HEALTH STATISTICS REPORT 2009

Transcription

1 REPUBLIC OF BOTSWANA HEALTH STATISTICS REPORT 2009 Price P30.00

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3 HEALTH STATISTICS 2009 Published by Statistics Botswana Private Bag 0024, Gaborone Tel: Fax Website: Contact Statistician: D. Motlapele Ministry of Health, Head Quarters: 8 th Floor Tel: Fax: Printed by and obtainable from Department of Printing and Publishing Services Private Bag 0081, Gaborone Tel: Fax: December 2012 COPYRIGHT RESERVED Extracts may be published if Source is duly acknowledged

4 HEALTH CARE FACILITIES BY DISTRICT IN THE REPUBLIC OF BOTSWANA G ± 14 Okavango Chobe 10 G 1 Ngamiland v ^ Tutume 12 G G 2 28 Charles Hill G 7 Gantsi G 13 Boteti v G Tonota 29 Serowe v North East!C Francistown 19 Selibe Phikwe v Bobirwa 4 3 G Palapye G v Mahalapye G 8 Kgalagadi North G Kgalagadi South G Kweneng West 20 G Mabutsane-Sub 21 v Jwaneng Southern 6 Goodhope 5 v v ^ G 22!C v G Kweneng East ^ XY South East!C Moshupa 9 Kgatleng 15 Gaborone 27 Tlokweng S.E.D.C 17 Lobatse 18 Legend XY Psychiastric Hospital G Primary Hospital Health District boundary Prepared by Cartography unit, CSO, Gaborone, 2010!C Referral Hospital ^ Private Hospital v District Hospital 24-- District_Numbers International Boundary Kilometers

5 P R E F A C E This is the thirty-first report presenting 2009 Health Statistics in Botswana. Quality Statistical information is a prerequisite for evidence based and developmental programmes at different levels. The information in this report is about all activities for policy formulation monitoring and evaluation purposes. All information in this report is based on routine data extracted from statistical returns compiled by health workers and medical records personnel from health facilities throughout the country. Data on non-institutional births and deaths have been included. The report comprises five sections: Section I: Health Facilities Section II: Health Personnel Section III: Out-patient Statistics Section IV: In-patient Statistics Section V: Mental Health Statistics Statistics Botswana greatly appreciates the Ministry of Health and of Local Government for the continuous support and the effort put in by the health workers and all other stakeholders involved in this process. I am grateful to the staff of the Department of Policy, Planning, Monitoring and Evaluation at the Ministry of Health (Health Statistics Unit) for working tirelessly and their dedication in the collection and compilation of this health report, ensuring its accuracy and reliability. A N Majelantle Statistician General December 2012 i

6 Contents Introduction... 1 Objective of the Report... 2 Method of data collection and processing... 2 Data Flow:... 3 Achievements... 4 Challenges... 4 Results HEALTH PERSONNEL Access to Primary Health Care Services in Botswana OUTPATIENT STATISTICS Outpatient Morbidity Sexually Transmitted Infections Family Planning (FP), Antenatal Care Visits and Condom Uptake Family Planning (FP) Antenatal Care Visits (ANC) Notifiable Diseases Eye Outpatient Non Institutional Statistics Mental Health INPATIENT STATISTICS Hospital Activities Morbidity and Mortality Morbidity of Infant, Children (<5yrs) and All Ages Neonatal Morbidity External Causes of Morbidity Mortality of Infant, children and all ages Neonatal Mortality External Causes of Death Births Birth weight Maternal Mortality Conclusion ii

7 Table of Figures Figure 1.1 Trends in health personnel by category Figure 1.2 Per centages of Health Personnel by Location Type Figure 1.3 Ratio of health personnel per outpatient attendance by health district Figure Per centage of Outpatient Attendances by Health Facility Type Figure Number of Sexually Transmitted Infection Attendances ( 000) Figure Sexually Transmitted Infections Attendances Figure Number of Family Planning and Ante Natal Care Visits ( 000) Figure Condom Uptake ( 000) Figure Trends in Selected Notifiable Diseases, Botswana Figure Trend in Outpatient Attendances for Diarrhea Figure 2.8.1: Trend of Psychiatric Attendances and Discharges: Figure Inpatient Morbidity and Mortality Figure Major Causes of Infant Morbidity, Figure 3.3.1a Major Causes of Child Morbidity, Figure 3.3.1b Major Causes of Inpatient Morbidity, Figure 3.3.1c Inpatient Morbidity by age group and sex Figure3.4.1 Major Causes of Neonatal Inpatient Morbidity: Figure 3.5.1Per cent distribution of Inpatient External Causes of Injuries (all ages excluding neonatal) Figure Major Causes of Infant Mortality, Figure 3.6.1a Major Causes of Child Mortality, Figure 3.6.1b Major Causes of Inpatient Mortality, Figure Age of a Neonate at death Figure Per cent Distribution of Major Causes of Inpatient Neonatal Mortality Figure 3.8.1Per cent distribution of External Causes of Death among Inpatients (all ages excluding neonatal) Figure Frequency Distribution of Birth Weight iii

8 Abbreviations A Alive Admin. Administration ANC Ante Natal Care BBA Born Before Arrival BCL Bamangwato Concession Limited C Case Cont d Continuation CSO Central Statistics Office D Death DHT District Health Team EXP Exposure F Female FP Family Planning GEN General GOVT. Government GYN Gynecology HSU Health Statistics Unit ICD-10 International Classification of Diseases 10 th Edition ICU Intensive Care Unit IHS Institute of Health Sciences ISOL. Isolation IUCD Intrauterine Contraceptive Device L. of Stay Length of Stay LBA Live Born Alive LBD Live Born Dead M Male MAT. Maternity MED. Medical MOH Ministry of Health N New N/S Not Stated NEC Not Elsewhere Classified OBSEV. Observation OBST Obstetric PAEDS. Pediatrics PNC Post Natal Care PSYCH Psychiatric R Repeat SB Still Birth SDA Seventh Day Adventist STI Sexually Transmitted Infection SURG. Surgical TB Tuberculosis TECH. Technical FWE Family Welfare Educator iv

9 Introduction This report analyzes national health statistics for The data are derived from service and administrative reports provided by public health facilities in Botswana. The service data consists of outpatient and inpatient attendances. The outpatient data has been aggregated with the exception of eye-out and psychiatric out-patient whilst inpatient data is patient based. A patient who presents two diagnoses/conditions in one visit is recorded as two cases. In the revised tool (MH1049/Rev2003), consultation is recorded either as new or repeat case. New consultation refers to a case where a patient is seeking health service for a condition for the first time, whereas repeat, refers to cases where a patient is getting services for the same condition for the second and subsequent time. Reported data are used to calculate the level of outpatient and inpatient morbidity and mortality, and to examine trends over time. The report also shows staffing patterns, access to health services, and non-institutional vital events nationally and by district. The non-institutional information is based on reported live births and deaths that occur outside the formal health system such as in homes. This report does not include information from private health practitioners. Notifiable disease surveillance is published in the report for the Epidemiology and Disease Control Unit (Public Health) in the Ministry of Health to monitor and control the outbreak and spread of contagious diseases. Notifiable diseases are reported on a weekly and monthly basis by the same unit. 1

10 Objectives of the report The report provides health statistics for Botswana in It includes a broad range of selected indicators, viz: health facilities, health personnel, outpatient and inpatient attendances, morbidity, mortality and obstetrics. Additionally, to provide a trend perspective, 2009 data is compared with the period Method of Data Collection and Processing There were 29 Health administrative Districts in Botswana in These Health Districts coincide with census and administration boundaries. Each facility was assigned a unique 5-digit identification number. The first two digits designate the district. The third digit designates the type of facility; that is hospital, primary hospital, and clinic or health post. The last two digits represent a specific facility within a district. These codes were used in data processing. Personnel data were collected in the last month (December) of the reporting year. Personnel printouts for the preceding year were sent to each unit in the Ministry of Health (including DHTs). The units then updated the printouts for the current year. Upon receipt of the latest staffing information, the HSU database was updated. Hence, the data does not show the staffing situation for the earlier months of the reporting year. The outpatient and inpatient data sets received from the reporting units were checked for among other considerations, completeness and relevance. Reporting facilities were also monitored to ensure they reported in a timely manner, and if not, the necessary follow-up was undertaken. Since 2004, the revised data collection tools were implemented along with consideration of International Classification of Diseases 10th edition (ICD-10) codes. Hence, the data were coded according to the ICD-10 th Edition (see appendix 2) and then captured and analyzed. The Health Statistics Unit uses Cs-Pro (Census & Survey Processing System) package for data capturing. Tabulation is done in Statistical package for Social Sciences (SPSS). 2

11 Data Flow As depicted in the schematic below, most data for the Annual Health Statistics Report originate in the health facilities, and reach the HSU through the District Health Team. There are a few notable exceptions when the HSU accesses the data directly from the health facilities. For instance, the Health Statistic Unit retrieves service data for Princess Marina, Nyangabgwe, Sekgoma Memorial and Maun hospitals through the Integrated Patient Management System (IPMS). In each health district, the Family Welfare Educators collect data on non-institutional births and deaths and transfer it to the DHTs which, in turn, register it with the HSU. Data Flow Schematic Diagram 3

12 Quality of Data This Annual Health Statistics Report reflects both successes and challenges related to the collection of health data in Botswana. Achievements Botswana is amongst few countries in Africa which started using the ICD-10 th edition, as of A good number of officers were trained in ICD-10 th edition throughout the country so that initial coding could be done at the health facility level. Data from all public health facilities are included in this report. Challenges The report does not examine data from private health facilities. As a result, the service data, especially in urban areas, cannot be taken as a comprehensive reflection of the overall service situation. Although all health facilities reports regularly using the standardized reporting instruments, there is still room for improvement. For instance, on processing data, the HSU staff often encounters missing values, poor legibility of records, and lack of internal consistency. Some health institutions consistently fail to provide up-to-date data on their staffing, resulting in underreporting of personnel data. Some of the health estimates maybe biased, especially in relation to the reporting of infant birth weight. First, the data on numerical birth weight exhibit considerable heaping on digits ending in 0 and multiples of 5. The heaping indicates that birth weight is rounded by medical personnel when they record it. For example, heaping at 3,100 grams and 2,500 grams was preferred. Exactly 3.9 per cent and 2.8 per cent of the infants were reported to have weighed 3,100 grams and 2,500g at birth, respectively. Misclassification of birth weights, especially at 4

13 2,500 grams, may possibly bias the prevalence of low birth weight downwards. Second, birth weight is not recorded for 0.7 per cent of infants. It is not clear whether these infants were never weighed, or data was simply never availed at the time of birth, it could also be that they were delivered at a different health facility. There has been a significant delay in the generation of this report due to multitude of factors. Nevertheless, the statistics were current at the time of collection and the report can still serve as a guide to the disease epidemiology and health service needs. Despite the above limitations, statistics in this report highlight trends in key morbidity and mortality indicators in Botswana. Secondly, the statistics were confirmed by staff of the Health Statistics Unit in the Ministry of Health for completeness, and accuracy. Thirdly, Health Information Officers at the health facilities were trained on ICD-10 th editions so that initial coding could be done at the level of the facilities. This arrangement provided coding quality assurance, and minimized the time spent on central-level coding. Moreover, the Health Information Officers at the facilities are well placed to quickly act on missing data by approaching the relevant healthcare provider. 5

14 RESULTS 1.0 HEALTH PERSONNEL Overall, from 2008 to 2009 the number of health personnel has increased across all categories with the exception of other professionals. Across districts, the number of professional doctors increased from 716 in 2008 to 819 in 2009; an increase of 14.4 per cent. This increase is a continuation of a trend in which the number increased from 591 in 2006 to 716 in The number of professional nurses increased from 5,616 to 5,816 between 2008 and The 2009 figure represents a 3.6 per cent increase in the number of professional nurses, compared to The number of professional nurses had decreased by 2.6 per cent during the 2007/2008 period, from 5,765 in 2007 to 5,616 in The number of finance and administration personnel in health facilities has been growing consistently between 2003 and 2007, with the latter year in particular recording a significant 32.7 per cent increase in the number of personnel. However, this category encompassed a large number of personnel with variable qualifications and occupations. It is debatable whether all personnel classified as such belong to this category. Figures from the 2008 analysis show that this category has shrunk. The shrinking of the finance and administration category was not a result of staff attrition, but rather because of the creation of a new category named industrial. The creation of this new category was necessitated by the fact that the finance and administration category was found to be too large and too varied, and contained within it, a significant number of industrial occupations. Thus the industrial category includes many personnel who were hitherto classified under finance and administration, shrinking the latter category. The 2008 data show that finance and administration had only 969 personnel while the industrial category expanded to 5,411. In 2009 there were 1,164 finance and administration personnel and 6,383 industrial personnel (see Figure 1.1). The other professionals category also experienced a significant decline of 16.8 per cent: from 2,286 in 2008 to 1,901 in Again, the decline in the number of personnel in this category in 2008 is a result of the creation of the industrial category, which absorbed a significant number from the other personnel classification. The main characteristic of the newly created industrial category is that it represents low paying manual jobs, some of which are transient. 6

15 Figure 1.1 Trends in health personnel by category Figure 1.2 shows the percentage distribution of health personnel by location. In 2009, Hospitals, Primary Hospitals and District Health Management Team (DHMT) accounted for 40.1, 14.3 and 35.5 per cent of all health personnel, respectively. These proportions are consistent with those registered for the same categories in The Ministry of Health and the Institute of Health Sciences registered the lowest proportions of health personnel. 7

16 Figure 1.2 Percentages of Health Personnel by Location Type Figure 1.3 shows the ratio of outpatient attendees to doctors and nurses. This ratio is obtained by dividing the number of outpatient attendees during the year, by the number of doctors and nurses, respectively. This gives the number of patients per doctor or nurse. Across all districts there is a relatively higher scarcity of doctors than nurses. In 2009 there were 819 professional doctors compared to 5,816 nurses. Consequently, the patient/doctor ratios are significantly higher compared to the patient/nurse ratios. Figure 1.3 shows the patient/doctor and patient/nurse ratios by Health District. While most health districts have patient/doctor ratios in the order of 500 patients per doctor or below, eight (8) health districts have significantly higher patient/doctor ratios, some of which are three to four times those prevailing in other districts. For example, Kweneng East and Gaborone have doctor/patient ratios in excess of 500 and 400 patients per doctor respectively, while Tutume, Mahalapye and Francistown have doctor/patient ratios in excess of 300 patients per doctor. 8

17 Figure 1.3 Ratio of health personnel per outpatient attendance by health district 2009 Districts with underreporting: Gaborone, Francistown and Orapa/Boteti Important to note that, two referral hospitals, Princess Marina in Gaborone health district and Nyangabgwe in Francistown health district, did not submit outpatient attendances. Therefore the ratio of professionals to outpatient attendances is underestimated for these districts. 1.1 Access to Primary Health Care Services in Botswana In Botswana, healthcare is delivered through a decentralized system with primary health care being the pillar of the delivery system. Botswana has an extensive network of health facilities (hospital, clinics, health posts, mobile stops) spread over the twenty nine (29) health districts. Historically, health services were under the management of both the Ministry of Health (MOH), which is responsible for all hospitals (referral, districts and primary) and the Ministry of Local Government, which was in charge of clinics, health posts and mobile stops. However recently, the operation of all 9

18 health facilities, including clinics, health posts and mobile stops were transferred to the Ministry of Health. Table gives a summary of populations with access to health services within a 15 km, 8km and 5 km radius of the nearest Health Facility by Urban/ Rural Residence. At national level, 84 per cent of population is within a 5 km radius of the nearest health facility. There is 11 per cent of population which is within 5 km to 8 km radius, which translate into a total of 95 per cent population within an 8 km radius. The urban areas data show that 96 per cent of urban residents are within a 5 km radius of the nearest Health Facility compared to 72 per cent of rural residents. Only 4 per cent of urban residents live within 5km to 8km radius of the nearest health facility. This entire 4 per cent is found in Palapye and Jwaneng areas. In rural areas, 72 per cent of population is within a 5 km radius of the nearest health facility, 17 per cent is within 5 to 8 km. Most of the remainder, 11 per cent is within 8 to 15 km radius. North East, Southern and Kgalagadi South all have (100%) their inhabitants within 5 km radius of a health facility. Maun, Serowe (excl. Palapye), Mahalapye, Kgatleng, Tutume and Gumare have per cent of their inhabitants within 5 km radius. Bobirwa, Ghanzi, Chobe and Kgalagadi North have per cent of their inhabitants within a 5 km radius. Kweneng West has the lowest proportion of population within a 5 km radius at 5 per cent. South East is at 14 per cent, followed by Boteti with 22 per cent. Kweneng West tends to have the highest proportion of its inhabitants (55.0%) residing between 8 and 15 km radius of the health facility. 10

19 Table Percentage of Population with Access to Primary Health Care Services within 15km, 8 km and 5 km Radius from Health Facility by Urban/Rural Residence - April 2007 Residence Percentage of Percentage of Percentage of population Between 8 and 15 km radius population Between 5 population Within 5 and 8 km radius from km radius from from facility facility. facility Urban Gaborone Francistown Lobatse Selibe Phikwe Jwaneng Orapa Palapye Tlokweng Urban Rural Maun North East Serowe (excl. Palapye) Bobirwa Kweneng East Southern Ghanzi Mahalapye Kgatleng Chobe Kgalagadi North Kgalagadi South Tutume Boteti (excl.orapa) Gumare South East (excl.tlokweng) Kweneng West Rural National Note: The information in Table was collected between December 2006 and April 2007 in all health districts in Botswana. Health districts were requested to submit distances that clients travel to access primary Health Facilities. The Health Statistics Unit then calculated proportion of population in given localities as per the given distances from the nearest facility using the 2007 Population projections. 11

20 2.0 OUTPATIENT STATISTICS Nationally, clinics are the most frequently used health facility for outpatient services. They account for 63.6 per cent of all outpatient attendances, followed by health posts (22.7%), hospitals (6.2%) and primary hospitals (7.5%). This pattern is consistent with government s policy of encouraging patients to utilize clinics and health post services prior to visiting hospitals. This pattern reflects the fact that clinics and health posts are the most numerous, most geographically spread, and therefore the most accessible of all types of health facilities. Figure Percentage of Outpatient Attendances by Health Facility Type Outpatient Morbidity A total of 4,399,276 disease cases were recorded for outpatient attendances in This is an increase of 22.1 per cent from 3,601,739 cases in The major contributing condition in outpatient morbidity was Other diseases/conditions, most notably cough and cold (28.3%), 12

21 followed by diseases of the respiratory system (19.0%), and the musculoskeletal system (9.2%) (Table 2.2.1). Table Top 10 causes of outpatient morbidity 2009 Diagnosis(Other diseases) Attendances Per cent Other diseases/conditions 1,189, Diseases of respiratory system (e.g. cough and cold) 949, Diseases of musculoskeletal system 475, Skin conditions 411, Hypertension 349, Eye diseases/conditions 150, Tonsillitis 137, Other External causes of injuries 122, HIV positive 88, Ear diseases/conditions 86, Causes Specified Above 3,960, Other Diagnosis 438, (All attendances) 4,399,

22 2.3 Sexually Transmitted Infections There were 305,932 total attendances for Sexually Transmitted Infections (STIs) in 2009, an increase of 9.5 per cent from 279,477 cases in 2008 (Figure 2.3.1). Notable is the increase in the STIs cases between 2003 and 2006; from 152,430 recorded in 2003 to 162,228 cases recorded in 2004 and a sharp rise to over 269,000 in 2006 (Figure 2.3.1). This increase probably is the result of reporting changes which in 2006 began to include HIV positive and AIDS cases in STI category. Figure Number of Sexually Transmitted Infection Attendances ( 000) STIs reports are much higher amongst females (62.6%) than males (37.4%). Among age groups, STIs are higher within the age group 30 years and above (55.8%) while 0-14 is the lowest, constituting 4.3 per cent (Table 3.5). The most common diagnosis of STIs in 2008 was HIV positive (88,079 cases) accounting for 28.8 per cent of total attendances, followed by vaginal discharge syndrome (21.0%). Other common conditions were AIDS (13.7%), lower abdominal pains (9.0%) and urethral discharge syndrome (9.5%)(Figure 2.3.2). 14

23 Figure Sexually Transmitted Infections Attendances Family Planning (FP), Antenatal Care Visits and Condom Uptake Family Planning (FP) Family planning (FP) visits have decreased by 4.0 per cent from 2,161,849 in 2008 to 2,075,162 in The number of new attendances in 2009 was 425,362 compared to 1,383,863 of repeat attendances. Table 3.7 shows the number of new and repeat FP visits in 2009 by preferred method of contraception. The preferred method of contraception for both new and repeat cases was the male condom 85.5 and 86.7 per cent, respectively. The second preferred method of FP was pill low dose (2.0% for new cases and 5.6% for repeat cases). Kweneng East health district reported the highest number of FP visits among all health districts in 2009 with a total of 477,327 attendances. 15

24 Antenatal Care Visits (ANC) The total number of antenatal visits in 2009 was 343,995. This represented an increase of 9.5 per cent from 314,087 visits in In 2009 only 343,995 ANC visits were recorded, and of this number, 50,218 were new and 293,777 were repeat cases. This represents an increase of 8.5 per cent in new visits and 10.0 per cent in repeat visits from the 2008 figures. The majority of attendances in 2009 were in the age groups with 109,966 visits, followed by the age group with 99,984 visits, and age group with 81,299 visits. These figures represent an increase of 8.7, 14.7 and 11.9 per cent from the 2008 attendances for the same age groups respectively. Gaborone health district recorded the highest number of antenatal visits at (38,991), followed by Kweneng East (32,957). Charleshill had the lowest number (1,705). Figure Number of Family Planning and Ante Natal Care Visits ( 000) 16

25 Figure Condom Uptake A trend analysis shows that use of condoms has been on the increase since For example, condom use increased from just fewer than 600,000 condoms in 2002 to just fewer than 1,000,000 condoms in Between 2004 and 2005, condom use slowed down before increasing sharply between 2005 and From 2006 to 2007 there was a decrease in condom use followed by a very steep rise between 2007 and In 2009 male condom use declined to 1,626,838 from 1,956,105 in 2008 which represent a 16.8 per cent drop in condom use. The foregoing figures refer to both male and female condom use. Female condom use was first recorded in The 2008 figure shows an uptake of 38,171 female condoms, comprising 9,716 new visits and 28,455 repeat visits. In 2009 female condom use stood at 45,715 comprising 23,425 new and 22,290 repeat visits. 17

26 2.5 Notifiable Diseases The notifiable disease category includes malaria, viral hepatitis, measles and diarrhoea. Figure reflects marginal fluctuations in the number of confirmed malaria, viral hepatitis and measles cases between 2002 and There was a marked increase in malaria cases during the period (from 1,284 cases in 2002 to 3,453 cases in 2004, 168.9% increase), followed by a significant decrease in 2005 (530 cases, 84.7% decrease), and an increase in 2006 (2,606 cases, 391.7% increase). The number of malaria cases recorded in 2007 was the lowest recorded during the periods. However, 2009 recorded less cases of malaria (885 confirmed cases) compared to 2008 (1,201 confirmed cases). From 2002 to 2009, the number of suspected measles and viral hepatitis were relatively low compared to malaria cases. The number of suspected measles cases was highest in 2005 and 2006 (926 and 732 cases respectively). In 2009 there was a sharp increase in the number of suspected measles cases. A total of 662 confirmed cases of measles were recorded in 2009 compared to 141 cases in 2008, representing a per cent increase. Viral hepatitis decreased from 352 cases in 2004 to 85 cases in It increased slightly between 2007 and 2008 (108 and 105 cases, respectively). 18

27 Figure Trends in Selected Notifiable Diseases, Botswana The recorded cases of diarrhoea are substantial (Figure 2.5.2). They were high in 2002 and 2003 (109,466 and 103,724 cases respectively). The recorded cases dropped by 68.0 per cent from 103,724 in 2003 to 29,322 in 2004, followed by an increase to 55,015 cases in Finally, between 2007 and 2008 diarrhoea cases recorded a 9.0 per cent decrease followed by a further drop of 18.5 per cent in 2009 compared to

28 Figure Trend in Outpatient Attendances for Diarrhoea Eye Outpatient The number of eye outpatient attendances in 2009 was 118,442 comprising 75,363 new and 43,079 repeat case compared with 104,720 in 2008 made up of 68,710 new and 36,010 repeat attendances. This represents a modest increase of 13.1 per cent from the 2008 total figure of 104,720 visits. The most age group attending most was 15 to 44 years which recorded 51,347 (43.4%) visits, followed by 65 years and above with 27,899 (23.6%). Females constituted 68,962 (58.2%) of the total number. These patterns of attendance by age group and gender are similar to those observed in Non Institutional Statistics In 2009, there were 220 non-institutional live births, which represent a decrease of 70.6 per cent compared to 749 recorded in However, between 2007 and 2008 there was an increase of 20

29 210.8 per cent from 241 non-institutional live births in 2007 to 749 live births in Most cases were reported at Gantsi health district followed by Bobirwa health district with 169 and 23, respectively (Table 3.12). A total of 104 non-institutional deaths were reported in 2009, a drop of 56.8 per cent compared to 241 cases in Goodhope health district reported most deaths with 34 cases followed by Bobirwa and Gantsi health district with 24 cases each. 2.8 Mental Health There has been an upward trend in the psychiatric attendances for the period 2002 to 2006 followed by a drop in 2007 (2% decrease from 42,433 in 2006 to 41,762 in 2007) and a further drop in 2008 (5% decrease from 41,762 in 2007 to 39,778 in 2008) followed by a moderate rise in 2009 (5% increase from 39,778 in 2008 to 41,908 in 2009) (See Figure 2.8.1). The highest number of psychiatric attendances recorded in 2009 was for schizophrenia with a total of 16,704 outpatient (42.7%) and 609 inpatient (21.9%). Other conditions that recorded high numbers are depressive episodes with a total of,5,547 outpatient (14.2%) and 109 inpatient (3.9%), other specified mental disorders due to brain damage and dysfunction and to physical disease with a total of 4,551 outpatient (11.6%) and 28 inpatient (1.0%), and schizoaffective disorders with 1,965 outpatient (5.0%) and 197 inpatient (7.1%). Other acute and transient psychotic disorders also recorded relatively high frequency at 1,813 outpatient (4.6%) and 259 inpatient (9.3%). Overall, male attendances were higher than female attendances in almost all the age groups and conditions. There were 20,585 male (52.6%) and 18,540 female outpatient psychiatric attendances (47.4%). The number of inpatient psychiatric attendances was 1,810 males (65.0%), and 973 females (35.0%). 21

30 Figure 2.8.1: Trend of Psychiatric Attendances and Discharges: INPATIENT STATISTICS 3.1 Hospital Activities Hospital activities were recorded and reported for general hospitals, primary hospitals and clinics with maternity wards. For the most recent five years ( ), the number of beds increased from 3,955 to 4,561 (15.3%) and inpatient admissions decreased from 175,125 to 174,867 (0.1%) respectively from 2005 to 2009 (Table 3.1.1). There was also an increase in number of patient days from 908,300 to 1,276,294 (40.5%) in the same period (Table 3.1.1). The frequency of inpatient deaths fluctuated between 2003 and There was a slight decrease (2.9%) in the number of inpatient deaths in 2009 (7,491) compared to 2008 (7,714). 22

31 Bed turnover rate is the average number of patients during the year that has occupied each bed at a given facility. The bed turnover rate for 2009 was 39.0 patients per bed. This rate varied only marginally from ; in the range 39 to 42. There has been a relatively steady increase in occupancy rate between 2003 and 2009 (Table 3.1.1). The occupancy rate for 2009 was 76.7 per cent, the highest observed since The average length of stay increased to seven (7) days. Table Trends in hospital Activities by Type: Number of Beds 3,816 3,889 3,955 4,059 4,155 4,239 4,561 Inpatient Admissions 142, , , , , , ,867 Inpatient Deaths 10,092 9,193 9,468 9,542 7,958 7,714 7,491 Patient Days 845, , , ,823 1,016,498 1,089,613 1,276,294 Occupancy Rate (%) Average length of stay (days) Bed turnover rate Newborns 38,278 36,328 42,484 42,270 42,746 42,331 44,517 Born before arrival 1,576 1,619 1,739 1,780 1,706 1,909 1,887 Discharged Alive (neonatal) Discharged Dead (neonatal) 39,893 38,079 44,151 43,656 43,282 43,849 45, , ,000 1, Morbidity and Mortality In 2009 there were 126,381 inpatient morbidities. This number represents a 0.5 per cent decrease from the 127,008 registered in Inpatient morbidity attendances had previously increased 23

32 between 2003 and 2005, then dropped slightly in 2006 before rising again in 2007, and declining in 2008 (Figure 3.2.1). There was a decline in inpatient mortality (7.1%) from 7,487 registered deaths in 2008 to 6,952 deaths in The number of deaths between the periods 2007 to 2009 and 2004 to 2006 remained relatively stable compared to morbidity, with very slight decrease in 2003 and 2004 (Figure 3.2.1). Figure Inpatient Morbidity and Mortality Morbidity of Infant, Children (<5yrs) and All Ages Causes of Infant Morbidity Figure shows major causes of infant morbidity in The results show that diarrhoea (25.4%), pneumonia (13.5%) and malnutrition/volume depletion (7.8%) accounted for a large 24

33 portion of infant morbidity in 2009, while other causes each accounted for about 3.4 per cent or fewer of infant sicknesses. Figure Major Causes of Infant Morbidity Causes of Child Morbidity Figure 3.3.1a shows major causes of child morbidity in The results show that diarrhoea accounted for a fifth (18.8%) of child morbidity, followed by pneumonia (11.6%). The rest of the major causes each accounted for less than one in every twenty cases of child morbidity. 25

34 Figure 3.3.1a Major Causes of Child Morbidity Causes of Inpatient Morbidity Figure 3.3.1b shows major causes of inpatient morbidity in While diarrhoea is still the most significant cause of general inpatient morbidity, it accounts for a relatively small percentage (4.8%) of all cases of inpatient morbidity compared to infant and child morbidity cases. Significantly, all of the identified major causes of general inpatient morbidity, with the exception of diarrhoea, each accounted for less than 4 per cent of the cases of inpatient morbidity in

35 Figure 3.3.1b Major Causes of Inpatient Morbidity Morbidity by Age and Sex Figure 3.3.1c shows morbidity by age group and sex. Attendance starts off low for younger ages, and reaches a peak for patients in the late twenties to mid-thirties before declining among those over 45 years. The pattern of attendance differs between males and females. At ages below fifteen, the number of males is slightly higher than that of females. However, beyond age 15 and into the mid-thirties, there are significantly more females than male attendees. Among men, the age groups 25-34, and 65+ account for 16.0 per cent, 14.6 per cent and 10.0 per cent of morbidity cases, respectively. Among women, age groups 15-24, and 35-44, account for 19.9 per cent, 30.0 per cent and 15.0 per cent of morbidity cases, respectively. Figure 3.3.1c further shows higher morbidity for male aged 1-4 (12.0%) compared to females children (5.0%) in the same age group. 27

36 Figure 3.3.1c Inpatient Morbidity by age group and sex Neonatal Morbidity Table 4.12 shows that there were 13,527 inpatient attendances for neonatal (aged less than 28 days) morbidity in 2009 compared with 12,541 inpatient attendances in The plurality of inpatient neonatal morbidity was caused by disorders related to length of gestation and fetal growth (49.8%), followed by fetus and newborn affected by maternal factors and by complications of pregnancy, labor and delivery (33.5%). The most frequent cause of neonatal morbidity (among the major causes of morbidity), was Other low birth weight which accounted for 27.3 per cent of inpatient attendances followed by fetus and newborn affected by caesarean delivery accounting for 8.6 per cent (Figure 3.4.1). 28

37 Figure3.4.1 Major Causes of Neonatal Inpatient Morbidity External Causes of Morbidity In 2009, there were 11,659 external causes of injuries resulting in inpatient attendance in Botswana (Table 4.19). This represents a decrease of 1.5 per cent from 2008 when there were 11,833 attendances. Males accounted for 7,039 (60.5%) in 2009 while females accounted for 4,600 (39.5%) of these attendances. Among men, the age group with the highest frequency of injuries by external causes was men from with 1,737 attendances (24.6% of all male external causes of morbidity). The greatest frequency of inpatient external injuries was caused by accidental exposure to unspecified factors constituting 56.2 per cent of all the injuries (Figure 3.5.1). 29

38 Figure 3.5.1Per cent distribution of Inpatient External Causes of Injuries (all ages excluding neonatal) Mortality of Infant, children and all ages Major Causes of Infant Mortality Figure shows major causes of infant inpatient mortality. They are pneumonia (19.3%); diarrhoea (18.2%); septicemia (9.1%); volume depletion (7.0%) and Broncopneumonia unspecified (3.4%). Additional identified major causes each accounted for a less than 3 per cent of the cases recorded in

39 Figure Major Causes of Infant Mortality Major Causes of Child Mortality Figure 3.6.1a shows the major causes of child mortality in Diarrhoea accounts for less than a fifth (16.2%) of child deaths, and is placed second to Pneumonia which leads the pack with 16.6 per cent of child deaths. 31

40 Figure 3.6.1a Major Causes of Child Mortality, 2009 Major Causes of Inpatient Mortality Figure 3.6.1b shows the major causes of general inpatient mortality in The results show that HIV disease resulting in other specified conditions accounts for 9.1 per cent of all deaths, followed by pneumonia (7.4%) and diarrhoea and gastroenteritis (4.9%). 32

41 Figure 3.6.1b Major Causes of Inpatient Mortality Neonatal Mortality In 2009, there were 547 institutional neonatal deaths (aged less than 28 days) in Botswana compared with 616 institutional neonatal deaths in Males accounted for 306 (55.9%) of this number while females accounted for 241 (44.1%). The data also show that the greatest proportion of deaths occurred among one day olds (18.3%)(Figure 3.7.1). The plurality of inpatient neonatal mortality was caused by respiratory and cardiovascular disorders specific to the perinatal period (38.9%), followed by disorders related to length of gestation and fetal growth (22.5%). The most common cause of neonatal deaths (among the major causes) was bacterial sepsis of newborn, unspecified (97 cases) accounting for 17.7 per cent of all neonatal deaths, followed by respiratory distress syndrome of newborn with 58 cases (10.6%)(Figure 3.7.2). 33

42 Figure Age of a Neonate at death

43 Figure Per cent Distribution of Major Causes of Inpatient Neonatal Mortality External Causes of Death In 2009, there were 272 deaths among inpatients admitted for external cause related morbidity. This represents a 19.5 per cent decrease from 2008 when there were 338 deaths attributed to external causes. Males accounted for 177 (65.1%) of the deaths, while females numbered 95 (34.9%). The age group with the most frequent mortality due to external causes was year olds, accounting for 64 (23.5%) of deaths. The most common underlying external cause of death (major causes only) was exposure to unspecified factor (33.5%), followed by accidental poisoning by and exposure to other and unspecified drugs, medicaments, unspecified place(12.1%) and persons injured in unspecified motor-vehicle accident (11.8%)(Figure 3.8.1). 35

44 Figure 3.8.1Per cent distribution of External Causes of Death among Inpatients (all ages excluding neonatal) Births In 2009 there were 48,708 inpatient births, of which 25,672 (52.7%) were male and 23,036 (47.3%) female. This shows an increase when compared with the 2008 figure of 40,878 inpatient births (19.2% increase). A small percentage (2.0%) of all births observed in 2009 was noninstitutional. A total of 42,892 births (89.1% of all inpatient births) were through normal delivery, and 4,516 (9.4%) were through cesarean section. The most frequent age of an inpatient mother giving birth was years, accounting for 15,005 (31.2%) of all mothers. Out of all institutional births, 699 were single stillbirths (1.5%) and 32 were twin stillbirths (<0.1%). The outcome of delivery was unspecified for 18 births (<0.1%)(See Table 4.14). 36

45 3.10 Birth weight Table 4.18 indicates that birth weight was reported for almost all infants (99.6%). Almost 9 in 10 (85.3%) of infants were reported to have weighed more than 2,500 grams at birth. A total of 6,941 (14.3%) of infants had a birth-weight under 2,500g. The percentage of infants with birth weight under 2,500 grams was variable by sex and district. The proportion of births with a weight less than 2,500 grams was 6.9 per cent among males and 7.3 per cent among females, and it varied from five per cent in South East District to 20 per cent of births in Gantsi and Chobe. Figure presents the birth weight distribution. The frequency distribution of birth weight is normal, but with an extended tail of very low birth weight infants (<1000 grams) and a small excess of large births (>4500 grams). Recorded birth weight ranged from 400 to 6,060 grams. Figure Frequency Distribution of Birth Weight Weight live birth (grams) Frequency Std. Dev = Mean = 2979 N = Weight live birth (grams) 37

46 3.11 Maternal Mortality As part of a collaborative effort to enable and improve the availability and quality of maternal mortality information, Statistics Botswana through its HSU and Ministry of Health are jointly ensuring the availability of number of live births and maternal deaths data. This section provides information on Maternal Mortality Ratio (MMR) in Botswana (Table ). The 2009 data show that there were 86 cases of maternal deaths recorded in Botswana resulting in the MMR of maternal deaths per 100,000 live births. This compares with 88 maternal deaths and MMR of in The most affected age group was and years. About a quarter (25.6%) of the deaths occurred to women in each of these age groups. HIV/AIDS constituted 12.8 per cent of maternal deaths. Immediate postpartum hemorrhage was 9.3 per cent and genital tract and pelvic infection following abortion and ectopic and molar pregnancy constituted 8.1 per cent (Table 4.17). The World Health Organization s International Classification of Diseases Volume 10 (ICD 10) was used for the purpose of classification. Table Botswana Maternal Mortality Ratio Institutional live births 46,404 Non-Institutional live births 220 Live Births 46,624 Maternal Deaths 86 Maternal Mortality Ratio (per 100,000 live births)

47 Conclusion This report examined health statistics on a broad range of indicators. The findings reveal disparities in health outcomes by year, health facility, health district and socio-demographic factors such as age, and sex. For instance, health risks for morbidity and mortality differ by age groups. Pneumonia, diarrhoea, septicemia and dehydration are significant causes of infant mortality. Children under the age of five usually die from diarrhoea and pneumonia. Inpatient deaths among all ages are mainly due to pneumonia, diarrhoea and tuberculosis. Data on maternal mortality ratio show a decrease in maternal deaths per 100,000 live births between 2008 and 2009, from to Child size at birth is variable by sex and district. The percentage of infants with a birth weight under 2,500 grams constitutes 6.9 per cent of all births for males and 7.3 per cent for females, and it ranges from 5 per cent in South East District to 20 per cent in Gantsi and Chobe. It is also worth noting that while Botswana has good access to modern health services and infrastructure, there are disparities in terms of doctor/patient ratios. Most of the districts had a patient/doctor ratio of fewer than 300 patients per doctor with the exception of Kweneng East which had a patient/doctor ratio of more than 500 patients per doctor. The scarcity of doctors in certain areas has implications for efficient health care provision in the country. The findings in this report are important for two reasons; first, the statistics convey valuable information about the health of Botswana society on a range of important indicators, secondly, the information could be useful for health planning, health management and program evaluation. 39

48 Table 1.1 Number of Health Facilities by Type and District Clinics Health Posts District Referral Hospital General Hospital Primary Hospital With Beds Without Beds Clinics With Nurse No Nurse Health Posts Health Facilities Ngamiland North-East Palapye Bobirwa Kweneng-East Southern(Kanye) Gantsi Mahalapye Kgatleng Chobe Kgalagadi-South Tutume Boteti Okavango Gaborone Francistown South East Lobatse S/Phikwe Kweneng West Mabutsane Jwaneng GoodHope Kgalagadi North Tonota-SubDistrict Moshupa Sub Tlokweng Sub Charleshill Serowe Admin Authority Mobile Stops Grand ,052 40

49 Table 1.2 Number of beds by ward and facility W a r d s Special Pri. Gen/ Paeds Male Female Short Care Onco. Facility Mat. Paeds Male Female Med. urg. Isol. TB vate Gen. Mat. Psych. Med. Surg. Med. Surg. Med. Surg. ICU Stay Unit ynae Eye logy ANC PNC Hospitals Maun Delta medical centre Sekgoma Memorial Scottish Livingstone SDA Mahalapye Deborah retief Orapa Princess Marina Gaborone Pvt. hospital Nyangabgwe Bamalete Lutheran Athlone State Mental BCL Mine Selebe Phikwe Jwaneng ,080 Primary Hospitals Masunga Palapye Bobonong Mmadinare Thamaga Gantsi Sefhare Kasane Tsabong Tutume Gweta Rakops Letlhakane Gumare Thebe-Phatshwa Good Hope Hukuntsi clinics Grand ,561 41