Analytical summary - Universal coverage
For ease of management and coordination, Botswana's public health sector is organized into 29 health districts through district health management teams. Each district is responsible for taking stock of its population to ensure accessibility of health services to all. The National Health Policy incorporates socioeconomic determinants of health such as poverty and lifestyle such that the economically disadvantaged populations have access to quality health care.
The involvement of local structures such as village development committees ensures identification of populations that need special attention, such as the poor, orphans and vulnerable populations, young people, older people and people with disability. The organization of the health care delivery system by facility level and the referral system provides some degree of standardization of service packages at different levels of facilities.
For instance, the range of services provided at the district hospitals is more comprehensive than that provided in clinics. Treatment guidelines are provided in health facilities to help standardize treatment, care and referral and enhance equity in service provision.
However, unless there is a form of social insurance with a defined service package, Botswana cannot claim universal coverage. The medical schemes that are available in the country cover only the 20% of the population that is constituted mainly by those who are employed.
The insured population can access high-technology specialized health services, partly paid for by the employer, while those without insurance (comprising mainly of the unemployed and the poor), have to pay 100% of the bill out-of-pocket to be able to access high-technology specialized services. Access to public sector high-technology specialized care for the uninsured is controlled through the referral system. The uninsured have therefore limited opportunity to choose the services that they prefer because the decision rests with the public service provider at the basic level who triages patients and determines who passes to the next level based on criteria such as disease category, demographic group or level of care.
Botswana has therefore yet to come up with a financing system that gives equal access to all. The country has not developed a reliable mechanism of determining who can afford to pay the nominal fee for health services and who can not.
Other potential challenges yet to be explored through systematic research include:
- the possibility of stigma of being classified as poor;
- the difficulty in determining income in the informal sector such as farming (particularly as Batswana may be reluctant to disclose their wealth);
- the cost of cost recovery that may actually exceed what is collected.