Speaking at a recent public lecture, Edwin Pule Afitile, an actuary and CEO of Empirica Actuaries, welcomed the renewed focus on healthcare but emphasized the importance of first determining whether the problems in the current system are purely financial or more fundamentally structural.
“If we determine that money can solve our problems, only then should we consider models like NHI. But if the problems are more structural, then we need to resolve those first,” said Afitile.
“One of the major issues may simply be inefficiencies in how we allocate and roll out the health budget.”
The NHI forms part of the ruling Umbrella for Democratic Change (UDC) election manifesto. Under the proposed system, every citizen would have access to medical aid — partially contributory for those employed, and fully state-funded for those without income.
Afitile cautioned, however, that taking on healthcare risk at a national level requires complex planning.
“Taking on the risk of illness for a single individual is already significant. Taking on the risk for an entire population introduces immense complexity that must be managed effectively,” he explained.
He noted that other countries, like Germany and the UK, offer useful lessons. Germany’s model pools citizen contributions into a national insurance fund, while the UK’s NHS takes a publicly funded approach, with notable differences in funding structure and delivery.
Afitile emphasized that Botswana’s National Health Insurance (NHI) goals will take a long time to achieve. He pointed to South Africa, where NHI discussions began in 1994 but remain unresolved to this day. With Botswana only starting the conversation in 2018, expecting full implementation within five years would require a significant commitment of resources and planning capacity.
He also revealed that Empirica Actuaries has prepared groundbreaking research on Botswana’s NHI, which will be presented at the Joint Colloquium of Actuaries in São Paulo, Brazil next month. This research shows a blueprint for implementing the NHI including the development of a Botswana NHI Index.
The ongoing development of this research can be followed at the Empirica Actuaries NHI dedicated website: www.bubblegum1.com, which will serve as a central hub for updates.
The Botswana Doctors Union (BDU) echoed the call for caution. During the same public lecture, BDU president Dr. Kefilwe Selema stressed that reform must begin by fixing internal inefficiencies in the current healthcare system.
“Efficiency doesn’t come from introducing NHI alone. It requires structural changes, including a clear separation between the government’s role as regulator and provider,” he said.
Selema pointed out that the private sector’s effectiveness comes from clearly defined responsibilities, and urged government to restructure primary healthcare by equipping it with adequate resources and personnel. This, he argued, would reduce long-term costs and ease the burden on tertiary healthcare facilities.
He also criticised the system’s over-reliance on curative care, calling instead for a stronger focus on preventive care.
Selema further addressed the challenge of staff retention, stating that poor working conditions and uncompetitive salaries discourage skilled professionals from remaining in the system. He called for better remuneration, improved work environments, and a national skills audit to guide targeted training programs.
“We need to connect the Ministry of Health and the Ministry of Tertiary Education so that training is aligned with actual workforce needs.”
Assistant Minister of Health, Lawrence Ookeditse, reaffirmed the government’s commitment to the NHI, calling it a step toward universal health coverage and equity in access.
“We still have a system where your economic status determines the quality of care you receive. We want to change that,” he said at a Boitekanelo College budget seminar.
He said the government will strengthen primary healthcare to ensure that vulnerable populations are not left behind.
Private medical aid providers appear to welcome the NHI, seeing it as complementary rather than competitive.
Moraki Mokgosana, Principal Officer at BOMAID, said the NHI should be seen as a partnership to fund national healthcare efforts.
“We’re a health funder, just like the government. We operate as a social enterprise and see the NHI as a beacon of light that can work alongside our efforts,” he said.
While the NHI is an ambitious and noble goal, both experts and practitioners caution that its success hinges on more than funding alone. Without structural reform, strategic planning, and realistic expectations, the NHI risks becoming yet another well-intended policy that fails to address the root problems of Botswana’s healthcare system.
