title: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Ministry of Health, Gaborone, Botswana.
authors.forename: Onalenna
authors.initials: O
authors.lastname: Seitio-Kgokgwe
authors.affiliation: Department of Preventive and Social Medicine, School of Medicine, University of Otago, Dunedin, New Zealand.
authors.forename: Robin Dc
authors.initials: RD
authors.lastname: Gauld
authors.affiliation: Department of Preventive and Social Medicine, School of Medicine, University of Otago, Dunedin, New Zealand.
authors.forename: Philip C
authors.initials: PC
authors.lastname: Hill
authors.affiliation: School of Health Sciences at Canterbury, Christchurch, New Zealand.
authors.forename: Pauline
authors.initials: P
authors.lastname: Barnett
keywords: Botswana; Public Hospitals; Service Delivery; World Health Organization Health System Performance Assessment Framework (WHO HSPSF)