International Journal of Health Policy and Management

International Journal of Health Policy and Management

Analysing the Stewardship Function in Botswana’s Health System: Reflecting on the Past, Looking to the Future

Document Type : Original Article

Authors
Onalenna Seitio-Kgokgwe 1, 2
Robin DC Gauld 3
Philip C. Hill 3
Pauline Barnett 4
1 Ministry of Health, Gaborone, Botswana
2 Institute of Development Management, Gaborone, Botswana
3 Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
4 School of Health Sciences, University of Canterbury, Christchurch, New Zealand
10.15171/ijhpm.2016.67
Abstract
Background
In many parts of the world, ongoing deficiencies in health systems compromise the delivery of health interventions. The World Health Organization (WHO) identified four functions that health systems need to perform to achieve their goals: Efforts to strengthen health systems focus on the way these functions are carried out. While a number of studies on health systems functions have been conducted, the stewardship function has received limited attention. In this article, we evaluate the extent to which the Botswana Ministry of Health (MoH) undertook its stewardship role.
 
Methods
We used the WHO Health Systems Performance Assessment Frame (HSPAF) to guide analysis of the stewardship function of the Botswana’s MoH focusing on formulation of national health policies, exerting influence through health regulation, and coalition building. Data were abstracted from published and unpublished documents. We interviewed 54 key informants comprising staff of the MoH (N = 40) and stakeholder organizations (N = 14). Data from documents was analyzed through content analysis. Interviews were transcribed and analyzed through thematic analysis.
 
Results
A lack of capacity for health policy development was identified. Significant policy gaps existed in some areas. Challenges were reported in policy implementation. While the MoH made efforts in developing various statutes that regulated different aspects of the health system, some gaps existed in the regulatory framework. Poor enforcement of legislation was a challenge. Although the MoH had a high number of stakeholders, the mechanisms for stakeholder engagement in the planning processes were weak.
 
Conclusion
Problems in the exercise of the stewardship function posed challenges in ensuring accountability and limited the health system’s ability to benefit from its stakeholders. Ongoing efforts to establish a District Health System under control of the MoH, attempts to improve service delivery at a national level and political will to strengthen public-private engagement mechanisms are some of the prospects that can improve the MoH’s stewardship function.
Keywords
Botswana
Health Policy
Health System
Stewardship
Health Legislation
Subjects
  1. World Health Organization (WHO). The World Health Report 2000: Health systems: Improving performance. Geneva: WHO; 2000.
  2. World Health Organization (WHO). The Oaugadougou Declaration on Primary Health Care. Brazzaville: WHO Regional Office for Africa; 2008.
  3. World Health Organization (WHO). The Tallin Charter: Health systems for health and wealth. Copenhagen: WHO Regional Office for Europe; 2008.
  4. Kapoor N, Kumar D, Thakur N. Core attributes of stewardship; foundation of sound health system. Int J Health Policy Manag. 2014;3(1):5-6. doi:10.15171/ijhpm.2014.52
  5. Siddiqi S, Masud TI, Nishtar S, et al. Framework for assessing governance of the health system in developing countries: gateway to good governance. Health Policy. 2009;90(1):13-25.
  6. Mikkelsen-Lopez I, Wyss K, De Savigny D. An approach to addressing governance from a health system framework perspective. BMC International Health and Human Rights. 2011;11(13). doi:10.1186/1472-698X-11-13
  7. Kaufmann D, Kraay A, Zoido-Lobaton P. Governance Matters. Washington: The World Bank; 1999.
  8. United Nations Development Programme (UNDP). Governance for sustainable human development: a UNDP policy document. New York: UNDP; 1997.
  9. Graham J, Amos B, Plumptre T. Principles for good governance in the 21st century. Policy brief no. 15. Ottawa: Institute on Governance; 2013.
  10. Islam M, ed. Health systems assessment approach: A how-to-manual. Submitted to the U.S. Agency for International Development in collaboration with Health Systems 20/20, Partners for Health Reformplus, Quality Assurance Project, and Rational Pharmaceutical Management Plus. Arlington, VA: Management Sciences for Health; 2007.
  11. Saltman RB, Ferroussier-Davis O. The concept of stewardship in health policy. Bull World Health Organ. 2000;78(6):732-739.
  12. Management Science for Health. How to govern the health health sector and its institutions effectively. The eManager. 2013, No. 1.
  13. Seitio-Kgokgwe O. Organizational Structure of the Botswana Ministry of Health: Impact on Performance. Dunedin: Preventive and Social Medicine, University of Otago; 2012.
  14. World Health Organization (WHO). Everybody's business: Strengthening health systems to improve health outcomes: WHO's framework for action. Geneva: WHO; 2007.
  15. Travis P, Egger D, Davies P, Mechbal A. Towards better stewardship: concepts and critical issues. Geneva: WHO; 2002.
  16. Seitio-Kgokgwe O, Gauld R, Hill P, Barnett P. Redesigning a Ministry of Health's organizational structure: exploring implementation challenges through Botswana's experiences Int J Health Plan Manage. 2014. doi:10.1002/hpm.2275
  17. Seitio-Kgokgwe O, Gauld R, Hill P, Barnett P. Development of the National Health Information Systems in Botswana: Pitfalls, Prospects and Lessons. Online Journal of Public Health Informatics. 2015;7(2). doi:10.5210/ojphi.v7i2.5630
  18. Roberts MJ, Hsiao W, Berman P, Reich MR. Getting Health Reform Right: A Guide to Improving Performance and Equity. New York: Oxford University Press; 2004.
  19. Bennett S, Hanson K, Kadama P, Montagu D. Working with the non-state sector to achieve public health goalls. Geneva: WHO; 2005.
  20. 20.   Nishtar S. Public-private 'partnerships' in health- a global call for action. Health Res Policy Syst. 2004;2:5. doi:10.1186/1478-4505-2-5
  21. Central Statistics Office (CSO). Population and housing census: preliminary results. Gaborone: CSO; 2011.
  22. Ministry of Health (MoH). National health accounts. Gaborone: MoH; 2012.
  23. Central Statistics Office (CSO). Health statistics 2000. Gaborone: CSO; 2003.
  24. Ministry of Finance and Development Planning (MFDP). National Development Plan 9: 2003/4-2008/9. Gaborone: MFDP; 2003.
  25. Ministry of Finance and Development Planning (MFDP). National Development Plan 1970/75. Gaborone: MFDP; 1970.
  26. Ministry of Health (MoH). A situational analysis of health insurance (Medical Aid) in Botswana’s formal sector: A health financing study. Gaborone: MoH; 2004.
  27. Ministry of Health (MoH). Republic of Botswana National Health Accounts. Gaborone: MoH; 2006.
  28. Yin RK. Case Study Research: Design and Methods. 3rd ed. London: Sage Publications; 2003.
  29. Creswell JW. Research Design: Qualitative, Quantitative and Mixed Methods Approaches. 2nd ed. London: Sage Publications Inc; 2003.
  30. Teddlie C, Tashakkori A. Foundations of Mixed Methods Research: Integrating Quantitative and Qualitative Approaches in the Social and Behavioural Sciences. Thousand Oaks: Sage; 2009.
  31. Babbie E, Mouton J. The Practice of Social Research. Cape Town: Oxford University Press Southren Africa; 2001.
  32. Miles MB, Huberman AM. Qualitative Data Analysis. 2nd ed. Thousands Oaks: Sage Publications; 1994.
  33. Ministry of Health (MoH). Corporate performance plan 2000-2005. Gaborone: MoH; 2000.
  34. Ministry of Health (MoH). A review of the organizational structure of the MoH in Botswana: Final report Gaborone: MoH; 2002.
  35. British Council. A review of the organisational structure of the MoH in Botswana: Discussion document stakeholders meeting 19 June 2002. Gaborone; MoH: 2002.
  36. Ministry of Health (MoH). National Health Policy. Gaborone: MoH; 1995.
  37. Molutsi P, Lauglo M. Decentralisation and health systems performance: the case of Botswana. Gaborone: MoH; 1994.
  38. GoB. Public Health: Chapter 63:01. Gaborone 1981.
  39. GoB. Private Hospitals and Nursing Homes Act. Gaborone 1989.
  40. GoB. Drugs and Related Substances Act No. 18 of 1992. Gaborone 1992.
  41. GoB. Botswana Health Professions: Chapter 61:02. Gaborone 2001.
  42. GoB. Nurses and Midwifes: Chapter 61:03. Gaborone 1997.
  43. Ministry of Finance and Development Planning (MFDP). National Development Plan 8: 1997/98-2002/03. Gaborone: MFDP; 1997.
  44. Ministry of Health (MoH). National health service situational analysis report. Gaborone: MoH; 2009.
  45. Bossert T, Beauvais J. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: a comparative analysis of decision space. Health Policy Plan. 2002;17(1):14-31.
  46. Danishevski K, Balabanova D, McKee M, Atkinson S. The fragmentary federation: experiences with the decentralized health system in Russia. Health Policy Plan. 2006;21(3):183-194.
  47. Bossert T, Chitah MB, Browser D. Decentralization in Zambia: resource allocation and district performance. Health Policy Plan. 2003;18(4):357-369. doi:10.1093/heapol/czg044.
  48. Tenbensel T. Health targets. Health Policy Monitor. 2007. Survey no: 10.
  49. Mills A. Decentralization concepts and issues: a review. In: Mills A, Vaughan JP, Smith DL, Tabibzadeh I, eds. Health System Decentralization: Concepts, Issues, and Country Experiences. Geneva: WHO; 1990.
  50. Buse K, Mays N, Walt G. Making Health Policy. London: Open University Press; 2005.
  51. Hanson K, Berman P. Private health care provision in developing countries: a preliminary analysis of levels and compositions. Health Policy Plan. 1998;13(3):195-211.
  52. McPake B, Anne M. What can we learn from international comparisons of health systems and health system reform? Bull World Health Organ. 2000;78(6):811.
  53. Harding A, Preker A. Understanding organizational reforms The corporatization of public hospitals. Washington DC: The World Bank; 2000.
  54. Ensor T, Weinzierl S. Regulating health care in low- and middle-income countries: Broadening the policy response in resource constrained environments. Soc Sci  Mede. 2007;65(2):355-366.
  55. Balabanova D, Oliveira-Cruz V, Hanson K. Health sector governance and implications for the private sector. Washington DC: Result for Development Institute; 2008.
  56. Barnes J, O'Hanlon B, Feeley F, Mckeon K, Gitonga N, Decker C. Kenya private health sector assessment. Bethesda, MD: Private sector partnership-One Project, Abt Associates, Inc; 2009.
  57. Caines K. Best Practice Principles for Global Health Partnership Activities at Country Level. http://www.eldis.org/go/home&id=20999&type=Document#.V0m2m-RdTfY. Published2005.
  58. Cahill K, Fleming D, Conway M, Gupta S. Global Health Partnerships: Assessing Country Consequences. WHO/The World Bank; 2005.
  59. Downs TJ, Larson HJ. Achieving Millennium Development Goals for health: Building understanding, trust and capacity to respond. Health Policy. 2007;83:144-146.
  60. Seretse Khama IK. Speech by H.E. Lieutenant General Seretse Khama Ian Khama-President of the Republic of Botswana and BDP Party President at the National Council 22/5/10. Tautona Times. May 2010.
  61. Seitio-Kgokgwe O, Gauld R, Hill P, Barnett P. Assessing performance of Botswana’s public hospital system: the use of the World Health Organization Health System Performance Assessment Framework. Int J Health Policy Manag. 2014;3(4):179-189. doi:10.15171/ijhpm.2014.85
  62. Rubin HR, Pronovost P, Diette GB. The advantages and disadvantages of process-based measures of health care quality. Int J Qual Health Care. 2001;13(6):469-474.
International Journal of Health Policy and Management
Volume 5, Issue 12
2016
Pages 705-713

  • Received Date 07 August 2015
  • Revised Date 24 May 2016
  • Accepted Date 25 May 2016
  • First Published Date 01 December 2016
  • Published Date 01 December 2016