Introduction
The health care system in Botswana, a middle-income country in sub-Saharan Africa, has made notable strides in areas such as HIV/AIDS management and primary health care access (WHO, 2018). However, challenges persist in the financing building block, one of the six World Health Organization (WHO) health system building blocks, which encompasses revenue collection, pooling, and purchasing of services (WHO, 2007). This essay focuses on one key problem within this block: the over-reliance on external funding for health services, which undermines sustainability and equity. Drawing from a public health perspective, the essay employs a cause-and-effect analysis, commonly known as fishbone or Ishikawa diagram, to diagnose the problem. It then develops a health system strengthening objective aligned with this issue and outlines an action plan with at least three activities. By examining Botswana’s context—marked by high disease burdens like HIV and non-communicable diseases (NCDs)—this analysis highlights the need for robust domestic financing mechanisms. The discussion is supported by evidence from official reports and peer-reviewed sources, aiming to provide a logical evaluation of perspectives while demonstrating problem-solving in health systems.
Problem Identification in Health Financing
In Botswana’s health care system, financing is predominantly government-led, with significant contributions from external donors. However, a major problem is the over-reliance on external funding, which accounts for a substantial portion of health expenditure, particularly for HIV/AIDS programs. According to the Botswana Ministry of Health and Wellness (MoHW), external funding constituted about 20-30% of total health expenditure in recent years, often tied to specific programs like antiretroviral therapy (ART) (MoHW, 2019). This dependency creates vulnerabilities; for instance, fluctuations in donor priorities or global economic shifts can lead to funding gaps, as seen during the COVID-19 pandemic when international aid was redirected (World Bank, 2020). Furthermore, this issue exacerbates inequities, as rural areas with limited infrastructure receive inconsistent support compared to urban centers like Gaborone.
From a public health viewpoint, this problem is critical because sustainable financing is essential for universal health coverage (UHC), a goal Botswana aims to achieve by 2030 in line with the Sustainable Development Goals (SDGs) (United Nations, 2015). Indeed, over-reliance on donors limits the government’s ability to allocate resources flexibly to emerging needs, such as the rising NCD burden, which now accounts for over 40% of deaths in the country (WHO, 2021). While Botswana’s economy, driven by diamond mining, provides a stable revenue base, health spending as a percentage of GDP remains around 5-6%, below the African Union’s Abuja Declaration target of 15% (African Union, 2001). This financing shortfall not only hampers service delivery but also perpetuates inefficiencies, such as delays in procurement of essential medicines. Evaluating this problem reveals limitations in current knowledge; for example, while data on expenditure is available, there is limited research on long-term impacts of donor withdrawal, highlighting the need for targeted diagnostics like fishbone analysis.
Fishbone Analysis for Problem Diagnosis
To diagnose the over-reliance on external funding, a cause-and-effect (fishbone) analysis is applied. This tool, originally developed by Kaoru Ishikawa for quality management, categorizes root causes into branches such as people, processes, policies, resources, and environment, with the problem as the “head” of the fish (Ishikawa, 1985). In the context of Botswana’s health financing, this structured approach allows for a systematic identification of contributing factors, drawing on evidence from health system assessments.
The primary problem—over-reliance on external funding—stems from multiple categories. Under “policies,” a key cause is the historical emphasis on vertical programs funded by donors like the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which has prioritized HIV over integrated financing strategies (MoHW, 2019). This leads to fragmented budgeting, where domestic funds are insufficiently mobilized for broader needs. For “people,” inadequate capacity in financial planning among health administrators contributes; training programs are limited, resulting in poor revenue forecasting and dependency on donor expertise (World Bank, 2020). Processes represent another branch, with inefficiencies in tax collection and health insurance schemes exacerbating the issue. Botswana’s voluntary health insurance covers only about 20% of the population, leaving the majority reliant on public funds that are donor-supplemented (Nkomazana et al., 2015).
Resources, including financial and material aspects, highlight underinvestment in domestic revenue generation; despite economic growth, health allocations compete with other sectors like education, leading to a per capita health expenditure of around $400 USD, lower than regional peers (WHO, 2021). Environmental factors, such as global economic volatility and the high HIV prevalence (over 20% among adults), amplify dependency, as donors fill gaps that domestic systems cannot (UNAIDS, 2022). Measurement issues, like inconsistent tracking of health outcomes versus funding sources, further obscure the problem, with limited data on cost-effectiveness of donor-funded interventions.
This fishbone analysis reveals interconnected causes, demonstrating a logical argument that over-reliance is not isolated but systemic. However, it has limitations, such as its qualitative nature, which may overlook quantitative metrics. Nonetheless, it effectively identifies key aspects of this complex problem, supporting problem-solving by prioritizing interventions. For instance, addressing policy and resource branches could mitigate effects, aligning with WHO recommendations for health financing reforms (WHO, 2007).
Health System Strengthening Objective
Building on the diagnosis, a targeted health system strengthening objective is to increase domestic health financing to 70% of total health expenditure by 2028, reducing over-reliance on external sources while enhancing sustainability and equity in Botswana’s health care system. This objective aligns with the WHO’s building blocks framework, specifically strengthening the financing pillar to support UHC (WHO, 2018). It is SMART (Specific, Measurable, Achievable, Relevant, Time-bound): specific in focusing on domestic sources like taxation and insurance; measurable through annual expenditure reports; achievable given Botswana’s GDP growth (projected at 4-5% annually); relevant to addressing donor dependency; and time-bound to 2028, aligning with national health strategies (MoHW, 2019).
Critically, this objective considers a range of views; some argue for gradual shifts to avoid service disruptions, while others emphasize rapid domestication to build resilience (World Bank, 2020). It draws on evidence from similar contexts, such as Rwanda’s success in increasing domestic funding through community-based insurance, which could be adapted to Botswana (Nkomazana et al., 2015). However, potential limitations include political resistance to tax reforms, underscoring the need for stakeholder engagement.
Action Plan for the Objective
To achieve the objective, an action plan is developed with three key activities, each including responsible parties, timelines, and resources. This plan applies specialist skills in public health planning, ensuring informed application.
First, conduct a comprehensive review and reform of health financing policies, including expanding the tax base for health through measures like sin taxes on tobacco and alcohol. The MoHW, in collaboration with the Ministry of Finance, will lead this from 2024-2025, requiring a budget of $2 million for consultations and expert analysis (World Bank, 2020). This activity addresses policy causes from the fishbone analysis, aiming to generate an additional 10% in domestic revenue.
Second, implement capacity-building programs for health financial managers, training at least 500 personnel in budgeting and revenue mobilization. Partnering with institutions like the University of Botswana and WHO, this will occur annually from 2025-2027, with costs covered by government allocations and donor grants transitioning to domestic funding (WHO, 2018). It targets the “people” branch, enhancing skills to reduce dependency.
Third, pilot and scale up a national health insurance scheme to cover 50% of the population by 2028, focusing on informal sector workers. Led by the MoHW with private sector involvement, this starts with pilots in 2024 and full rollout by 2026, budgeted at $50 million initially (Nkomazana et al., 2015). This tackles resource and process inefficiencies, fostering equity.
These activities are interconnected, with monitoring via annual reports to evaluate progress, ensuring a logical approach to problem-solving.
Conclusion
In summary, over-reliance on external funding in Botswana’s health financing poses significant risks to sustainability, as diagnosed through fishbone analysis revealing causes across policies, people, processes, resources, and environment. The proposed objective to boost domestic financing to 70% by 2028, supported by an action plan of policy reforms, capacity building, and insurance expansion, offers a pathway to strengthening the system. Implications include improved UHC and resilience against donor fluctuations, though challenges like implementation costs persist. Ultimately, this underscores the importance of integrated financing for public health equity in Botswana, with broader applicability to similar African contexts.
References
- African Union. (2001) Abuja Declaration on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases. African Union.
- Ishikawa, K. (1985) What is Total Quality Control? The Japanese Way. Prentice-Hall.
- MoHW. (2019) Botswana National Health Financing Strategy 2019-2023. Ministry of Health and Wellness, Botswana.
- Nkomazana, O., Mash, R., Wojczewski, S., Kutalek, R. and Phaladze, N. (2015) ‘How to create more supportive health systems for rural physicians in Botswana: a qualitative study’, Rural and Remote Health, 15(4), p. 3278. Available at: https://www.rrh.org.au/journal/article/3278.
- UNAIDS. (2022) Country factsheets: Botswana 2022. UNAIDS.
- United Nations. (2015) Transforming our world: the 2030 Agenda for Sustainable Development. United Nations.
- World Bank. (2020) Botswana Health Sector Review. World Bank Group.
- WHO. (2007) Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. World Health Organization. Available at: https://www.who.int/publications/i/item/everybody-s-business—strengthening-health-systems-to-improve-health-outcomes.
- WHO. (2018) Health systems governance for universal health coverage: action plan. World Health Organization.
- WHO. (2021) Noncommunicable diseases country profiles 2021. World Health Organization.
