{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T07:04:39Z","timestamp":1783926279006,"version":"3.55.0"},"reference-count":51,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T00:00:00Z","timestamp":1783900800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Primary health care (PHC) systems across many low- and middle-income countries increasingly rely on mixed provider environments involving public, private, and mission-based actors. Public\u2013private partnerships (PPPs) are often promoted as a way of improving coordination and expanding access to care. However, many PHC partnerships continue to be governed through highly centralized and compliance-oriented arrangements that may limit flexibility, trust, and long-term collaboration. Botswana provides a useful case for examining how PPPs are governed within a health system experiencing fiscal pressure, medicines supply challenges and ongoing PHC restructuring.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This study relies on a theory-based qualitative documentary analysis of policy documents, government reports, gray literature, and peer-reviewed research relevant to PHC governance and PPP implementation in Botswana and comparable low- and middle-income country settings. Concepts such as health systems governance, stewardship and systems thinking guided the analysis with due attention to financing arrangements, accountability systems, provider relationships and implementation dynamics within mixed health systems.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Four recurring governance barriers were identified as factors affecting PPP implementation in PHC. These included hierarchical administrative approaches that limit collaboration and local adaptation; weak financing credibility and purchasing uncertainty; limited community-facing accountability; and gaps between national policy ambition and district-level implementation capacity. The analysis also identified emerging opportunities related to digital health systems, integrated service delivery approaches, and more flexible partnership practices that may strengthen coordination across providers.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The findings suggest that PPP performance in PHC depends less on formal contracts alone and more on the wider governance conditions shaping relationships between public institutions, providers, and communities. In Botswana, partnership arrangements are more likely to function effectively when financing systems are credible, accountability extends beyond administrative reporting, and local implementation systems are adequately supported. The study contributes to wider debates on PHC governance by highlighting the importance of stewardship, coordination, and institutional trust in sustaining partnerships within mixed health systems.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1862905","type":"journal-article","created":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T06:07:21Z","timestamp":1783922841000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Reimagining public\u2013private partnerships for primary health care in Africa: a governance and systems analysis of emerging models in Botswana"],"prefix":"10.3389","volume":"14","author":[{"given":"Thabo Lucas","family":"Seleke","sequence":"first","affiliation":[{"name":"Political Science and Public Administration, University of Botswana","place":["Gaborone, Botswana"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,13]]},"reference":[{"key":"B1","unstructured":"Geneva\n          World Health Organization\n          The World Health Report 2008: Primary Health Care (Now More Than Ever)\n          \n          2008"},{"key":"B2","doi-asserted-by":"crossref","DOI":"10.1596\/13613","volume-title":"Assessing Public Expenditure on Health from a Fiscal Space Perspective","author":"Tandon","year":"2010"},{"key":"B3","unstructured":"Barroy\n              H\n            \n            \n              Sparkes\n              S\n            \n            \n              Dale\n              E\n            \n            \n              Kutzin\n              J\n            \n          \n          Geneva\n          World Health Organization\n          Assessing Fiscal Space for Health Expansion in Low- and Middle-Income Countries: A Review of the Evidence\n          \n          2018"},{"key":"B4","doi-asserted-by":"publisher","first-page":"1461","DOI":"10.1016\/S0140-6736(18)31829-4","article-title":"Revisiting Alma-Ata: what is the role of primary health care in achieving the sustainable development goals?","volume":"392","author":"Hone","year":"2018","journal-title":"Lancet."},{"key":"B5","doi-asserted-by":"publisher","first-page":"596","DOI":"10.1016\/S0140-6736(16)00342-1","article-title":"What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries","volume":"388","author":"Mackintosh","year":"2016","journal-title":"Lancet."},{"key":"B6","doi-asserted-by":"publisher","first-page":"160","DOI":"10.9745\/GHSP-D-13-00031","article-title":"mHealth innovations as health system strengthening tools: 12 common applications and a visual framework","volume":"1","author":"Labrique","year":"2013","journal-title":"Glob Health Sci Pract."},{"key":"B7","doi-asserted-by":"publisher","first-page":"685","DOI":"10.1093\/heapol\/czs132","article-title":"Health governance: Principal\u2013agent linkages and health system strengthening","volume":"29","author":"Brinkerhoff","year":"2014","journal-title":"Health Policy Plan."},{"key":"B8","doi-asserted-by":"publisher","first-page":"i45","DOI":"10.1093\/heapol\/czr025","article-title":"Making health markets work better for poor people: the case of informal providers","volume":"26","author":"Bloom","year":"2017","journal-title":"Health Policy Plan."},{"key":"B9","doi-asserted-by":"publisher","first-page":"1453","DOI":"10.1016\/S0277-9536(02)00142-9","article-title":"Trust and the development of health care as a social institution","volume":"56","author":"Gilson","year":"2003","journal-title":"Soc Sci Med"},{"key":"B10","volume-title":"Central Medical Stores Reform and Supply Chain Assessment Report 2010\u20132012","year":"2010"},{"key":"B11","volume-title":"Report of the Auditor General on the Accounts of Government Ministries, Departments and Selected Agencies","author":"Auditor","year":"2018"},{"key":"B12","volume-title":"Government Notice No. 742 of 2024: Transfer of primary health care services from the Ministry of Health to the Ministry of Local Government and Traditional Affairs","year":"2024"},{"key":"B13","unstructured":"DailyNews\n              Botswana\n            \n          \n          2025, July 27\n          Primary Health Care Functions Relocation Milestone"},{"key":"B14","unstructured":"Gilson\n            \n            \n              L\n            \n          \n          Geneva\n          World Health Organization\n          Health Policy and Systems Research: A Methodology Reader\n          \n          2012"},{"key":"B15","doi-asserted-by":"publisher","first-page":"e1001073","DOI":"10.1371\/journal.pmed.1001073","article-title":"Building the field of health policy and systems research: framing the questions","volume":"8","author":"Sheikh","year":"2011","journal-title":"PLoS Med."},{"key":"B16","unstructured":"de Savigny\n              D\n            \n            \n              Adam\n              T\n            \n          \n          Geneva\n          World Health Organization\n          Systems Thinking for Health Systems Strengthening\n          \n          2009"},{"key":"B17","doi-asserted-by":"publisher","first-page":"625","DOI":"10.1136\/bmj.323.7313.625","article-title":"Complexity science: the challenge of complexity in health care","volume":"323","author":"Plsek","year":"2001","journal-title":"BMJ."},{"key":"B18","volume-title":"Thinking in Systems: A Primer","author":"Meadows","year":"2008"},{"key":"B19","volume-title":"Thinking, Fast and Slow","author":"Kahneman","year":"2011"},{"key":"B20","doi-asserted-by":"publisher","first-page":"20","DOI":"10.1111\/j.1745-6916.2008.00058.x","article-title":"Why heuristics work","volume":"3","author":"Gigerenzer","year":"2008","journal-title":"Perspecti Psychol Sci."},{"key":"B21","volume-title":"The Economic Institutions of Capitalism","author":"Williamson","year":"1985"},{"key":"B22","doi-asserted-by":"publisher","first-page":"1453","DOI":"10.1016\/S0277-9536(02)00142-9","article-title":"Trust and the development of health care as a social institution","volume":"56","author":"Gilson","year":"2003","journal-title":"Soc Sci Med."},{"key":"B23","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1016\/j.worlddev.2015.03.011","article-title":"Social accountability: what does the evidence really say?","volume":"72","author":"Fox","year":"2015","journal-title":"World Dev."},{"key":"B24","unstructured":"Geneva\n          World Health Organization\n          A Vision for Primary Health Care in the 21st Century: Towards Universal Health Coverage and the Sustainable Development Goals\n          \n          2018"},{"key":"B25","unstructured":"Geneva\n          World Health Organization\n          Operational Framework for Primary Health Care: Transforming Vision into Action\n          \n          2020"},{"key":"B26","doi-asserted-by":"publisher","first-page":"27","DOI":"10.3316\/QRJ0902027","article-title":"Document analysis as a qualitative research method","volume":"9","author":"Bowen","year":"2009","journal-title":"Qual Res J."},{"key":"B27","volume-title":"Botswana Health Financing Profile","year":"2016"},{"key":"B28","volume-title":"Strategic Purchasing in Health Care: A Roadmap to Better Outcomes","year":"2017"},{"key":"B29","unstructured":"Gaborone\n          Government of Botswana\n          Summary Report of the National Forensic Audit Programme\n          \n          2026"},{"key":"B30","doi-asserted-by":"publisher","first-page":"153","DOI":"10.2471\/BLT.10.077339","article-title":"Performance-based financing: Just a donor fad or a catalyst towards comprehensive health-care reform?","volume":"89","author":"Meessen","year":"2011","journal-title":"Bull World Health Organ."},{"key":"B31","doi-asserted-by":"publisher","first-page":"e0141091","DOI":"10.1371\/journal.pone.0141091","article-title":"Community participation in health systems research: a systematic review assessing the state of research, the nature of interventions involved and the features of engagement with communities","volume":"10","author":"George","year":"2015","journal-title":"PLoS ONE."},{"key":"B32","doi-asserted-by":"publisher","first-page":"735","DOI":"10.1162\/qjec.2009.124.2.735","article-title":"Power to the people: evidence from a randomized field experiment of a community-based monitoring project in Uganda","volume":"124","author":"Bj\u00f6rkman","year":"2009","journal-title":"Q J Econ."},{"key":"B33","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1016\/j.socscimed.2010.10.019","article-title":"Health sector decentralization and local decision-making: decision space, institutional capacities and accountability in Pakistan","volume":"72","author":"Bossert","year":"2011","journal-title":"Soc Sci Med."},{"key":"B34","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1002\/pad.255","article-title":"Decentralisation in Africa: goals, dimensions, myths and challenges","volume":"23","author":"Smoke","year":"2003","journal-title":"Public Admin Dev."},{"key":"B35","doi-asserted-by":"publisher","first-page":"801","DOI":"10.1186\/s12913-024-11279-3","article-title":"Healthcare workers' views on decentralized primary health care management in Lesotho: a qualitative study","volume":"24","author":"Birru","year":"2024","journal-title":"BMC Health Serv Res"},{"key":"B36","volume-title":"National eHealth Strategy","year":"2020"},{"key":"B37","unstructured":"Geneva\n          World Health Organization\n          WHO Guideline: Recommendations on Digital Interventions for Health System Strengthening\n          \n          2019"},{"key":"B38","doi-asserted-by":"publisher","first-page":"1284","DOI":"10.1126\/science.1258926","article-title":"Prioritizing integrated mHealth strategies for universal health coverage","volume":"345","author":"Mehl","year":"2014","journal-title":"Science."},{"key":"B39","doi-asserted-by":"publisher","first-page":"332","DOI":"10.1186\/s12913-024-10802-w","article-title":"Quality improvement in public\u2013private partnerships in low- and middle-income countries: a systematic review","volume":"24","author":"Iroz","year":"2024","journal-title":"BMC Health Serv Res."},{"key":"B40","doi-asserted-by":"publisher","first-page":"236","DOI":"10.1111\/1759-5436.12101\/abstract","article-title":"Context matters: a causal chain approach to uncovering the social accountability results","volume":"72","author":"Joshi","year":"2015","journal-title":"World Dev."},{"key":"B41","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1093\/heapol\/czr083","article-title":"Community accountability at peripheral health facilities: a review of the empirical literature and development of a conceptual framework","volume":"27","author":"Molyneux","year":"2012","journal-title":"Health Policy Plan."},{"key":"B42","volume-title":"National Health Policy: Towards a Healthier Botswana","year":"2011"},{"key":"B43","volume-title":"Botswana National Strategic Framework for Health Logistics and Supply Chain Management 2023\u20132027","year":"2023"},{"key":"B44","doi-asserted-by":"publisher","first-page":"1513","DOI":"10.1016\/S0277-9536(98)00234-2","article-title":"Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance","volume":"47","author":"Bossert","year":"1998","journal-title":"Soc Sci Med."},{"key":"B45","doi-asserted-by":"publisher","first-page":"2","DOI":"10.1016\/j.worlddev.2013.01.002","article-title":"Decentralization and governance","volume":"53","author":"Faguet","year":"2014","journal-title":"World Dev."},{"key":"B46","doi-asserted-by":"publisher","first-page":"365","DOI":"10.1093\/heapol\/czr054","article-title":"Understanding pathways for scaling up health services through the lens of complex adaptive systems","volume":"27","author":"Paina","year":"2012","journal-title":"Health Policy Plan."},{"key":"B47","doi-asserted-by":"publisher","first-page":"371","DOI":"10.1093\/heapol\/czh052","article-title":"Accountability and health systems: toward conceptual clarity and policy relevance","volume":"19","author":"Brinkerhoff","year":"2004","journal-title":"Health Policy Plan."},{"key":"B48","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1002\/pad.1846","article-title":"Stewardship and health systems strengthening: an overview","volume":"39","author":"Brinkerhoff","year":"2019","journal-title":"Public Adm Dev"},{"key":"B49","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1111\/1759-5436.12101","article-title":"Reading the local context: a causal chain approach to social accountability","volume":"45","author":"Joshi","year":"2014","journal-title":"IDS Bull"},{"key":"B50","doi-asserted-by":"publisher","first-page":"160","DOI":"10.9745\/GHSP-D-13-00031","article-title":"mHealth innovations as health system strengthening tools: 12 common applications and a visual framework","volume":"1","author":"Labrique","year":"2013","journal-title":"Global Health Sci Pract"},{"key":"B51","unstructured":"Primary Health Care"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1862905\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T06:07:25Z","timestamp":1783922845000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1862905\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,13]]},"references-count":51,"alternative-id":["10.3389\/fpubh.2026.1862905"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1862905","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,13]]},"article-number":"1862905"}}