Gaborone — On an ordinary morning at a government clinic, the queue moves slowly. Mothers cradle children. Elderly patients lean heavily on walking sticks.
When at last they reach the dispensing window, many brace themselves for an answer they already expect.
"Ga gona molemo." Your medication is out of stock.
Across Botswana, this phrase has become an unsettling refrain, one that signals not just inconvenience, but growing anxiety, interrupted treatment and, in some cases, worsening illness.
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What might appear to patients as sporadic stock-outs is, according to health experts and former officials, the visible symptom of a long-standing and deeply rooted failure within the country's public health system.
Former Permanent Secretary in the Ministry of Health, Ms Ruth Maphorisa, says Botswana's current medicine shortages are not sudden. They are the result of structural weaknesses that have quietly accumulated over many years.
Ms Maphorisa served as Permanent Secretary between April 2018 and December 2019. While she notes that shortages during her tenure were less severe, she says persistent procurement inefficiencies, weak supply chain systems and the absence of real-time health data left the system vulnerable to collapse.
At the heart of the problem, she explains, is procurement. Botswana's medicine procurement process is lengthy and complex, shaped by rigid tendering procedures and a heavy dependence on imported pharmaceuticals. As a small market, the country struggles to compete for supplier attention in an increasingly volatile global pharmaceutical industry.
"Medicine procurement needs a special kind of dispensation, suppliers want volume and our requests are not always robust enough," she said, adding that the situation is further complicated when tenders are contested in court, often bringing procurement to a standstill.
She further said when disputes arise, the ministry is forced into emergency procurement, which is a costly alternative and often resulted in inflated prices. She recalls moments when unresolved legal battles risked costing the ministry close to P10 million within a short period.
To address these hurdles the Ministry of Health with the Public Procurement Regulatory Authority (PPRA) and international partners, introduced reforms aimed at allowing more flexible procurement and reducing legal bottlenecks. While these changes improved emergency responses on paper, Ms Maphorisa cautions that they are not enough.
"As long as we do not have real-time data, supplies will continue to run out without timely intervention," she said.
She also believes government must rethink its relationship with the private sector. Strategic partnerships, she argues, could strengthen blood services, equipment leasing and laboratory operations -- areas where inefficiencies have left infrastructure underutilised.
"When we build facilities without equipping them adequately, those investments end up underutilised," she said, adding that government could learn valuable lessons from private sector efficiency.
Beyond systems and structures, Ms Maphorisa stresses the importance of transparency and community engagement. Drawing on lessons from past diarrhoeal outbreak responses, she says involving frontline workers and communities often yields practical, locally informed solutions.
"When people on the ground are brought along, they understand the challenges best and often surprise you with effective solutions," she said.
For healthcare workers, the crisis is painfully familiar. Ms Esther Mogakolodi, a retired midwife with 48 years of experience, says medicine shortages have shadowed her entire career -- but never at this scale.
Over decades of service, she witnessed intermittent stock-outs of essential medicines, from painkillers and antibiotics to drugs for chronic conditions. She is worried particularly about patients with chronic conditions such as diabetes and hypertension, many of whom depend on uninterrupted medication to stay alive and functional.
"Many people are struggling to afford their medication and some are resorting to self-medicating or skipping doses altogether, that can lead to worsening symptoms and serious health complications," she said.
The psychological toll, she adds, is immense. Civil society organisations have raised similar alarms. In 2022, the Botswana Network on Ethics, Law and HIV/AIDS (BONELA) reported widespread stock-outs across districts, affecting everything from paracetamol to essential chronic illness medicines.
Of particular concern was the shortage of Methyldopa, a drug critical for managing high blood pressure during pregnancy. BONELA linked the absence of the drug to premature births after less effective substitutes were used.
Academic research paints an equally troubling picture. A study led by Dr Onalenna Seitio-Kgokgwe, Assessing Performance of Botswana's Public Hospital System, identified poor governance structures, limited management autonomy and inefficient supply chain management as key weaknesses.
"The ministry provides the money for the procurement of medicines, with efficient procurement and distribution systems, the drugs should be adequate for national needs, but supply chain management is inefficient," the study noted.
While Botswana prides itself on ensuring that most citizens live within five kilometres of a health facility, proximity, the study warned, does not guarantee access to treatment. Patients often move from clinic to clinic, spending scarce time and money in search of medicines.
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The Office of the Ombudsman's report, Under Strain: Inside Botswana's Public Health Care Crisis, further exposed deep-rooted failures at Princess Marina Hospital, including overcrowding, staff shortages and service breakdowns , symptoms of systemic governance problems rather than isolated incidents.
A 2023 study by Nkaelang Modutlwa, Dr Sehlule Moyo and Ndumiso Tshuma echoed these findings, pointing to low pharmaceutical manufacturing capacity, inefficient logistics and administrative delays. Botswana's small and uncompetitive market, the researchers noted, has only intensified the crisis.
"The human cost is considerable," the study concluded. "Patients are pushed into private pharmacies where prices are unaffordable, leading to skipped doses, abandoned treatment and heightened risks of complications and drug resistance."
Despite government reforms aimed at diversifying suppliers and improving supply chain management, progress remains slow. For many Batswana, the medicine crisis is no longer an abstract policy failure, it is a reality. BOPA
BOPA
