Socio-demographic characteristics of the informants

A total of twelve (12) informants participated through modes such as face-to-face interviews (n = 5), online, and telephone platforms (n = 7). Informants were employed at academic institutions (n = 1), government (school, Vector control and Ministry of Health headquarters) (n = 6) community members (village health and Village development committees, political councilor (n = 3), UN Agencies (WHO) (n = 2). Seven (7) of the interviewees had participated in NTD initiatives such as being part of the technical working group for the NTD master plan, developing the NTD strategy, the schistosomiasis mapping exercise and MDA in school and working as officers for the NTD program, and five (5) had collaborated with the WHO NTD Department. Table 2 presents their socio-demographic characteristics.

Key findings from document analysis

The Ngamiland schistosomiasis control program policy for 1985–1993, the NTD Master plan for 2015–2020 plans, and other significant regional and international protocols and conventions with relevance to the development of the schistosomiasis control program in Botswana were reviewed and analysed. The analysis was done based on content, context, processes, and actors.

Content. The Ngamiland schistosomiasis control program for 1985–1993 had clearly stated objectives, and interventions, and used surveys as monitoring and evaluation tools for the performance of the program. The implementation plans highlighted key interventions, and targets derived from the World Health Assembly resolution 54.19 [1, 28]. The control program was deficient as it omitted content on snail control interventions, health education, and behavior change strategies. Moreover, the focus of the program was primarily on treating the SAC [28] and little attention was paid to other groups at risk of the disease. Our analysis also found that good policy intentions and practice could not be sustained over time because the policy lacked dedicated resources. It is also worth noting that, a decision to use a 10% prevalence as an upper limit for initiating maintenance of control alone without considering treatment coverage rate and continued surveillance, limited control of the disease, hence its resurgence post-1993. After the abandonment of the program in 1993, the MOH officials and partner organizations reviewed NTD global policy documents and cascaded and adopted them to formulate national NTD control plans. The documents which specifically inspired the plans were the NTD Roadmap setting targets for 2020. Adopted from the aforementioned documents, the Botswana NTD Master Plan 2015–2020 was formulated. The plan comprehensively outlines the goal targets and interventions for the control and prevention of schistosomiasis.

Context. The fundamental contextual elements that shaped the development of the schistosomiasis policies for Botswana were the burden of schistosomiasis, donor support and dependence. The review revealed that the schistosomiasis policy formulation was initiated to control morbidity for the disease. The Ngamiland schistosomiasis control program of 1985–1993 would not achieve the morbidity control target without external aid, making development partners' support essential to maintaining service delivery. The NTD master plan came into being to augment the limitations of the national response plan which only focused on high prevalence areas and lacked mapping of NTDs and yet wished to eliminate them. The policies analysed within the context of the country, region, and other international protocols are all relevant in terms of providing contextual guidance for the control of schistosomiasis. The limitation we gathered during the analysis was the lack of domestic funding and resource allocation for policy implementation.

Process. The master plan was formulated after a comprehensive consultative forum led by the MOH, WHO, and the Ministry of Education. WHO led the process by bringing a consultant from the Schistosomiasis Control Initiative (SCI). A pertinent concern with the schistosomiasis policies was that they needed updating. The Ngamiland policy (1985–1993) and the Botswana NTD master plan for 2015–2020, were outdated and not approved. The Ngamiland Schistosomiasis Control Program 1985–1993 has outlived its time, as was formulated more than 3 decades away. There is a need to review and revise these policy documents to align them with any new developments. At the time of the development of the Ngamiland control program, the schistosomiasis mansoni was the most prevalent but the situation has changed to schistosomiasis haematobium as the high-ranking type of disease currently. Moreover, the assessment for NTD strategic plan development showed that no (zero) district was mapped or had a known status of endemicity. In this regard, the policy lacked evidence for its actual formulation.

Actors. The analysed documents resided at the MOH, which removes the challenge of fragmentation. The added advantage of the policies reviewed is that they embraced the multi-stakeholder approach in policy formulation and implementation as espoused by the NTDs control approaches. The Botswana 2015–2020 master plan specifically highlights the important role of multi-stakeholder participation and involvement in policy formulation and implementation. However, the stakeholders for both the Ngamiland policy and the 2015–2020 Master plan were skewed toward the MOH and WHO. There was little representation of other key stakeholders like the MLGRD, water and sanitation, wildlife and tourism, the Ministry of Agriculture, and others. Moreover, the stakeholder analysis revealed the lack of structured representation from a systemic perspective of them coming from national, district, and local level settings. There was minimal participation of local communities, the NGO sector, and the private sector participation in the policy formulation, implementation, and evaluation. Most of the actors were roped in for their technical and financial assistance. This approach negatively impacted the sustainability of the policy interventions.

Table 3 summarizes the results from the informant interviews into five (5) broad themes and sub-themes according to the HPTF. Theme I was about phases of the control program, while Theme II was about schistosomiasis being no longer a priority, Theme III was the implementation of policy not strongly embedded at the community level, Theme IV was global and national initiatives, and Theme V was about the fact that policy was driven by the international community and NTD champions.

Table 3 Summary of theme and sub-themesTheme I: Phases of the control program

The key informant interviews revealed that schistosomiasis was a serious infectious disease in the 1980s. Endemic districts used the terms “Thutisa Madi, thota Madi” meaning blood in urine, to describe the disease. Interviews with informants revealed three sub-thematic phases for the control policies which were;

The morbidity phase

This was the phase that placed the control and prevention of schistosomiasis control as a high-level priority, especially for the Ngamiland district where morbidity was high. Cooperation among sectors to combat the disease within the district was developed and the program received support from WHO. According to the informants, the policy aimed at reducing the prevalence of the disease and lessening heavy infections among SAC, and very little attention was paid to other groups at risk of the disease. Key informants also reported that the disease control interventions included diagnostics, treatment, data management, and surveys. A decision to use a 10% prevalence as an upper limit for initiating maintenance of control was set. Key informants stated that this phase was about policymaking for the prioritization of schistosomiasis control in Botswana. The output of this phase was a centralized disease control program mostly operated by the Ministry of Health with technical and financial support from WHO. The morbidity control phase marked a success for the control of the disease as one informant mentioned;

“The past efforts for the program was a success story that Botswana wrote… countries were brought here to come and see what Botswana did” – (Medical entomologist, informant #12).

Climate change caused the policy agenda to resurface

Eventual neglect of the control program came in 1993, and it was until 2015 that the mapping of schistosomiasis indicated significant rates. An informant from the government associated this phase with the resurgence of the disease which brought back the disease onto the policy agenda. Unlike other vector-borne diseases, the informants mentioned that schistosomiasis lacks environmental control interventions. In the discussion of the changing dynamics in the transmission of the disease, one informant stated that;

“Rain is occurring at times it never used to, floods are in places where they never appeared, and we are now getting schistosomiasis in communities that were never schisto endemic…. Batswana are a mobile community moving three homesteads with their diseases” - (Program manager, Informant #2)

Furthermore, the key informants pointed out that the lack of targeted interventions during the neglect phase was associated with the negative climate change on the disease. One key informant echoed that:

“Targeting hot spots communities in endemic areas where there are likely environmental changes than doing the historic blanket MDA, was needed for the control of the disease” - (Program manager, informant #1)

Refocus on morbidity control

In response to a regrettable phase of neglect of the program, a plan to occasionally map hot spots and conduct country-wide surveillance of NTDs including schistosomiasis was devised in 2015. The mapping survey then revealed a high prevalence of schistosomiasis. According to WHO and MOH informants, the schistosomiasis country policy agenda was revised, to include aspects of the NTD global policy documents, cascading them to formulate national NTD control plans. One informant mentioned that the output was a guideline document on morbidity control and robust and standardized M&E systems. Adopted from the global guidance, the Botswana NTD Master Plan 2015–2020, was developed. The plan comprehensively outlines the Interventions for the control and prevention of schistosomiasis. Accordingly,

“The country is doing its first time MDA countrywide.” (Program manager, informant # 2)

Theme II: schistosomiasis no longer a priority

The control program was enacted in 1985 to counter the impact of the disease. The coordination of the program was done by the Ministry of Health and WHO offices. The policy changes which followed were influenced by internal and external factors. When asked what was needed for the implementation of a schistosomiasis interruption policy in Botswana, informants mentioned that many of the control interventions were ineffective, outlining the main contextual challenges of the policy. Moreover, following the attainment of low prevalence thresholds, the government decided not to give schistosomiasis the priority it deserved and consequently failed to come up with policies and surveillance measures supporting sustained control.

One informant lamented that:

“The schistosomiasis program was strong at some stage to the point when the MOH felt they had done away with the disease and thought there was no need to spend energy and resource on it. The MOH never took into account that when you bring a disease to elimination, the program must stay alive so that it tracks the resurgence of the disease….but the disease was allowed to run wild” - (Medical Entomologist, Informant # 12)

The chronic nature of the disease has been associated with the lack of prioritization of the diseases. An informant stated that:

– “When a disease does not cause fatality, people are slow to react, like in the case of schistosomiasis”.-(Policy maker, Informant # 8)

Inadequate resources

Consequent to the lack of prioritization of the disease, the national control program was abandoned, and domestic funding, research, involvement, and coordination of actors of different sectors within the NTDs community were neglected as well. Key informants lamented the absence of an organized disease control program which led to a lack of financial resources which an informant described as;

“A speech of the pipeline machinery, without action”. - (Policy marker, Informant #8).

Of importance to note was the lack of a nationwide program where informants stated that;

“Currently the NTD program is nested within the TB program and doesn't have its budget. We depend on partners; and WHO is the only partner currently. So that poses a challenge in terms of expanding beyond school-aged children, because WHO only funds MDAs for SAC. We also are not able to reach the district as frequently as we would like to for surveillance. Staffing is also an issue because the program staff is also TB staff”. - (Program manager, informant #2)

Informants indicated that the water and sanitation situation in the Ngamiland district was generally poor and recommended the engagement of the community towards improving the water and sanitation situation. Expanding on the resource constraint issue, informants explained that creating an NTD label was fundamental to schistosomiasis receiving less attention than other diseases. Another part of the NTD framing argued by key informants was that of the “elimination or eradication of schistosomiases in Botswana in 1993”. According to the informants, the use of the words created a loss of focus for the national control program. An informant explained that:

“The word neglected, simply means we know and we neglected! It's good that we know, and we have since reminded ourselves that there is a need for us to give the disease a new focus on control. We had started very strong and lapsed on the way, hence we started again” - (Medical entomologist, informant #12).

Theme III: implementation of policy not strongly embedded at the community level

Community based key informants shared a comparison of the implementation of malaria and diarrhoeal diseases, pointing out that the control activities for the two diseases were strongly enchored on community partnerships citing the sub-themes below:

Lack of robust community participation and health promotion

The key informants in the Okavango district lamented the lack of community participation in health education, water, and sanitation measures which in turn hampered the uptake of disease prevention efforts. The need for health education and sanitary facilities was overly emphasized by the community informants. Compared to malaria and other vector-borne diseases, the level of health education for schistosomiasis was low among SAC. A key informant pointed out the need for intensive community education at the clinics, in the homes, in schools, and in “kgotla” (traditional) meetings. One informant stated that;

“Since our communities have a lot of water-based activities like fishing, teaching communities about protective clothing when washing clothes at the river is very vital. If the schistosomiasis health personnel could do like malaria and HIV, the people will change their behaviors”. - (VDC/community leader Xakao Village, informant # 5).

Lack of knowledge caused poor uptake of services

The District Management Team (DHMT) and community key informants alluded to a lack of knowledge of the disease among communities even in endemic areas. Even though the disease has existed for decades within the district, informants mentioned that the communities lack knowledge because children, fishermen, and farmers wade the waters without protective clothes and still defecate and urinate in rivers. One informant stated:

–“If education is given to communities, changes in behavior are realized. Our children have been taught about playing in the water and the danger of crocodiles killing them and they have since stopped, people accept health education and without it, at times negative consequences like using mosquito nets for fishing can result” - (Teacher at school and Community leader, Informants # 4 and 5)

Multi-sectoral approach

A multi-sector approach was mentioned as key to the schistosomiasis control policy. In a discussion with a DHMT leader, it became evident that a multi-sectoral approach produced results for the malaria program and its deficiency in the schistosomiasis program brought negative ramifications. Collaboration with environmental health, local authorities, communities, and other sectors of the government and civil society organizations were viewed as important for health education and disease prevention efforts. The informants described the lack of internal and external collaboration; operations and control strategies as “implementation in silos”. An informant shared that;

–“The DHMT was not aware of schistosomiasis control policies because they were never informed about it” - (DHMT manager, Informant # 7)

Theme IV: global and national initiatives

The process of initiating the Schistosomiasis policy was based on the high prevalence of the disease in the 1980s. While several key informants postulated that the MOH led the agenda-setting and exerted the most influence in the policy process, they also noted the support from WHO and the country`s quest to adhere to and reach the global health agenda as push factors for the development of policy plans. Of importance to note were the following sub-theme.

Integration

According to key informants in the study, in the early 1980s, the control and prevention program for schistosomiasis was integrated into the existing MOH primary healthcare system, where health education, adequate water supplies, and sanitation were successfully integrated into the healthcare system in Ngamiland. The program was anchored on a strong PHC base which the country had. The integration also involved teaching about the disease in varied health training programs and conducting in-service sessions. An informant from the health training sector alludes that:

“All health workers were aware of the disease, and focal persons were available at district and national levels to do supervisory visits” (Lecturer, Informant # 1).

The key informants reported the integration efforts vanished with the discontinuation of the program after the country attained the set targets of elimination.

Lack of evidence-based programming

The discontinuation of surveillance and mapping of disease took place in 1993 when the program focused on testing through Kato Katz and praziquantel treatment for those diagnosed with the disease. A historic account from one key informant revealed that from 1993 to 2015 prevalence estimates were not frequently determined, marking a collapse in surveillance modalities for the diseases. The country formulated and implemented policy changes to catch up with the neglect of the disease. However, the lack of national conversations among NTD champions, and deficient political ownership of the disease were noted as hindrances to the implementation of the policy. Moreover, a key informant explained that;

“It was only in 2015 that the control program was resuscitated through a WHO-funded mapping exercise. This was a response to the WHO elimination targets hence the drafting of the 2015–2020 NTD master plan”. - (Policy Maker WHO, informant #8).

The informant further echoed the need for continued surveillance as a means of generating evidence for the policy and emphasized it by saying;

– “Mapping of the disease is important at all phases of the disease, from control to the pre-elimination and elimination phase, to avoid dancing in a cycle”.- (Medical entomologist, Informant #12)

Lack of vector control and management strategies (VCMS)

For a longer duration, the Botswana control program omission of mollusciciding in the control program hindered the control of schistosomiasis and hence the disease resurged. This has not brought sustained interruption of transmission in Botswana. An informant uttered that;

– “The lack of a program at the ministry currently means that the program is only aligning with WHO strategies which could lack the Botswana context. There is a national VCMS but since the NTD program does not have a budget at MOH, its implementation has been limited”. - (Vector control manager, informant #6)

Theme V: push from international community and NTDs champions

The major actors in the development of the schistosomiasis policy plans were the MOH and WHO. WHO`s support for the policy process and implementation continued to be the strongest in the control of schistosomiasis in Botswana. The schistosomiasis control program for the period 1985–1990, comprised a multi-sectoral national Schistosomiasis Taskforce which operated a fund from the Enda Mc Connel Clark Foundation of New York and assistance from MOH and technical support from the WHO Geneva office. Since then the program operated on minimal financial support from MOH with WHO expertise, evidence, and global guidance for Botswana to adopt and domesticate. Other Botswana government actors included the then Ministry of Local Government and the Ministry of Education through schools. The communities consumed services at primary healthcare facilities.