Assessing performance of Botswana’s public hospital system: the use of the World Health Organization Health System Performance Assessment Framework

Background: Very few studies have assessed performance of Botswana public hospitals. We draw from a large research study assessing performance of the Botswana Ministry of Health (MoH) to evaluate the performance of public hospital system using the World Health Organization Health Systems Performance Assessment Framework (WHO HSPAF). We aimed to evaluate performance of Botswana public hospital system; relate findings of the assessment to the potential for improvements in hospital performance; and determine the usefulness of the WHO HSPAF in assessing performance of hospital systems in a developing country. Methods: This article is based on data collected from document analysis, 54 key informants comprising senior managers and staff of the MoH (N= 40) and senior officers from stakeholder organizations (N= 14), and surveys of 42 hospital managers and 389 health workers. Data from documents and transcripts were analyzed using content and thematic analysis while data analysis for surveys was descriptive determining proportions and percentages. Results: The organizational structure of the Botswana’s public hospital system, authority and decision-making are highly centralized. Overall physical access to health services is high. However, challenges in the distribution of facilities and inpatient beds create inequities and inefficiencies. Capacity of the hospitals t o deliver services is limited by inadequate resources. There are significant challenges with the quality of care. Conclusion: While Botswana invested considerably in building hospitals around the country resulting in high physical access to services, the organization and governance of the hospital system, and inadequate resources limit service delivery. The ongoing efforts to decentralize management of hospitals to district level entities should be expedited. The WHO HSPAF enabled us to conduct a comprehensive assessment of the public hospital system. Though relatively new, this approach proved useful in this study

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

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

Development of the systems thinking for health actions framework: a literature review and a case study

BACKGROUND: Systems thinking is an approach that views systems with a holistic lens, focusing on how components of systems are interconnected. Specifically, the application of systems thinking has proven to be beneficial when applied to health systems. Although there is plenty of theory surrounding systems thinking, there is a gap between the theoretical use of systems thinking and its actual application to tackle health challenges. This study aimed to create a framework to expose systems thinking characteristics in the design and implementation of actions to improve health. METHODS: A systematised literature review was conducted and a Taxonomy of Systems Thinking Objectives was adapted to develop the new 'Systems Thinking for Health Actions' (STHA) framework. The applicability of the framework was tested using the COVID-19 response in Pakistan as a case study. RESULTS: The framework identifies six key characteristics of systems thinking: (1) recognising and understanding interconnections and system structure, (2) identifying and understanding feedback, (3) identifying leverage points, (4) understanding dynamic behaviour, (5) using mental models to suggest possible solutions to a problem and (6) creating simulation models to test policies. The STHA framework proved beneficial in identifying systems thinking characteristics in the COVID-19 national health response in Pakistan. CONCLUSION: The proposed framework can provide support for those aiming to applying systems thinking while developing and implementing health actions. We also envision this framework as a retrospective tool that can help assess if systems thinking was applied in health actions

Assessing Performance of Botswana’s Public Hospital System: The Use of the World Health Organization Health System Performance Assessment Framework

Background: Very few studies have assessed performance of Botswana public hospitals. We draw from a large research study assessing performance of the Botswana Ministry of Health (MoH) to evaluate the performance of public hospital system using the World Health Organization Health Systems Performance Assessment Framework (WHO HSPAF). We aimed to evaluate performance of Botswana public hospital system; relate findings of the assessment to the potential for improvements in hospital performance; and determine the usefulness of the WHO HSPAF in assessing performance of hospital systems in a developing country. Methods:This article is based on data collected from document analysis, 54 key informants comprising senior managers and staff of the MoH (N= 40) and senior officers from stakeholder organizations (N= 14), and surveys of 42 hospital managers and 389 health workers. Data from documents and transcripts were analyzed using content and thematic analysis while data analysis for surveys was descriptive determining proportions and percentages. Results: The organizational structure of the Botswana’s public hospital system, authority and decision-making are highly centralized. Overall physical access to health services is high. However, challenges in the distribution of facilities and inpatient beds create inequities and inefficiencies. Capacity of the hospitals to deliver services is limited by inadequate resources. There are significant challenges with the quality of care. Conclusion:While Botswana invested considerably in building hospitals around the country resulting in high physical access to services, the organization and governance of the hospital system, and inadequate resources limit service delivery. The ongoing efforts to decentralize management of hospitals to district level entities should be expedited. The WHO HSPAF enabled us to conduct a comprehensive assessment of the public hospital system. Though relatively new, this approach proved useful in this study

Organizational Structure of the Botswana Ministry of Health: Impact on Performance

The Botswana Ministry of Health was prompted to review its organizational structure as part of public sector strategies to improve performance, and as a response to an internal review in 2000 which concluded that performance was unsatisfactory. A team of consultants was engaged to review the existing structure. A new structure was adopted in 2005. This PhD study was designed to assess performance of the Ministry following adoption of this structure. The overall goal of this study was to assess the impact of the 2005 organizational structure on the Ministry’s performance. Taking a case study approach, and using a mixed methods design, this study used the WHO Health Systems Performance Assessment Framework as a conceptual model to assess the Ministry’s performance in four key health system functions:- stewardship, health financing, resource generation and service provision. Performance indicators were identified for each function and used to assess the Ministry’s performance. Data were collected through document review, interviews with key informants comprising of policy makers, senior Ministry of Health officials, staff in charge of key processes at the Ministry (N=40), key stakeholders (N=14), surveys of health workers (N=389) and health managers (N=42), and focus group interviews (3) of health workers in two referral hospitals. The organizational structure adopted in 2005 fitted well with policy objectives. However, this structure was not adequately implemented, and hence had limited impact on the Ministry’s performance. Failure to fully implement this structure was attributed to ineffective management of the restructuring process and limited human resource capacity to undertake new responsibilities. The Ministry had limited capacity for policy development, strategic planning and oversight. Rapid turnover of senior management exacerbated the leadership challenges. The health system in Botswana is adequately funded by the government and has the potential to ensure universal access to health care services. However, the Ministry of Health has chronic challenges in financial management including poor revenue collection, inadequate budget management, under-expenditure, and limited use of evidence to support resource allocations decisions. The government made considerable investment in health infrastructure increasing physical access to services for the majority of the population. Yet, inadequate planning and management of human resources and medical equipment, and ineffective supply management systems, contributed to imbalance in key health system resources undermining delivery of services. Provision of health services in public hospitals was limited by over-centralization of decision-making and control of resources at the Ministry headquarters, inadequate resources, and poorly motivated workforce. Efforts to strengthen the health system in Botswana need to focus on building leadership capacity to support all the functions of the system. Reconsideration of the governance structures of public hospitals to improve performance is essential

Organizational Structure of the Botswana Ministry of Health: Impact on Performance

The Botswana Ministry of Health was prompted to review its organizational structure as part of public sector strategies to improve performance, and as a response to an internal review in 2000 which concluded that performance was unsatisfactory. A team of consultants was engaged to review the existing structure. A new structure was adopted in 2005. This PhD study was designed to assess performance of the Ministry following adoption of this structure. The overall goal of this study was to assess the impact of the 2005 organizational structure on the Ministry’s performance. Taking a case study approach, and using a mixed methods design, this study used the WHO Health Systems Performance Assessment Framework as a conceptual model to assess the Ministry’s performance in four key health system functions:- stewardship, health financing, resource generation and service provision. Performance indicators were identified for each function and used to assess the Ministry’s performance. Data were collected through document review, interviews with key informants comprising of policy makers, senior Ministry of Health officials, staff in charge of key processes at the Ministry (N=40), key stakeholders (N=14), surveys of health workers (N=389) and health managers (N=42), and focus group interviews (3) of health workers in two referral hospitals. The organizational structure adopted in 2005 fitted well with policy objectives. However, this structure was not adequately implemented, and hence had limited impact on the Ministry’s performance. Failure to fully implement this structure was attributed to ineffective management of the restructuring process and limited human resource capacity to undertake new responsibilities. The Ministry had limited capacity for policy development, strategic planning and oversight. Rapid turnover of senior management exacerbated the leadership challenges. The health system in Botswana is adequately funded by the government and has the potential to ensure universal access to health care services. However, the Ministry of Health has chronic challenges in financial management including poor revenue collection, inadequate budget management, under-expenditure, and limited use of evidence to support resource allocations decisions. The government made considerable investment in health infrastructure increasing physical access to services for the majority of the population. Yet, inadequate planning and management of human resources and medical equipment, and ineffective supply management systems, contributed to imbalance in key health system resources undermining delivery of services. Provision of health services in public hospitals was limited by over-centralization of decision-making and control of resources at the Ministry headquarters, inadequate resources, and poorly motivated workforce. Efforts to strengthen the health system in Botswana need to focus on building leadership capacity to support all the functions of the system. Reconsideration of the governance structures of public hospitals to improve performance is essential

Adoption and Utilization of Integrated Patient Management System in Botswana Public Health Facilities

Information and Communication Technology (ICT) use in the healthcare sector has gained momentum over a period of time. The aim of this study was to evaluate the adoption and utilization of the integrated patient management system (IPMS) in health facilities in Botswana. A mixed-method approach was adopted in this study. The simple sampling procedure was adopted and used among the sample size of four hundred and twenty healthcare workers. The quantitative questionnaire and interviews were used to collect data for this study. The findings of this study showed that IPMS adoption brings about better performance and is very productive for a tiring healthcare setting. The results also show that the use of IPMS helps medical practitioners to deliver quality healthcare service and it benefits the population at large since services become faster and more efficient. This recommends that all health facilities should be provided with enough and relevant resources and support needed to effectively use and reap the benefits of the IPMS. In addition, the Ministry of Health and Wellness and all the concerned education stakeholders need to make sure that ICT adoption and use in healthcare are maintained and encouraged through training and workshops so that the user is well-equipped with the appropriate use of technology to achieve the desired results

A Review of the User Fees Policy for Primary Healthcare Consultations in Botswana: Problems With Effective Planning, Implementation and Evaluation

Background: The Government of Botswana introduced user-fees for primary healthcare consultations in 1975. The policy has remained in place since then, although the fee has remained largely unaltered despite rising inflation. Early reviews of the policy pointed to problems in its implementation, but there has been no evaluation in the past 20 years. The aim of this study was to review the policy to assess whether documented issues with its implementation have been addressed. Methods: This qualitative study involved interviews with 32 key informants: 18 policy-makers and 14 front-line revenue collectors. Data were analysed thematically using a template approach with constructs from an established organizational capacity assessment framework used as predetermined categories to guide data collection and analysis. Results: Limited administrative and management capacity has been a major hindrance to effective implementation of the policy. The lack of infrastructure for effective revenue collection led to misappropriation of funds. Lack of clear guidelines for health facilities on how to implement the policy generated interdepartmental conflicts. Study participants believed the current policy was unlikely to be cost-effective since the cost of collecting fees probably exceeded the revenue it generated. Conclusion: If the Botswana Government persists with the policy then it needs to improve organizational capacity to collect and manage revenues efficiently. However, policy thinking since the turn of the century has turned away from user-charges in healthcare as they impede the move towards universal access. It is timely therefore to consider alternative financing approaches that are more effective and a more equitable means of paying for healthcare.</jats:p