Leadership and governance
The leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system. It is about the role of the government in health and its relation to other actors whose activities impact on health. This involves overseeing and guiding the whole health system, private as well as public, in order to protect the public interest.
It requires both political and technical action, because it involves reconciling competing demands for limited resources in changing circumstances, for example with rising expectations, more pluralistic societies, decentralization or a growing private sector. There is increased attention to corruption and calls for a more human rights based approach to health. There is no blueprint for effective health leadership and governance. While ultimately it is the responsibility of government, this does not mean all leadership and governance functions have to be carried out by central ministries of health.
Experience suggests that there are some key functions common to all health systems, irrespective of how these are organized:
- Policy guidance: formulating sector strategies and also specific technical policies; defining goals, directions and spending priorities across services; identifying the roles of public, private and voluntary actors and the role of civil society.
- Intelligence and oversight: ensuring generation, analysis and use of intelligence on trends and differentials in inputs, service access, coverage, safety; on responsiveness, financial protection and health outcomes, especially for vulnerable groups; on the effects of policies and reforms; on the political environment and opportunities for action; and on policy options.
- Collaboration and coalition building: across sectors in government and with actors outside government, including civil society, to influence action on key determinants of health and access to health services; to generate support for public policies and to keep the different parts connected – so called "joined up government".
- Regulation: designing regulations and incentives and ensuring they are fairly enforced.
- System design: ensuring a fit between strategy and structure and reducing duplication and fragmentation.
- Accountability: ensuring all health system actors are held publicly accountable. Transparency is required to achieve real accountability.
An increasing range of instruments and institutions exists to carry out the functions required for effective leadership and governance. Instruments include:
- sector policies and medium-term expenditure frameworks
- standardized benefit packages
- resource allocation formulae
- performance-based contracts
- patients' charters
- explicit government commitments to non-discrimination and public participation
- public fee schedules.
Institutions involved may include:
- other ministries, parliaments and their committees
- other levels of government
- independent statutory bodies such as professional councils, inspectorates and audit commissions
- nongovernment organization "watch dogs" and a free media.
This section of the health system profile is structured as follows:
The Ministry of Health in Botswana has the responsibility for the overall improvement and maintenance of national health. It sets broad policy directions, goals and strategies for health development and delivery.
The Ministry of Health is headed by the Minister, who provides political leadership. He is assisted by the Assistant Minister. The Permanent Secretary is the head of the executive arm of the Ministry. Under the Permanent Secretary there are four Deputy Permanent Secretaries one being the Director of Health Services and the remaining three heading Clinical Services, Preventive Services and Corporate Services.
The Ministry has 11 departments led by Directors (see figure). The departments are:
- Policy, Planning, Monitoring and Evaluation
- Health Sector Relations and Partnership
- Ministry Management
- AIDS Prevention and Care
- Clinical Services
- Public Health
- Health Inspectorate
- Health Hub
- MASA (antiretroviral treatment)
- Corporate Services
- The Office of Strategy Management, which is a new division to oversee the Ministry’s strategy and projects.
Through an open democratic decision-making process, the Government of Botswana’s policy formulation and review process ensures that every citizen and every sector of the economy make a contribution to the overall national policy framework.
Since 2010, with the exception of environmental health, all primary health care services that had been provided by the Ministry of Local Government have been relocated to the Ministry of Health. Now the responsibility for all public health facilities has been taken by the 29 district health management teams, each of which has a designated geographical area. District health management teams are organized into curative, preventive and corporate services.
The districts develop plans that are aligned to the national strategy and negotiate a budget with the Ministry of Health annually. Entrusting all health care delivery to district health management teams ensures decentralization of the delivery of services to communities.