title: Analysing the Stewardship Function in Botswana's Health System: Reflecting on the Past, Looking to the Future.
abstract: BACKGROUND
  In many parts of the world, ongoing deficiencies in health systems compromise the delivery of health interventions. The World Health Organization (WHO) identified four functions that health systems need to perform to achieve their goals: Efforts to strengthen health systems focus on the way these functions are carried out. While a number of studies on health systems functions have been conducted, the stewardship function has received limited attention. In this article, we evaluate the extent to which the Botswana Ministry of Health (MoH) undertook its stewardship role.
  
  
  METHODS
  We used the WHO Health Systems Performance Assessment Frame (HSPAF) to guide analysis of the stewardship function of the Botswana's MoH focusing on formulation of national health policies, exerting influence through health regulation, and coalition building. Data were abstracted from published and unpublished documents. We interviewed 54 key informants comprising staff of the MoH (N = 40) and stakeholder organizations (N = 14). Data from documents was analyzed through content analysis. Interviews were transcribed and analyzed through thematic analysis.
  
  
  RESULTS
  A lack of capacity for health policy development was identified. Significant policy gaps existed in some areas. Challenges were reported in policy implementation. While the MoH made efforts in developing various statutes that regulated different aspects of the health system, some gaps existed in the regulatory framework. Poor enforcement of legislation was a challenge. Although the MoH had a high number of stakeholders, the mechanisms for stakeholder engagement in the planning processes were weak.
  
  
  CONCLUSIONS
  Problems in the exercise of the stewardship function posed challenges in ensuring accountability and limited the health system's ability to benefit from its stakeholders. Ongoing efforts to establish a District Health System under control of the MoH, attempts to improve service delivery at a national level and political will to strengthen public-private engagement mechanisms are some of the prospects that can improve the MoH's stewardship function.
authors.affiliation: Ministry of Health, Gaborone, Botswana.|Institute of Development Management, Gaborone, Botswana.
authors.forename: Onalenna
authors.initials: O
authors.lastname: Seitio-Kgokgwe
authors.affiliation: Department of Preventive and Social 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, University of Otago, Dunedin, New Zealand.
authors.forename: Philip C
authors.initials: PC
authors.lastname: Hill
authors.affiliation: School of Health Sciences, University of Canterbury, Christchurch, New Zealand.
authors.forename: Pauline
authors.initials: P
authors.lastname: Barnett
mesh_terms: D001902:Botswana; D003299:Cooperative Behavior; D003695:Delivery of Health Care; D006077:Government Agencies; D033161:Government Regulation; D006285:Health Planning; D006291:Health Policy; D006801:Humans; D011050:Policy Making; D012941:Social Responsibility
keywords: Botswana; Health Legislation; Health Policy; Health System; Stewardship