From Health Emergency to Opportunity
On 26 August 2025, President Duma Boko declared a national public health emergency, citing the collapse of the medical supply chain, medicine shortages across hospitals and clinics, and an immediate need for emergency procurement and military‑led distribution. The announcement underscored the depth of systemic pressures, procurement inefficiencies, fiscal headwinds from a weak diamond market, and a heavy disease burden, now converging into an acute crisis.[1][2]
As unsettling as this moment is, it can also be a pivot point. Botswana is entering its demographic‑dividend window, the period when the share of working‑age citizens is high relative to dependants. This creates a rare chance to turn today’s emergency into long‑term prosperity if we fix foundational health, water, sanitation & hygiene (WaSH), and infrastructure systems. Furthermore, we need to align education, jobs, and financing to productive urban growth.[3][4]
1. Botswana Health and WaSH Landscape
Health services
- Public footprint: As of 2013 the Ministry of Health (MoH) administered 664 facilities, including 35 hospitals. Day‑to‑day operations are being deconcentrated to 27 District Health Management Teams (DHMTs) and referral hospitals.[5]
- Private footprint: ~468 private facilities (including 8 private hospitals and more than 100 pharmacies) serve mainly insured and urban populations. Nine medical aid schemes (MAS) cover ~17% of Batswana.[5]
Disease burden—Communicable + Non-Communicable Diseases (NCDs)
- HIV/AIDS remains defining: adult prevalence was ~19.9% in 2025; all citizens are eligible for free ART. The country has achieved UNAIDS 95-95-95 targets.
- Tuberculosis (TB), lower respiratory infections, diarrhoeal disease, and neonatal complications also weigh heavily.
- Meanwhile NCDs (cardio‑metabolic disease, cancers, diabetes) are rising.[5]
- Life expectancy rebounded from the AIDS trough and stand at ~70 years in 2025; on current trends it can reach ~74 by 2043, and ~75 with an ambitious Health/WaSH push.
- Infant mortality is on a long decline, is estimated at 25.56 deaths per 1,000 live births, reflecting a 2.26% decline from 2024.[3]
WaSH coverage: gains, gaps, and stark inequities
- Water access (2022 Census analytics): Cities/towns show 97% of households with improved safe water infrastructure; rural areas ~52%; overall averages mask deep district disparities (e.g., Okavango Delta 2%; CKGR 10.7%).[6]
- Sanitation: ~90% of city households have improved sanitation; urban villages ~53%; rural areas ~22%. Flush toilets dominate in major towns; pit latrines/dry compost systems are prevalent in many rural districts.[6]
- Systemic issues: UNICEF’s 2023 sector analysis flags policy fragmentation, institutional underinvestment, and data gaps, especially for sanitation in schools, slowing SDG 6 progress.[7]
2. Demographics & Labour: Botswana’s Window Is Opening
- Population is projected to reach ~3.3 million by 2043; fertility fell from 6.7 (1970) to 2.63 (2025) and is on the decline.
- The working‑age share is expected to grow from 63.96% (2025) to ~67% (2043). Botswana entered its dividend window this year, with the working‑age to dependant ratio crossing 1.77:1 and strengthening through the 2030s–40s (median age ~30 by 2043).[3]
- A ratio above 1.5 is generally favorable for economic productivity, as it suggests a strong base of potential workers relative to dependents.
- This demographic structure supports Botswana’s potential for growth, especially if employment opportunities and skills development keep pace
- However, this dividend is not automatic. To convert it into incomes and jobs, we must raise learning quality, expand productive employment (especially in tradables), and deliver universal basic services to lift labour productivity.[4]
- The clarion call by the leadership to therefore fix the health crisis is well informed. But not only do we need to fix the health sector, the other pillars on employment creation, learning quality, economic inclusion, among others are equally critical.
3. Funding & Infrastructure Gaps: What the numbers say
- Health financing mix: The government covers ~57% of total health expenditure; private spending has surged since 2005 via MAS. Out‑of‑pocket (OOP) shares are comparatively low (~5%).[5]
- Inequity: In 2010, MAS spent BWP 4,885 per member vs BWP 1,536 per capita in the public system—two unequal systems for two populations.[5] That means those accessing the private health gets a cover almost three times those accessing the public health highlighting the high inequality in the populace.
- HIV fiscal weight: HIV has consumed ~40–65% of total health spending in various years; donor flows have declined, demanding more domestic financing and efficiency.[5]
- Aggregate financing gap: An earlier MoH analysis estimated a BWP 1.6 bn shortfall in 2015, rising towards BWP 3 bn/year by 2023—driven by primary care needs and an expanding HIV programme (worsened if “Test & Treat” is fully scaled without offsets).[5] As per the president’s declaration, a target of P5billion is required to meet the current needs in the health sector.
- Electricity access (development enabler): In 2023, access stood at ~71% (urban ~81%, rural ~28%). With a strong Infrastructure scenario, national access could reach ~85% by 2043 (rural ~72%).[3]
4. Strategy: Turning an Emergency into a Demographic‑Dividend Playbook
Below is a summary of the steps articulated under the presidential emergency plan with some suggestions on other think tanks on the path forward.
Stabilise Health Now (90–180 days) – The Plot
- Fixing the medical supply chain
* Stand up an Emergency Procurement & Logistics Cell with Treasury and BDF; publish open contract data, framework prices, and vendor scorecards to end price inflation and leakage (as flagged in the President’s address).[1]
* Pool procurement for ARVs, TB, insulin and oncology lines; accelerate registration of quality generics. Evidence suggests savings and fewer stock‑outs.[5] - Financial bridge
*Use the announced emergency envelope to clear arrears to private facilities/suppliers and lock in volume‑price deals for the next 12–18 months while a structural reform is designed.[1] - Clinical continuity
*Protect high‑impact services: ART, TB, maternal & neonatal care, essential NCD medications; deploy nurse‑pharmacist task‑teams to ration and substitute safely where required (guided by standard treatment guidelines).[5]
Repair the System (12–36 months)
Beyond the emergency, below are some points to consider for locking in the short-term gains for long term prosperity.
i) Primary care & WaSH “Big Push” (human capital first)
- Primary health care (PHC): Expand the Essential Health Services Package (EHSP) with community‑anchored prevention (HIV, SRH, TB), child nutrition, hypertension/diabetes control, and mental health. Pay PHC providers by risk‑adjusted capitation plus results‑based bonuses—not historic budgets.[5]
- WaSH for outcomes: Target rural and low‑coverage districts (Okavango, CKGR, Kweneng West, Ngamiland West) with district compacts combining boreholes/piped schemes, on‑site sanitation upgrades, and school WASH (separate, safe facilities for girls). Tie funding to independent verification (JMP methods).[6][7]
- Impact: In the AFI “Health/WaSH” scenario, life expectancy is ~1 year higher by 2043 vs business‑as‑usual; infant mortality falls further—small changes with large lifetime returns to productivity.[3]
ii) Jobs & skills to use the dividend
- With rising unemployment, there is need to create employment at unprecedented levels. Quick wins can be obtained in labour-absorbing industries such as agriculture, agro-processing, construction and services.
- Additionally, investment can be made in Manufacturing (light manufacturing, agro‑processing, pharmaceuticals, green building materials) as this yields the largest poverty reduction and higher GDP per capita.
- We also need to raise learning quality (Botswana already spends heavily). Countries that have developed fast focused on vocational and technical training.[3]
- Digital literacy has also become a big necessity in a knowledge economy. What is critical is digital inclusion. No one should be left behind.
iii) Power for development
- Implement the Integrated Resource Plan with a fast‑track solar + storage programme and targeted rural mini‑grids; ring‑fence funds to upgrade transmission & distribution where losses are highest.
- Developmental payoff: electricity accessibility, rural population inclusion, more firms, more formal jobs.[3]
iv) Finance it Sustainably
- Efficiency first:
- Reform the medicines policy: pooled procurement, essential list rationalisation, generic substitution; standard treatment guidelines with e‑prescribing.
- Purchasing reform: revitalizing primary health care and implement Diagnosis-Related Groups (DRG)‑style payments for hospitals; service‑level agreements with public and private providers, paid for outputs.
- Technology enablement
- Closing the financing gap without over‑burdening households:
- Sin‑tax earmarks (alcohol/tobacco) scaled toward 75% allocation to health (as previously modelled).
- Payroll health contribution for formal sector (e.g., 2% ≈ BWP ~459 m in 2016), paired with government subsidies for low‑income and informal workers via a national risk pool.
- Reform MAS: redefine MAS to supplement the Essential Health Service Package (EHSP); enable cross‑payment (MAS reimburse public facilities) to end free‑riding and reduce inequity.
- Blended finance: structured corporate contributions for workforce health; development‑partner guarantees for WaSH/solar mini‑grids.[5]
5. Benefitting from a crisis!
Botswana’s health emergency is a stress test of our systems and a catalyst. If we stabilise the supply chain, push hard on Primary Health Care + Water Sanitation and Health, and line up skills, power, and productive urbanisation with the right financing and governance, we will not just avert today’s crisis, we will harvest our demographic dividend and bend poverty down decisively over the next two decades.
Healthy, well‑nourished, and infection‑free children learn better; healthy adults are more productive. We need to nourish the labour that powers a dividend!
References
[1] Botswana declares public health emergency as clinics run … – TimesLIVE
[2] Botswana declares public health emergency over medicine shortage
[3] AFI-Geographic-Futures-Botswana 3
[4] Harnessing+and+advancing+Africa’s+future+demographic+dividend+_TG_def
[5] Botswana Health-financing-landscape-analysis 1
[6] An Assessment of WASH Practices_2022PHC Presentation_11-12062024 [7] Water, Sanitation and Hygiene (WASH) Sector Analysis for Botswana