{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T05:54:45Z","timestamp":1781848485425,"version":"3.54.5"},"reference-count":44,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T00:00:00Z","timestamp":1781827200000},"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. Health Serv."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Botswana's health system has been characterized in terms of its handling of HIV\/AIDS and the comparability of public-sector delivery. These characterizations have pretty good bedrock. The 2025 declaration of an official public health emergency, after disruptions of the supply of almost all essential medicines, threw a spanner in the works. Public discourse changed in response. The conversation now became primarily about budgetary and supply chain procurement challenges. While these were concerns, there were several other issues, the most troubling being the absence of a systemic response to the multiple challenges and warnings that had been identified. We argue that the systemic response evidenced largely by the empty coffers and the absence of innovation-crisis stewardship indicates a concentration of executive authority in an overwhelmingly clinical, militarized, and potentially damaging supply zone.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>The analysis is grounded in the reviewed literature on health system governance and the system's lens that has been used to decenter public knowledge on the surface of recurring, persistent, and self-reinforcing institutional logics. The analysis is further informed by governance and decision theory, particularly the principal-agent theory, to identify likely facilitative mechanisms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Looking at the medicines shortage with this lens, there was a steady, predictable, and alarming succession of steps: signals were allowed to build, no corrective measures were taken, and emergency procedures were instituted and outside assistance was used, in particular, to stabilize the situation. Some of the more immediate and focused assistance from the United Nations was additional evidence of the absence of medicines caused by the routine care of the government. Central Medical Stores and hospital-level accountability were being discussed, and the absence of integration and accountability among the many professional areas likely caused delays in critical situations. The HIV governance arrangements of Botswana at that time illustrate an improvement in the ability to both detect and respond to the situation in a more consolidated fashion.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The governing stress test of the 2025 episode is more significant than a one-off operational failure. Aimed at preventing the same situation from happening, further measures are needed that integrate clinical approval with management and financial administration, reinforce emergency measures, and create an environment of learning to influence the medicines system. Although some of the planned initiatives may have an impact, the authority and accountability gaps will continue to be the main issues that concern the leadership.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/frhs.2026.1851498","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T05:47:10Z","timestamp":1781848030000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Stewardship configuration and medicines governance under fiscal stress: lessons from Botswana's 2025 health emergency"],"prefix":"10.3389","volume":"6","author":[{"given":"Thabo Lucas","family":"Seleke","sequence":"first","affiliation":[{"name":"Department of Politics and Public Administration, University of Botswana","place":["Gaborone, Botswana"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Keitseope","family":"Nthomang","sequence":"additional","affiliation":[{"name":"Department of Social Work, University of Botswana","place":["Gaborone, Botswana"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,6,19]]},"reference":[{"key":"B1","first-page":"1","article-title":"Leadership and HIV\/AIDS: botswana\u2019s experience","volume":"4","author":"Phumaphi","year":"2003","journal-title":"Harv Health Policy Rev"},{"key":"B2","doi-asserted-by":"crossref","first-page":"3338","DOI":"10.1001\/jama.1992.03490230068030","article-title":"Confidential HIV testing and condom promotion in Africa","volume":"268","author":"Allen","year":"1992","journal-title":"JAMA"},{"key":"B3","volume-title":"Botswana Country Progress Report","year":"2005"},{"key":"B4","year":"2025"},{"key":"B5","year":"2025"},{"key":"B6","year":"2025"},{"key":"B7","volume-title":"Public Health Sector Faces Critical Supply Shortages","year":"2025"},{"key":"B8","volume-title":"BONU decries Dangerous Shortages and Demands Accountability","year":"2024"},{"key":"B9","volume-title":"Nurses\u2019 Union Calls for Leadership Change at Ministry of Health","year":"2024"},{"key":"B10","volume-title":"Botswana: Selected Macroeconomic and Governance Context","year":"2024"},{"key":"B11","volume-title":"Botswana: 2024 Article IV Consultation\u2014staff Report, Press Release, and Statement by the Executive Director for Botswana","year":"2024"},{"key":"B12","volume-title":"Monetary Policy Report","year":"2024"},{"key":"B13","doi-asserted-by":"publisher","first-page":"142","DOI":"10.4161\/23288604.2014.968005","article-title":"Health product supply chains in developing countries: diagnosis of root causes of underperformance","volume":"1","author":"Yadav","year":"2015","journal-title":"Health Syst Reform"},{"key":"B14","volume-title":"Global Surveillance and Monitoring System for Substandard and Falsified Medical Products","year":"2017"},{"key":"B15","volume-title":"Last Mile Health Supply Chains in Africa: Challenges and Solutions","year":"2020"},{"key":"B16","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1080\/23288604.2019.1596050","article-title":"Improving supply chains for essential drugs in low- and middle-income countries: results from a large-scale randomized intervention","volume":"5","author":"Vledder","year":"2019","journal-title":"Health Syst Reform"},{"key":"B17","first-page":"1","article-title":"Perceptions of nurses on the crisis in Botswana\u2019s health sector","volume":"21","author":"Phaladze","year":"2019","journal-title":"Afr J Nurs Midwifery"},{"key":"B18","year":"2025"},{"key":"B19","volume-title":"Press Statement on Governance Crisis in the Ministry of Health","year":"2024"},{"key":"B20","volume-title":"Thinking, Fast and Slow","author":"Kahneman","year":"2011"},{"key":"B21","year":"2017"},{"key":"B22","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":"B23","doi-asserted-by":"crossref","DOI":"10.1596\/978-0-8213-7548-8","volume-title":"Governing Mandatory Health Insurance: Learning from Experience","author":"Savedoff","year":"2008"},{"key":"B24","volume-title":"Leadership and Leadership Development in Healthcare: The Evidence Base","author":"West","year":"2015"},{"key":"B25","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":"B26","doi-asserted-by":"publisher","first-page":"1124","DOI":"10.1126\/science.185.4157.1124","article-title":"Judgment under uncertainty: heuristics and biases","volume":"185","author":"Tversky","year":"1974","journal-title":"Science"},{"key":"B27","volume-title":"Botswana Multi-Sectoral Strategy for the Prevention and Control of Non-Communicable Diseases 2018\u20132023","year":"2018"},{"key":"B28","year":"2025"},{"key":"B29","year":"2025"},{"key":"B30","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1186\/1478-4505-12-51","article-title":"The application of systems thinking in health: why use systems thinking?","volume":"12","author":"Peters","year":"2014","journal-title":"Health Res Policy Syst"},{"key":"B31","volume-title":"Systems Thinking for Health Systems Strengthening","author":"de Savigny","year":"2009"},{"key":"B32","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":"Br Med J"},{"key":"B33","doi-asserted-by":"publisher","first-page":"298","DOI":"10.1016\/j.leaqua.2007.04.002","article-title":"Complexity leadership theory: shifting leadership from the industrial age to the knowledge era","volume":"18","author":"Uhl-Bien","year":"2007","journal-title":"Leadersh Q"},{"key":"B34","volume-title":"Leadership for a High-Performing Civil Service","year":"2017"},{"key":"B35","volume-title":"African Economic Outlook 2024","year":"2024"},{"key":"B36","volume-title":"The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth","author":"Edmondson","year":"2018"},{"key":"B37","first-page":"265","article-title":"Exploring the consequences of governance and service delivery breakdowns","volume":"34","author":"Scott","year":"2019","journal-title":"Health Policy Plan"},{"key":"B38","volume-title":"The World Health Report 2008: Primary Health Care\u2014now More Than Ever","year":"2008"},{"key":"B39","doi-asserted-by":"publisher","first-page":"391","DOI":"10.1016\/S0140-6736(19)31877-6","article-title":"Primary health care as a foundation for universal health coverage","volume":"394","author":"Bitton","year":"2019","journal-title":"Lancet"},{"key":"B40","doi-asserted-by":"publisher","first-page":"e1001779","DOI":"10.1371\/journal.pmed.1001779","article-title":"Building the field of health policy and systems research: an agenda for strengthening","volume":"12","author":"Bennett","year":"2015","journal-title":"PLoS Med"},{"key":"B41","first-page":"i1","article-title":"Health policy and systems research: progress and challenges","volume":"35","author":"Mayhew","year":"2020","journal-title":"Health Policy Plan"},{"key":"B42","first-page":"110","article-title":"Cultural and institutional norms shaping nurse leadership and professional authority","volume":"19","author":"Kagwanja","year":"2020","journal-title":"Int J Equity Health"},{"key":"B43","year":"2026"},{"key":"B44","year":"2026"}],"container-title":["Frontiers in Health Services"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1851498\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T05:47:14Z","timestamp":1781848034000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/frhs.2026.1851498\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,19]]},"references-count":44,"alternative-id":["10.3389\/frhs.2026.1851498"],"URL":"https:\/\/doi.org\/10.3389\/frhs.2026.1851498","relation":{},"ISSN":["2813-0146"],"issn-type":[{"value":"2813-0146","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,19]]},"article-number":"1851498"}}