The high cost of health maladministration

Innocent Selatlhwa | Monday January 26, 2026 06:00

According to a recently released report by the Ombudsman Stephen Tiroyakgosi, the effect and impact of the systemic failures on the public health system are clinical, financial, ethical and social.

The Ombudsman posits that the systemic inefficiencies come with heavy financial consequences. The investigation revealed that facilities have and continue to resort to emergency interventions to rectify failures. “For instance, hospitals have reported insufficient budget to be a challenge, consequently, hospitals are unable to function optimally. Additionally, hospitals end up outsourcing certain services. For example, at Letsholathebe II Memorial Hospital, the government pays millions of Pula to the private sector for the service of airlifting of critical patients,” the report states.

Additionally, Tsabong Primary Hospital was found to have had to outsource emergency ambulances due to the shortage of ambulances. It was noted that on average, there are usually two to three functioning ambulances in public health care facilities.

“This results in facilities resorting to outsourcing of ambulance services, and the same is at a cost of P7000-P10000 per referral as in the case of Tsabong Primary Hospital,” the Ombudsman states.

Further, the report states that as at August 2025, the MoH reported that the government owed private hospitals approximately P433 039 793.62. This debt, investigators reveal, reflects an over-reliance on the private sector to fill gaps that the public system should be able to manage. The MoH report indicates that the public health facilities have almost the same number of specialists as in the private sector.

“In short, the financial burden of bad governance and maladministration is measurable, persistent, and preventable,” they state.

The Ombudsman posits that systemic failures or challenges invite corruption: They state that the Central Medical Stores management decries years of budgetary constraints, unqualified personnel, and poor oversight, and this has created an environment for maladministration and corruption to fester.

“In 2008, there was a P21 Million fraud case against companies that had submitted invoices for payment of services that were never rendered to CMS. It became clear that there had been a collusion between the companies who provided services and supplies and the officers of the CMS,” the investigators state.

Furthermore, the investigation reveals that the MoH had submitted that there had been malfeasance and maladministration within the CMS that had led to irregular processes of procurement, whereby it issued letters of commitment that transgress public procurement rules and laws. These letters of commitment, they state have no backing in law, because the procurement law provides that all sales must follow the normal cause and that a Government Purchase Order (GPO) be raised before any deliveries and payments are made.

“As a result of this cycle, CMS currently faces an outstanding debt of P385, 237, 327.29 to suppliers,” they state. These failures, the Ombudsman states, are not just financial but are also ethical, stating that they erode the moral foundation of public service. They posit that officers take advantage of systemic weaknesses, sometimes deliberately avoiding their duties and referring patients unnecessarily to private hospitals for services that could have been delivered within public facilities. They state that the absence of proper supervision and reporting allows such practices to persist unchecked.

“Ultimately, maladministration in health care becomes self-perpetuating: poor systems breed corruption, corruption drains resources, and resource scarcity justifies further dysfunction,” they state.

The investigation has revealed that the health facilities are experiencing long waiting lists, resulting in excessively delayed access to specialist care. “For example, as of July 2025, at Scottish Livingstone Hospital, the Eye Clinic has a long waiting list. The waiting list for Sekgoma Memorial Hospital (SMH) under the ophthalmology department is five months, general surgery 12 months, Paediatrics 11 months, obstetrics & gynae six months, internal medicine nine 9 months and under the ophthalmology department the waiting period for cataract operations is generally 12-24 months,” states the report.

The Ombudsman further found that Letsholathebe II Memorial Hospital under audiology, the list of patients waiting to be supplied with hearing aids, is at 186, which stems from a backlog from 2022. The report states that, on average, only 13 hearing aids can be purchased per year.

“Mahalapye District Hospital is known as a centre of excellence for orthopaedics, resulting in a disproportionately high patient volume, including approximately 180 patients awaiting arthroplasty procedures as at July 2025. Moreover, some patients wait over months to get a CT scan as well as for critical surgery,” they state. It was further identified that the Obstetrics and Gynaecology department at Sekgoma Memorial Hospital in July 2025 was managing a backlog of 141 patients with various gynaecological conditions who have been awaiting surgical intervention since 2022.

These delays, they state stem from a combination of factors, including severe shortages of healthcare personnel, inadequate medical equipment, and insufficient resources to maintain or procure essential machinery.

“It is worth highlighting that such delays are not just numbers on a spreadsheet; they translate to real-world suffering. Systemic failures can lead to medical errors, delayed treatments, and compromised patient safety,” the investigation reveals.

The investigation reveals that lack of specialist personnel is the outcome of poor and inadequate workplace planning, attrition and retention strategies and incentive packages for specialists. One of the effects of poor workplace planning, they state is the Ministry training a specialist nurse or doctor for the designated Centre of Excellence, and then proceeding to transfer that specialist nurse and doctor to another facility which is not a centre of excellence.

They also note that there is dire shortage of medicines and medical commodities. “This impacts patients’ recovery and results in poor management of diseases. Poor care leads to unnecessary suffering, persistent symptoms, and loss of function and in extreme cases, even death,” they state.

Infrastructure deficiencies were also found to compromise care. At Athlone District Hospital, for example, they investigation revealed that the operating theatre lacks a receiving and recovery room, conditions that fall short of accepted clinical standards. Such lapses in facility design and maintenance, they state place patients at avoidable risk and undermine the integrity of care.

“These are just not abstract administrative issues. They translate into human suffering, professional frustration, and preventable loss of life,” they state.

The Ombudsman submits that public confidence in Botswana’s public health care system, which was once the national pride, is eroding, stating that things stand, patients are driven towards private healthcare because it's perceived to be faster and reliable, even if it means paying out of pocket.

This shift, the Ombudsman states further strains public health resources. “Skilled professionals migrate to the private sector, leaving already understaffed hospitals even more stretched. This has a ripple effect, and fuels longer waiting times, more referrals, and declining quality of care,” they state.

Further, the Ombudsman states that staff attrition is also exacerbated by burnout on the remaining staff, as the workload exceeds the number of service providers. This, they state may also cause personnel to make medical errors. “Consequently, the government will be faced with litigation costs as a result of the medical errors. This becomes a financial quagmire that feeds into a vicious cycle of systemic inefficiency.”

Healthcare workers are also casualties of the system according to the Ombudsman. The report states that many face burnout from impossible workloads, lack of support, and no access to tools of trade. “They experience “moral distress”, the anguish of knowing what good care looks like but being unable to provide it,” reads the report.