11 hours ago
8
Shortages of medicine in Botswana forced me to declare a public health emergency last year. Patients went without treatment – not because health workers failed them, but because the system did. For a nation committed to universal healthcare, free at the point of use, it was a moment of hard truth.
Even outwardly strong public health systems can be fragile. As donor assistance bites across the continent, governments cannot afford to delay building resilience.
As a stable, middle-income country, Botswana was only ever a peripheral recipient of aid. Yet when diamond revenues – the country’s primary export – fell amid a market downturn, the fiscal shock was no different in effect.
For many, the conclusion was simple: less revenue leads to worse health outcomes.
The reality is more nuanced. Diamond revenues enabled Botswana to build a universal public health system. Even in one of the world’s most sparsely populated countries, most people in Botswana are rarely more than five kilometres away from a clinic.
Yet the same diamond revenues that built our system also masked its weaknesses. Problems were paid away rather than fixed. Drug prices were inflated many times over. Supply chains were inefficient. Public capacity was hollowed out through outsourcing. These failures did not suddenly appear but accumulated over the years.
Falling revenues simply made them impossible to ignore. When healthcare systems face a moment of reckoning, the same prescription is reliably offered: inject more “private-sector rigour” into inefficient public health delivery. But greater reliance on private provision fragments care, raises costs and diverts scarce health budgets into profit margins.
Private providers have an important role to play. Still, where care can be delivered at cost within a strong public system, it is simply more affordable – and more sustainable – than outsourcing it.
Moreover, when healthcare is outsourced, accountability becomes blurred. But when shortages hit, it is the government that people turn to. Democratic responsibility cannot be subcontracted.
Botswana is expanding public capacity. We are bringing our largest private hospital into public ownership to relieve pressure on overstretched facilities.
We are restructuring the national medicines procurement body, making it autonomous to cut bureaucratic delays. A national health intelligence centre will soon be operational, using real-time data to forecast medicine demand and prevent shortages. And once the health insurance bill passes parliament, health funding will be ringfenced – ending our exposure to swings in commodity markets.
Together, these reforms will determine whether a mother can find antibiotics for her child, or whether a patient needing dialysis must travel huge distances for care.
But no country of two-and-a-half million people can fully secure its medicine supply alone. Africa must ultimately produce more of the treatments its people rely on. The African Continental Free Trade Area (AfCFTA), which brings 55 countries into a single market, offers a chance to do what Europe and Asia did decades ago: build regional pharmaceutical industries designed to serve public health first.
Pharmaceutical manufacturing needs scale and predictable demand. AfCFTA provides both, turning fragmented national markets into a regional economy large enough to draw investment. It also creates the conditions for governments to use African suppliers in public procurement, turning health budgets into a driver of industrial development.
AfCFTA has been largely ratified, yet implementation remains uneven. Now governments must give it force through their laws, their institutions and their choices.
Ambition for the continent only works when governments take responsibility at home.
Resilience is not created by spending alone; it is built through public capacity, which only governments can sustain. Botswana has learned this through crisis. Diamond revenues built our healthcare system; dependence on them weakened it. Shock exposed the cracks. Now reform must rebuild it.
-
Duma Gideon Boko is president of Botswana
