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Posted Feb 27. 2009

Botswana's Health Future Remains Fraught With Challenges, Massaro Warns

Massaro

Botswana's health future remains fraught with challenges despite the nation's exemplary governance, a Law and Medical School professor told students Monday.

Thomas Massaro, Harrison Foundation Professor of Medicine and Law, said his experience setting up a medical school in Botswana revealed a host of healthcare problems the African nation is facing.

Massaro's interest in Botswana began with a desire to learn more about African health care. He got his wish five years ago when the University of Virginia and the University of Botswana extended their 25-year institutional partnership to the field of health, setting up a small grant for orphans.

“I was on the next plane, literally,” he said. 

He said Botswana was a model country in the African continent and hence a useful laboratory for testing healthcare reform. Unlike most African nations, Botswana has a dominant tribal structure, multi-racial democracy and one primary local language. It also has no history of European colonization, civil wars or apartheid. 

As a result, the country has seen rapid economic growth and social progress. Botswana is characterized as a middle-income country with a high purchasing power, and was the world's fastest-growing economy from 1969 to 1999.

“Health experts say ‘If we can't do it in Botswana, then it probably can't be done in Africa.’ Things are so positive and stable there that you can really be optimistic about making a difference,” he said.

A good example of Botswana's success is its bold steps to contain the AIDS pandemic. Botswana's free anti-retroviral drugs program, Prevention of Mother-to-Child Transmission (PMTCT) program and stellar education system earned it global fame. Last year, Botswana's former president Festus Mogae won a prestigious $5 million Mo Ibrahim Prize for Achievement in African Leadership partly due to his management of the disease.

“The response has been world class,” Massaro said.

But even these painstaking efforts have fallen short. The country still has the world's second-highest HIV prevalence rate – a whopping 17.7 percent. Assiduous government intervention has failed to produce behavioral changes among adolescents or reduce stigma and discrimination. Even when lavish hospitals are constructed, they often face doctor or equipment shortages. The disease has led to a steep drop in life expectancy and skyrocketing unemployment and infant mortality.

“The AIDS pandemic has challenged every aspect of government and civil society in Botswana. It is quite a significant challenge and one that could see the country disappear off the face of the Earth if nothing is done about it,” Massaro said.

Massaro argued that part of the government's problem lay in its complex legal system. As a British protectorate neighboring South Africa, Botswana developed a dual legal system that was influenced by the Roman-Dutch model but still preserved tribal laws after independence in 1966. As a result, the central government often gets into conflicts with local villages over health laws.

“We see a fair amount of tension between the Ministry of Health and the Ministry of Local Government in this area,” he said.  

Reflecting on his efforts to construct a medical school in Botswana, Massaro warned that there is much room for improvement. For one, Botswana loses a sizable percentage of medical students to brain drain as they leave for Western countries. When the school sent about 100 students to medical school with a full scholarship over 10 years, only 67 returned to practice in Botswana.

“There is always this nice idea of building medical schools. But the only way to keep doctors in the country is to grow them locally.”

Massaro said his experience from visiting seven southern African countries impressed upon him the importance of exposing students to medical work in the local villages and towns to build a sense of identity as to what real doctors do. In addition, he feels that medical schools must not only be centers for learning, but also producers of politically active health professionals to influence government policy.

“My personal opinion is that the most important role of a medical school is to determine Botswana's health policy because, today, there is no one determining that health policy,” he said.

In order to achieve this goal, the medical school has a 12-month internship program, which leads to licensing and full clinical privileges. Massaro has also set a goal for Botswana to have one doctor per 1,000 people by 2030, which will require the school to keep 80 percent of medical students in the country.

“It may be tough, but somebody's got to set a goal, and it's a rational goal at least,” he said. 

Massaro has made several trips to Botswana over more than five years. He is also associate dean for graduate medical education and director of performance improvement at the University of Virginia Medical Center.

The event was sponsored by the Health Law Interest Group.

• Reported by Prashanth Parameswaran