Background:

When policy implementation is not regularly monitored and evaluated, it risks irrelevance to changing conditions and, over time, its original purpose can even be forgotten. In 1975, the government of Botswana instituted co-payments for public healthcare, a policy which has remained largely unaltered since its introduction with the exception of two increases in the fee- level. Therefore, this study aims to critically analyze the institutional design and operation of Botswana’s co-payment policy for public healthcare.

Methods:

Using documentary analysis and interviews with 32key informants, Botswana’s longstanding policy requiring a modest co-payment in public healthcare facilities was analysed. Data were analysed thematically in an inductive way. Results:

The findings revealed the policy was not monitored, rarely evaluated and became both ineffective and inefficient, costing more to administer than was received in revenue. The Ministry of Health and Wellness no longer had a copy of the original policy and there was no corporate memory of its original purpose. Informants were confused about the policy and why it was still in place after four decades. There was absence of requirements for monitoring and evaluation in the original policy. The top-down policy development failed to explain rationale for policy and mobilize popular support leading to civil society ignorant of the policy.

Conclusions:

The consequences of policy amnesia in this study are evident. The lack of timely policy evaluation influenced discretionary powers for administrators applying the co-payment leading to the problems of partiality. Uneconomic financial returns as a result of inflation and poor enforcement mechanisms con- tinued without causing concerns. That might have been undermined by placing emphasis on the role of central actors and ignoring the involvement and significance of the local actors, who are in a much better situation to propose and implement purposeful policies.

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