Botswana president declares diamond-funded health system failed

Botswana’s president, Duma Boko, has declared that the country’s diamond-funded public health model has “failed” and needs rebuilding—an unusually candid admission from a government long marketed as a stable, middle-income African success story.

In an article for the Guardian’s global development section, Boko writes that medicine shortages forced him to declare a public health emergency last year. Patients went without treatment, he argues, not because frontline staff failed but because the system did. The proximate shock was fiscal: a downturn in the diamond market—Botswana’s primary export—hit state revenues and exposed how dependent “free at the point of use” care had become on commodity rents.

But Boko’s more interesting claim is that the revenue drop merely revealed long-accumulated dysfunctions that were previously easy to buy off. He lists inflated drug prices, inefficient supply chains, and a hollowing-out of public capacity via outsourcing. When money is abundant, procurement can be treated as an accounting exercise; when it tightens, every weak link becomes a shortage.

The political economy is predictable. A tax-financed monopoly health system faces soft budget constraints: managers do not personally bear the cost of overpricing, leakage, or bad forecasting, while politically connected suppliers can extract rents through opaque tenders. Outsourcing can worsen this by inserting profit margins and contracting layers while diffusing accountability—Boko notes that when shortages hit, citizens blame the government anyway, even if delivery has been subcontracted.

Ringfencing does not create resources; it merely pre-commits future taxpayers. A dedicated funding stream can stabilise cashflow, but it can also entrench a spending silo that becomes harder to audit and easier to defend politically. Likewise, “autonomous” procurement agencies often evolve into semi-detached fiefdoms unless their incentives are tied to measurable outcomes—unit prices, stockout rates, delivery times—published in a way that allows external scrutiny.

Boko argues that Africa must ultimately produce more medicines domestically and points to the African Continental Free Trade Area (AfCFTA) as a route to scale, predictable demand and regional pharmaceutical manufacturing. That is plausible in theory; industrial policy tends to recreate the same rent-seeking dynamics at a larger scale, with licences, subsidies and protected incumbents.

Botswana’s dilemma is therefore broader than diamonds. A system built on windfall rents can deliver impressive coverage while quietly accumulating inefficiency. When the windfall fades, governments discover that “universal” is easy to promise and expensive to operationalise—especially when nobody in the chain has to pay personally for getting it wrong.