BOTSWANA Reproductive Health for Youth at the Workplace by yaohongm


									UNFPA Case Study: BOTSWANA: Reproductive Health for Youth at the Workplace, May 1, 2003, New York, TSD

                     Reproductive Health for Youth at the Workplace

Contributors:            Helen Jackson, HIV/AIDS/STI Adviser, UNFPA Country
                         Technical Support Team, Harare, Zimbabwe; and
                         Joseph Pitso, National Consultant, Botswana University

Fieldwork:               December 2001

This case study is the result of a two-year UNFPA comparative study in 9 countries:
Benin, Botswana, Ecuador, Madagascar, Mongolia, Namibia, Nicaragua, Paraguay and
Ukraine. Based on a rapid assessment protocol, it is intended to inform programme
managers on approaches, and discuss what works or not, from projects that introduce RH
education and services into the military setting in peacetime contexts. Each study
provides information about national RSH needs, including gender and HIV/AIDS issues,
in the countries studied; describes military organisation, life and culture; documents the
history of the projects; describes the approaches adopted for capacity building, behaviour
change communication, provision of RH services -including condom programming and
HIV testing, when relevant- and gender mainstreaming; highlights related lessons learned
on partnership; and makes recommendations for sustaining and strengthening these
initiatives. Important consideration is given to critical policies of gender and human
rights in relation to civilian populations and internal military life, and possible future

Project name:            Reproductive Health for Youth at the Workplace (BOT/98/P05)

Duration:                1998-2002 (builds on two earlier projects)

Partners:                Botswana Defence Forces, Occupational Health Unit of the
                         Ministry of Health, National AIDS Coordination Agency, African
                         Youth Alliance. Linkages with UNDP AIDS in the Workplace
                         project, Men, Sex and AIDS Project and external agencies such as
                         the Botswana Network of AIDS Support Organizations

Budget:                  UNFPA had allocated US$196,000 in direct funding for the project
                         for five years, but in order to stay within annual ceilings was
                         unable to meet this goal or to provide funds beyond 2000. During
                         the first two years, $39,200 was allocated to the project per year,
                         but actual expenditure was reportedly lower, and the government is
                         absorbing some of the cost. The Ministry of Health now pays the
                         salaries for the programme implementers within the Occupational
                         Health Unit.

Beneficiaries:        Young men in the uniformed services (including military, police,
                      immigration and prison services), their families and sex partners.


This project is a good example of cooperation between the Ministry of Health and the
Botswana Defence Force. It also extends a strategy used in an earlier employment-based
family welfare initiative to a different thematic area, HIV prevention. The project aims to
train cadres of “worker educators and distributors” to provide peer education and
counselling, distribute contraceptives and provide referrals for treatment of sexually
transmitted infections.

This project targets young men (age 18 to 30) in the Botswana Armed Forces, who spend
extensive periods away from home in an active sexual culture where HIV is rampant. The
urgency associated with preventing HIV/AIDS in this country provides an entry point for
raising awareness about other aspects of reproductive health and rights, to a group with
generally low gender sensitivity and a problem with gender-based violence. Because the
Botswana military is a highly regarded group, changes in their attitudes and behaviour
could be highly influential.

The long-term strategy of this project is for each military camp to have an HIV/AIDS
committee, including counsellors and peer educators. Their primary task will be to
promote condom use and provide accurate information about HIV and other sexually
transmitted infections. Toward this end, the project plans included considerable training
and capacity-building activities, but various factors delayed their implementation. The
project had two key achievements at the time of this review. One was a series of one-day
sensitization workshop involving senior and mid-level personnel. The workshops covered
a broad range of issues that affect family life, from safe motherhood to teenage problems
and substance abuse, and have generally been well received. The project also conducted a
needs assessment that focused on sociocultural attitudes, values, beliefs and practices
around gender, sex, sexuality, contraception, HIV/AIDS and sexually transmitted
infections. The results of this assessment were used to design peer education and group


Reaching and convincing top personnel that reproductive health is a military concern is a
time-consuming but critical activity because it increases motivation and assures wider

A needs assessment at the outset is a crucial step that can inform project design and
improve results. This should involve in-depth key informant interviews as well as focus
group discussion with direct beneficiaries.

Building on previous initiatives with the military calls for increased donor coordination,
especially when the same unit of government agencies, such as in this case, the
Occupational Unit of the Ministry of Health, is involved.

A single-focus, prescriptive approach to HIV prevention has limitations: the wider link
with gender, reproductive and sexual health concerns is lost, and people become inured to
and depressed by discussions of HIV/AIDS alone. Conversely, young people have high
interest in sex and sexuality, and an inclusive focus allows HIV/AIDS to be raised more

Moving from vertical focus on family planning or HIV/AIDS prevention to a wider
reproductive health and gender perspective is not straightforward and requires careful
preparation, such as advocacy seminars with top leaders and mid-level trainers and
service providers, better communication between health and social welfare units of the
military and ensuring access to reproductive health commodities.

Condom programming and educational initiatives are interdependent. Behaviour change
communication that promotes the use of condoms is more likely to succeed if condoms
are readily available.

                                       Country Context

At the start of the third UNFPA Country Programme in 1998, Botswana’s population
(approximately 1.6 million in 2000) was characterized by high population growth (3.5 per
cent), high levels of teenage pregnancy, a young population and a particularly severe
HIV/AIDS epidemic. The overall contraceptive prevalence rate was 42.5 per cent in
1996, with a teenage pregnancy rate of about 30 per cent. Mean age at first sex was
reported as 17.5 for girls, with mean age at first delivery at 18.6 years. Youth aged 20 to
29 accounted for 40 per cent of reported AIDS cases in June 1997 and 41 per cent of all
HIV-positive pregnant women. HIV prevalence is particularly high in the Kasani border
town, with 53 per cent antenatal HIV infection. However, rural-urban differences in
prevalence are narrowing. HIV prevalence was estimated at 35 per cent in 2000,
nationwide. Prevalence within the uniformed forces is uncertain, but can be assumed to
be at least as high as antenatal prevalence in their base areas.

Selected Indicators: Botswana

        Population (millions)                     1.6
        Population growth rate (%)                 0.5
        Life expectancy M/F                       36.5/35.6
        Maternal mortality per 100,000            480
        live births
        Infant mortality per 1,000 live            67
        Total fertility rate (2000-2005)          3.94
        Contraceptive prevalence (any             33/32
        method/modern method)
        Per cent illiterate (over 15) M/F         25/19
        HIV prevalence (%) (15-24) M/F            15.84/34.31

   Source: State of the World Population 2001

Life expectancy in Botswana was estimated at 47.4 years in 1999, whereas without AIDS
it would have been over 65. Rapidly escalating ill health and deaths among young and
middle-aged people and a steep rise in orphans are certain. This increasing morbidity and
mortality contributes to greatly increased household poverty despite the comparative
wealth of the nation overall.

Marked gender inequity and inequality are apparent, particularly in the sphere of
reproductive and sexual health. The majority of both male and female youth have
multiple sexual partners: males primarily for pleasure and to meet peer expectations and
females because of material benefits as well as peer pressure (the idea that something
must be wrong with them if they cannot attract males) and coercion. Gender-based
violence is widespread. Males typically use sex to prove manhood, with little concern for
female pleasure. High “numbers of rounds” with a woman, and numbers of partners are

badges of masculinity. Group sex among youth is increasing, according to anecdotal
reports. Condoms are viewed negatively, and female condoms have not yet been widely
promoted in Botswana.

Reproductive and sexual health services, although widely available, have generally
targeted women only, through family planning and antenatal, birthing and postnatal care.
Approximately 90 per cent of the people of Botswana live within 15 kilometers of a
health centre, but the demand for reproductive and sexual health services is low,
particularly among youths. Reasons given for this are lack of information on services,
unfriendly attitudes of service providers to youths, and inconvenient hours. The
Government of Botswana aims to improve access to family planning services and
information and counselling, increase the involvement of men in reproductive and sexual
health, and expand training for family planning service providers. Youth-friendly services
are being developed in the third Government of Botswana/UNFPA programme cycle
1998-2002. Increasing male involvement is a major focus, and greatly needed.

With mortality rates so high, population growth in Botswana is no longer a primary
concern. Instead, helping young people to reduce transmission of sexually transmitted
infections, including HIV, and to prevent unwanted pregnancy have become priority
concerns. The government has declared AIDS a national disaster, stating that Botswana is
in a “state of war” against the “invader.” At the end of 2001, in addition to widespread
availability of treatment for opportunistic infections, the public health service pledged to
introduce free antiretroviral treatment. This will be distributed initially from four selected
sites where training has taken place and diagnostic tests (CD4 counts) are available.

The rationale for targeting youth in the Botswana military is based on the urgent need to
improve reproductive and sexual health among this mobile, male-dominated workforce,
among whom a sexually active and gender-insensitive culture is prevalent. Behaviour
change among this cohort is anticipated to also impact positively on the civilian
communities they interact with.

                       The Botswana Defence Forces

The Botswana Defence Forces were established in 1977 in response to aggression from
the Rhodesian armed forces during the struggle for independence. Previously, the
government had not felt the need for such military expenditure. The force was built up
from the Botswana Mobile Unit of the police force and, unlike most militaries in Africa,
had no colonial history or experience, no pre-existing military hardware and few trained
military personnel. The Botswana Defence Forces embarked on intensive training and
have a reported reputation of good discipline and high standards. A voluntary draft was
restricted to healthy males aged 18 to 24 (except for professional posts), with clear
minimum educational requirements determined for different levels of recruitment. Child
soldiers have never been used by the military.

The Botswana Defence Forces comprise five brigades (The First and Second Brigades,
the Artillery Brigade, Air Defence and the Armory Brigade). Each brigade has three

battalions made up of four companies, each with four platoons of five sections, each with
10 men. In total, if all posts are occupied, this would total 2,400 men per brigade, plus
civilian personnel, for a total military force of about 12,000.

Information was not obtained on the proportion of national expenditure earmarked for
defence. However, government is concerned not to incur excessive defence expenditures
while retaining a professional military force.

Military life

Most personnel live with their families within large compounds when not posted
elsewhere on duty. The largest camps or compounds are outside Gabarone, Francistown
and other urban centres, and men are typically posted for border patrol in Kasani to the
north and other areas. Women are only recruited into the military for civilian posts, for
instance as social workers, nurses and secretaries. Men are also recruited into a variety of
professions besides combat: in engineering, medicine, administration and other support
fields. Full gender equity and equality are effectively ruled out, as women’s posts in the
military are limited to civilian roles.

The most common out-of-camp posting is a two-month assignment on border patrol. In
theory this may include matrimonial visits, but in practice they are reported to occur
rarely. Before and after the assignment, a family welfare meeting takes place, primarily to
discuss financial and practical issues, although this could be extended to include
reproductive and sexual health.

Gender-based violence is actively discouraged, but limited opportunities are provided for
discussion and counselling, if needed. When gender-based violence does occur, the
incidents are considered to be beyond military jurisdiction and are supposed to be
handled by civil authorities. The official policy of the Botswana Defence Forces prohibits
sex while men are deployed away from home, and disciplinary action may in theory be
brought if the policy is breached. Nonetheless, it is assumed that the men are sexually
active, and condoms are freely supplied from readily accessible sources. Those who
contract sexually transmitted infections are encouraged to seek early treatment at the
health clinic without penalty.

No written code of conduct addresses gender equity or reproductive and sexual health
concerns or human rights. This lack seems to reflect a focus on control and obedience ,
rather than on the human rights of personnel. Nevertheless, the military is deeply
concerned about the reproductive and sexual health of its personnel, especially in terms
of HIV prevention.

Army discipline is a double-edged sword. It can enforce attendance at meetings. But this
does not guarantee those attending will benefit. Moreover, military personnel tend to
respond to top-down instruction and communication, in line with their own hierarchical
work culture, and the same modality probably applies to changing reproductive and
sexual health and gender relations.

When on tours of duty outside the country, the Botswana Defence Forces are required to
abide by the UN code of conduct. During the 1990s, UN peacekeeping forces, or “blue
helmets,” were involved in missions in Lesotho, Somalia, Mozambique and Rwanda and
apparently their reputation in this regard is very good.

 Sex talk in the military

 Language used within the armed forces reflects a culture that condones multiple sexual
 contacts of various kinds. Peer educators and counsellors reported that men typically
 have a wife or a queen (highest priority girlfriend), then a “2IC,” or second in
 command, followed by one or more “posts” (girlfriends based in different posting sites,
 and openly shared between men who are on duty there at different times). “Short fires”
 or “shorties” refer to casual sexual encounters with neighbours’ domestic workers. In
 addition, men frequent sex workers in town. Kudos refers to “free fall,” a term taken
 from airplane diving without a parachute, and meaning sex without a condom. “Real
 men” are still seen as those with a full set of relationships, although contracting sexually
 transmitted infections has apparently lost its earlier allure, partly because of AIDS.

 This is the broad sexual culture, presumably with many minor variations and individual
 exceptions, within which adolescent reproductive and sexual health efforts must have
 relevance and gain acceptance. AIDS provides a critical entry point into this milieu,
 since men are aware and afraid of it. Their fear needs to be translated into consistent,
 positive action for prevention.

  Because of the HIV screening policy in place, new recruits are known to be
 seronegative. Thus, reaching them before they engage in high-risk unprotected sex is a
 major window of opportunity for HIV prevention. Older soldiers can be a crucial in
 reaching them with prevention messages. Conversely recruits can rapidly be induced
 into purchasing cheap sex organized by older troopers on their behalf for a beer or two.

                             Project strategies and implementation

Clearly, the military men in Botswana, who are part of a virile sexual culture and spend
long periods away from home, are at high risk for contracting HIV. This is a critical
audience and setting to target for male involvement in reproductive and sexual health,
particularly HIV prevention and changing gender relations. Young recruits are the most
crucial cohort to reach.

The project reviewed here addresses HIV prevention using an educational strategy
established in an earlier project. The UNFPA-supported Population, Family Welfare
Education and Services at the Workplace project (1994-1997) was implemented by the
Occupational Health Unit, one of four units in the Community Health Services Division
of the Ministry of Health. That initial project did not involve the armed forces, but did

establish a strategic foundation for the one reviewed here. Its aim was to improve the
quality of life of workers by improving services and increasing knowledge and skills
regarding contraceptives, family planning, budgeting, production and other related areas,
including population and family welfare education. This was to be accomplished through
sensitization and awareness-raising, increasing capacity among worker and employer
organizations, strengthening the capacity of the Occupational Health Unit, producing
communication and training materials to encourage behaviour change, and increasing
condom distribution and usage. A cadre of peer worker educators and distributors
(WEDS) was formed within the workplace, with training in communication and
counselling, reproductive and sexual health, distribution of contraceptives, and referral
for sexually transmitted infections.

Starting in 1992, a separate programme called “AIDS in the Workplace” was mounted by
the same Occupational Health Unit and did include the armed forces. Initially funded by
the US Agency for International Development and the European Union, it now has
UNDP support through the National AIDS Coordination Agency. Its main achievement
has been training peer educators at several levels to increase knowledge of HIV/AIDS
and to promote behaviour change. At Mogoditshane, Gabarone, the post of HIV/AIDS
coordinator has been created for a social worker at the rank of captain. This overall
coordinator forwards committee reports to the commander of the Botswana Defence
Forces. Annual workplans are drawn up and submitted to the Ministry of Health’s
AIDS/STI Unit. Each main military camp now has an HIV/AIDS committee of
counsellors and peer educators under the HIV/AIDS coordinator within the Social
Welfare Office. The primary aims of the committees are to ensure accurate
HIV/AIDS/STI information and to promote safer sex through condom use.

Who did what?

The current UNFPA-supported project is being implemented by the same Occupational
Health Unit within the Ministry of Health. Unfortunately, however, this project was
initiated without detailed knowledge of the “AIDS in the Workplace” programme, so no
synergy was developed between them until recently. The two staff in the Occupational
Health Unit who were involved in the “AIDS in the Workplace” programme have left,
and the two staff recruited for the Government of Botswana/UNFPA projects are now
responsible for both programmes and are merging them into one. They hope to recruit
two more staff to assist and plan to utilize the peer educators trained in the ongoing AIDS
in the Workplace programme.

A national professional was recruited by UNFPA for the first two years of the project to
assist with design and development, and the UNFPA field office and country technical
support team provided further assistance in strategy development and audience analysis.

Training and capacity building

Training and capacity-building activities formed a large part of the initial project design,
but many of these activities were not implemented as initially planned for a number of

reasons: late realization that sensitization of senior staff was required first to achieve
acceptability of the project, and the need for a rapid audience analysis to inform strategy
design. Delays also occurred because of the reduced availability of funds, staffing
shortages in the Occupational Health Unit, and the end of contract of the national project
professional who had played a leading role.

The revised plan is to:

•   Update and redesign training materials (2001) for field testing in early 2002;
•   Strengthen the capacity of district health trainers to decentralize into districts their
    work on reproductive and sexual health and adolescent reproductive and sexual
•   Build organizational capacity to implement the reproductive and sexual health
    project, including the training of worker educators and distributors;
•   Strengthen project personnel in the Occupational Health Unit regarding reproductive
    and sexual health and adolescent reproductive and sexual health, and in data
    processing skills;
•   Train youth worker/educator trainers in using participatory modules to disseminate
    information on adolescent reproductive health issues and services, including on
    HIV/AIDS and sexually transmitted infections, to their peers and families, and to
    integrate reproductive health into their club activities (not yet done);
•   Train personnel in workplaces, including the disciplined forces, to plan, organize and
    provide reproductive and adolescent reproductive health services, including
    HIV/AIDS/STI prevention, a referral system and record keeping (not yet done).

Lessons in capacity building:

Careful peer and counsellor selection is essential to ensure that trainees are motivated to
undertake their roles effectively. Regular back-up training and supportive supervision
could also strengthen motivation and competence.

Behaviour change communication

Work has commenced on revising the training materials for peer educators and on
behaviour change communication materials, incorporating the results of an audience
analysis. The rapid audience analysis involving focus group interviews was undertaken as
a baseline in 1999. This analysis highlighted critical sociocultural values, attitudes,
beliefs and practices around gender, reproductive health, sexuality, HIV/AIDS and
sexually transmitted infections, providing a wealth of information on which to base
training, peer education and discussions among young people in general. Participants
included youths (age 18-30) in male and female groups drawn from the armed forces and
other employment sectors. It provided essential information to guide the project through
peer education and group discussions. Some of the findings were:

•   Gender inequality and inequity are marked.

•   Young men engage in sex for pleasure and peer approval, women for peer approval
    and material benefit.
•   Much first sex for women is coerced.
•   Multiple partners are a norm.
•   Teenage pregnancies are common.

The sociocultural audience analysis highlighted essential information to guide the project
in workplaces in general. It indicated the depth and nature of perceptions and priorities
among youth that influence how they receive reproductive and sexual health messages,
and the barriers to behaviour change. Nonetheless, it failed to gain the full depth of
sociocultural experience specific to the armed forces that the present review obtained
from key informant and focus-group interviews.

Key informants such as health educators, social workers and nurses within the military
may provide more in-depth information and insights than focus group interviews with
peer educators. Such an approach should be routinely adopted in projects in reproductive
and sexual health, and should guide implementation modalities.

New recruits are taught about reproductive and sexual health and HIV/AIDS, but the
sessions are reported to be brief and not nearly sufficient.

Opportunities for open discussion and exploration of complex feelings, attitudes, values
and beliefs that inform sexual behaviour have greater chance of influencing gender
relations and sexual activity than simple information-sharing. The “Men, Sex and AIDS”
project under the Botswana National Youth Council provides an insightful example of
how to achieve this.

A series of one-day sensitization workshops have taken place with military, police and
prison services, as well as with management from other areas of employment. These
involved senior and middle-ranking personnel, and focused on a broad range of
reproductive and sexual health and gender issues. All officer cadets were reportedly
reached directly or through follow-up by other sensitized staff. Topics for orientation

•   Themes from the Population Family Welfare Education and Services in the
    Workplace project, which included: responsible family life and parenthood,
    responsible sexual behaviour, safe motherhood, alcohol and substance abuse,
    managing family resources, productivity, sexually transmitted diseases and
    HIV/AIDS, population and development, and teenage problems, all with a gender-
    sensitive approach
•   Reproductive and sexual health concerns as follows: sexually transmitted diseases,
    update on HIV/AIDS and transmission and progression, management, HIV

As the project has not yet gone beyond the initial sensitization workshops it cannot be
evaluated with respect to widespread behaviour and attitude change in the armed forces.

The “AIDS in the Workplace” project had been helpful in raising awareness about HIV
and ensuring condom distribution. Linking the two projects is anticipated to be a
productive, synergistic way forward. In addition, the Botswana Defence Forces will link
with the African Youth Alliance initiative regarding publications and potential

Lessons in BCC:

A single-focus, prescriptive approach to HIV prevention has limitations: the wider link
with gender, reproductive and sexual health concerns is lost, and people become inured to
and depressed by discussions of HIV/AIDS alone.

In-depth probing is often needed to elicit sensitive information from key target groups for
behaviour change. In fact, informants such as health educators, social workers and nurses
within the military may provide more in-depth information and insights than focus group
interviews with direct beneficiaries.

Opportunities for open discussion and exploration of complex feelings, attitudes, values
and beliefs that inform sexual behaviour have greater chance of influencing gender
relations and sexual activity than simple information-sharing.

Health service delivery, including RH and HIV/AIDS

This project did not have a reproductive health services component. However, the
Botswana Defence Forces do offer free health services to all employees and their
immediate families. Most families live on army bases, and all main bases have clinics
staffed by a doctor, nurses, first aid providers and family welfare educators. Supplies are
reported to be sufficient. On occasion, health clinics also treat patients from the local
community if they cannot obtain medication or other treatment from public sector

Each company within the Botswana Defence Forces also has military training for eight
weeks a year that includes a short unit on HIV/AIDS and reproductive health, supported
by materials from the Botswana Network of AIDS Support Organizations (BONASO)
and, recently, by the “Men, Sex and AIDS” Project (now linked with a national youth
organization). First aid workers are trained in-house at the Institute of Health Sciences.

HIV screening and follow-up

The Botswana Defence Forces undertake routine HIV screening of recruits as part of
their medical exam and reject any who are HIV-positive. These failed recruits are
informed merely that they have a medical condition for which they should see their
doctor. Once in the military, further mandatory screening does not take place, but
voluntary counselling and testing services are available in the main clinics. These
services are mostly utilized on a referral basis from medical staff when people are ill. A
policy of confidentiality is in place. Those who become ill with HIV-related diseases are

redeployed to less stressful work for as long as they can cope and are then retired with
full terminal benefits.

After discharge, access to Botswana Defence Forces health services officially ends. This
is hard on dying patients and their families, who also lose their military housing. Patients
are referred to whatever local care services may exist in the area of their new homes.
Through an arrangement with an NGO, the Second Brigade has started to offer voluntary
testing and counselling once a fortnight in a designated room in the camp. It remains to
be seen how many people will take advantage of it.

The military provides staff with HIV/AIDS counselling and peer education training at the
Institute of Development Management, through sponsorship by UNDP via the
AIDS/Sexually Transmitted Diseases (STI) Unit in the Ministry of Health.

Lessons in RH services

A knowledge base on HIV/AIDS has already been built up within the army, but has not
been sufficiently linked with wider issues of gender and reproductive and sexual health.

There is a real effort by military staff to provide pre and post-test counseling. However,
condom programmeming is not addressed satisfactorily and remains uncoordinated with
educational initiatives.

How Were Gender d Rights Issues Addressed?

The project addresses gender and human rights considerations within the area of
reproductive and sexual rights, particularly through a focus on effective male
involvement. In the early stages of the project, senior and middle level military staff
were resistant to focusing on reproductive and sexual health and gender because they did
not appreciate the relevance of these topics to the armed forces. The sensitization
workshops appear to have been effective in changing this attitude: many of those
excluded from the workshops have requested further workshops, and demand has grown
for peer education and further training to continue. Moreover, the Botswana Defence
Forces took over funding for the workshops and assisted with logistics.

The senior and mid-level staff of the Botswana Defence Forces appear to recognize the
importance of gender relations and reproductive and sexual health within the armed
forces as an integral part of their efforts to address HIV/AIDS. They seem to understand
the seriousness of the epidemic in Botswana, and how critically this will impact them.
Thus HIV/AIDS is an entry point to achieving wider gender and reproductive and sexual
health benefits, and UNFPA is well placed to take this forward.

The military does not consider itself to be a “human rights” organization so much as a
disciplined force. The Botswana Defence Forces do provide seminars and other
opportunities for learning about reproductive health and offer health services for staff and

their families. In this sense, they do observe good employment practices to safeguard
health and basic reproductive rights.

Lessons learned in promoting gender equity

Although reluctant at the beginning, the gender sensitization workshops appear to have
been effective in changing attitude of officers: many of those excluded from the
workshops have requested further workshops, and demand has grown for peer education
and further training to continue.

                        Institutionalization and moving forward

The growing commitment of the Government of Botswana to respond to HIV/AIDS
creates an opportunity to expand reproductive and sexual health, to encourage male
involvement and improve gender equity and equality. The mid-term review
recommended that the government take over funding, and it undertook this commitment
through the Ministry of Health, the National AIDS Coordination Agency and the
Botswana Defence Forces themselve, which have consistently supported the sensitization
workshops. They funded the workshops themselves and allowed staff the time to attend
them. Hence UNFPA expenditure for the workshops was limited to project staff travel
and accommodation costs and equipment.

Under the auspices of the government, the project aims to eventually reach the entire
Botswana Defence Forces, including small camps and postings as well as the main ones.
This will help it reach the mobile personnel at wherever they are stationed. One concern
is that without clear time frames for implementation, the activities may fall behind. The
change to full government funding and institutionalization of the project as a government
programme, while increasing sustainability, has incurred considerable administrative and
financial delays.

Another sign of institutionalization of reproductive health into the military is the fact that
the Botswana Defence Forces led national World AIDS Day activities for 2000 and 2001
with the focus on male involvement and head the national committee on male
involvement under the Botswana National AIDS Coordination Programme.

The project was hindered by insufficient communication between the medial and social
welfare departments of the Botswana Defence Force.

Building political support

Sensitization and the full backing of senior personnel took longer to achieve than
originally anticipated. However, no direct opposition to these projects was encountered
from communities or from religious or traditional healers. The project reaches the police
force, immigration and prison services, and a wide range of companies in the private
sector, as well as the military. It is reported to be highly valued by the various uniformed
forces, many of whom previously had a weak understanding of reproductive and sexual

health issues and had experienced the consequences of mishandling issues related to
sexuality, HIV/AIDS, other sexually transmitted infections and teenage pregnancies.

Reaching and motivating top personnel is essential. Once they are motivated, they can
demand wide participation in workshops, discussions and talks. However, the time and
effort required to achieve the solid commitment of senior staff was initially
underestimated, since reproductive and sexual health issues were perceived as falling
beyond their purview.

Current sexual behaviour remains highly risky, but the top-down command approach of
the military could be harnessed to promote condom use on a wide-scale, rather than
attempting to change the entrenched, sexually active culture of the military. However,
reroductive health services need to go much further, in linking with the worker educator
and distributors, counselors and peer educators to help the men take more responsibility
around sex.

Keeping HIV/AIDS as a separate project has limitations: the wider link with reproductive
and sexual health concerns is lost, and people become inured to and depressed by
discussions of HIV/AIDS alone. Conversely, young people have high interest in sex and
sexuality, and an inclusive focus allows HIV/AIDS to be raised more effectively.

The comparative advantage of incorporating a broad reproductive and sexual health
agenda is illustrated by the following comment made when the Occupational Health Unit
team visited a prison: “We thought you were the AIDS people and we were not willing to
come. But now that we know you are talking about all these other issues, we’ll be there.”

Lessons learned in political will and institutionalization

The growing commitment of the Government of Botswana to respond to HIV/AIDS
creates an opportunity to expand reproductive and sexual health, to encourage male
involvement and improve gender equity and equality.

Reaching and motivating top personnel is essential. Once they are motivated, they can
demand wide participation in workshops, discussions and talks. However, the time and
effort required to achieve the solid commitment of senior staff was initially
underestimated, since reproductive and sexual health issues were perceived as falling
beyond their purview.

Keeping HIV/AIDS as a separate project has limitations: the wider link with reproductive
and sexual health concerns is lost, and people become inured to and depressed by
discussions of HIV/AIDS alone. Conversely, young people have high interest in sex and
sexuality, and an inclusive focus allows HIV/AIDS to be raised more effectively.

ANNEX 1 Documents reviewed
AIDS/STD Unit (1993) ‘Current and Future Dimensions of the HIV/AIDS Epidemic in Botswana’.
   Ministry of Health: NACP 16. Government of Botswana, Gaborone

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ANNEX 2       Data sources

The methodology includes review of relevant documentation, interviews with key
informants, and focus group interviews with primary and secondary beneficiaries.

Data were obtained from the Country Programme Assessment, baseline rapid audience
assessment, the component project document, quarterly and annual reports, as well as
from key informant and focus group interviews within Botswana Defence Forces and
interviews with Occupational Health Unit staff, the previous project leader, UNFPA and
the Men, Sex and AIDS Project. An external evaluation is scheduled next year.

   Key Informants outside BDF

Ms Dorcas Temane, Assistant Country Representative
Ms Kelebogile Motlhanka, Project Officer, Occupational Health Unit
Ms Lucia Mwakikunga, Project Officer, Occupational Health Unit
Ms Laone Scheffers, previous National Professional Project Person

ANNEX 3 Participants as key informants and in focus groups in BDF

Headquarters Sir Seretse Khama Barracks (SSKB)

Name           Rank/Civilian         Occupation
Dr. Bhalla     Captain               Medical Doctor
Dr. Menon      Captain               Medical Doctor
Dr. Molope     Major                 Medical Doctor
Osenetso       Second Lieutenant     Nurse:MCH/FP
Kgomotso       Second Lieutenant     Family Welfare Educator
Mahatelo       Civilian Nurse        S/Nurse

Glen Valley

Name           Rank/Civilian         Occupation
Kenosi         Major                 Acting Glen Valley commander
Ditsela        Captain               Social Worker/Deputy Botswana Defence Forces
                                     HIV/AIDS coordinator
Moatlhodi      Major                 Chaplain
Basame         Corporal              Peer educator

Francistown Botswana Defence Forces 2nd Brigade

Name             Rank/Civilian             Occupation
Oye              Major                     Acting Commander 2nd Brigade

Ms Letsile      Civilian                    Social Worker
Ms Pelaelo      Civilian                    Community Health Nurse
Mr Makataya     Second Lieutenant           Public Health Educator
Matebele        Lieutenant                  HIV/AIDS Counselor (Head, True Men )

Thebephatshwa Air Base

Name            Rank/Civilian               Occupation
Kgomo           Major                       Lab Technician
Makepe          Captain                     General Health Commander
Madanika        Civilian                    Public Health Educator
Kegakilwe       Second Lieutenant           Opthalmic Nurse
Boiretsemang    Lieutenant                  General Nurse
Matseke         Civilian                    General Nurse
Moloi           Civilian                    Registered Nurse

Peer Educators for 2nd Brigade (Francistown)

Name                         Role
Rammolai                     Peer educator
Amos                         Peer educator
Segobai                      Peer educator
Mhiko                        Peer educator
Ogomoditse                   Peer educator
Rathapo                      Peer educator
Machola                      Peer educator
Maramane                     Peer educator/Peer counselor
Maswabi                      Peer educator

Other persons contacted in their Individual Capacity

Name              Rank/Civilian                  Occupation
Mojela            Captain                        Botswana Defence Forces overall
                                                 HIV/AIDS Coordinator
Matebele          Lieutenant                     HIV/AIDS Counselor, Head, True Men
L.Scheffers       Former UNFPA NPPP              UNFPA reproductive and sexual health
                                                 Project Officer
G.D. Temane       UNFPA Country Assistant        UNFPA Country Assistant
L. Mwakikunga     Civilian                       reproductive and sexual health Project
K. Motlhanka      Civilian                       reproductive and sexual health Project
Raboloko          BNYC                           Men, Sex and AIDS Project

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