As Botswana moves toward National Health Insurance under what I have termed Duma Care, global lessons especially from the United States’ Affordable Care Act suggest a simple but critical truth: financing reform cannot succeed without a strong primary health care foundation. This builds directly on my 29 March 2026 article, ‘Duma Care: Can National Health Insurance Deliver Without Strong Primary Health Care in Botswana,’ which raised the foundational question of system readiness. In the weeks ahead, this forms part of a broader series examining comparative NHI pathways drawing on Rwanda and Thailand, while engaging critically with South Africa and Ghana.
A fortnight ago, I argued that National Health Insurance (NHI), as framed through Duma Care, cannot succeed without a strong primary health care (PHC) foundation. That argument has since sparked reflection and debate. It is therefore important to go a step further not to retreat, but to clarify. It is necessary to explain why the comparison with Obamacare matters, and what Botswana can learn not as imitation, but as guidance.
The comparison is not about copying the United States. It is about understanding how politically visible health reforms behave when they meet real systems. That is where the story of Obamacare becomes instructive.
What Was Obamacare, really?
To fully appreciate the logic of the Affordable Care Act, it must be situated within its historical trajectory. The U.S. had, by 1965, already established significant public insurance programs: Medicare and Medicaid. While these initiatives broadened healthcare availability for seniors and those with limited means, a substantial number of working-age Americans remained uninsured.
Consequently, the system was characterized by fragmentation, offering only incomplete coverage rather than a unified solution. In the USA, the Affordable Care Act aimed to fix the problems in the existing health care system , rather than completely changing it.
The aim was clear: expand insurance coverage, reduce the number of people without it, lower healthcare costs, and establish essential protections for consumers.
It operated within a pre-existing framework, one defined by robust private insurance, cutting-edge hospitals, and a well-established regulatory apparatus.
Through insurance marketplaces, subsidies, Medicaid expansion, and protections against exclusion, it extended access within a functioning though unequal system.
Why That Design Matters?
The design of Obamacare reflected the system it entered. The United States already had service delivery infrastructure. The problem was not availability, but access. Institutional capacity also existed. Health Insurance markets and regulatory systems were already functional. Reform could therefore build rather than create.
Political factors also influenced the model’s development. Because a fully public system wasn’t feasible, a hybrid approach was chosen, combining public oversight with private service delivery.
Duma Care in Context
Botswana’s starting point is different. Duma Care is taking shape within a system that’s largely funded by public money, even as financial strains grow. National Health Accounts and recent budgets reveal that the government is still the primary source of funding. However, the available financial resources are shrinking, partly due to slower diamond revenues and the need to address other pressing needs.
Recent system shocks have made these pressures visible. The 2025 medicines crisis exposed vulnerabilities in procurement, financing flows, and coordination. Primary health care remains under-resourced relative to hospital-based care, while governance arrangements continue to evolve.
This is not a criticism. It is a reality. And it matters because NHI is not simply about mobilising funds; it is about how those funds move through a system that must already deliver care consistently. At this point, the comparison with Obamacare becomes a diagnostic tool.
At the same time, discussions around new financing instruments including proposals linked to a national fund managed through structures such as the Botswana Development Corporation add complexity. While resource mobilisation is necessary, the creation of parallel funding streams without integration risks fragmentation. International experience shows that multiple pools without unified governance can weaken accountability rather than strengthen efficiency. The question is therefore not whether to innovate, but whether new mechanisms are fully aligned within a coherent system.
The Core Difference
The distinction is simple but profound. Obamacare expanded access within a system that was already functioning. Duma Care is being introduced into a system still adjusting to fiscal and operational pressures.
In the United States, the central question was how to make care affordable. In Botswana, the question must first be whether the system can deliver care reliably before financing expands. Without that assurance, reform risks amplifying existing weaknesses.
It is precisely when financing ambition outpaces system readiness that reform begins to encounter friction sometimes quietly, sometimes visibly.
Global experience reinforces this point. Ghana expanded coverage but later faced payment delays and sustainability pressures. South Africa continues to grapple with governance and institutional readiness. Zimbabwe’s fragmented financing weakened coordination. These are not failures of ambition. They are reminders that financing reform cannot substitute for system capacity.
Why Primary Health Care Must Come First?
This brings us to the central issue. Primary health care is not peripheral. It is the foundation.
When primary healthcare works well, patients receive timely care, chronic illnesses are managed, and hospitals are less likely to be overwhelmed.
This approach also helps control expenses, resulting in more consistent care.
Where PHC is weak, the opposite occurs: bypassing, congestion, rising costs, and fragmentation.
Countries such as Thailand and Rwanda succeeded because they invested in PHC before expanding insurance. Their reforms were sequenced.
Botswana’s healthcare system illustrates the consequences of imbalance. The situation at Sir Ketumile Masire Teaching Hospital shows how tertiary facilities can become overburdened when primary care and referral systems aren’t working well.
These facilities, instead of just being specialized centers, are also responsible for managing conditions that should have been treated earlier. This situation increases costs and puts a strain on the healthcare system.
The issue is not the existence of advanced care, but the order in which system capacity is built.
Is Botswana Ready for NHI?
This is where honesty is required. Botswana has important strengths: a history of public investment, a functioning private sector, and strong political commitment to universal health coverage.
However, there are also clear constraints. Fiscal pressures are increasing. Supply chains have shown fragility. Primary health care remains uneven. Governance systems are still consolidating.
These conditions suggest that while the direction of reform is correct, sequencing matters. Botswana might not be quite prepared for a nationwide rollout of the National Health Insurance scheme as it stands.
This is not a rejection of reform. It is a call for alignment between ambition and readiness.
If Duma Care is to succeed, reform must strengthen the system rather than stretch it.This requires prioritising primary health care, improving governance clarity, and stabilising financing and procurement systems. These are not delays. They are prerequisites.
International experience shows that when these foundations are in place, financing reforms can deliver. Without them, even well-designed policies struggle.
Lessons from Obamacare
There are still lessons Botswana can draw. Political leadership matters. Communication and honesty matters. Equity must remain central. Reform can be incremental.
Most importantly, Obamacare did not attempt to fix everything at once. It expanded coverage within a system already capable of delivering care. That sequencing made it possible.
Duma Care is a powerful and necessary idea. It speaks to fairness, dignity, and the right to health. But systems are not built on vision alone. They are built on capacity, coordination, and trust.
The comparison with Obamacare is not about imitation. It is about fit. Botswana now stands at a critical moment. It can implement NHI in a way that is both effective and sustainable.
The question is not whether to move forward. It is how to move forward wisely. The risk is not that Botswana is moving in the wrong direction, but that it may be moving faster than the system can sustain. In health systems, pace without preparation often comes at a cost.
The author has training and experience in global health policy and financing. He holds a Master of Public Administration from the University of Botswana and completed an MSc in Global Health Policy and Management as a Fulbright Scholar in Boston, United States, where health care financing formed a core area of study, including the Affordable Care Act, National Health Accounts, and health systems strengthening. He also served as a Global Health Fellow at the World Health Organization headquarters in Geneva, Switzerland. He holds a PhD in Health Policy and Systems Research from the London School of Hygiene and Tropical Medicine and is affiliated with the University of Botswana. He also served as a volunteer on the 2012 United States presidential election campaign team of Barack Obama, supporting community mobilisation efforts in New Hampshire.