2023. Botswana - Systematic Country Diagnostic Update: At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C. : World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/ documentdetail/099112023112034378/bosib056106b900660a7d8068fe9cad99f2 Figure 5. The poverty rate is high39 90 Extreme poverty rate (percentage) 80 70 60 50 40 30 20 BWA 10 0 6,5 7,5 8,5 9,5 10,5 LN (GDP per capita, PPP, US$)* Source: World Bank, 2023. Botswana - Systematic Country Diagnostic Update: At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C. : World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/ documentdetail/099112023112034378/bosib056106b900660a7d8068fe9cad99f2 39 The chart includes countries with PPP GDP per capita of less than US$25,000 only. 25 Figure 6. Poverty reduction is slowing 2008 2009 2016 2022 Imputation 30,6 19,3 percent 16,1 14,0 11,6 6,2 6,0 4,6 2,9 1,9 Poverty Poverty Gap Poverty Severity Headcount Index Source: World Bank, 2023. Botswana - Systematic Country Diagnostic Update: At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C.: World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/ documentdetail/099112023112034378/bosib056106b900660a7d8068fe9cad99f2 Figure 7. The level of inequality is very high 0,7 0,6 Botswana 0,5 Gini coefficient 0,4 0,3 0,2 0,1 0 Ranking of 164 countries Source: World Bank, 2023. Botswana - Systematic Country Diagnostic Update: At a Crossroads - Reigniting Efficient and Inclusive Growth (English). Washington, D.C.: World Bank Group. https://documents.worldbank.org/en/publication/documents-reports/ documentdetail/099112023112034378/bosib056106b900660a7d8068fe9cad99f2 26 Inequality in Botswana has strong geographic aspects affecting human capital service delivery and outcomes. Botswana is a highly urbanized country with around 70 percent of the population living in towns, cities or urban villages.40 The recent World Bank’s Botswana Poverty Assessment41 highlights that poverty rates in rural areas actually increased by 2.5 percentages points between 2009 and 2016 and the gap between urban and rural widened. Labor income was the main driver of poverty reduction in urban areas. Poverty remained highest among children, large families, female-headed households, and people with lower levels of education. This high level of inequality and the vast and sparsely populated rural areas drive up costs for service delivery and human capital outcomes outside of urban villages and towns. For instance, access to electricity and improved sanitation is significantly lower in rural areas and in poor villages and while electrification of villages has been steadily improving in the last decade, there is very little progress for the poorest villages.42 Providing human capital and social services in rural and remote areas with poor electrification and access to sanitation is a challenge in Botswana and adds to the costs. Moreover, rural areas often present logistical challenges not only to service delivery but also accountability. Oftentimes, they are not as politically or economically integrated as the rest of the country, and there is an information gap between service providers and service users.43 The government of Botswana has shown a strong commitment to human capital development in recent years. A testament to this commitment is the high levels of spending on health, education and social protection compared to other UMICs. Botswana spends nearly 4.8 percent (2017) of its GDP in public spending on health, which is higher than both the regional average (2.4 percent) and the average for countries in the same income group (4 percent).44 For education, spending reached 7.1 percent of GDP in 201945 46 although one third of this allocation went to tertiary education. In terms of social protection, Botswana spent nearly 2.647 percent of GDP in 2018/19, of which 1.1 percent was on contributory pension programs for public employees and 1.5 percent was on non-contributory social assistance programs. However, not very much of this goes to programs targeted to the poorest. Despite these commitments, the high levels of investment are not delivering quality human capital outcomes. Botswana currently has a score of 0.41 on the World Bank’s Human Capital Index (HCI). This implies that a child born in Botswana just before the pandemic will be 41 percent as productive when she grows up as she could be if she enjoyed complete education and full health. The HCI is a composite measure of key human capital outcomes across health (child survival, stunting, and adult survival rates) and the quantity and quality of schooling (expected years of school and harmonized test scores). The score for Botswana is slightly higher than the average for the Sub-Saharan Africa region (0.40) but lower than the average for upper middle-income countries (0.56). 40 Urban villages are localities usually with a population of 5,000 or more inhabitants and at least 75 percent of the employed population is engaged in economic activities other than subsistence agriculture. 41 World Bank, 2023. Botswana Poverty Assessment, forthcoming. 42 World Bank, 2023. Botswana Poverty Assessment, forthcoming. 43 Kosec, K. and Wantchekon, L. 2020. Can information improve rural governance and service delivery?, World Development, Volume 125,104376, ISSN 0305-750X: https:// doi.org/10.1016/j.worlddev.2018.07.017. 44 World Bank, 2023. The World Bank in Botswana: Overview: https://wwwworldbank.org/en/country/botswana/overview 45 World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://openknowledge.worldbank.org/server/api/core/bitstreams/16edcf93- 7384-5de9-8c9c-b491c04d81bc/content 46 More recent data from UNESCO Institute for Statistics, 2020 suggests a higher percentage at 8.74 percent of GDP: https://data.worldbank.org/indicator/SE.XPD.TOTL. GD.ZS?locations=ZG-BW 47 This excludes the 1.13 percent of GDP spent on tertiary sponsorship and scholarships which, in this document. is counted as part of the education sector spending data quoted. 27 Table 1. Botswana’s Human Capital Index, Benchmarked Against Comparators Botswana Sub- Lower Upper Low High Indicator 2020 Saharan Middle Middle Income Income Africa Income Income T M F Probability of survival to age 5 0.96 0.96 0.97 0.93 0.93 0.96 0.98 0.99 Expected years of school 8.11 7.72 8.51 8.3 7.6 10.4 10.4 13.2 Harmonized Test Scores 391 381 401 374 356 392 411 487 Learning adjusted years of 5.08 4.71 5.47 4.97 4.33 6.52 6.84 10.29 schooling Survival rate from age 15-60 0.80 0.75 0.84 0.74 0.75 0.80 0.86 0.92 Fraction of children under 5 not 0.68 - - 0.69 0.65 0.75 0.87 0.80 stunted Human Capital Index (HCI) 0.41 0.39 0.44 0.40 0.38 0.48 0.56 - Source: Constructed by the World Bank from data in World Bank Human Capital Index database, 2022: https://databank.worldbank. org/source/human-capital-index Note: T: Total; M: Male; F: Female. Similarly, Botswana’s human capital appears to be lagging when compared to the global average score of 0.56 for UMIC (Figure 8), stressing the need to improve efficiency of investments in people to enhance the productivity of its next generation. Gender-wise, in Botswana, the HCI for girls (0.44) is higher than boys (0.39). Among South Africa Customs Union (SACU) countries, Botswana’s HCI is lower than Namibia (0.45) and South Africa (0.43), but similar to Lesotho (0.41) and higher than Eswatini (0.37). Figure 8. Human Capital Index Scores in Sub-Saharan Africa 0,70 UMIC Average; 0,56 0,60 0,50 SSA Average; 0,40 0,41 0,40 0,30 0,20 0,10 0 Chad Niger Liberia Sierra Leone Cote d’Ivoire Angola Burkina Faso Rwanda Madagascar Burundi Ethiopia Zambia Tanzania South Africa Eswatini Togo Congo, Rep. Nambia Zimbabwe Kenya Seychelles Source: Constructed by the World Bank from data in World Bank Human Capital Index database, 2022: https://databank.worldbank. org/source/human-capital-index 28 There are differences in average spending per student between urban and rural areas. While disaggregated HCI scores for rural/urban are not readily available, several indicators related to health and education show a rural-urban divide in human capital accumulation – a vicious cycle that simultaneously contributes to and results in higher poverty in remote areas. For instance, the under-five mortality rate is nearly 40 percent higher in rural areas (per 1,000 live births) compared to cities (per 1,000 live births) and urban villages (per 1,000 live births).48 Similarly, the stunting rate in rural areas is also much higher (32.1 percent) compared to urban centers (25.7 percent).49 Moreover, nearly 96 percent of the urban population had access to a primary health care center within 5km radius, compared to 72 percent of the rural population in Botswana.50 Similarly, even though primary education is free in Botswana, learning gaps between urban and rural areas are prevalent due to differences in quality and resources, with urban schools more likely to have better amenities as show in Table 2 below: Table 2. Resource differentials across various dimensions, percent, TIMSS 2015 Urban school Village/small town school School has library 55 47 More than 250 books in school library 64 52 More than 25 books in classroom library 64 52 Reading homework less than once a week 32 21 Teacher has a degree 23 19 Class size 30 31 Source: Public Expenditure Review of the Basic Education Sector in Botswana. http://documents.worldbank.org/curated/ en/925981586798022916/Public-Expenditure-Review-of-the-Basic-Education-Sector-in-Botswana Student-to-teacher ratios are low and do not differ greatly across regions. The average primary student-to-teacher-ratio in 2017 was 25.7:1, ranging between a low of 21.3:1 in Kgalagadi and 26.7:1 in the remote areas of Ghanzi to 27.2:1 in North West district. There are differences in average spending per student between urban and rural areas, with schools in large cities on average spending nearly three times more per student compared to urban villages and rural areas (Table 3). Table 3. Average spending per student by level of schooling and location, 2015-16 (in BWP per year) Pre-primary Primary Junior secondary Senior secondary Cities 6,579 6,020 4,990 6,266 Urban villages 4,883 1,004 1,254 2,116 Rural 1,937 459 1,091 4,724 Source: Public Expenditure Review of the Basic Education Sector in Botswana. http://documents.worldbank.org/curated/ en/925981586798022916/Public-Expenditure-Review-of-the-Basic-Education-Sector-in-Botswana 48 Monamo, T.T., Navaneetham, K. and Keetile, M., 2023. Socio-economic differentials of under-five mortality in Botswana: an application of the indirect estimation method. J Public Health (Berl.). https://doi.org/10.1007/s10389-023-01980-8 49 UNICEF/WHO/World Bank Joint Malnutrition Estimates - Country Level Stunting Estimates https://data.unicef.org/topic/nutrition/malnutrition/ 50 Statistics Botswana, 2017. Health Statistics Stas Brief 2007 – 2015. https://www.statsbots.org.bw/sites/default/files/publications/Health%20Statistics%20Stats%20 Brief%202007_2015.pdf 29 These differentials directly contribute towards the gaps in learning outcomes which in turn limits human capital attainment. A 2019 review of Botswana’s education sector found that Form 3 students that fail the Junior Certificate Examination (JCE) disproportionately come from poor households. Given the higher incidence of poverty in remote areas, these students are likely to be located in villages and small towns. This, in turn, restricts their participation in higher education and human capital attainment. Figure 9 shows that a higher percentage of the population with post-school education reside in urban centers. Although this may reflect urban-rural disparity in educational achievement, it may also reflect mobility from rural to urban areas-with educated youth gravitating towards locations with tertiary institutions and higher job opportunities. Despite challenges, it is important to note that there is a merit- based pathway for bright students throughout the education system Figure 9. Percentage of the population with post-school education by age group for selected districts, 2011 Gaborone Francistown Central Serowe Palapye Ngamiland East Ghanzi Kgalagadi South 50% 45% 40% 35% 30% % average 25% 20% 15% 10% 5% 0% Age 20-29 Age 30-39 Age 40-49 Age 50-59 Age 60+ Source: Calculated from 2011 census. Source: Public Expenditure Review of the Basic Education Sector in Botswana. http://documents.worldbank.org/curated/ en/925981586798022916/Public-Expenditure-Review-of-the-Basic-Education-Sector-in-Botswana The country has made considerable investments in its fight against HIV/AIDS. The HIV/AIDS pandemic resulted in a demographic reversal and declining life expectancy, and in 2017 15.4 percent of all 0-17-year- olds (international definition51) were orphans. Life expectancy at birth had improved for both men and women from a low of 51 years in 2002 to a peak of 67 years in 2017 due to significant gains in the HIV response. Botswana has attained the 95-95-95 (percent of persons living with HIV/AIDS aware of their status, on treatment, and virally suppressed) target for persons aged 15-64 years living with HIV.52 By 2022, Botswana had realized a 66 percent reduction in new HIV infections and a 36 percent reduction in AIDS-related deaths since 2010.53 Botswana is also on course to eliminate vertical transmission (pregnant mother to child) having attained the Silver Tier.54 Botswana’s incidence: prevalence ratio55 of 1.26 heralds a gradual fall in the total population of persons living with HIV/AIDS while the incidence: mortality ratio of 0.71 heralds 56 a decline in deaths among persons living with HIV/AIDS meaning they are living longer healthy lives.57 58 As a result, Botswana is one of 5 countries in the African region that is on the path to end AIDS by 2030.59 The success story is describes in Box 1. 51 6.1 percent using the national definition. 52 Joint United Nations Programme on HIV/AIDS (UNAIDS), 2023. The path that ends AIDS: UNAIDS Global AIDS Update 2023. Geneva:. License: CC BY-NC-SA 3.0 IGO 53 Joint United Nations Programme on HIV/AIDS (UNAIDS), 2024. Country Factsheets Botswana. https://www.unaids.org/en/regionscountries/countries/botswana 54 WHO Regional Office for Africa, 2022. Regional Validation Report on Path to Elimination of Mother-to-Child Transmission of HIV in Botswana, 2018 and 2019. Brazzaville: License: CC BY-NCSA 3.0 IGO https://iris.who.int/bitstream/handle/10665/363815/9789290234791-eng.pdf?sequence=1&isAllowed=y 55 The incidence: prevalence ratio is the number of new infections occurring per year in a population divided by the number of persons living with HIV in that same population. It is estimated that maintaining this ratio below 3 percent will result in a decline in an epidemic over time, with the potential for elimination. 56 The incidence: mortality ratio is the ratio of the number of people who become HIV infected per year to the number of people among those already infected who die from any cause per year. When this number is less than one, the population of people living with HIV/AIDS falls; and when it is greater than one, the size of that population grows. 57 Ghys P.D., Williams B.G., Over M., Hallett T.B., Godfrey-Faussett. P., 2018. Epidemiological metrics, and benchmarks for a transition in the HIV epidemic. PLoS Med.;15(10):e1002678. doi: 10.1371/journal.pmed.1002678. PMID: 30359372; PMCID: PMC6201869. 58 Joint United Nations Programme on HIV/AIDS (UNAIDS), 2024. Country Factsheets. Botswana 2022 https://www.unaids.org/en/regionscountries/countries/botswana 59 Joint United Nations Programme on HIV/AIDS (UNAIDS), 2023. The path that ends AIDS: UNAIDS Global AIDS Update 2023. Geneva: Licence: CC BY-NC-SA 3.0 IGO 30 Box 1: Reasons for Botswana’s HIV/AIDS Successes • High level political commitment and aggressive leadership highlighted by sustained presidential-level support. For example, President Festus Mogae established the first African national prevention of mother to child transmission programme in 19991, and was the first African President to take a public HIV test in 2003 to increase public awareness and buy-in2. • Early adoption and rapid scale up of evidence-informed strategies and policies.3 For example, Botswana was an early adopter of integrase inhibitor dolutegravir4, working through a public-private partnership5, and other strategies such as enhanced testing, male circumcision and eliminating mother to child transmission6. Botswana was the first country in eastern and southern Africa to provide free and universal HIV treatment to PLWHA7. Scale up was also assisted by innovative approaches such as the decentralization of the HIV/AIDS response through district and village multi-sectoral AIDS committees, as well as community-based interventions to test, treat and care for PLWHA and their communities.8 9 • Performance measurement and accountability including to global mechanisms. The implementation and scale up on high-impact interventions has been accompanied by setting ambitious, specific, and epidemiologically meaningful targets, coupled with cycles of review and adaptation.10 These adaptations were based on Botswana’s and its partners’ capacity for performance measurement through epidemiologic assessments including routine surveys;11 high-quality laboratory capacity including resistance testing and genomic analysis;12 and economic analysis including development of investment cases.13 • Adequate financial investment underwritten by domestic public expenditure. Botswana’s response to the HIV has been underwritten from the onset by a significant role for public expenditure.14 The Government’s expenditure on HIV/AIDS was backed by its expenditure on health in general including investments in existing and new health infrastructure that supported service delivery, and financing for activities such as training.15 • Effective and adaptive partnerships coordinated through clear strategies. Botswana’s policy commitments on the HIV/AIDS response have been elucidated in strategies, with the first strategy being key in streamlining a hitherto fragmented response.16 The development of this strategy was supported through a public-private partnership, which also enabled a crucial investment in the response: the donation of ARVs.17 The private sector was also key in increasing access to HIV testing and treatment.18 The rapid implementation of evidence-informed policies points to the strong collaboration between political and scientific leaders.19 Civil society and individual activists also played a significant role in the successful response including providing support for the implementation of programs and issues such as reducing social stigma and decriminalization of same-sex relationships.20 Full references to Box 1 can be found in Annex 2. Gender equality and women’ empowerment in Botswana has progressed over the past 20 years, with Botswana having made significant strides toward equal treatment of women under the law. According to the World Bank’s latest report on Women, Business and Law, Botswana’s score went up from 38.1 in the early 2000s to 63.8 in 2023 – a jump of over 25 points.60 Despite this progress, the pace of legal reforms towards gender equality has slowed down in recent years. At the same time, gender-based violence (GBV) remains prevalent in Botswana, with nearly two-thirds of women experiencing abuse at least once in their lifetime according to the United Nations Population Fund – nearly twice the global average. A smaller, but still high proportion of men (44 percent) admit to perpetrating GBV. The most common form of GBV experienced by women is intimate-partner violence. While the Government of Botswana passed the Domestic Violence Act in 2008, a United Nations study in 2012 found only 46.2 percent of women and 42.5 percent of men were aware of the legislation.61 To mitigate the socio-economic impact of the COVID-19 pandemic, the government of Botswana introduced a range of initiatives to support the most vulnerable households. The government was able to respond to the COVID-19 pandemic better than many African countries, introducing measures to provide a food relief program to help vulnerable informal sector workers whose livelihood were significantly affected by the pandemic. Existing essential social services and social protection programs continued and the public works program, Ipelegeng, remained partially operational. 60 World Bank, 2018. Women, Business and the Law project. https://wbl.worldbank.org/en/wbl 61 UNDP, 2012. The Gender Based Violence Indicator Study – Botswana. https://www.undp.org/sites/g/files/zskgke326/files/migration/bw/GBV-Indicators-Botswana-report.pdf 31 32 II. Assessment of Human Capital Outcomes Across the Lifecycle Improving human capital outcomes in Botswana requires holistic investments in nutrition, health, education, skills development, employment, and social protection to meet the needs of individuals at different stages of life. To do so, an important first step is assessing the state of human capital development in the country to identify deficiencies and disparities and to understand the determinants of the observed gaps. The findings of such an assessment can then form the basis to identify priority challenges and inform the design of the country’s policy and programmatic response to address them. In line with this approach, this Policy Note presents an in-depth assessment of the status of human capital development in Botswana and identifies the priority challenges across the key social sectors involved in human capital development. The Policy Note uses a lifecycle framework to undertake an in-depth diagnostic of human capital development in the country. The lifecycle approach places a strong emphasis on investing in human capital development holistically, involving all relevant sectors, and as a continuum - following the trajectory of an individual’s life. It focuses on three critical stages of an individual’s life— (i) Early Childhood; (ii) School Age; and (iii) Youth to Adulthood (including old age) (see Figure 10). This approach recognizes that early childhood, starting with the prenatal stage, forms the foundation for lifelong health, all future learning, and overall wellbeing, while investments during the school years and beyond reinforce developments in the early years, leading to further human capital accumulation. Moreover, the approach considers the complementarity of investments made across human capital development sectors and during the different stages of the lifecycle for synergistic effects. 33 Figure 10. A Lifecycle framework to examine inequalities in human capital Figure 10: A Life cycle framework to examine inequalities in human capital development development Early School Age Youth to childhood Children Adulthood (Pregnancy to Age 5) (Age 6-17) (Age 18 and older) Source: Adapted from Human Development Project, World Bank, 2021 A. Early Childhood (From Pregnancy to Age 5) Improving early childhood care and development (ECCD) outcomes should be a priority for any country as it forms the foundation for its citizens to reach their full human capital potential. Global evidence shows that healthy development in the early years, specifically, the time from pregnancy to age 5, provides the basis for all future health, educational achievement, and thereby economic productivity in adulthood. Conversely, poor early childhood outcomes threaten human capital development during the school years and beyond, leading to loss of human capital potential and economic productivity for individuals, their communities, and their country.62 63 64 There are several important and interlinked domains for ECCD, including physical, cognitive, socio- emotional, and linguistic development areas. If a child is healthy and well-nourished and receives early stimulation to support her learning strongly correlates with progress in several of these developmental domains and can thereby serve as good proxies for success on key ECCD outcomes. Progress in improving early childhood health, nutrition, and learning-related outcomes are the driving factors behind some of the critical gaps discussed in detail below. Botswana’s framework for ECCD cuts across the core human capital sectors. UNICEF worked with the Government of Botswana (Ministry of Education and Skills Development (MoESD), Ministry of Local Government and Rural Development (MLGRD), and Ministry of Health (MoH)) to develop the national framework for ECCD shown in Figure 11. The framework is also accompanied by a costed Implementation Plan and an Inter-Ministerial Technical Committee chaired by the MoESD. However, tracking, monitoring and reporting of the framework could be improved. 62 Black, M.M., Walker, S.P., Fernald, L.C.H., Andersen, C.T., DiGirolamo, A.M., Lu, C., McCoy, D.C., Fink, G, Shawar, Y.R., Shiffman, J., Devercelli, A.E., Wodon, Q.T., Vargas- Barón, E. and Grantham-McGregor. S., 2017. Lancet Early Childhood Development Series Steering Committee. Early childhood development coming of age: science through the life course. The Lancet. Jan 7;389(10064):77-90. doi: 10.1016/S0140-6736(16)31389-7. Epub 2016 Oct 4. PMID: 27717614; PMCID: PMC5884058. 63 Heckman, J.J. and Masterov, D.V., 2007, The Productivity Argument for Investing in Young Children. Applied Economic Perspectives and Policy, 29: 446-493. https://doi. org/10.1111/j.1467-9353.2007.00359.x 64 Grantham-McGregor, Sally, et al., 2007. Developmental potential in the first 5 years for children in developing countries. The Lancet, Volume 369, Issue 9555, 60 – 70. 34 Figure 11. Botswana’s Framework for ECCD PRE-CONCEPTION TO BIRTH BIRTH TO 5 YEARS 5-6 YEARS PROGRAMMES PROGRAMMES PROGRAMMES • FAMILY PLANNING • NEW BORN CARE & INITIATION OF • SCHOOL HEALTH • ANTENATAL CARE BREASTFEEDING • NEW BORN CARE • IMCI CASE MANAGEMENT • SAFE DELIVERY • ROUTINE VACCINATIONS & CHILD MINISTRY OF HEALTH DAYS • PMTCT HEALTH • NUTRITION: BREASTFEEDING, COMPLEMENTARY FEEDING MANAGEMENT OF MALNUTRITION • CHILD WELFARE CLINICS: GROWTH MONITORING, FOOD RATIONS • MICRO-NUTRIENT SUPPLEMENTS (VIT A & ZINC) PROGRAMMES PROGRAMMES MINISTRY OF • REGULATION OF TEACHERS & • ORIENTATION EDUCATION CURRICULUM DEVELOPMENT (3-6 YEARS) PROGRAMMES & SKILLS • SCREENING, REFERAL OF U5S WITH • PRE-PRIMARY DEVELOPMENT DISABILITIES CLASSES PROGRAMMES PROGRAMMES • CHILD PROTECTION • PRE-PRIMARY MINISTRY • CARE OF ORPHANS & OTHER VULNERABLE FACILITIES & OF LOCAL CHILDREN (OVCS) - FOOD BASKETS PLAY AREAS GOVERNMENT • SCHOOL FEEDING & RURAL • POVERTY ALLEVIATION DEVELOPMENT • REGULATION OF PRE-SCHOOLS • GRANTS TO NGO SUPPORTED DAY CARE CENTRES Source: UNICEF, 2018. A Policy Framework for Early Childhood Development: From preconception to reception: https:// platform.who.int/docs/default-source/mca-documents/policy-documents/policy/BWA-CH-50-01-POLICY-2018-eng-ECD-Policy- Framework.pdf Botswana’s progress in improving child survival is slowing, even as its performance lags most income group peers (Figure 12 and Figure 13). Following a steady fall between 2010 and 2016 (from 62.6 to 43.5 per 1,000 live births), the decline in under-five mortality rate (U5MR) per 1,000 live births has slowed with U5MR in 2021 estimated at 34.9.65 U5MR is consistently higher among boys than girls: in 2021, the U5MR per 1,000 live births was 38.2 for boys compared to 31.1 for girls.66 The slowed performance is in part due to stagnation during the same period in neonatal mortality rates (NMR) which were at an estimated 25.7 per 1,000 live births in 2010, 21.0 per 1,000 live births in 2016, and 18.0 per 1,000 live births in 2021.67 Although infant mortality has declined in Botswana over the years, it remains comparable with the global average and significantly higher than other UMICs. The current infant mortality rate is approximately 28.3 deaths per 1,000 live births (2021), just at par with 28.4 deaths globally and comparable and slightly lower than other countries such as Namibia (29.4) and higher than South Africa (26.4).68 On the other hand, the average infant mortality rate for UMICs is approximately 9.6 per 1000 live births indicating that the infant mortality in Botswana is nearly three times higher compared to other countries in the same income group.69 Maternal mortality declined from 188.9 per 100,000 live births in 2011 to 127 in 2015 but increased slightly to 130.5 in 2020.70 65 World Bank, 2021. World Development Indicators. https://data.worldbank.org/indicator/SH.DYN.MORT?locations=BW 66 Ibid 67 Ibid 68 Ibid 69 Ibid 70 Statistics Botswana, 2023. Key Statistics, http://www.statsbots.org.bw/ 35 Figure 12. Under-Five Mortality Rate per 1,000 Live Births, Botswana and Peer Countries 70 60 Botswana 50 Namibia 40 South Africa 30 Thailand Malaysia 20 Upper Middle Income Countries 10 0 2010 2012 2014 2016 2018 2020 2021 Source: World Bank using Data from World Development Indicators Figure 13. Neonatal Mortality Rate per 1,000 Live Births, Botswana and Peer Countries 70 60 Botswana 50 Namibia 40 South Africa 30 Thailand Malaysia 20 Upper Middle Income Countries 10 0 2010 2012 2014 2016 2018 2020 2021 Source: World Bank using Data from World Development Indicators The presence of high neonatal mortality rates in a setting where 99 percent of births occur in health facilities raises concerns regarding the quality of antenatal, perinatal, and post-natal care services. Data from 2007 suggests that 73.3 percent of women attended at least four antenatal care visits during their pregnancy, against the WHO target of 90 percent.71 Data on the post-natal care target of 80 percent of women who have just given birth accessing postnatal care within two days of delivery, and the percentage of newborns who have postnatal contact with a health provider within two days of delivery are unavailable. However, available data suggest that there are variations in health utilization by health district72 which may link to observable differences in health outcomes across administrative districts such as still birth rates per 1,000 live births.73 In 2020, for example, districts such as Sowa, Lobatse, Kgalagadi North, Francistown and Gantsi had still birth-rates significantly higher than the national average based on reported administrative data (Table 4). The MoH is strengthening its MPDSR capacity including through training of healthcare workers. However, a recent assessment of its MPDSR system noted the absence of an integrated maternal and perinatal death national committee for addressing system-level gaps contributing to maternal and neonatal deaths.74 71 Statistics Botswana, 2009. Botswana Family Health Survey 2007-2008 72 Statistics Botswana, 2021. Outpatient and Preventive Health Statistical Brief 2019 73 Statistics Botswana, 2021. Vital Statistics Report 2019 74 UNFPA ESARO, 2023. Maternal and Perinatal Death Surveillance and Response. Status Report 2021: Assessment of Countries in East and Southern Africa https://esaro. unfpa.org/sites/default/files/pub-pdf/esaro_mpdsr_status_report_final.pdf 36 Table 4. Still birth rate per 1,000 total births by district of usual residence Still birth rate per District of usual residence Live births Still births Total births 1,000 total births Gaborone 3,276 62 3,338 18.57 Francistown 1,908 42 1,950 21.54 Lobatse 567 20 587 34.07 Selibe Phikwe 581 7 588 11.90 Orapa 143 1 144 6.94 Jwaneng 239 0 239 0.00 Sowa 32 1 33 30.30 Southern 3,567 42 3,609 11.64 Barolong 1,629 20 1,649 12.13 Ngwaketse West 508 6 514 11.67 South East 1,893 23 1,916 12.00 Kweneng East 7,217 100 7,317 13.67 Kweneng West 1,656 12 1,668 7.19 Kgatleng 2,807 55 2,862 19.22 C.Serowe Palapye 5,809 70 5,879 11.91 C. Mahalapye 4,434 57 4,491 12.69 C.Bobonong 2,579 21 2,600 8.08 C.Boteti 2,198 20 2,218 9.02 C. Tutume 5,453 102 5,555 18.36 North East 1,880 20 1,900 10.53 Ngamiland East 3,438 47 3,485 13.49 Ngamiland West 2,309 9 2,318 3.88 Chobe 557 11 568 19.37 Gantsi 1,560 34 1,594 21.33 Kgalagadi South 1066 12 1,078 11.13 Kgalagadi North 569 14 583 24.01 Total 57,875 808 58,683 13.77 Source: World Bank using Botswana Vital Statistics Report, 2020. Note: The total excludes residents of other countries (n=761 live births, 26 still births) and not stated (n=10 live births, 0 (zero) still births). 37 Botswana’s relatively high adolescent fertility rate (49.1 per 1,000 women ages 15-19) is an important driver of poor early childhood outcomes as well as poor maternal health outcomes.75 This figure is nearly double the average for UMICs (28 per 1,000 women ages 15-19 years). HIV prevalence, 2.7 percent, in the same age group contributes to worse health outcomes for themselves and their children. In one study, adolescents living with HIV had increased likelihood of anemia in pregnancy and infants with preterm birth and being underweight at birth.76 Childbearing at a young age also increases the chances of complications during pregnancy and childbirth. Vital statistics from 2020 reported that 13.3 percent of all infants born to mothers aged 15-19 years had low birth weight. Other evidence suggests that 11.6 percent of babies of mothers aged 15-19 years experienced birth injuries compared to 6.7 percent and 3.0 percent of women aged 20-34 years and more than 35 years respectively.77 Adolescents tend to have lower antenatal care attendance rates and lower attainment of key socioeconomic characteristics such as educational and income level which are key predictors of good neonatal and child health outcomes. Undernutrition among children ages 6-59 months remains a challenge in Botswana as evidenced by high levels of stunting and micronutrient deficiency. Estimates suggest that stunting remains largely unchanged from 25.9 percent in 2010 to 22.8 percent in 2020 as was the prevalence of underweight and wasting.78 This means that the rate of children under five that are not stunted (68 percent) is significantly less than in both LMIC (75 percent) and UMIC (87 percent) countries.79 An estimated 43.3 percent of children aged 6-59 months had anemia in 2019, while vitamin A supplementation coverage was estimated at 69 percent in the same year.80 Rates of exclusive breastfeeding for the first six months were equally low in boys (31.9 percent) and girls (28.1 percent) in 2017.81 Some children younger than 4.5 years of age in Botswana attend community based ECCD centers whereas those 4.5 years and above attend public pre-primary (reception classes). Data on enrolment, attendance and quality of services offered in the community centers is lacking, although there is a general perception that quality is poor. Although a majority (81.6 percent) of government primary schools in Botswana have implemented the national pre-primary program (provision of one year of pre-primary or reception classes), the student enrolment rate remains low.82 Meeting the objectives of universal access, equity, inclusivity, and quality in pre-primary education remains a challenge in Botswana. Evidence suggests that the main barriers to effective program rollout include challenges with the public institutional environment (e.g., funding, inter- governmental coordination), policy design (e.g. the physical infrastructure delivery model, administrative barriers, enrolment policy), and program implementation (enrolment practices, teaching personnel, learning materials, assessment of learners). International evidence indicates that participation in high- quality preschool programs has substantial impacts on children’s learning and future economic returns, especially for  socially disadvantaged  groups.83 84 85 As such, an increase in preprimary enrolment in Botswana is likely to have a positive impact on the lives of learners well beyond the early grades and into adulthood. 75 United Nations Population Division, World Population Prospects 76 Jackson-Gibson, M., Zash, R., Mussa, A. et al. 2022. High risk of adverse birth outcomes among adolescents living with HIV in Botswana compared to adult women living with HIV and adolescents without HIV. BMC Pregnancy Childbirth 22, 372 (2022). https://doi.org/10.1186/s12884-022-04687-y 77 Gobopamang L. and Majelantle, R.G., 2001. Health implications of early childbearing on pregnancy outcome in Botswana: insights from the institutional records, Social Science & Medicine, Volume 52, Issue 1, 2001, Pages 45-52, ISSN 0277-9536, https://doi.org/10.1016/S0277-9536(00)00121-0 78 UNICEF/WHO/World Bank Joint Malnutrition Estimates - Country Level Stunting Estimates https://data.unicef.org/topic/nutrition/malnutrition/ 79 See HCI outcomes in Table 1 above. 80 World Bank, 2023. World Development Indicators. https://databank.worldbank.org/source/world-development-indicators 81 https://data.unicef.org/country/bwa/ 82 Pillar, L.J. and Haricharan, S.J., 2023. ‘Early Childhood Care and Education in Botswana: Implications for access and quality’, South African Journal of Childhood Education 13(1), a1268. https://doi.org/ 10.4102/sajce.v13i1.1268 83 Barnett, W.S., 2011. Effectiveness of early educational intervention Science, 333 (6045) pp. 975-978 https://www.science.org/doi/10.1126/science.1204534 84 Engle, P.L., Fernald, L.C.H., Alderman, H., Behrman, J., O’Gara, C., Yousafzai, A., De Mello, M.C., Hidrobo, M., Ulkuer, N., Ertem, I. and Iltus, S., 2011. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet, 378 (9799) (2011), pp. 1339-1353, 10.1016/ S0140-6736(11)60889-1 85 Yoshikawa, H., Weiland, C., Brooks-Gunn, J., Burchinal, M.R., Espinosa, L.M., Gormley, W.T., Ludwig, J., Magnuson, K.A., Phillips, D., Zaslow, M.J., 2013. Investing in our future: the evidence base on preschool education. Society for Research in Child Development and Foundation for Child Development.https://eric.ed.gov/?id=ED579818. 38 Botswana does not yet measure early learning and development including gross motor development, fine motor coordination and visual motor integration, emergent numeracy and mathematics, emergent literacy and language and cognitive and executive functioning. Administering early learning and development measurements (such as Measuring Early Learning and Quality Outcomes (MELQO)86 or the Ages and Stages Questionnaire (ASQ)87 regularly can inform policies and interventions related to nutrition, stimulation, and early childhood education. In addition, any gaps in development can be identified early and children and families can be provided with timely necessary support to strengthen development and learning outcomes. Botswana does not have a cash-based infant and child grant for poor households with young children. This is despite the global evidence showing that targeted grants for children living in poor households, especially in female headed households, contribute to covering child related costs like buying school uniforms and supplies, presenting the child for health checkups, and increasing the nutritional value of meals. On the other hand, Botswana has some programs providing in-kind and some additional cash benefits for vulnerable children including orphans. Box 1 summarizes some of the impact evaluation evidence of South Africa’s main social grant programs related to human capital outcomes. Box 2: Social protection programs and their impact on human capital – evidence from South Africa A significant amount of research has been conducted on the impacts of social grants on health, nutrition, and education outcomes of children in South Africa. Some key findings are highlighted below. Education The impacts of social grants on education outcomes tend to be positive. Receipt of South Africa’s Child Support Grant (CSG) has also been found to be positively associated with progress through the schooling system (Coetzee, 2013; Case et al. (2005)). Similarly, income from the OPG has been found to positively impact rates of school attendance (Leibbrandt et al., 2010; Standish- White and Finn, 2015). Case and Menendez (2007, p.162) also find evidence of a positive impact of the Older Persons Grant (OPG) on school attendance, but mainly for girls, with the impact being observed when the pensioners are female. Nutrition, Food Security, and Hunger The impact of social grants on nutrition and related outcomes in South Africa, such as prevalence of hunger, are mixed and seem to be dependent on the exact outcome variable used. Estimated effects also seem to be mediated by the gender of the grant recipient. The effect of the CSG on nutrition related outcomes varies. Waidler and Devereux (2019) find no impact of the CSG, while Coetzee (2013) finds a small positive effect of the CSG on households’ food expenditure, and on children’s height-for-age. A more recent study by Chakraborty and Villa (2022) finds that increased income from the CSG alleviates extreme malnutrition (underweight and obesity) among female beneficiaries. There is also evidence showing that the OPG is associated with improvements in nutrition related outcomes of children (Duflo (2000; 2003); Waidler and Devereux (2019); Case and Menendez (2007)). Duflo (2000; 2003) shows a more nuanced picture, estimating that the effect is driven by grants received by women with a bigger impact being observed on female children. 86 World Bank, 2017. Overview MELQO: Measuring Early Learning Quality and Outcomes. https://unesdoc.unesco.org/ark:/48223/pf0000248053 87 Ages and Stages Questionnaire Website, 2023. https://agesandstages.com/asq-online/ 39 Box 2: Social protection programs and their impact on human capital – evidence from South Africa (cont.) Health and well-being Social grants, including the disability grant, have been shown to improve health outcomes in South Africa. Knight et al. (2013) show that the disability grant enabled households to care for members undergoing anti-retroviral treatment for HIV. Kilburn et al. (2018) find that receipt of a conditional cash transfer was associated with reduced risk of physical violence, but not for sexual violence, and had positive effects on delaying sexual debut and the number of sexual partners in the preceding 12 months. Further, the authors find a reduction in the risk of intimate partner violence. Finally, Eyal and Burns (2018) find large and significant protective effects of receipt of cash transfers on teenagers’ mental health, including by reducing parental depression. Source: World Bank, 2023. https://www.worldbank.org/en/news/press-release/2023/08/02/dar-es-salaam-afe- declaration-african-leaders-make-important-commitments-to-investing-in-human-capital#:~:text=The%20Dar%20 es%20Salaam%20Declaration,is%20no%20time%20to%20waste. However, the government is making inroads to devise a strategy to reorganize its main social assistance programs along the lifecycle stages - including the early years. This may involve considering a cash-based child grant targeted to children in poor households by building on the Vulnerable Groups Feeding Program (VGFP), the Destitute Persons Program (DPP) and Orphan Care.88 In 2023, discussions on how to consolidate programs are ongoing and progress towards a concrete implementation plan has been slow. The United Nations Development Program has supported the MLGRD with a proposal for how to consolidate the social assistance programs for each segment of the lifecycle. Figure 14 lays out the programs across the lifecycle and the red oval captures the programs currently supporting the early years. 88 Government of Botswana, 2020. National Social Protection Framework Implementation Plan. 40 Figure 14. Reviewing social assistance support for infants and young children. LIFE-COURSE Pregnant women School age Youth Working Old age and Infants children age STAGE Old Age Pension Orphan care TS School &S CURRENT feeding Ipelegeng Destitute PROGRAMMES VGFP persons Needy NC students WV P CH Pregnant women >18s BC <5s <18s PWDs TB patients Older School Student persons Infant grant Child grant meals loans Ipelegeng grant PROPOSED Other PROGRAMMES Disability grant Temporary Social Support Programme Source: Government of Botswana, 2020. National Social Protection Framework (NSPF) Implementation Plan. Notes: TB=tuberculosis, VGFP=Vulnerable Groups Feeding Program, NC=Needy Children Program, TS&S= Tertiary Sponsorships and Scholarships WVP=World War Veterans Pensions, CHBC=Community Home-Based Care Program, PWDs=persons living with disabilities. The Vulnerable Groups Feeding Program (VGFP) provides take home rations to vulnerable children aged six months to five years, pregnant and lactating women, as well as patients with tuberculosis and lepra.89 Health clinic staff screen patients for selection and the monthly rations consist of complementary foods for children aged 6 to 60 months. Sugar, beans, and vegetable oil are provided to children aged 37 to 60 months as well as to medically selected adults. However, the continued high levels of malnutrition among children in Botswana suggests that the VGFP is not having the desired impacts. This is partly due to the fact that families do not give the rations exclusively to the child, if at all. In addition, delivery to clinics is inconsistent and the intended beneficiaries do not always receive their ration.90 At the same time, many children in remote areas where parents and guardians are nomadic are not taken to health clinics regularly and, therefore do not get their ration regularly. In addition to providing income support to poor households with young children, social protection programs could contribute to early childhood development outcomes by strengthening their links with ECCD programs. The importance of early childhood development is well recognized in Botswana and is fully articulated in the Policy Framework for Holistic Early Childhood Development. At the same time, the Botswana Nutrition Strategy is an important document in moving the nutrition agenda forward. However, both policy documents have yet to find their way into social protection programming on any scale. The MLGRD is tasked with providing early childhood programs at the community level, but most poor children do not have access to the programs. Moreover, parents who benefit from social assistance are not provided with any consistent nutrition and parenting education and this is a missed opportunity. Moving forward, Botswana will need to close the gap in provision of parenting and nutrition education programs for infants and young children using creative, low-cost strategies. Madagascar, for example, has integrated ECCD into a cash transfer program (Box 3). 89 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 90 Powis, K. et al. 2015. Determinants of Malnutrition among Children under 5 Years of Age in Five Health Districts in Botswana, Ministry of Health/Botswana_Harvard AIDS Institute Partnership, Gaborone. 41 Box 3: Madagascar: Promoting the Early Years through a Cash Transfer Program In Madagascar, a social assistance cash transfer program is being used to promote good parenting practices. Parenting education focuses on creating a playful and fun environment for children and parents, including daycare (creche mobile) for Cash-for-Work participants; empowering women to take decisions; and supporting parents to spend more time with stimulating interaction with their children. Mother Leaders organize monthly “Well-being Meetings” to discuss citizenship, leadership and self-confidence, essential family practices (best practices for families in hygiene and health), early childhood development (cognitive stimulation), and reproductive health. The focus is on having fun and interacting and creating a playful environment for children and parents. During these monthly ‘Well-Being Meetings”, women sing, dance, discuss, learn, exchange, design sets of toys, and use toys in groups organized by Mother Leaders. Mother Leaders facilitate planning of how to spend the cash transfer for a wide array of beneficial items. Women expand their consumption choice set and make more purposeful, concrete deliberations on what they buy. Mother Leaders facilitate self-affirming and positive identity priming discussions with their groups when the women come to collect their cash on the transfer day. Women feel affirmed in their ability to uphold the good parent identity and increase interactions with their children, which in turn leads to better health outcomes. B. School Age Children (Age 6-17) Children and adolescents of school-going age go through significant physical, emotional, and cognitive development. It is a period where substantial investments are needed to ensure that children enroll in school on time, stay and complete their education, and learn and acquire the wide range of knowledge and skills they need to transition into adulthood. Moreover, continued investments in their nutrition and health are needed to ensure their physical, mental, and social development, all of which are essential for their long-term overall human capital development and well-being. The Government of Botswana prioritizes education. In 2019, a significant amount of Botswana’s GDP (7.1 percent) was spent on education.91 Although this percentage was high compared to other countries, about one third of this amount went towards tertiary education (for subsidies to universities and bursary/loans to students). Thus, spending on basic education may not have been so high in international comparison. The basic education budget was largely spent on salaries and other recurrent costs, leaving little scope for capital spending. Whereas per pupil spending was estimated at US$893 in primary and US$1,693 in secondary school, indications were that spending per tertiary student was about six times as much. However, the high spending on universities was relatively inequitable, as only a minority of individuals could benefit, with a gross tertiary enrolment rate only 23.4 percent.92 Student enrolment is high in the early grades but drops off significantly after Form 3 (junior secondary). As can be seen from a comparison of enrolment in every grade between 2007 and 2017 (Figure 15), patterns of enrolment across grades remained relatively stable but there was a sharp drop in enrolment after Form 3. Similarly, Table 5 shows that whereas the Gross Enrolment Ratio (GER) was 100 at the primary level, it was 96 at the junior secondary level and dropped to 62 at the senior secondary level in 2017. 91 More recent data from UNESCO Institute for Statistics suggests a higher percentage at 8.74 percent of GDP: UNESCO Institute for Statistics, 2023. Government Expenditure on Education, Botswana. https://data.worldbank.org/indicator/SE.XPD.TOTL.GD.ZS?locations=ZG-BW W 92 World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://openknowledge.worldbank.org/server/api/core/bitstreams/16edcf93- 7384-5de9-8c9c-b491c04d81bc/content 42 Figure 15. Enrolment by Grade, 2007 and 2017 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Std 1 Std 2 Std 3 Std 4 Std 5 Std 6 Std 7 Form 1 Form 2 Form 3 Form 4 Form 5 2007 2017 Source: Calculated from EMIS data, 2007 and 2017 Table 5. GER and NER at different education levels Gross Net Gross Net School Level (age group) Population Enrolment Enrolment Enrolment Enrolment Ratio (GER) Ratio (NER) Primary (ages 6-12) 339,521 339,447 293,974 100 87 Junior Secondary (ages 13-15) 131,639 126,490 75,488 96 57 Senior Secondary (ages 16-17) 88,068 54,748 25,300 62 29 Total Primary plus Secondary 536,253 520,685 394,762 97 74 (ages 6-17) Source: Authors’ calculations based on Botswana EMIS data, 2017. Challenges with access, high repetition rates in the early grades, and poor quality of education play a role in this drop at senior secondary level. Given that schooling is free in Botswana, the cost of schooling does not explain the stark drop in participation at Form 3. One possible explanation is the low supply of secondary schools at this level. In 2019, there were 826 primary schools, 211 junior secondary schools and 33 senior secondary schools in the country, with 50 unified schools offering both junior and senior secondary education.93 The need to travel far distances to attend school may inhibit participation. For example, in 2017, since schools were located at far distances, 17 percent of junior secondary school students and 35 percent of senior secondary students attended boarding schools, not a desirable option for students given perceptions of poor quality in boarding schools. Another explanation may be high rates of repetition in the early grades linked to subsequent dropout at this level, particularly among boys. Repetition is high in the early grades with boys more likely to repeat a grade than girls. This early grade bulge is caused by: (i) persistently high (or increasing) ratio of enrollment in Grade 1 relative to the population of appropriate age, (ii) low progression from Grade 1 to Grade 2, (iii) a permanently high Gross Intake Ratio into Grade 1, and (iv) low provision of pre-primary coverage.94 Figure 16 shows this trend from Standard 1 to Standard 7 between the years 2012 and 2017. As the figure 93 World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://openknowledge.worldbank.org/server/api/core/bitstreams/16edcf93- 7384-5de9-8c9c-b491c04d81bc/content 94 World Bank, 2018. Facing Forward: Schooling for learning in Africa. https://elibrary.worldbank.org/doi/epdf/10.1596/978-1-4648-1260-6 43 shows, although overall repetition decreased between Standard 1 and Standard 7, the discrepancy between repetition rates of boys and girls persisted throughout the early grades. Further study is needed to explore reasons behind the higher repetition rates of boys in these years. However, given that boys are more likely to repeat in the early grades, their older ages in Form 3 may increase their likelihood of choosing income generating opportunities over schooling at this stage. Figure 16. Grade Repetition Rates in Primary Grades by Gender, 2012-2017 14 12 Grade Repetition Rate 10 (0-100%) 8 6 4 2 0 Std 1 Std 2 Std 3 Std 4 Std 5 Std 6 Std 7 Female 2012 Female 2017 Male 2012 Male 2017 Source: Government of Botswana EMIS, 2017 and UNESCO Institute for Statistics, 2012. Bold steps taken by the government have led to near universal completion rates in primary and lower secondary school in the country. Since the requirement to pass the PSLE prior to entering junior secondary school was removed, all students are admitted to Form 1 (junior secondary) after completion of Standard 7 (the final year of primary). As a result, the country has achieved near universal completion in primary and junior secondary school. For example, in 2015, the overall primary school completion rate in Botswana was 95 percent and the junior secondary school completion rate was 99 percent.95 Finally, poor quality of education may play a role in low participation in senior secondary school. Students in Botswana are required to pass the Junior Certification Exam (JCE) in Form 3 in order to move on to senior secondary school. This structural approach to filtering students based on student performance may contribute to increasing dropouts. Many students fail to pass the JCE and are therefore unable to progress into senior secondary schools. For example, in 2017, only 36 percent of candidates for the JCE achieved a C or better grade.96 Perceptions of poor quality of education in senior secondary may be associated with a low demand for education beyond Form 3 among learners as well as their families, particularly in the face of competing income generating opportunities. Further exploration is required to determine the extent of impact this factor may have on learners’ decision to drop out. Botswana is one of the only countries in the region participating in regional learning assessments, indicating a willingness to benchmark learning at a global level and a commitment to focus on learning outcomes. Botswana has participated in three rounds of the international assessment program carried out by the Southern and Eastern African Consortium for Monitoring Educational Quality (SACMEQ I, II, and III), four rounds of Trends in International Math and Sciences Study (TIMSS) (2003, 2007, 2011, and 2015), and one round of the Progress in International Reading Literacy Study (PIRLS, 2011). Botswana was the only African country that participated in the PIRLS/TIMSS joint survey of reading, mathematics, and science in 2011. 95 UNESCO Institute for Statistics, 2022: https://data.worldbank.org/indicator/SE.PRM.CMPT.ZS?end=2015&locations=BW&start=1985 96 World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://documents.worldbank.org/pt/publication/documents-reports/ documentdetail/925981586798022916/public-expenditure-review-of-the-basic-education-sector-in-botswana 44 Performance on regional assessments reflects low learning outcomes despite huge investments. In SACMEQ (2007), despite being one of the richest and most developed economies in the region, Botswana performed around the middle in countries of southern and eastern Africa in reading and mathematics. In TIMSS (2011), while over 90 percent of Grade 4 children in many countries performed above the low international benchmark, only 37 percent of Standard 6 children in Botswana achieved this. Similarly while more than 20 percent of Grade 4 children in the leading countries performed above the high international benchmark in all three subjects, only 3 percent of Botswana Standard 6 children performed above the international benchmarks in all three subjects, In TIMSS (2015) (Grade 8/9 mathematics), Botswana scored 391, which was at the lower end of scores achieved by participating countries (Figure 17). Figure 17. Botswana Performance in TIMSS Grade 8/9 Mathematics, 2015 Singapore 621 Korea, Rep. of Chinese Taipei Hong King SAR Japan Russian Federation Kazakhstan Canada Ireland England United States Slovenia Hungary Norway (Gr 9) 512 Israel Lithuania Australia Sweden Malta Italy New Zealand United Arab Emirates Malaysia 465 Turkey Bahrain Georgia Lebanon Qatar Iran, Islamic Rep. of Thailand Chile Oman Performance in Egypt Kuwait Botswana (Gr 9) 391 TIMSS Gr 8/9 Mathematics Jordan Morocco in context, 2015 South Africa (Gr 9) 372 Saudi Arabia 0 100 200 300 400 500 600 700 Although performance has not been encouraging thus far, continued participation in regional and international assessments will allow Botswana to track progress in learning at a global level and gauge performance of its education system at regular intervals. Botswana’s willingness to track learning outcomes along with other countries regionally and globally is a strong testament to the government’s commitment towards improvement of the education system overall. However, Botswana has not participated in the last rounds. Analysis of student performance in Pre-PIRLS (2011), TIMSS (2011) and TIMSS (2015) indicated that the key determinants of learning levels in Botswana were socio-economic status of school, region, and gender. The socio-economic status of schools (average socio-economic status of children in a school) was a strong indicator of student performance (rather than household income level). This means that on average, a poor child in a school that had mainly children from wealthy backgrounds was likely to perform better than a child of rich parents in a school serving mainly poor children. Region was also a key determinant of learning; in 2017, only two out of Botswana’s ten districts performed above 40 percent on the Junior Certificate Examination: Southeast district with 53 percent and Northeast district with 47 percent. Finally, gender was a key determinant of student performance; female students in Botswana significantly outperformed their male counterparts on assessments of learning. Reasons for this female advantage in performance (and persistence in school) require further exploration. 45 Availability and timely analysis of data is required for policy and planning purposes. Education data are not readily available in the country; enrolment data lag by two years. While international and regional assessment data are available and do provide important trend data on how Botswana is doing compared to OECD and regional peers, these assessments are conducted infrequently and are not sufficient for policy, planning, and regular monitoring purposes. Finally, since budgetary data are often not disaggregated at the regional level, it is not possible to separate school spending from other categories of spending, limiting analysis. Although COVID-19 led to school closures, some distance learning approaches show promise in strengthening learning outcomes in the long run, especially given the challenges of poorer performance or rural students, long distances to secondary schools and unfavorable boarding school conditions. According to UNESCO’s Global Monitoring of School Closures from March 2022, during COVID-19, Botswana experienced 11 weeks of full school closure and a total of 20 weeks of partial school closure (Figure 18). Figure 18. UNESCO’s Global Monitoring of School During school closures, content was delivered through television and radio, although the impact of these interventions needs to be explored. The potential of low-tech, low-cost text messaging combined with phone calls were found to have large, positive impacts on student learning, were effective in closing learning gaps, and increased parental engagement in children’s learning. Finally, E-Thuto, an interactive learning platform, was implemented in the north-eastern region of Botswana. This served close to 35,000 students, from primary to high school level and received the United Nations Public Service Award. Responsibility for education is split across different ministries, causing inefficiencies in education financing and resource flows. Most of the recurrent budget is located within the MoESD (a majority of this is for the personnel costs of teachers as well as the staff of Ministry and regional education offices), and part of it falls under MLGRD (for items such as primary school stationery and school feeding). The development budget is also split between MLGRD for construction of primary classrooms and schools, MoESD for the financing of secondary school and classrooms and Ministry of Infrastructure for actual construction of secondary schools and classrooms. This fragmentation of budget makes it almost impossible to see the allocation of education spending for each level. This division of functions across different ministries has an impact on the governance and management of the education system, including teachers, and on the efficiency of resource flows and resource use. For instance, there is a shortage of classrooms in the country and while the staffing situation in schools is favorable, class sizes are often large. Similarly, the allocation of resources to building classrooms is not linked to decisions regarding the enrolment or appointment of teachers. Finally, although the provision of school textbooks falls under the responsibility of regional offices, MLGRD provides all learning resources other than textbooks.97 It is vital to strengthen cooperation between MoESD, MLGRD and Ministry of Infrastructure to improve allocation of funds, planning and budgeting for building schools and classrooms. Local, innovative solutions to school construction may offer efficiency gains. One possible model to explore is the “unconventional home-grown school construction” model employed by the Government of Rwanda whereby community members participated in the construction of school buildings, cutting 97 World Bank, 2019. Public Expenditure Review of the Basic Education Sector: https://documents.worldbank.org/pt/publication/documents-reports/ documentdetail/925981586798022916/public-expenditure-review-of-the-basic-education-sector-in-botswana 46 cost and time and building community solidarity and ownership of schools in the process.98 There are other low-cost community construction models from around the world that could be considered which use locally available and sustainable materials and traditional techniques in the construction of school buildings.99 Teacher management and training offer another area for efficiency gains. As of 2019, although student teacher ratios were favorable in Botswana (25.7 for primary and 11.9 for secondary schools) there was a large oversupply of teachers in certain subjects such as English, Setswana, history, and geography, causing long waiting lists for these positions. A large number of education graduates did not enter the system due to long waiting lists and low levels of retiring teachers. Teachers are the most expensive item on the recurrent budget, yet very little was known about teaching practice in the classroom. Insufficient teacher training may be a key factor in understanding the country’s low performance on student assessments. Teacher preparation, which is the responsibility of the regional education offices, was constrained by lack of funds and subject specialists. Decentralization of the teacher training function has not proven successful and subsequently there was insufficient teacher training and continuous professional development provided to teachers. Pre-and in-service training should focus on strengthening the quality of teaching at the classroom level to support strengthening learning outcomes in the country. Finally, deployment practices were seen as unfair by rural teachers, who were often demotivated. Many teachers remained in remote areas longer than they had anticipated and became disillusioned with their jobs, which may have affected their motivation and work effort. There was an identified need to develop a teacher recruitment policy and teaching professional standards and redesign the deployment process for teachers so that each teacher serves a set, limited tenure in rural areas.100 Efficient spending of education funds is key to ensuring that Botswana’s strong investments in education translate to strong learning outcomes for school age children. Botswana spends a good deal of resources on education. Ensuring that these funds are focused on improving the quality of teaching and learning in the classroom is key to strengthening learning outcomes for the students of Botswana. The main social protection programs for school age children are the Primary and Secondary School Feeding Programs which accounts for 20 percent101 of social assistance expenditures.102 School feeding costs vary considerably among middle income countries, but Botswana spends more per student than most countries.103 Average costs for middle income-countries are about US$50 per student compared to US$107 per student in Botswana (in 2012/13). More analysis of the cost-benefits and impacts of the school feeding program on schooling outcomes and learning is needed to assess the value for such a high per student investment. • The Primary School Feeding Program provides a free midday meal to children who attend public primary schools, with two meals provided to children in boarding schools. The meals consist of sorghum porridge, maize, stewed beef, beans, bread, and ultra-high temperature milk and is intended to be equal to one-third of daily dietary needs. The meal may also include locally procured seasonal fruits and vegetables. The program is managed by the MLGRD and implemented through the local government structure. The latest data on number of beneficiaries made available to the World Bank for the Primary School Feeding Program was for FY12/13, when 268,761 children benefitted from the program. During FY2017/18 expenditures for the Primary School Feeding program together with the Vulnerable Groups Feeding Program were about BWP714 million (US$66.4 million), equivalent to 0.38 percent of the GDP. 98 Government of Rwanda Ministry of Education, 2020. MINEDUC calls upon Rwandans to participate in school construction activities under unconventional and home- grown approaches. https://www.mineduc.gov.rw/news-detail/mineduc-calls-upon-rwandans-to-participate-in-school-construction-activities-under-unconventional- and-home-grown-approaches 99 World Economic Forum, 2022. ‘How a pioneering architect faced rejection and used design to drive social change and sustainability’. https://www.weforum.org/ agenda/2022/10/francis-kere-pritzker-prize-architecture-social-change-sustainability/ 100 World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://openknowledge.worldbank.org/server/api/core/bitstreams/16edcf93- 7384-5de9-8c9c-b491c04d81bc/content 101 Excluding administrative expenditures. 102 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 103 Woolnough, L. et al ed., 2016. Global School Feeding Sourcebook: Lessons from 14 Countries, Imperial Press, London. 47 • The Secondary School Feeding Program provides a free midday meal to students in public secondary schools. Students in secondary boarding schools receive two meals per day. The program is implemented by the MoESD. Secondary schools receive an allocation from the Ministry based on enrollment and schools procure food, hire cooks, and pay for other operating costs of school feeding. In FY2015/16, there were 183,896 beneficiaries. In FY2017/18, expenditures on secondary school feeding were BWP308.5 million (US$30.2 million), or 0.16 percent of GDP.104 In addition, two other smaller programs target school-age children. The Needy Students/Needy Children Allowances provide educational support to dependents of destitute persons or orphans who are no longer minors but who are still attending school. As per the National Youth Policy, beneficiaries who are still going to school can benefit up to age 35. Beneficiaries receive school uniforms, toiletries, and other educational items. The Orphans Allowance supports children who have lost one or both parents and is not means-tested. Beneficiaries receive a SmartSwitch card, or a food basket valued at about BWP500- 700 (US$46.9-65) per month.105 Orphans also receive a school uniform, other clothes, transportation, cash benefits, fee waivers for health and education, and psychosocial support from MLGRD social workers. In FY2019/20, there were 24,351 beneficiaries of the Orphans Allowance with expenditures estimated at BWP222 million (US$24.6 million), or 0.11 percent of GDP.106 There is a degree of discretion in the implementation of the Orphans Allowance leading to variation in performance, including the distribution of benefits. Provision of psychosocial support is uneven and there are inadequate referral systems for other services. Although all orphans should receive a benefit, caregivers report that not all orphans under their care receive a benefit. The program has not been evaluated, particularly with respect to its impact on human capital development of children.107 As noted above, there is no comprehensive national cash-based social assistance programs in Botswana which supports children. However, there is scope to consolidate programs for young and school age children and to implement a comprehensive safety net for children in poor households (Figure 19). With such a program, it would be possible to provide targeted interventions to encourage children from poor and vulnerable backgrounds to remain in school and progress through senior secondary school. Figure 19. Reviewing social assistance support for school age children LIFE-COURSE Pregnant School age Youth Working Old age women and children age STAGE Infants Old Age Pension Orphan care TS School &S CURRENT feeding Ipelegeng Destitute PROGRAMMES VGFP persons Needy NC students WV P CH Pregnant women >18s BC <5s <18s PWDs TB patients Older Infant grant Child grant School Student Ipelegeng persons meals loans grant PROPOSED Other PROGRAMMES Disability grant Temporary Social Support Programme Source: Government of Botswana, 2022. National Social Protection Framework (NSPF) Implementation Plan. 104 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 105 Ibid. 106 Ibid. 107 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 48 Botswana’s children are facing a burden of overnutrition resulting in a triple burden along with undernutrition and micronutrient deficiency from early childhood. About 9.1 percent of girls and 3.5 percent of boys aged 5-19 years were estimated to be obese in 2016 with these proportions expected to grow to 11.0 and 4.6 respectively by 2019.108 The Botswana Essential Package for Health includes intervention to promote healthy nutrition including in schools.109 However, an evaluation of the 2009 National School Health Policy (NSHP) identified policy design and implementation gaps that may be contributing to this including challenges with delivering effective health communication, human resources for health constraints and lack of organizational clarity.110 Experts have expressed concerns that only about one- third of Botswana’s 5-17-year-olds are meeting global recommendations for overall physical activity.111 New HIV infections among adolescents are a concern in the face of other successes in Botswana’s HIV/AIDS response. The incidence of HIV per 1,000 uninfected population ages 15-24 has declined from 8.5 in 2013 to 5.0 in 2021.112 However, adolescents and young people, particularly women, are thought to account for more than a third of new infections.113 Contributors to this include requiring parental consent for HIV testing and low levels of HIV knowledge among young people.114 Inter-generational relationships are also common with a third of sexually active adolescents and young women reporting having a partner five years or more older than them. Gender norms, such as beliefs about men’s power over women or masculine treatment seeking behaviors, are also thought to create barriers to boys for prevention, testing and treatment.115 Adolescent mental health is an emerging area of concern that is insufficiently addressed in county’s health policy and program. The limited evidence available confirms the prevalence of mental health concerns among adolescents including depression and substance abuse.116 Botswana’s mental health policy was last updated in 2003 but includes objectives to improve equitable access to mental health services. The density of mental health professionals of 21.1 per 100,000 population117 is higher than the median for upper-middle income countries of 14.7 per 100,000 and is made up mainly of mental health nurses and social workers. However, there is no specific or integrated policy for child and adolescent mental health and school-based mental health prevention and promotion programs are reported to be non-functional.118 Improving school health services forms part of the solution to improving the well-being of school- aged children. The draft updated NSHP seeks to address policy and implementation gaps in Botswana’s school health program. The proposed eight strategic areas include safe and conducive holistic learning environments, physical activity, and school-based health services. Implementing these strategies will require close coordination across the three ministries (health, education and skills development, and local government and rural development). Sustained and targeted investments will be required to meet plans to allocate resident nurses to schools, conduct regular clinical examinations and screenings, and manage health information across learning institutions and health service providers. 108 https://globalnutritionreport.org/resources/nutrition-profiles/africa/southern-africa/botswana/ Last Accessed Feb 28, 2023 109 Government of Botswana Ministry of Health and Wellness, The Essential Health Package for Botswana, 2010. https://www.moh.gov.bw/Publications/policies/ Botswana%20EHSP%20HLSP.pdf 110 Shaibu, S., and Nthabiseng, P., 2010. School health: The challenges to service delivery in Botswana. Primary Health Care Research & Development. 11. 197 - 202. 10.1017/ S1463423609990417. 111 Aubert, S., Barnes, J.D., Demchenko, I., et al. 2022. Global Matrix 4.0 Physical Activity Report Card Grades for Children and Adolescents: Results and Analyses From 57 Countries. J Phys Act Health. 2022 Oct 22;19(11):700-728. doi: 10.1123/jpah.2022-0456. PMID: 36280233. 112 World Bank, 2023. World Development Indicators. https://databank.worldbank.org/source/world-development-indicators 113 National AIDS and Health Promotion Agency, 2019. The 3rd National Multi-Sectoral HIV and AIDS Response Strategic Framework, NSF III 2019-2023. 114 Fifth Botswana AIDS Impact Survey (BAIS V) Summary Sheet https://www.statsbots.org.bw/sites/default/files/BAIS%20V%20Preliminary%20Report.pdf 115 ibid 116 Opondo, P.R., Olashore, A.A., Molebatsi, K., Othieno, C.J. and Ayugi, J.O., 2020. Mental health research in Botswana: a semi-systematic scoping review. J Int Med Res. 2020 Oct;48(10):300060520966458. doi: 10.1177/0300060520966458. PMID: 33115301; PMCID: PMC7607297. 117 Mental Health Atlas 2020 Country Profile: Botswana https://www.who.int/publications/m/item/mental-health-atlas-bwa-2020-country-profile 118 Ibid. 49 C. Youth to Adulthood (Ages 18 and older) Youth to adulthood is an important life stage that covers the transition from school to post-school education and training, to the labor market and economic productivity, to family formation, and gradually, to old age. During this stage of the lifecycle, there is a need for ongoing investments in human capital development. Continued education and skills training, access to gainful employment opportunities, high-quality health care, and social protection all remain imperative to ensure that individuals reach their human capital potential and live a full, productive, and healthy life. Youth and adults in Botswana, however, face numerous challenges in accessing education and skills development opportunities, staying healthy, and in finding meaningful economic opportunities. During the transition between school age into adulthood, many youths struggle to acquire relevant high-level skills and find employment. Often these challenges persist with many facing lifelong poverty and deprivation. Batswana also face poor health outcomes in youth and adulthood, driven by a heavy burden of disease and inequitable access to quality healthcare services, resulting in a short life expectancy that is much lower than what can be expected in the context of UMICs. Economic growth has not been enough to reduce unemployment which remains persistently high in Botswana. Based on the 2022 Botswana Quarterly Multi Topic Survey (Q4 2022), the overall unemployment rate is estimated at 23.4 percent (15-64 years, including own-use production) (Figure 20). Unemployment is higher among youth and women. Nearly two thirds of the unemployed are under the age of 34 (Botswana’s upper bound definition of youth). The economic shock caused by the COVID-19 pandemic took a toll on these population segments by reducing working opportunities and intensified other issues such as domestic violence in a context of increased stress. Figure 20. Population by Labor Market Status and Economic Activity, Q4 2022 Discouraged 12.1% Out of labor force 57,102 (inactive) 32.2% Other Working age 470,380 87.9% population, 413,278 15-64 years old: Unemployed 1,458,684 23.4% In labor force 231,370 67.8% 988,304 Employed 76.6% 756,933 Source: Botswana Quarterly Multi Topic Survey, Q4 2022 but adjusted to 18th ICLS standard. Notes: (a) “Discouraged” includes the following categories: Tired of looking for jobs, no jobs in area; No jobs matching skills, lacks experience; Considered too young/old by employers. “Other” includes in studies, training; and family household responsibilities (65 percent of them are inactive). (b) Labor market statistics are adjusted to the standard of the Eighteenth International Conference of Labour Statisticians (18th ICLS), which uses a previous definition of “employment” that includes own-use production (subsistence farmers), for comparability with the 2015/16 BMTHS. See: https://www.ilo.org/wcmsp5/groups/public/---dgreports/--- stat/documents/publication/wcms_220535.pdf 50 Women have a higher probability of being discouraged in the labor market while more men are employed than women. The 2015/16 Botswana Multi-Topic Household Survey indicates that employed workers are disproportionately male and skilled (Figure 21). Unemployed workers are disproportionately youth, poor, and reside outside of Gaborone.119 They are also less educated than the working-age population in general. People living with disabilities have a much lower labor force participation and face specific barriers. Discouraged workers (those who are no longer looking for work) are disproportionately female, poor, youth, rural, and reside outside of Gaborone. They are also less educated than the working-age population in general.120 Among those who are employed, 85 percent of women are engaged in services, compared with 67 percent of men. This pattern of high female engagement in services is pronounced for young and urban women. Conversely, women are much less likely than men to be engaged in industry: among those employed, 8 percent of women are in industry, compared with 21 percent of men.121 Figure 21. Labor market characteristics of employed, unemployed, discouraged workers 2015/16 GENDER EDUCATION AND TRAINING Working age 46 54 Working age 18 60 54 5 16 Discouraged 42 58 Discouraged 22 67 58 36 Employed 50 50 Employed 19 53 506 21 Unemployed 46 54 Unemployed 15 67 54 6 12 0 20 40 60 80 100 0 20 40 60 80 100 Percent Percent Male Female None Preschool Nonformal Primary Secondary TVET Tertiary Source: Raju, D. and Nxumalo, M., 2020. “Botswana National Employment Policy Development - Input Note”. World Bank. Women’s labor market attachment and success are weaker than those of men, as measured by several employment indicators. Women’s overall employment rate stands at 49 percent, 9 percentage points lower than for men at 58 percent employment (Figure 22). However, Botswana’s level of women’s labor market participation (measured by employment and labor force participation rates, age 15+) is high relative to selected peer countries and country groups. Beyond possible social norms that may underlie gender disparities in labor market attachment, institutional factors may also play a part. Evidence suggests that countries that reform their legal environment to provide for women’s economic participation observe greater gains in female labor force participation than countries that have not undertaken such reforms. The World Bank’s Women, Business and the Law122 project documents the legal origins of gender disparities for 189 countries, including Botswana. Legal shortfalls are greatest as measured by the “having children” and “starting a job” indicators. Paid maternity leave in Botswana is only 6 weeks (Employment Act Section 113) compared to the ILO standard of 14 weeks. Botswana also does not mandate equal pay for equal work and the law does not mandate nondiscrimination in employment based on gender. Building on the Women, Business and the Law project’s findings, the national employment policy should support legal reforms aimed at improving labor force outcomes for women. 119 Raju, D. and Nxumalo, M., 2020. “Botswana National Employment Policy Development - Input Note”. World Bank. 120 Raju, D. and Nxumalo, M., 2020. “Botswana National Employment Policy Development - Input Note”. World Bank. 121 Government of Botswana, 2016. 2015/16 Botswana Multi-Topic Household Survey. 122 World Bank, 2018. Women, Business and the Law project. https://wbl.worldbank.org/en/wbl 51 Figure 22. Employment rate by categorical groups, 2015/16 61 Non poor 52 38 Poor 31 75 Non youth 63 48 Youth 39 58 Urban 50 59 Rural 44 58 Overall 49 0 20 40 60 80 Percent Male Female Source: Raju, D. and Nxumalo, M., 2020. “Botswana National Employment Policy Development - Input Note”. World Bank. A range of opportunities is available to assist young Batswana transiting from school to the labor market, in particular the formal post-school education sector comprising of higher TVET, as well as different programs to support employability and entrepreneurship development. Overall, the landscape of opportunities is complex comprising numerous sub-systems and actors. Post-school education and training is strongly biased in favor of higher education. The post-school education and training sector in Botswana consists of 84 institutions registered and accredited by the Botswana Qualification Authority, of which 44 are considered higher education institutions, and 40 are TVET institutions, which include the lower-level brigades (Table 6). In 2021, the student population in post-school education and training was around 61,000 representing a gross enrollment rate of 21 percent. Only 11 percent of all post-school education and training enrollment is in TVET institutions reflecting the preference for academic qualifications and the low reputation of TVET in the country. With 58 percent, female students are overall well represented in post-school education and training, but they are underrepresented in TVET. 52 Table 6. Post-school Education and Training Overview, 2021 Number of Percent of total Percent female Type of institution Total enrollment institutions enrollment enrollment Higher Education Universities, public 4 24,673 40 62,2 Universities, private 7 8,395 14 55,2 Colleges of Education 4 1,546 3 68,5 Institutes of Health Science 7 1,074 2 66,6 Public Colleges 5 7,470 12 63,2 Private Colleges 13 9,184 15 60,7 Technical Colleges 4 1,999 3 45,2 TVET Vocational Training Centers 4 1,495 2 37,3 Brigades 36 5,321 9 33,8 Total 84 61,157 100 57,7 Source: HRDC, 2022. Tertiary Education Statistics 2021. Student support in post-school education and training favors students from better-off households who are likely to continue to higher education. Tertiary sponsorship grants covering all study-related costs as well as cost of living are given to all higher education students. In 2017/18, expenditure for scholarships added up to BWP2.2 billion, representing 43 percent of total assistance spending and 1.13 percent of GDP. However, as students from poor households are less likely to achieve higher education, the scholarship program supports mainly privileged students. Only 15 percent of beneficiaries of tertiary scholarships and 14 percent of beneficiaries of student allowances belong to the poorest quintile. On the other hand, more than half of beneficiaries (54-55 percent) of both programs are from the upper two quintiles. The incidence of the richest quintile is 28.5 percent for tertiary scholarships and 31 percent for student allowances (Figure 23). Introducing targeting and greater cost sharing into the Tertiary Sponsorship Program could free resources for targeted programs. 53 Figure 23. Distribution of Social Assistance Beneficiaries by Programs and Quintiles of Pretransfer Welfare, 2015/16 Destitute Persons (in-kind) 50,3 32,3 12,2 4,4 0,7 Needy Student 45,7 29,7 17,4 6,7 0,4 Ipelegeng 38,8 30,8 20,3 8,6 1,5 Old age pension 38,0 29,7 18,0 9,8 4,6 Orphan Care (in-kind) 34,0 22,1 27,1 10,7 6,0 School feeding (primary) 31,9 28,1 22,2 12,2 5,7 School feeding (secondary) 23,1 26,9 23,9 15,9 10,2 Tertiary scholaships 15,2 11,7 18,9 25,7 28,5 Student allowance 13,8 13,7 17,6 24,0 30,9 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent of Beneficiaries Poorest quintile Q2 Q3 Q4 Richest quintile Source: World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/ curated/en/099645103062256866/pdf/P1721750af4ddb0ce098d30b331412b0ab8.pdf Note: World Bank Analysis by welfare quintile using the Botswana Multi-Topic Household Survey 2015/2016. In addition to formal TVET, the government currently aims to build a widely accessible pre-vocational stream in secondary education. The roll-out of the Multiple Pathways model represents a major policy focus according to the new MoESD aiming to increase the reputation and attractiveness of TVET careers and to create “parity of esteem” with senior secondary qualifications. The multiple pathway model envisages to introduce at senior secondary school level in addition to mandatory core subjects (maths, English, Setswana, etc.) a choice between three parallel pathways in accordance with individual preferences and talents: (1) the vocational pathway; (2) the science and academic pathway; and the (3) humanities and social science pathway. Curricula are aligned with the National Credit and Qualifications Framework (NCQF). Students opting for the vocational pathway obtain both a vocational qualification and a senior secondary school leaving certificate. Pilot implementation of the approach started in 2021 in two secondary schools (Moeng College and Maun Senior) with an initial enrolment of 465 students. The second phase with twelve new vocational subjects offered in a larger range of senior secondary schools is planned to commence in 2023.123 The post-school education and training system is struggling to offer educational services at high quality and relevance and is not effective to tackle the pervasive youth unemployment challenge. By the end of 2022, one third (33.5 percent) of youth aged 15 to 35 were unemployed and 40 percent were considered not in employment, education, and training.124 TVET institutions, notably the brigades, suffer from an investment backlog caused by insufficient funding leading to outdated workshops, labs and ICT facilities. The revision of curricula responding to modern industry requirements and aligned with the NCQF has not been completed. Furthermore, the TVET system experiences a shortage of competent and qualified technical teachers, especially in critical fields of technical specialization. Young people’s study preferences do not match labor market needs. The majority of students opt for those occupational fields of study which are expected to lead graduates into white-collar jobs. Despite the shortage of technicians and engineers in the country, only some 21 percent of all students have chosen engineering, manufacturing and construction fields.125 Programs with low labor market absorption capacities, such as teacher training, accommodate high student rates, while TVET-level technical trade programs with considerable unmet market demand remain undersubscribed. Unfortunately, there is very 123 Government of Botswana, 2022. Ministry of Education and Skills Development. Joint Annual Education Sector Review 2022. 124 Statistics Botswana, 2022. Quarterly Multi-Topic Survey Quarter 4, 2022. V2. 125 Human Resource Development Council, 2022. Tertiary Education Statistics 2021 54 little information available on employment outcomes of graduates. One tracer study conducted in 2020 of some 800 TVET completers (graduation year 2018) suggested that only 17.1 percent graduates were employed in a field relevant to their studies.126 The lack of linkages between post-school education and training and the (private) employment sector is of particular concern and one of the major reasons for the low responsiveness of the education programs to the world of work. The TVET system is centrally managed and controlled by the MoESD. Institutions have no autonomy and leeway to make their own decisions on programs and resources in line with local market needs. There is no employer involvement at the level of TVET institution management, which has proven in other countries to be an effective mechanism to increase both quality and relevance of training contents and delivery. Work-based learning is underdeveloped, internships are mainly provided in public workplaces. Also, the Botswana Brigades, erstwhile famous for their training-with-production approach, are today operating as formal education institutions without systematic relationship to the world of work and the local communities in which they operate. The entire post-school sector is characterized by serious knowledge and information gaps, institutional fragmentation and insufficient coordination and collaboration among the different actors. The most recent reshuffling of ministerial responsibilities in the education sector has now brought all higher and TVET institutions under the auspices of the MoESD. There appears to be little coordination, on the other hand, in the employability and entrepreneurship promotion eco-system, and virtually no collaboration between these programs and the formal post-school education and training system. Such coordination would be critical to support graduates developing employability skills or accessing relevant entrepreneurship support services, and to direct unemployed youth to skills development options. To facilitate the transition from school to work and to support access to the labor market, Botswana has a number of Active Labor Market Programs (ALMP) including the Ipelegeng public employment program and a number of youth employment programs. Ipelegeng is a labor-intensive public works program with an objective to provide short-term employment support to members from low-income households while carrying out community-identified projects. During FY2018/19, the program generated 839,930 temporary employment slots. While there are several design weaknesses in the program, Ipelegeng has positive features that should be retained, such as the high participation rate of women. The Youth Development Fund, which supported over 10,000 youth-owned enterprises since its inception in 2009, the Tirelo Sechaba national youth service program and the Graduate Internship Program are examples for established programs with wide outreach at the national level. Programs are administered by different ministries.127 In 2017, total spending on youth employment programs was BWP870 million or about 0.5 percent of GDP.128 More than two-thirds of spending was on job creation programs. The composition of these programs seems to address the main vulnerabilities but there are significant overlaps on program design and objectives. Programs have been criticized129 for limited effectiveness, caused mainly by concept and program design weaknesses and poor implementation. A number of non-governmental actors are also involved including NGOs such as Young Africa Botswana and private firms such as Debswana. Programs and initiatives can be clustered into employment promotion (employability programs), providing skills development, work experience and labor exchange services, and entrepreneurship development (job creation) interventions offering business knowledge, capital, and other inputs. Overall, the landscape of non-governmental initiatives is not well-documented, and information about performance and outcomes hardly available. Throughout youth, adulthood, and old age a number of risks occur which can affect human capital and development outcomes. The main risks are related to unemployment or loss of income from the labor 126 Botho University Consultancy Group, 2021. Tracer Study of TVET Graduates in Work Based Learning and Employability in Botswana. 127 Including the Ministry of Agriculture and Food Security; Ministry of Employment and Labour Productivity; Ministry of Education and Skills Development; Ministry of Youth, Sports, and Culture Development; and the newly created Ministry of Entrepreneurship, and by public agencies. 128 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 129 Ibid. 55 market; childbirth and childcare responsibilities (mainly for women); illness and disability; shocks due to climate change and other events such as floods or fires; and old age and death or a breadwinner. Social protection and health systems need to provide support to these age groups, both when shocks occur but also to build the resilience and prevent major loss of productive human capital. A large percentage of Botswana’s population are benefiting from social protection programs including those aimed at addressing poverty and inequality and support youth and adults to engage in productive activities. According to the Botswana Multi-Topic Household Survey (BMTHS) 2015/16, nearly 56 percent of the total population and 79 percent of the poor benefit from at least one social protection program. However, 21 percent of the poor are not covered by any type of social protection program. More than half (54 percent) of beneficiaries of social protection programs belong to the poorest 40 percent of the population.130 The main poverty targeted program for poor individuals is the Destitute Persons Program (DPP) which benefits close to 40,000 individuals. In addition, around 6,000 people receive the Disability Allowance. The DPP provides cash and in-kind benefits to persons classified as permanently or temporarily destitute. In Botswana a permanent destitute is an individual who is unable to sustain themselves due to disability, a chronic health condition, or insufficient assets and income sources. A temporarily destitute person is one who is temporarily incapacitated or unable to support themselves due to floods, fire, motor vehicle accidents, ill-health, etc. The program was launched in 1980 and is administered by the MLGRD. Beneficiaries of the DPP receive a cash payment in addition to a food basket. The food basket is payable in-kind in the form of actual commodities or in the form of a SmartSwitch electronic food coupon that can be used for point-of-sale purchases in designated private shops. The food basket and electronic card are valued at between BWP500-600 (US$46.9-55.8) per month. In addition, each destitute person receives a cash benefit of BWP300 (US$ 27.9) per month, payable at post offices or designated pay points. Destitute Persons Program beneficiaries are also eligible for various other in-kind benefits, including shelter, burial, and other basic needs. All categories of destitute persons are exempted from payment of publicly provided services, including medical fees, school fees, water charges, service levies, and electricity charges. Combined, expenditures on the program represent about 0.22 percent of GDP (FY2018/19). Botswana’s social protection system has a significant impact on poverty and inequality reduction in Botswana. The poverty rate of 16 percent would go up to almost 24 percent, and the poverty gap would increase from 4.6 to 9.5 percent if social protection transfers were eliminated. In the absence of social assistance programs, the poverty headcount would increase from 16 percent to 22.8 percent – while the poverty gap would go up from 4.6 percent to 7.9 percent.131 However, there are multiple opportunities for improved efficiency and efficacy of the social protection system in Botswana, including implementation of the Single Social Registry, improving targeting and data management, introducing a more efficient benefit delivery systems, strengthening case management, and reallocating spending to programs that have the greatest impact on reducing poverty. Government has embarked on an agenda to strengthen the social assistance system, but the reform program could be broadened and deepened with a view to maximizing efficiency, effectiveness, and crisis responsiveness. Botswana also lacks a strong poverty focused flexible program that can be scaled up both vertically and horizontally in case of shocks. The existing means tested programs are not flexible enough to expand vertically or horizontally in case of a shock and were not used to respond during the COVID-19 pandemic. Instead, the government introduced measures to provide a food relief program in response to COVID-19 to help vulnerable informal sector workers whose livelihoods were significantly affected by the pandemic. Identifying these informal workers, in the absence of a registry, was quite challenging for the MLGRD as social workers had to go around to interview and register them. These efforts - while commendable - exposed gaps in the shock responsiveness and adaptiveness of the social protection system. 130 Ibid. 131 Ibid. 56 Botswana’s life expectancy at birth has improved for both men and women likely due to significant gains in the HIV/AIDS response. Women enjoy a longer life expectancy at birth than men in Botswana: 68.1 versus 63.1 years in 2021.132 Each gender has gained about five years over the last decade but the gap between women and men has grown. Botswana has successfully attained the 95-95-95 (percent of persons living with HIV aware of their status, on treatment, and virally suppressed) target for persons aged 15-64 years living with HIV. Some gaps remain, however, such as the low levels of viral suppression among females aged 15-24 years (74.9 percent compared to 81.8 percent in males of the same age), and males aged 25-34 years (71.0 percent compared to 91.7 percent of females of the same age).133 The prevalence of HIV among females is 3-times higher than males in the key age groups of 20-24, 25-29 and 30-34.134 Even with near universal delivery in health facilities, maternal mortality ratios have remained largely unchanged. Botswana’s maternal mortality ratio per 100,000 live births has declined from 151.5 per 100,000 live births in 2014 to 130.5 in 2020135 but remains high relative to peer countries: the UMIC average was estimated to be 44 per 100,000 in 2020.136 The main causes of maternal mortality include abortions, infections, ante- and post-partum hemorrhage and hypertension.137 Factors such as absence or failure to implement protocols, poor organizational management, delays in orderings tests or performing interventions, delays in consulting or availability of senior clinical staff, and stock outs of essential supplies, coupled with delayed health seeking including during the antenatal care have been cited to impede good clinical outcomes.138 The system for routinely monitoring availability of essential medicines and the status of the supply chain is weak which is further exacerbated by challenges such as poor forecasting and quantification and insufficient operational autonomy for health facilities.139 Botswana is concurrently experiencing a significant burden from non-communicable diseases (NCDs) and injuries. The Global Burden of Disease Study 2019 lists ischemic heart disease, stroke, road injuries, diabetes, and interpersonal violence among the top ten causes of death and disability in Botswana.140 The probability of dying between ages 30 and 70 years from one of the four main NCDs (cardiovascular disease, cancer, chronic respiratory disease, and diabetes) was estimated at 27 percent in 2019.141 This increased risk of morbidity and mortality from NCDs is driven in part by an estimated 61.5 percent increased exposure to the risk of high body-mass index, 39.4 percent increased exposure to high fasting plasma glucose and a 28.2 percent increase in exposure to high blood pressure between 2009 and 2019.142 Cervical cancer is the leading cause of new cases of and death from cancer in Botswana, followed by female breast cancer, while Kaposi sarcoma, which occurs in both males and females, is third.143 Despite the reduction in poverty levels, 12 percent of the elderly population live in poverty. A combination of risks increases the vulnerability of this group: low levels of educational attainment (57.4 percent never been to school), living in single-person households (17 percent among men, 9 percent among women), increasing rates of disability with aging, and low levels of contributory private pension, partially compensated with large coverage of elderly household members by non-contributory Old Age Pension (OAP) program.144 132 World Bank, 2023. World Development Indicators. https://databank.worldbank.org/source/world-development-indicators 133 Fifth Botswana AIDS Impact Survey (BAIS V) Summary Sheet https://www.statsbots.org.bw/sites/default/files/BAIS%20V%20Preliminary%20Report.pdf 134 Ibid. 135 Statistics Botswana, 2020. Botswana Maternal Mortality Ratio 2020 136 WHO, 2023. UNICEF, UNFPA, World Bank Group, and UNDESA/Population Division. Trends in Maternal Mortality 2000 to 2020. Geneva, World Health Organization, 2023 https://data.worldbank.org/indicator/SH.STA.MMRT?locations=XT 137 ibid 138 Madzimbamuto, F.D., Ray, S.C., Mogobe, K.D., et al., 2014. A root-cause analysis of maternal deaths in Botswana: towards developing a culture of patient safety and quality improvement. BMC Pregnancy Childbirth 14, 231 (2014). https://doi.org/10.1186/1471-2393-14-231 139 National Strategy Office, 2019. Making Essential Medicine Available to Citizens in Botswana: Results of the Rapid Evaluation on Medicine Supply Chain (MSC) in Botswana https://vision2036.org.bw/sites/default/files/resources/Rapid%20Evaluation%20of%20Medicines%20Supply%20Chain.pdf 140 Vos, Theo, et al., 2019. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study, The Lancet, Volume 396, Issue 10258, 1204 - 1222 141 World Bank, 2023. World Development Indicators. https://databank.worldbank.org/source/world-development-indicators 142 Murray, Christopher, J. L. et al., 2019. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study. The Lancet, Volume 396, Issue 10258, 1223 - 1249 143 Global Cancer Observatory Botswana, 2020. https://gco.iarc.fr/today/data/factsheets/populations/72-botswana-fact-sheets.pdf 144 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 57 Botswana has introduced strategies to enhance the health of older persons. The Health and Active Ageing Program launched in 2022 aims to, among others, improve access to and quality of health services for older persons aged 60 and above. The initiative would help meet the needs of older persons a majority of whom have bad self-perceived health status and are living with chronic disease conditions.145 The program’s multi-sectoral strategic objectives include creating an age friendly built and social environment, investing in appropriate human resources and improving public service support for older persons. The OAP program is a universal social pension payable to citizens 65 years and older but private sector social insurance is largely unavailable. The program is administered by the MLGRD. Applicants are required to register with the Pension Office at their local district office. Payment is made in cash, either through the Post Office or via direct deposit into the beneficiary’s bank account. A beneficiary who receives the allowance through bank deposit or by a proxy is required to make a life declaration once every six months. In FY 2019/20, the average benefit was BWP530 per month for each program beneficiary but has been quickly increased to BWP630 per month in 2022 and BWP730 (US$53) per month in 2023. There has long been a defined benefit pension scheme for government employees in Botswana. In the 1990s a decision was taken to transition to a contributory defined contribution scheme, and the Botswana Public Officers Pension Fund was established in 2001, and now covers all permanent government employees. A World Bank review also identified gaps in provision of social care services for the elderly, including home- based care, day care, and residential care, and this will become more acute as the elderly population grows.146 145 Mhaka-Mutepfa, M. and Wright, T. C., 2022. Quality of Life of Older People in Botswana. The International Journal of Community and Social Development, 4(1), 104–126. https://doi.org/10.1177/25166026211064693 146 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ P1721750af4ddb0ce098d30b331412b0ab8.pdf 58 59 60 III. Discussion – Implications of Botswana’s Human Capital Investments on Growth and Transformation The previous chapter laid out the human capital outcomes along the stages of the lifecycle as well as the programs and policies implemented by the government (and with the support of non-government actors) to strengthen human capital in Botswana. In sum, the chapter concluded that human capital outcomes across the board are lower than what is expected given the level of health, education, and social protection investments made by the government. In this chapter we discuss the relationship between human capital outcomes, economic growth and poverty reduction and highlight, based on research by the World Bank and others, the implications of the low human capital outcomes in Botswana on longer term development prospects. We conclude that at present human capital levels, the Botswana labor market does not have the relevant and/or sufficient skills to deliver productively at the level needed of a UMIC or HIC-status economy. To address this challenge, we discuss the need to improve the efficiency by which the investment in human capital is allocated and used to strengthen outcomes and to maximize its contribution to Botswana’s future inclusive economic growth. 61 A. The contribution of human capital to growth and poverty reduction There is plenty of international evidence that human capital is one of the main drivers of economic growth globally. Having a healthy and well-educated work force is positively linked to increased productivity and economic growth. Data indicate that each additional level of educational attainment is associated with improved labor market outcomes for individuals.147 People with higher levels of education are more likely to be and stay employed, learn new skills, and earn more than those with lower levels of education. Investments in education also bring positive public returns since educated citizens are likely to earn more, pay higher taxes over their lives, and cost the government less in terms of social entitlements and welfare. Growing evidence reflects the importance of high-quality early childhood care and education in contributing towards long-term social and economic benefits, including supporting learning in upper grade levels, increasing equity and social mobility, and reducing poverty.148 Social protection has also been shown to have significant impacts on reducing poverty and inequality levels across the globe. For Botswana, without its social protection transfers (from 29 programs across nine ministries), the poverty rate of 16 percent in 2016 would have been almost 24 percent, and the poverty gap would have been 9.5 percent instead of 4.6 percent.149 Negative impacts on human capital can also have negative impacts on economic growth. A recent study shows that health crises in African countries have dynamic negative long-term spillover effect on labor productivity, such that a 1 percent increase in the health burden, all else equal, would reduce labor productivity by 13 percent in the continent’s upper- middle-income economies, 17 percent in the lower-middle-income economies, and 19 percent in the low- income economies, respectively.150 Given the demographics of countries in Africa, sustained investments in health, education, and social protection have been lauded as especially important for growth across the continent. In African countries, including Botswana, the population is young and there is an opportunity to reap the benefits of the demographic dividend in the next 30 years. The Africa Human Capital Heads of State Summit held in Dar-es-Salam in July-August 2023 (see Box 4) highlighted that robust economic growth development are a combination of a) smart physical infrastructure investments, b) appropriate economic policies, and c) timely and sustained human capital investments. In fact, the lessons learned from the East Asian tiger countries like South Korea, Malaysia, and Singapore demonstrate that sustained strategic investment in human capital contributed to between one third and a half of all economic growth. It is also evident from these countries that the important investments in public health and education pre- dated the period of faster economic growth. 147 https://gpseducation.oecd.org/revieweducationpolicies/#!node=41761&filter=all 148 Ibid. 149 World Bank, 2021. Review of Social Protection Programs and Systems in Botswana. 150 Mobosi, I.A., Okonta, P. O. and Nwan Kwo, C.E., 2022. Health burdens and labor productivity in Africa’s middle- and low-income economies: Implication for the COVID-19 pandemic, Journal of Knowledge Economics, October 17 (2022), 1-19. doi: 10.1007/s13132-022-01058-y. 62 Box 4: Dar-es-Salam Declaration: Commitment to invest in Human Capital On August 2, 2023, African leaders from 43 countries agreed to step up efforts to strengthen the quantity, efficiency, and impact of investments in their people in the newly announced Dar es Salaam Declaration. Sub-Saharan Africa scores the lowest of all the world’s regions on the World Bank’s Human Capital Index (HCI) yet faces a youth bulge that could be leveraged to supercharge African economies if the right policies and investments are implemented today. The leaders met for two days at the inaugural Africa Human Capital Heads of State Summit convened jointly by the Tanzanian government and the World Bank. The summit was a call to action at the highest level to the importance of investing in Africa’s people as a core driver of innovation, productivity, resilience, and growth on the continent. It also underscored the urgency of addressing Africa’s young and rapidly growing population, and the need to create productive employment and functioning markets that can make the most of these changing demographics. The Dar-es-Salam Declaration constitutes tangible financial and policy commitments made by African leaders to prioritize investing in people with a focus on reaping a demographic dividend. The declaration recognizes that Africa’s most important asset is its people and there is no time to waste. Source: World Bank, 2023. https://www.worldbank.org/en/news/press-release/2023/08/02/dar-es-salaam-afe- declaration-african-leaders-make-important-commitments-to-investing-in-human-capital#:~:text=The%20Dar%20 es%20Salaam%20Declaration,is%20no%20time%20to%20waste. In the case of Botswana, economic analysis shows that the low HCI will limit future growth aspects. According to the World Bank’s forthcoming study of the drivers of growth in Botswana151, the low human capital accumulation, compared to countries with similar income levels, will limit future growth prospects. The study simulates Botswana total factor productivity (TFP) at the level of Chile’s, Mauritius’ and Malaysia’s TFP growth by year 2036 and shows that its GDP per capita falls short to meet the HIC threshold. For Botswana to reach higher TFP like the three comparator countries there is a need to accelerate the economy’s ability to innovate in research and development and patents developments for instance – both strongly correlated with high levels of human capital. But compared to other countries with the same GDP per capita, Botswana’s HCI is 30-40 percent less (Figure 24). The margins by which Botswana lags these comparator countries indicate that innovation is still below par irrespective of the establishment of institutions meant to drive such developments. Increasing the quality and relevance of education and training in Botswana to better align learners with labor market needs will raise TFP.152 151 World Bank, 2023. Drivers of Growth Botswana, forthcoming. 152 Ibid. 63 Figure 24. The relationship between HCI and income level across the globe, 2020 0,9 0,8 Human Capital Index, 2020 0,7 Mongolia 0,6 Georgia 0,5 Tunisia Lebanon Gabon Congo Namibia South Africa 0,4 Botswana 0,3 0,2 6,5 7,0 7,5 8,0 8,5 9,0 9,5 10,0 10,5 11,0 11,5 12,0 Natural logarithm GDP per capita, 2020 (PPP, US$) Source: World Bank, 2023. Botswana Poverty Assessment, forthcoming. Furthermore, labor market factors are key determinants of both poverty and inequality reduction. Analysis conducted as part of the World Bank’s Poverty Assessment153 shows that labor income was the main driver of poverty reduction in urban areas from 2009-16 and the downward trend in the share of employed adults in rural households contributed to higher rural poverty. Moreover, the primary contributors to inequality as measured by the latest national household surveys were related to labor market factors, particularly skills differences (Figure 25). Figure 25. Factors contributing to inequality in Botswana, 2010 and 2015 39,1 40 35,1 35,6 27,9 30 25,9 Contribution to Inequality 20,3 20 10,6 10 0 Demographics Education Labor market Location 2010 2015 Source: World Bank, 2022. Inequality in Southern Africa: An Assessment of the Southern African Customs Union. Washington, DC: World Bank. Botswana Poverty Assessment. 153 World Bank, 2023. Botswana Poverty Assessment, forthcoming. 64 B. Improving the efficiency of current spending and spending more on early years to maximize human capital outcomes For Botswana’s labor market to deliver the productive outputs needed to sustain and further transform the economy from UMIC status to HIC status and continue to reduce poverty and inequality levels, a more prepared and skilled labor force is needed. This would require addressing both the stock (individuals already in the labor market) and the flow (individuals who will enter the labor market in the future) constraints of skilled workers. In the short term, short term skills programs and support to reorient existing labor supply towards growth-oriented sectors would be important. In the longer term, however, more efficient delivery of basic human development services is needed including early investments to prepare children to growth and learn at school; ensuring that the education and skills system delivers quality learning and are fit for the demands of the private sector; ensuring access to quality health services which contributes to better productivity and longevity of workers; and using social protection mechanisms to support the poorest households to access equitable and quality services, and cushioning them in case of temporary income loss and to reenter the labor market after shocks hit. Nevertheless, current investment strategies in human capital could be better targeted to achieve the right outcomes. This Note points out that while Botswana spends significant resources on health, education, and social protection (over 14 percent of GDP in total) there are inefficiencies in the process of transforming these inputs and outputs into better human capital outcomes. Understanding where the inefficiencies in the delivery system occur and addressing them are of importance in Botswana. In addition to better efficiency of current spending, more funding is required to support the youngest individuals in Botswana. Early childhood care and development (ECCD) of children ages 0-5 has been underfunded in the country with few programs being directed to this segment of the population where global evidence suggests countries get the biggest return on investment. More funding is required to support a comprehensive social grant for infants and toddlers, to expand the provision of quality services in ECCD centers and pre-schools, and to support better nutrition programs for children. There is room for better coordination between different ministries these services for children in a holistic way. Five areas that require attention for enhancing the value-for-money in the human development delivery systems are identified in this Note: 1. Ensuring funds are better targeted towards the poorest segments of the population and more funding goes to programs that support children from poor households. • The Government of Botswana spends about 7.1 percent of GDP on education and training, but about one-third of this budget goes to tertiary education (for subsidies to universities and bursary/loans to students).154 In 2017/18, expenditure for scholarships added up to BWP2.2 billion, representing 43 percent of total social assistance spending and 1.13 percent of GDP. However, more than half of beneficiaries (54-55 percent) of the scholarship program are from the upper two quintiles (richest 40 percent) of the population. This raises questions on whether this group needs the financial support to continue their education or whether allocating a portion of these funds to students from lower income households on the basis of need and merit, could be better use of funds. Introducing targeting and greater cost sharing into the Tertiary Sponsorship Program could free resources for other pro-poor programs. • Moreover, in social protection spending on programs for adults and elderly consume a large share of resources including for the Old Age Pension program and Ipelegeng public works. For children, the program with the largest resource envelope is the school feeding programs where Botswana spends much more per student than most other middle-income countries. More analysis of the benefits is needed to assess the value for such high investment. Very little is spent on targeted 154 World Bank, 2019. Public Expenditure Review of the Basic Education Sector in Botswana. https://openknowledge.worldbank.org/server/api/core/bitstreams/16edcf93- 7384-5de9-8c9c-b491c04d81bc/content; More recent data from UNESCO Institute for Statistics suggests a higher percentage at 8.74 percent of GDP: UNESCO Institute for Statistics, 2023. Government Expenditure on Education, Botswana. https://data.worldbank.org/indicator/SE.XPD.TOTL.GD.ZS?locations=ZG-BW W 65 assistance to support children in poor households. Prioritizing sufficient resources towards primary care programs and programs that specifically assist poor households with children is an important policy action towards improving their health, nutrition, and schooling outcomes at an early age. • Botswana’s domestic government health expenditure is significant at 4.4 percent of GDP in 2020.155 As highlighted in the preceding sections, this level of health spending is not resulting in desired health outcomes. Reorienting spending towards primary care is a means towards enhancing efficiency as it provides a platform for offering quality health services in an equitable and cost- effective way. The ongoing development of the primary care revitalization strategy provides an opportunity for rethinking spending patterns to provide comprehensive and coordinate care that extends beyond facility-based health services. • Finally, our analysis shows that achievements in poverty and inequality reduction are uneven across the country. While the national poverty headcount decreased between 2009/10 and 2015/16, poverty in rural areas increased by 2.5 percentages points during the same period and human capital outcomes are much lower in rural areas. Providing human capital services in rural and remote areas is more expensive and careful consideration is needed with regards to how to most effectively and efficiently provide services in these areas to ensure that children receive the same opportunities to thrive and later contribute to the labor market as adults compared to children growing up in urban areas. The analysis of education services shows that Botswana had successes in providing distance learning during the Covid-19 pandemic which could provide lessons for technology supported service delivery in rural areas. 2. Measuring outcomes that matter and generating information to guide real time policy action • The analysis has identified the need to strengthen results measurement and monitoring of core indicators to focus attention more strongly on advancing human development outcomes. Measurement needs to be undertaken frequently and organized in a way that it feeds into decision making to adjust programming based on the results. • But there are gaps in data relating to routine information systems, periodic assessments and specific analytics that would contribute to tracking and improving performance of services across the entire human capital lifecycle. With reference to early childhood health, individual patient data is critical to improving comprehensiveness and coordination of care within and across sectors for key health outcomes such as nutrition (e.g., stunting, overweight, deficiencies etc.), survival (e.g., neonatal, and maternal mortality) and quality of life. Aggregate data also support key health system functions such as the distribution of key inputs (e.g., reorienting towards primary care), organizational structures (e.g., decentralization) and monitoring of performance (e.g., availability of essential medicines). Botswana’s information systems do not sufficiently address these needs owing to challenges of scale, interoperability, timeliness, and translation for use. The National eHealth Strategy proposes to address these gaps including through establishment of a national eHealth platform and a standards and interoperability framework. However, implementation of the strategy and other actions to urgently address these gaps is required. These other actions include (i) strengthening capacity of key institutions such Statistics Botswana, Ministry of Health, universities and research institutions in information management, use and reporting; and (ii) adopting a digital in health approach which emphasizes, among others, an integrated focus on digital health solutions that are patient focused, systems-oriented and strategically aligned with government-wide transformation efforts. • With regards to Education, conducting routine learning assessments and using regular, disaggregated learning outcome data for planning resource allocation to teaching and learning inputs and reforms will strengthen the sector’s orientation to results. There is an urgent need 155 WHO Global Health Expenditure Database, 2023. https://apps.who.int/nha/database/Select/Indicators/en 66 to review and strengthen the existing Education Management and Information System (EMIS) with potential inclusion of data on teachers that helps the sector map its teacher recruitment, development, and deployment needs on a regular basis. These operational reforms will allow policy makers to make strategic, evidence informed policy decisions such as allocation of expert teachers to areas of need and remedial support to struggling learners. Moreover, Botswana does not participate in the commonly used international assessment related to early childhood cognitive and socio-emotional development. Measuring and tracking these types of indicators is imperative to assessing the readiness of children when they start school at reception class and Standard 1. It would also provide a basis for understanding the quality of teaching and care in pre-school and ECCD centers. In many HIC and UMIC countries, measuring the quality of early childhood education services and learning outcomes for learners allows countries to ensure that learners are successful early on, that they persist in school, and have greater learning outcomes as they move through the education system. In this way, early childhood education measurement can contribute towards improvement in Botswana’s HCI score overall. Better costing data is also needed for both health and education service provision. 3. Strengthening cross-sector coordination for social sector service delivery • Keeping the focus on outcomes through the generation of data will allow attention to be paid to specific results areas across the life cycle and requires cross sectoral/cross ministerial coordination to maximize results. • For ECCD, a coordinating framework is in place with clear roles for MoH, MoESD, and MLGRD. An implementation plan is in place but tracking and reporting of the activities across ministries is weak. More could be achieved, especially in terms of ensuring that children in poor households benefit from well-coordinated services related to healthcare, nutrition, early stimulation in ECCD centers, and child protection. Moreover, social protection programming has not yet implemented any direct links to ECCD center enrollment and nutrition programs on any scale. A social registry which clearly identifies low-income households with young children and monitors the provision of care to them would be helpful in this regard. Programs and local institutions that support these children such as with post-natal care, vaccinations, supplemental feeding, cash transfers or other forms of social assistance, and cognitive development could use this registry information to tailor and target their services specifically to these households and monitor the children from conception to school-age. • Similarly for education, the responsibility for service provision is split across MoESD and MLGRD causing inefficiencies. MoESD has the larger mandate for delivering the services including teachers and textbooks, and policy and institutional reforms concerning the curriculum, data, and quality. MLGRD is responsible for provisioning inputs like infrastructure for primary schools, school feeding, and select teaching-learning materials. Both the recurrent and capital budgets are split between the ministries and a large share goes for teacher costs. Occasional misalignment of deliverables and poor sequencing of activities between the two ministries lead to potential wastage and redundancies. This causes inefficiencies in the delivery of quality education – for instance there is a shortage of classrooms, and while the staffing to student ratio is favorable, class sizes are often large. • In the post-school and skills development sector there is significant institutional fragmentation and insufficient coordination and collaboration among the different actors. While the recent reshuffling of ministerial responsibilities in the education sector has brought all higher and TVET institutions under MoESD, there is still insufficient coordination between these sub-sectors in terms of articulation of courses (e.g. credits being transferred from TVET courses to universities), and coordination with the private sector and the labor market information system which sits under the Ministry of Labor and Home Affairs. This note also points out the lack of coordination in the employability and entrepreneurship promotion eco-system, and virtually no collaboration between these programs and the formal post-school education and training system. 67 4. Reviewing service delivery chains to incentivize performance of the biggest budget items and course correct early • The biggest budget items in the health and education budget relate to health workers and teachers as well as essential medicines and textbooks. Tracking the performance of staff and procurement of goods is a good place to start when trying to address inefficiencies in spending. • In health, strengthening efficiency of service delivery can begin by focusing on availability of key inputs such as essential medicines and supplies and human resources for health. The MoH should strengthen information availability on essential medicines and distribution of health personnel through digital solutions, while strengthening the capacity of key institutions such as the Central Medical Stores in inventory management and supply planning. Leveraging more on decentralized structures, as shown by the successes of the HIV/AIDS response, is key for enhancing efficiency particularly through a primary care approach. Greater district-level decision making has the potential to enhance the link between resource use and outputs while ensuring quality of care and the responsiveness of the health system. • In education, efficiency of service delivery can be strengthened in a few different ways. Firstly, stronger communication between and collaboration among the various ministries charged with cross-sectoral activities (such as provision of early childhood services or building school infrastructure) will contributed towards improving efficiency of service delivery in the sector. Secondly, through carefully planned management of the teacher workforce, including solid preparation of teachers in both content and pedagogy, hiring and allocating teachers in a way that meets identified needs across the country, providing teachers with the right amount of coaching and support to strengthen teacher satisfaction with their roles to subsequently improve the quality of teaching and learning in the classrooms and boost retention of teachers in the workforce. Thirdly, by taking regular inventory of educational materials, such as textbooks and supplies in schools as well as gathering and reporting student learning outcomes routinely so that policy decisions are based on evidence and respond appropriately to the needs in the sector in a timely manner. Finally, efficiency can be strengthened by focusing efforts to improve the quality of and participation in preprimary education in the country so that students arrive in primary well prepared to learn, student retention in the early grades is reduced, and transition through to higher grades is eased. • For social protection there are multiple opportunities for improved efficiencies and efficacy in the administration and delivery of benefits, including implementation of the Single Social Registry, improving targeting and data management, more efficient benefit delivery systems, strengthening case management, and reallocating spending to programs that have the greatest impact on reducing poverty. Government has embarked on an agenda to strengthen the social assistance system, but the implementation is slow without significant movement in the last two years. Maintaining 30 social assistance programs creates administrative and spending inefficiencies. 5. Benefitting from private sector collaboration and expertise • Botswana’s private sector has been a key contributor to its health system gains, including in its response to HIV/AIDS and COVID-19 pandemics. Botswana should build on this by formalizing public-private collaborations through the development of specific guidance for health sector collaborations. This will delineate and streamline the various forms of collaboration e.g., by specifying which areas of collaboration are likely to yield greatest gains. For example, service delivery could be enhanced through public-private networked service models that offer comprehensive and coordinated services while making the best use of existing capacity and expertise in both sectors. Botswana could also standardize its provider payment and information sharing systems to align the two sectors while improving accountability for quality and performance across the health system. 68 • Strengthening the capacity of critical public institutions is key to befitting from private sector collaboration and expertise. The Botswana Medicines Regulatory Authority and the National Drug Quality Control Laboratory, for example, can provide a regulatory environment that allows of great access to health products and technologies including through providing a supportive platform for research and development or even local manufacturing. Strengthened and capable health professional regulators can provide confidence for private sector investment in health workforce development and provision e.g., by availing information on health labor markets or procedures for registration. • In education and skills training, rather than taking on all aspects of financing and delivery of services, the public sector may take on the role of financing and regulating service delivery by inviting private actors into the sector. The competition from, and among private actors, in the education space may trigger an improvement in the quality of service delivery, allowing more and better services to be delivered across the sector. It is important to note that benefitting from private sector partnerships will require that clear guidelines, strong contracting mechanisms and service delivery benchmarks as well as strong quality assurance systems are put in place by MoESD. Public Private Partnerships in education work well when there is an adequate supply of places in non-state schools to meet government needs, they are targeted at low-income students, they are budgeted properly, a systemic approach is applied, outcomes-based accountability is used and providers are given autonomy. 69 70 IV. A Multisectoral Framework to Accelerate Human Capital Development This note concludes that advancing human capital development is critical for Botswana to propel itself towards a HIC status in the next one to two decades. Prudent mineral wealth management and strategic investments in infrastructure, human development, and basic services have put Botswana on a path of strong economic growth and poverty reduction and has helped to affirm its stable UMIC status. However, progress has slowed down in the recent decade, and it is time for Botswana to review its policies and priorities to ensure efficient value-for- money for its human capital investments. Critical indicators such as stunting, child mortality rates, learning outcomes, and adolescent fertility rates are below what is expected of a HIC-aspiring nation with Botswana’s potential. Overall, Botswana’s HCI score indicates that a child born today will only be 40 percent as productive when she enters the labor force as she would have been if she had enjoyed full health and education. With the willingness and commitment of decision makers and the capacity base built by the solid investments so far there is significant potential to accelerate progress. Significant resources are already committed in the health, education and social protection sectors. But the efficiency by which these are spent needs improvement. More attention should be paid to supporting early childhood programs, measurement of young children’s development, learning outcomes throughout the school years, quality of and utilization of health services, and the efficiency of social protection spending. By focusing the attention to final outcomes Botswana can reach transformational impact to meet the changing development and economic needs in the path towards HIC status. Smart human capital investments will also be critical in an ever-fluctuating world which recently suffered the impacts of the COVID-19 pandemic and the subsequent poly-crisis, but also in reprogramming inclusive growth strategies towards a greener economy. In August 2023, Botswana signed the Dar-es-Salam Declaration (see Box 4), committing to focus efforts towards growth of human capital in the country. This section highlights priority policy recommendations for the three lifecycle stages: early childhood, children of school going age, and youth and adulthood. In addition, a discussion is provided at the end of the chapter of system level issues which cut across the lifecycle. Table 7 and Table 8 lay out recommended short and medium terms actions to take for each of the three core ministries: MoESD, MoH and MLGRD. 71 A. Policy priorities for early childhood Investing in early childhood, to ensure that children thrive in their physical, cognitive, and socioemotional development is one of the key priorities for Botswana’s human capital development agenda. From the analysis presented above, four priority areas emerge: A. Strengthen the utilization and quality of maternal, neonatal and child health services: Health and nutrition outcomes for young children in Botswana are below expectations given Botswana’s income level. That means that the potential of children will not be fully optimized as highlighted by a HCI score of 0.41. Leveraging on the successes of the HIV/AIDS pandemic recovery may provide a platform for rapid gains in utilization and quality of care for early childhood. These include (i) a systematic approach to health promotion and prevention (e.g., encouraging exclusive breastfeeding and antenatal care attendance), (ii) routine use of clinical information to support quality improvement at team, departmental and facility levels; (iii) rapid system-level adaptation to changes in evidence to enhance quality of care (e.g., through the establishment of a permanent clinical guidelines committee) ; and (iv) performance monitoring and reporting including using real- time data (e.g., by strengthening the capacity of Ministry of Health’s M&E unit to perform analysis of routine data). Botswana’s proposed pivot to enhancing primary care provides an opportunity to leverage on these learnings and implement strategic interventions at scale using an approach that is also likely to enhance equity. For example, it provides an opportunity to enhance the role of Community Health Workers in delivering integrated health and social services. B. Explore strategies to increase participation of children in pre-primary school and early childhood stimulation programs. Provision of early childhood stimulation and pre-primary education can take many forms ranging from in-home care to community-based centers to government-led centers and classrooms attached to public primary schools. In Botswana, there is a need to track the various existing platforms for early childhood care and education, noting patterns of participation across regions and income levels, and identifying the needs of caregivers. Early childhood care and education will require a cross- ministerial approach including sectors of health, education, and local government supporting and mandating private sector engagement. Botswana may consider conducting an institutional analysis of what collaboration across the various actors currently looks like and approaches that may be explored for strengthened implementation of early childhood care and education services across the country. Countries such as Rwanda and South Africa offer examples of innovative approaches to consider, particularly in rural areas. Early childhood care development and education programs may offer opportunities for entrepreneurship and employment in communities, particularly for women. C. Consolidate safety nets for young children and link poor households to programs providing early stimulation and health and nutrition services. The strategies and approaches for improving nutrition outcomes (stunting, wasting, etc.) need to be reviewed. Current programs which provide food and supplemental feeding may not reach the most vulnerable children and there is little evidence which programs are working and not working. There is scope to consolidate several of the existing programs targeting young children and considering a cash-based program for infants and young children (even through the school age years). Such a program, using a social registry to identify and target the poorest households, could serve as a platform for ensuring that the same households also get access to maternal and child health services and nutrition programs. At the same time, it would be important to build in pathways for households to exist out of social assistance when possible and be linked to productive activities and income generation opportunities. 72 B. Policy priorities for children of school going age During the school going years, key priorities for Botswana include: (a) strengthening data and measurements; (b) deepening the knowledge base related to the drivers of education outcomes, (c) reassessing of social protection approaches for supporting poor students, and (d) considering adolescent mental health issues. A. Develop and regularly administer standardized, national learning assessments to follow progress in learning across primary and secondary levels. With completion and access rates being relatively high in Botswana (at least until Form 3) more attention needs to be paid to the quality of education and the real learning outcomes in the classroom. Administering early childhood development assessments such as MELQO or the ASQ would allow the Ministry to identify areas of support that may be required by learners early on. This data could inform planning for the pre-primary grade(s) ensuring that learners enter Standard 1 well prepared to learn. Conducting national standardized learning assessments in the foundational subjects of reading and mathematics at the primary and secondary levels (in Standard 3, Standard 6, and Form 2) every 2 years will help the MoESD keep track of learning outcomes in foundational skills and allow for strategic and targeted planning in the early grades. At the secondary level, a national learning assessment in science may also be administered to gauge learning and for planning purposes. B. Undertake analytical work to identify key causes of secondary school dropout and repetition and propose practical solutions to address these challenges. Causes of repetition (especially for boys in the early grades) and school dropout (around Form 3) should be explored more deeply so that associated factors may be addressed. Potential areas of inquiry may include poor quality of teaching, low accessibility of secondary schools and the teaching and learning environment in boarding schools. Findings from this analytical work may help to identify learners at highest risk and should inform policy and practice moving forward. C. Consolidate safety nets for school age children; assess the impacts of food and in-kind support; and target social protection to encourage poorer students to continue through secondary school. Poverty is a main driver of schooling outcomes in Botswana, poor students are more likely to drop out of school early, and learning outcomes are worse in more rural and remote areas. The main social protection interventions focus on providing school feeding and other food and in-kind handouts to orphaned children. However, these programs consume significant resources and have not been evaluated relative to their cost-benefit and effectiveness for improving school outcomes. Moreover, as noted in the policy recommendations for young children, there is a need to consolidate the many small safety net programs for children (0-18 years) and consider targeted cash-based approaches for poor households with children to address their constraints to invest in human capital including helping with school related direct and indirect expenses, proper nutrition, and utilization of health care. D. Leverage existing school-based health interventions to enhance effective coverage of key services School-based health interventions may provide a platform for dealing with the challenges faced by Botswana’s children of school going age, including adolescents. For example, health promotion and prevention activities such as health education and physical activity sessions could be integrated with school curriculums or implemented as part of the school health policy. Similarly, schools could be used as a delivery platform for interventions to address adolescent mental, sexual, and reproductive health such as adolescent-friendly health services. The ongoing revision of the NSHP provides an opportunity to address previously identified design and implementation gaps while responding to emerging challenges such as mental health and the high incidence of HIV infections in this age group e.g., by integrating child and adolescent mental health and school based mental health prevention and promotion programs in the NSHP. 73 C. Policy priorities for youth to adulthood Policies to support youth, into adulthood and then old age are many and cut across several sectors. First and foremost are programs which support young people to effectively access gainful employment after school and contribute to the growth sectors of the economy. Second, while working or in periods of vulnerability during the productive years health care, social protection and employment policies are needed to allow workers and their household members they support to live prosperous and healthy lives into old age. A few policy priorities can be noted: A. Improve coordination among skills development and ALMP programs and conduct systematic outcome monitoring of existing interventions. A number of skills development, entrepreneurship and employability programs exist in Botswana. Some are provided by the state and some by private sector. To better support youth to transition out of education into productive employment – formal or self-employment – there needs to be a stronger coordination of programs across providers. Global evidence shows that programs which pay careful attention to implementation and who support youth in a flexible way over time achieve the best results. In Botswana, rigorous evaluation of ALMP programs is largely missing and should be strengthened to improve the effectiveness, efficiency, and equity effects of programs and to identify approaches which work to encourage youth to access and stay (self-) employed and where the most value for investment can be found. Strengthening coordination of labor market programs requires significant cross-ministerial collaboration and coordination with private sector and industry actors. B. Focus new investment in post-school education and training on skill areas with a high growth potential, notably digital skills and green skills. To catch up to the industrialized world as planned for 2036, Botswana should thoroughly review its post-school education and training offers to nurture a culture of innovation and achieve alignment with current and future workforce and skills needs. This requires reinforcing linkages with the world of work in its education and training system and strengthening the focus on TVET-level skills development to ensure more and better qualified artisans and technicians are available in the labor market. Revising the current student support system, which is favoring better off households, and integrating TVET-level learners into the public student sponsorship scheme would help making TVET programs more accessible to youth from poor and vulnerable households. Of particular importance is re-directing education and training offers towards skills needed in dynamic sectors with high-growth potential. It is paramount to develop a strong focus on digital skills development to raise the country’s global competitiveness. This requires dedicated investments in new programs for jobs in the ICT market, overhaul of curricula to address emerging digital development in conventional professions and interventions to increase digital literacy for all. The latter particularly applies to vulnerable youth in the labor market who need to be capacitated for technology-based communication, production and processes in the job market. Furthermore, Botswana’s huge potential for renewable energy production and export offers enormous job chances for Botswana’s youth, but it will require massive investments into green skills development. C. Strengthen quality of adult care to address premature mortality and quality of life. Addressing adult care is key to sustaining improvements in healthy life expectancy following the gains made in HIV/AIDS. Interventions to address the high levels of maternal deaths include improving availability and use of clinical guidelines and protocols, enhancing core competencies of staff to deal with leading causes of maternal mortality such as post-partum hemorrhage, improving team- based approaches to providing clinical care, and improving availability of essential medicines such as those to manage post-partum hemorrhage. Improving primary care will provide the continuous and comprehensive care that is required to tackle NCDs, and other chronic diseases, specifically 74 by enhancing adherence to treatment, improving monitoring of clinical status and implementing preventive interventions such as screening for risk factors. Enhancing the capacity of emergency medical services through both ambulatory and fixed sites is also critical to effectively manage the sequelae of these diseases such as stroke and myocardial infarction. Community health workers can also be leveraged to provide integrated health and social services particularly to elderly persons for example to improve access to medicines or basic diagnostics for disease monitoring or for support accessing social assistance and old-age pension support. D. System level issues cutting across the lifecycle While important policy actions can be considered for specific periods across the lifecycle there are several system level aspects of human capital development which span across the lifecycle. This includes investments in key inputs, management information systems, improvements in processes for essential procurement, data management, targeting and identification systems, and approaches to responding to and preparing for future climate change and pandemic crises and building household resilience to shocks. A. Strategic investments in key health inputs delivered through a primary health care approach. More strategic investments in inputs such as human resources for health, essential medicines and essential equipment and diagnostics will be required to improve health service delivery use and quality across the life course. For example, enhancing maternal and neonatal care will require ready availability of essential medicines by addressing identified gaps in forecasting, quantification, warehousing, and distribution functions. Addressing adolescent health will require investments that address factors such as mental, sexual, and reproductive health such as in adolescent friendly health services and school-based delivery of services. Similarly, enhancing survival from NCDs such as cancer will requires strengthening of early diagnostic capacity by healthcare workers and the diagnostics system. Aligning these investments through revitalization of primary health care is crucial to guaranteeing efficiency, equity, and quality of health services. The ongoing revision of the human resources for health strategic plan should address some of these gaps by signposting the government on key human resource gaps and strategies to address them. A similar approach to supply chain management, accounting for both essential medicines and diagnostics, is warranted given ongoing challenges. Strengthening the capacity of key institutions such as the health professional regulators, Central Medical Stores, Botswana Medicines Regulatory Authority, and the National Drug Quality Control Laboratory should also be embedded in these strategies to ensure follow through. B. Accelerating reforms to health service purchasing to deliver effective coverage. Health service purchasing reforms are key to making the most of the financial resources available to the Botswana health system. Improvements are required to better link payments to the type and quality of care received. These include (i) changes to provider payment systems in both private and public sectors e.g., away from the extremes of fee for service or line-item budgets towards blended systems that account for quality and performance; (ii) strengthened information sharing and use among health service providers and purchasers (including private) of health services; (iii) granting greater financial and operational autonomy to public health facility boards and managers; and (iv) optimising use of all available capacity, for example, through networked service delivery and formalized public-private collaboration. Initial steps would be to develop an implementation plan to accompany the draft health financing strategy with clearly identified transitions towards greater refinement of the health financing system; and strengthen capacity of key institutions such as Ministry of Health in health service purchasing. 75 C. Building social protection delivery system for better targeting and identifying poor and vulnerable households to focus human capital investment. Building on the momentum on recent achievements, the government should work towards making the social registry fully operational which would be a significant step towards improving the efficiency of social protection in Botswana. The dynamic, real-time relevant, social registry will help the government to better understand the economic reality of households and benefits provided and help promote coordination between programs including health and nutrition interventions. It would be important to ensure enough resources for expansion and sustainability of a social registry. It will require sustained financing. D. Invest in the shock responsiveness and pandemic preparedness of human development delivery systems. As crisis - climate change induced, pandemics, and wars and political instability – become more frequent ensuring that education provision, health services, and social protection programs are flexible to adjust to new circumstances also become more critical. Evidence from around the globe show that when plans and systems for how to adjust to emergencies and provide alternative forms of services are set up ahead of time, the cost of intervention is lower and the effectiveness for achieving results are higher. For education, the COVID-19 crisis showed us how the importance of alternative ways of providing schooling for students via distance learning etc. to reduce irreversible learning losses. For health, pandemic preparedness and plans to address outbreaks need to be part of national plans. For social protection, being able to scale up support in affected areas and to affected populations quickly and timely not only reduces the negative impacts of temporary shocks but can also help build the resilience of households to future crisis. 76 Table 7. Recommended short term actions (1-2 years) Local Govt and Rural Health Education Development Early Years • Conduct a • Assess the quality of • Consolidate demographic and pre-primary services programs for young health survey or in Botswana and draft children (early equivalent (e.g., plan for improvement years and school multiple indicator years) and develop a • Institute public cluster survey), to cash-based, poverty awareness campaigns better understand key targeted program to increase health indicators such for poor households participation in as neonatal mortality. with children linked preprimary education to supporting use of • Develop a strategy ECCD, health care for addressing and school retention persistently poor nutrition outcomes • Introduce a such as stunting harmonized poverty targeting In school • Update the school • Examine factors mechanisms health strategy to allow contributing towards through which to schools to serve as a high levels of objectively identify delivery platform for secondary school poor and vulnerable adolescent-friendly drop -out among households – health services learners and draft plan especially those with to respond to these children factors. • Institute routine national learning assessments in reading, mathematics and science at primary and secondary levels. In labor market • Develop • Improve coordination • Assess the impact implementation plan among skills of social assistance for the primary health development and programs on care revitalization ALMP programs and poverty reduction, strategy with a focus conduct systematic resilience and coping on implementation outcome monitoring of mechanisms, and capacity for integrated existing interventions food-security of poor service delivery e.g., households to inform for NCDs further program consolidation 77 Table 8. Recommended medium term actions (3-5 years) Local Govt and Rural Health Education Development Early Years • Develop and implement • Conduct regular • Together with strategy for addressing assessments of Moh and MoESD poor neonatal and child preprimary service strengthen health outcomes quality and child coordination with development and the private sector on • Strengthen capacity learning outcomes to provision of ECCD of healthcare workers gauge progress over services and availability of time. essential medicines • Build links between and supplies for • Provide consistent social assistance delivery of quality support to strengthen programs for children health services the content and with other services pedagogical skills of related to nutrition • Leverage on digital preprimary teachers in and early stimulation solutions to strengthen the country performance management and improvement In school • Enhance capacity of • Strengthen teacher • Transform the school health services preparation, social registry into to provide mental training, and support a dynamic, real health services mechanisms in the time information country to increase system serving to teacher satisfaction inform policy and and retention in the programming of sector. human development service delivery to • Conduct routine poor and vulnerable national learning households – assessments in especially children reading, mathematics and science at primary and secondary levels and ensure that the data guides policy decisions. 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Global Electrification Database, WHO/UNICEF Joint Monitoring Program (JMP) for Water Supply, Sanitation and Hygiene (washdata.org), UN Population Division, UNESCO, and UN Group for Child Mortality Estimation) World Economic Forum, 2022. ‘How a pioneering architect faced rejection and used design to drive social change and sustainability’. https://www.weforum.org/agenda/2022/10/francis-kere-pritzker-prize- architecture-social-change-sustainability/ World Health Organization, 2022. Mental Health Atlas 2020 Country Profile: Botswana https://www.who. int/publications/m/item/mental-health-atlas-bwa-2020-country-profile Yoshikawa, H., Weiland, C., Brooks-Gunn, J., Burchinal, M.R., Espinosa, L.M., Gormley, W.T., Ludwig, J., Magnuson, K.A., Phillips, D., Zaslow, M.J., 2013. Investing in our future: the evidence base on preschool education. Society for Research in Child Development and Foundation for Child Development.https://eric. ed.gov/?id=ED579818. 84 Annexes Annex 1: World Bank Support to Botswana on Human Capital Development World Bank Lending Operations Botswana – Programmatic Economic Resilience and Green Recovery Development Policy Loan (P175934) World Bank board approval date: June 11, 2021 Botswana – Programmatic Economic Resilience and Green Recovery Development Policy Loan II (P176810) World Bank board approval date: June 19, 2023 Advisory Services and Analytics Project Name and Number Completion Date Review of Social Protection Programs and Systems in Botswana (P172175) https://documents1.worldbank.org/curated/en/099645103062256866/pdf/ 2021 P1721750af4ddb0ce098d30b331412b0ab8.pdf Skills Development and Employment Provision in Botswana (P175444) Forthcoming Botswana Public Expenditure Review in Health (P179933) Forthcoming 85 Annex 2: Box 1 Endnotes 1 US Embassy Botswana, 2020. Legends of the Botswana HIV Response Calendar 2020 https://bw.usembassy.gov/ wp-content/uploads/sites/125/Embassy-Gaborone_PEPFAR-Legends-Calendar-2020.pdf 2 Farahani, Mansour et al., 2013. Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysis The Lancet Global Health, Volume 2, Issue 1, e44 - e50 https://www.thelancet.com/ journals/langlo/article/PIIS2214-109X(13)70149-9/fulltext#seccestitle130 3 Jacqui Thornton, 2022. Botswana’s HIV/AIDS success, The Lancet, Volume 400, Issue 10351, Pages 480-481, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(22)01523-9. 4 Government of Botswana Ministry of Health, 2016. Handbook of the Botswana 2016 integrated HIV clinical care guidelines. Gaborone. https://aidsfree.usaid.gov/sites/default/files/botswana_art_2016.pdf 5 Ramogola-Masire, D., Poku, O., Mazhani, L., et al., 2020. Botswana’s HIV response: Policies, context, and future directions. J Community Psychol; 48: 1066–1070. https://doi.org/10.1002/jcop.22316 6 Centers for Disease Control and Prevention, 2022. Partnerships for Success: CDC help Botswana Exceed targets for ending its HIV epidemic, 4 years early https://www.cdc.gov/globalhivtb/who-we-are/success-stories/ success-story-pages/partnership-for-success.html#:~:text=In%20July%202022%2C%20Botswana%20 announced,status%20will%20receive%20sustained%20antiretroviral 7 Joint United Nations Programme on HIV/AIDS (UNAIDS), 2019. Feature Online Story: Botswana enters new phase of HIV response https://www.unaids.org/en/resources/presscentre/featurestories/2019/june/20190620_botswana 8 UNICEF, 2019. Botswana Budget Brief Fiscal Year 2019/20 HIV /AIDS https://www.unicef.org/esa/media/6346/file/ UNICEF-Botswana-2019-HIV-AIDS-Budget-Brief.pdf 9 Thornton, J., 2022. Botswana’s HIV/AIDS success, The Lancet, Volume 400, Issue 10351, Pages 480-481, ISSN 0140- 6736, https://doi.org/10.1016/S0140-6736(22)01523-9. 10 Ibid 11 Such as the Botswana AIDS Impact Surveys 12 Haseltine, William, A., 2022. An End to HIV in Botswana. Why Can’t We Accomplish the Same un the US?, Forbes (Online) https://www.forbes.com/sites/williamhaseltine/2022/08/17/an-end-to-hiv-in-botswana-why-cant-we- accomplish-the-same-in-the-us/ 13 Center for Global Development, 2015. Millions Saved: Case Studies (Online) Making the Impossible real; Botswana’s Mass Antiretroviral Therapy Program http://millionssaved.cgdev.org/case-studies/botswanas-mass- antiretroviral-therapy-program 14 Joint United Nations Programme on HIV/AIDS (UNAIDS), 2020. Botswana National AIDS Spending Assessment 2018/19 – 2019/20 https://unaids-test.unaids.org/sites/default/files/media/documents/NASAreport_ botswana_2018-2020_en.pdf 15 Farahani, Mansour et al., 2013. Outcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: a longitudinal analysis The Lancet Global Health, Volume 2, Issue 1, e44 - e50 https://www.thelancet.com/ journals/langlo/article/PIIS2214-109X(13)70149-9/fulltext#seccestitle130 16 Bill and Melinda Gates Foundation, 2006. What We’re Learning: Working with Botswana to Confront Its Devastating AIDS Crisis https://docs.gatesfoundation.org/documents/achap.pdf 17 Ibid. 18 Center for Global Development, 2015. Millions Saved: Case Studies (Online) Making the Impossible real; Botswana’s Mass Antiretroviral Therapy Program http://millionssaved.cgdev.org/case-studies/botswanas-mass- antiretroviral-therapy-program 19 World Health Organization, 2020. Botswana: Fulfilling the promise of an AIDS free generation in Africa https:// www.who.int/about/accountability/results/who-results-report-2020-mtr/country-story/2021/botswana 20 High Court of Botswana Gaborone, 2019. Judgement in the Matter between Letsweletse Motshidiemang (applicant) and Attorney general (Respondent0. Available from: https://www.chr.up.ac.za/images/researchunits/sogie/ documents/LM_vs_The_Attorney_General_judgment_June_2019_complete.pdf 86 87 88