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Analytical summary - Health financing system

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Botswana operates a democratic system in which Parliament oversees the Government’s budgetary process. Budget ceilings are based on annual fiscal forecast. A dual budget process of separately reconciled recurrent and capital budget, all coordinated by the Ministry of Finance and Development Planning, is adopted. The ministries select projects based upon programme priorities determined by sector strategies. Government funding for health is distributed to the Ministry of Health (64%), National AIDS Coordinating Agency (9%) and the Ministry of Education and Skills Development (3%).

The remaining 24% goes to private financing agents such as insurance schemes, households and nongovernmental organizations. A cost recovery consultation fee of US$ 70 is charged for clients visiting public health facilities. Foreigners pay a little more (US$ 4). Antiretroviral and sexual and reproductive services are offered free to citizens.

Wages and salaries account for a large proportion of the Government of Botswana's expenditure. The country’s wage bill as a percentage of gross domestic product and of total Government expenditure was reported to be the largest in Africa in 2008. Salaries and allowances have averaged 55% of the Government’s recurrent health expenditure. The total health expenditure and the proportion of gross domestic product allocated to health exceed the 15% minimum of the Abuja Declaration.

Funding for health care is mainly from the Government, with international agencies contributing only modestly, mainly in the area of HIV/AIDS. Medical insurance schemes include the Botswana Public Officers Medical Aid Scheme, Medical Aid Society, Pula Medical Aid Fund, and Itekanele Health Scheme. There are some insurance brokers that provide health insurance coverage for those who move across Botswana and other countries.

Health care private sector spending increases public sector spending by one third (Second Country Assessment). Reflecting both the commitment to invest in health and the increasing burden of HIV/AIDS, the Government’s expenditure on health per capita increased from US$ 10 to US$ 330, and development expenditure on health increased from US$ 39.3 million to US$ 1.7 billion between 1975 and 2009.

The Public Procurement and Asset Disposal Act of 2002 uses a decentralized approach with public entities made responsible for managing procurement with the role of oversight, regulation, and monitoring and evaluation. Open bidding is the default procurement approach. The regulatory framework for procurement provides for an administrative review board, which is responsible for the resolution of complaints submitted.

The Government employs a computerized system for expenditure management accounting and financial reporting with commitment control being built into the system. However, some expenditure is still managed manually through a votes’ ledger. Tax payers are registered in a comprehensive database system that is directly linked to other relevant Government registration systems. The penalties for non-compliance are set sufficiently high to be effective.

Institution of measures to reduce salary bills and reconciliation of the budget for hospital care and preventive care to reflect emphasis on prevention are some of the areas that the Government still needs to address.