Author: Tshepang Kekonnwe
A roof protects a house, yet it becomes a costly gesture without walls or a foundation. Botswana faces this exact risk as it rethinks healthcare financing. The government currently works toward a National Health Insurance (NHI) scheme to expand coverage. This move signifies an attempt to transition away from point-of-service user fees. However, this funding reform unfolds within a health system struggling with medicine shortages. Strained service delivery further complicates the introduction of new financial models. In these conditions, changing the funding mechanism without restoring healthcare quality prioritizes form over function. Consequently, the Organisation must argue that financing reform must follow functionality to be effective. Otherwise, the state risks building a “roof” that offers its citizens no real protection.
A User Fee Model That No Longer Pays
Botswana introduced user fees for primary healthcare in 1975 to recover costs. The state intended for these fees to ease pressure on government spending. Despite inflation and population growth, the policy has remained largely stagnant for over fifty years. Citizens currently pay a nominal P5 fee for three months of unlimited access. Most economists regard this figure as economically insignificant in the modern market. Recent studies indicate that the administrative cost of collecting these fees likely exceeds the revenue. This failure highlights a poor return on investment and weak public financial management. Furthermore, the administrative system relies on manual processes and suffers from staff shortages. Because the treasury absorbs all revenue, facilities lack the incentive to improve collection.
When Paying at the Clinic Undermines Universal Access
User fees directly undermine the principles of equality and universal health access. The government maintains a legal and political commitment to Universal Health Coverage (UHC). Charging patients at the point of care creates a fundamental contradiction with this goal. While the state exempts the poor and elderly, enforcement remains dangerously weak. Evidence suggests that user fees discourage low-income groups from seeking timely care. This delay ultimately increases long-term health costs and economic burdens. Moreover, institutional failures weaken the policy as the Ministry of Health provides limited guidance. Conflicting policies often confuse staff by demanding fees while insisting they turn no one away. Such oversight failures lead to misappropriation of funds and security risks in many facilities.
The Shift Toward NHI — and Its Risks
The failure of cost-sharing policies prompts a shift toward mandatory health insurance models. International bodies like the WHO now discourage user fees due to their negative equity effects. Insurance systems offer a more predictable and equitable alignment with UHC goals. The government aims to achieve a UHC index of 75 by the year 2030. This plan requires diversifying financing beyond the central government budget. The Botswana Economic Transformation Plan (BTAP) guides this national economic and healthcare transition. By reducing the government’s spending share, the state hopes to stabilize the national economy. However, shifting the burden from the treasury to the people requires a high level of public trust. Without demonstrable system improvements, the public may view insurance as a new tax rather than a benefit.
Function Before Finance
Some critics argue that countries can move directly into NHI schemes without prior reforms. Historically, Botswana has provided public health services at little to no cost. Because citizens face limited financial risk at the point of use, they feel little incentive to pay premiums. Many households view insurance as an unnecessary burden in a constrained economy. This perception creates a significant hurdle for any self-financed insurance scheme. A roof cannot hold if the walls beneath it continue to crumble. Therefore, the government must stabilize basic service delivery before introducing complex insurance reforms. Financing reform should always follow functionality to ensure value for the taxpayer. If the state ignores these structural weaknesses, it will leave the people exposed to a failing system.
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