Healthcare Botswana Style

As Americans debate the best way to reform health care, I thought I'd share how the average Batswana sees a doctor. I've had some personal experience working in the Gaborone West clinic with an incredible staff of dedicated and caring professionals. The are under-resourced, under-staffed, and frustrated but provide health care to more than 200 people every 8 hours with 2 practitioners. This does not include the maternity/child health section of the clinic. Think about your regular doctor's office that may see 24-36 patients/practitioner in the amount of time. The health care is NOT perfect and (frankly) I have some problems with what they do but all-in-all anyone can see a practitioner anytime, including the middle of the night with the 24-hour clinics. Private insurance, practitioners, and hospitals do exist and reportedly provide a significantly higher level of care.

When a Batswana arrives at the clinic, the patient pulls out their medical records. Yes, the patient keeps all the medical records for themselves! There is not any central record keeping or recording - and absolutely no computers in the health care process in the clinics! The patient reports to a reception area where they pay P5 (about 70 cents) to see the doctor or nurse. Their record (blue for men/boys, pink for women/girls) is stamped and they sit to wait to be screened. Many people decorate their folders with pictures of their favorite entertainment or sports stars. Others fold up the paper and stuff it in their back pocket.

The screening consists of taking the blood pressure and temperature. We use old-fashioned glass thermometers here! Weights are not taken as there aren't any scales in the clinic. After this basic screening, the patients sit in line on long wooden benches. No numbers. No one calling out names to come to see the doctor. They just one-by-one go into the consultation rooms in the order they first arrived. At 12:45, the clinic closes for lunch and all the patients leave the building. At 1:45, they get back in line in the same order they were before without fighting, arguing, pushing, shoving, or doing anything else that I imagine Americans doing in the same situation. At 4:30, the clinic closes. Waiting patients are told to come back the next morning or to travel to one of the 24 hour clinics. Everyone is out of the building by 4:31.

In the consultation room, the patients see either a doctor or nurse. The nurses have full prescription authority here. There isn't much time spent on complete medical history or catching up on what happened since the last visit. The practitioners don't seem to remember the patients and the patients do not see the same practitioner each time. There is a focused assessment of the reported problem: mostly colds and headaches for which a list of medications is prescribed (including antibiotics, pain relief, vitamins) according to established government protocols. The patient leaves the room at completion of the exam, walks to the dispensary (in the same building) and gets the prescribed meds and leaves.

There are many sexually transmitted infections (STI) that we see. Unsafe sex is often practiced as evidenced by the HIV-infection rates. It's interesting to note that of my patients, 9 of 10 were women! The men don't seem to come in and report. It's the women who do and often the men (who gave them the STI) blame the women of being unfaithful resulting in physical abuse and more reasons for the men to be unfaithful. There are few (if any) sterile instruments to perform internal exams which means that digital exams must be done. These are done without lubrication and are painful to the women.

There is a horrible lack of instruments. For example, our clinic has only one stethoscope (we'll be leaving ours) and one blood pressure cuff. One size fits all whether the patient is an 80 pound 14 year old or a 250 pound hypertension patient. The results are extremely unreliable and vary widely. There is one otoscope (the silver thing they use to look in your ears) and one of the disposable ear pieces that snaps on the end to allow us to see deep into the outer ear canal. The ear piece is stored in an old medicine bottle filled with "spirits" (alcohol), fished out with a paper clip, and used over and over again. We'll be leaving a couple hundred ear pieces.

The situation with soap and hand sanitizer, and toilet paper, is just as bad.

Free drugs are available at the clinic and the latest-and-greatest are available. At the same time, this system is a jumble of paradoxes: they use the latest generation drugs that aren't paid for by insurance companies in the US but don't have the low dose aspirin (81mg or 125mg) suggested for hypertension prophylaxis. They have all the latest chemo drugs but doctors have to mix the medications themselves. Health care is available to all but with questionable quality. Prescriptions are free but antibiotics are over-prescribed. Universal access creates very long lines which inhibits the incentive to go for wellness checks. There is an intense focus on infectious diseases but unsanitary conditions exist.

In some ways this is how I see the US system going: health care available to all through a government program with private insurance available to those who want/need/can afford it. And I like that idea. Unfortunately, we have a very different infrastructure and well-established medical business model that will make such a solution difficult. At least in Botswana, there is a common, cultural believe that health care is a basic human right - and I agree. I personally believe societies have an ethical responsibility to provide health care to all. Our moral code as health care providers require that we (1) do good, (2) do no harm, (3) allow an individual to make their own choices, and (4) to serve in a just and fair manner.