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 Data were abstracted from published and unpublished documents.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
