Assessing performance of Botswana’s public hospital system: the use of the World Health Organization Health System Performance Assessment Framework

Abstract

Background: Very few studies have assessed performance of Botswana public hospitals. We draw from a large research study assessing performance of the Botswana Ministry of Health (MoH) to evaluate the performance of public hospital system using the World Health Organization Health Systems Performance Assessment Framework (WHO HSPAF). We aimed to evaluate performance of Botswana public hospital system; relate findings of the assessment to the potential for improvements in hospital performance; and determine the usefulness of the WHO HSPAF in assessing performance of hospital systems in a developing country. Methods: This article is based on data collected from document analysis, 54 key informants comprising senior managers and staff of the MoH (N= 40) and senior officers from stakeholder organizations (N= 14), and surveys of 42 hospital managers and 389 health workers. Data from documents and transcripts were analyzed using content and thematic analysis while data analysis for surveys was descriptive determining proportions and percentages. Results: The organizational structure of the Botswana's public hospital system, authority and decision-making are highly centralized. Overall physical access to health services is high. However, challenges in the distribution of facilities and inpatient beds create inequities and inefficiencies. Capacity of the hospitals to deliver services is limited by inadequate resources. There are significant challenges with the quality of care. Conclusion: While Botswana invested considerably in building hospitals around the country resulting in high physical access to services, the organization and governance of the hospital system, and inadequate resources limit service delivery. The ongoing efforts to decentralize management of hospitals to district level entities should be expedited. The WHO HSPAF enabled us to conduct a comprehensive assessment of the public hospital system. Though relatively new, this approach proved useful in this study. Implications for policy makers • Public hospitals are under pressure to improve their performance. There is a need to understand how they function and the challenges they face that affect how they perform.• Centralization of decision-making and authority over resources needed for delivery of services negatively affect the functioning of the hospital. There is a need to reconsider how the hospital system is organized.• In monitoring access to services, it is important to go beyond national averages to consider sub-national or regional differences.• Access to services is also determined by availability of resources. Implications for publicComprehensive assessment of public hospitals enabled identification of strengths and weaknesses in the system that can be used to inform development of policies and strategies to improve the system. The framework used to guide this study allowed for different stakeholders perspectives making the assessment more holistic.

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