Reimagining public-private partnerships for primary health care in Africa: a governance and systems analysis of emerging models in Botswana.

Background: 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-private 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. Methods: 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. Results: 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. Conclusion: 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.