The World Bank has warned that Botswana’s public health system is facing a persistent essential medicines crisis. The bank says stockouts are being driven by systemic failures in forecasting, procurement, data management, warehousing and distribution.
The findings are contained in the Botswana Health Public Expenditure Review which paints a picture of a health system receiving relatively high budget allocations but struggling to convert public spending into reliable services for citizens. The report states bluntly that ‘challenges with stockouts of essential medicines in the public sector are a continuing concern.’
According to the World Bank, Central Medical Stores (CMS) tracks the availability of vital, essential and necessary medicines, but all three categories remained below the government’s 97 percent availability target during the three years for which data was available. The World Bank says previous assessments had already shown that CMS order-fill rates had been declining since 2014. The report identifies poor forecasting and quantification caused by poor-quality data, irrational medicine use, including prescribers’ preference for branded medicines, procurement processes that are not aligned with health-sector needs, and inadequate warehousing and distribution capacity.
The World Bank also takes aim at Botswana’s fragmented information management systems, warning that they may fail to provide government with timely, adequate and actionable information.
‘The absence of quality data undermines the ability of government and partners to plan, monitor, and evaluate health performance,’ the report states. The weaknesses extend to monitoring and accountability. The report highlights the lack of regular data-quality audits, inadequate capacity to synthesise and use strategic information and the absence of key structures such as a national monitoring and evaluation plan. District Health Management Teams also lack sufficient personnel dedicated to monitoring and evaluation, while accountability for programme data quality is largely concentrated among national-level programme leaders.
But the medicines crisis is only one symptom of what the World Bank describes as a broader problem of inefficiency in Botswana’s health expenditure. The report says weak budgeting and public financial management arrangements are contributing to poor performance, including weak links between annual work plans and budgets, insufficient decentralisation of spending responsibilities, poor budget execution and weaknesses in information used for planning. The World Bank cites evidence that in 2019 only 14 percent of the Vulnerable Groups Feeding Programme ration reached intended recipients, while in districts with the highest prevalence of moderate and severe underweight, the proportion was estimated to be as low as 7 percent.
Despite relatively high health allocations, Botswana’s public health expenditure is described as inefficient with recurring expenditure consuming 96 percent of total public health spending on average between 2017/18 and 2020/21, leaving development spending crowded out. The report also says spending is heavily skewed towards hospitals, which are generally less cost-effective than primary healthcare, while inadequate investment in medical equipment contributes to referrals to private providers locally and abroad.
Botswana is also spending heavily on private healthcare providers and specialists. Fees paid to private providers accounted for 7 percent of total public health expenditure, rising from about P524 million in 2017/18 to P958 million in 2021/22.The World Bank warns that the concentration of spending within the Ministry of Health further obscures accountability and makes it difficult to track resources against strategic health objectives. The report says the Department of Health Services Management accounted for about 87 percent of Ministry of Health expenditure, effectively creating what it describes as a ‘ministry within a ministry.’