Abstract
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.