Political polarization has emerged as a major issue in the world of public health and health policy. Research has highlighted the role of political and ideological polarization in health policy, public trust, vaccine uptake, responses to the pandemic, and health outcomes at the population level (Fraser et al., 2022 ; Nayak et al., 2021 ; Oberlander, 2024 ). Much of this research has examined the effect of conflicts between citizens, political parties, and interest groups on the adoption and implementation of health policies.
The COVID-19 pandemic has underscored the critical need to comprehend the effects of political polarization on health systems and public health decision-making. These contributions have significantly advanced understanding of the relationship between politics and health. However, comparatively less attention has been given to how polarization may emerge within the institutional architecture responsible for designing, financing and implementing health policy itself. Health systems increasingly involve multiple organisations operating across different sectors of government. Ministries of Health, Ministries of Finance, local government authorities, procurement agencies, regulatory institutions, development partners and private-sector actors frequently share responsibility for achieving common health policy objectives. While such institutional diversity can strengthen health-system performance, it also creates new governance challenges that extend beyond political competition or ideological disagreement.
Health policy and systems research has consistently shown that effective health systems depend on more than adequate financing, infrastructure and human resources. They also depend on governance. Governance provides the institutional arrangements through which authority is exercised, decisions are made, resources are allocated and accountability is maintained. It determines how different institutions work together in pursuit of shared public good (Frenk, 1994; Travis et al; 202). Existing governance frameworks emphasise stewardship, coordination, accountability, transparency and institutional capacity as essential characteristics of well-functioning health systems (Siddiqi et al., 2009; Brinkerhoff and Bossert, 2014; WHO, 2007). These frameworks recognise that improving health outcomes depends not only on the performance of individual institutions but also on the quality of relationships between them.
Health policy and systems research also recognises that health is not produced exclusively within hospitals, clinics or consulting rooms. Nor is health-system performance determined solely by physicians, nurses or other clinical professionals. Modern health systems depend on the interaction of political institutions, public administration, financing systems, procurement agencies, local government, regulatory authorities, development partners and communities. Improving population health therefore requires governance arrangements that enable these institutions to work together towards shared public objectives rather than operate as isolated organisations (WHO, 2007; Frenk, 1994).
This broader systems perspective is increasingly reflected in contemporary scholarship, which argues that medicines governance, particularly during periods of fiscal stress, should be understood as a stewardships and governance challenge rather than simply a procurement or clinical problem ( Seleke and Nthomang, 2026).
Governance scholars have also examined institutional fragmentation, describing situations in which multiple organisations, rules and governance arrangements become increasingly dispersed and difficult to coordinate (Biermann et al., 2009). Although this literature has largely developed within environmental governance and international relations, its central insight-that fragmented institutional arrangements may weaken collective action-is highly relevant to contemporary health systems. Nevertheless, institutional fragmentation primarily describes the structural organisation of institutions. It pays comparatively less attention to how relationships among institutions evolve during periods of reform, particularly when organisations responsible for a common policy objective progressively diverge in their mandates, operational priorities and accountability arrangements.
Institutional Polarization
Institutional polarization refers to the progressive divergence of authority, accountability, mandates and decision-making among institutions responsible for a shared health policy objective. It occurs when organisations established to pursue common policy goals increasingly operate through parallel responsibilities, competing priorities and disconnected accountability arrangements, reducing institutional coherence and making policy implementation more difficult. Institutional polarization does not necessarily imply institutional conflict or institutional failure. Rather, it describes a governance condition in which relationships between institutions become progressively less integrated despite the continued functioning of individual organisations.
The concept builds upon, but is distinct from, institutional fragmentation. Fragmentation is primarily concerned with the existence and organisation of multiple institutions. Institutional polarization shifts attention towards the quality of relationships between those institutions. It asks whether authority remains coherent, whether accountability is clearly understood, whether financing arrangements reinforce coordination, whether procurement responsibilities are aligned, whether communication reflects a shared governance narrative and whether stewardship continues to integrate the system. In this way, institutional polarization complements existing governance frameworks by providing an additional analytical lens through which health-system reform may be examined.
Botswana provides an important opportunity to explore this proposition. Since 2024, the country has embarked on one of the most significant periods of health-sector reform since Independence. These reforms include the decentralisation of primary health care, restructuring of medicines governance, emergency institutional arrangements following the 2025 medicines crisis, and the introduction of innovative financing mechanisms intended to strengthen health-system resilience. Individually, each initiative seeks to improve health-system performance. Collectively, however, they also raise broader questions regarding institutional coherence, coordination and long-term stewardship. Rather than evaluating the performance of individual organisations, this paper examines whether the evolving institutional architecture continues to support coherent implementation of shared health policy objectives.
To illustrate the proposed concept, this commentary introduces six interrelated domains through which institutional polarization may be examined: authority, accountability, financing, procurement and logistics, strategic communication, and stewardship. Owing to the scope of a commentary, these domains are presented as a conceptual framework to guide future empirical analysis rather than examined exhaustively. The framework provides a structured lens through which institutional relationships may be analysed as Botswana’s health-sector reforms continue to evolve.
Institutional Polarization in Practice
Botswana’s recent health-sector reforms provide an important opportunity to illustrate the proposed framework. Since 2024, the country has undertaken significant institutional changes, including the transfer of primary health care to the Ministry of Local Government, emergency interventions following the 2025 medicines crisis, and the introduction of new financing arrangements intended to strengthen medicines security. These reforms were intended to strengthen health-system performance. They also created new institutional relationships that require careful coordination.
Viewed through the lens of institutional polarization, the central question is not whether these reforms were necessary. Reform is an essential part of health-system development. The more important question is whether evolving institutional arrangements continue to operate coherently towards shared policy objectives.
This commentary proposes six analytical domains through which institutional polarization may be examined: authority, accountability, financing, procurement and logistics, strategic communication, and stewardship. Together, these domains encourage attention to relationships between institutions rather than the performance of individual organisations alone. They ask whether mandates remain clear, whether accountability is understood, whether financing reinforces coordination, whether procurement responsibilities are aligned, whether communication presents a coherent governance narrative, and whether stewardship continues to integrate the health system during periods of reform.
This perspective has practical implications. Health-system reform should not be evaluated solely by the creation of new institutions or the announcement of new initiatives. It should also be assessed according to whether institutional relationships become more coherent over time. New governance arrangements should therefore be accompanied by clear reporting structures, transparent accountability mechanisms, regular public communication and well-defined institutional responsibilities. These principles strengthen trust, support implementation and enable continuous institutional learning.
Institutional polarization does not suggest institutional failure. Rather, it provides a complementary governance lens for understanding why implementation
challenges may persist despite the commitment of multiple institutions to the same public objective.
The concept therefore extends existing discussions of political polarization by drawing attention to the relationships within the institutional architecture of health systems. Botswana provides an important illustration of this governance challenge. More importantly, it demonstrates how health policy and systems research can move beyond describing reform towards developing concepts that help explain how reform succeeds, where it struggles, and how institutional coherence can ultimately be strengthened.
This commentary introduces institutional polarization as a complementary governance lens for understanding how institutional relationships shape health policy implementation during periods of reform. Rather than focusing on political or ideological divisions, it draws attention to the coherence of authority, accountability, financing, procurement and logistics, strategic communication, and stewardship across institutions pursuing shared health objectives.
Owing to the scope of a commentary, these analytical domains have been introduced rather than examined in detail. Subsequent papers will apply this framework to Botswana’s ongoing health-sector reforms, exploring each domain individually through the lenses of medicines governance, primary health-care decentralisation, emergency financing, institutional accountability and stewardship. Collectively, these studies will further refine the concept of institutional polarization and assess its usefulness as a governance framework for understanding health-system reform in Botswana and comparable health systems.
About the author
Dr Thabo Lucas Seleke is a Health Policy and Systems Research scholar whose work focuses on health systems governance, stewardship, implementation science and public sector reform. He holds a PhD in Health Policy and Systems Research from the London School of Hygiene and Tropical Medicine and an MSc in Global Health Policy and Management as a Fulbright Scholar in Boston, United States. He has also completed advanced training in cross-disciplinary qualitative health research at King’s College London. During his doctoral studies, he contributed to postgraduate teaching at LSHTM within the Faculty of Public Health and Policy. Dr Seleke previously served as a Global Health Fellow at the World Health Organization in the Department of Pandemic and Epidemic Diseases and currently serves as Deputy Chair of Botswana’s National Health Research Ethics Committee (NHREC) under the Ministry of Health.