ABSTRACT:
Equity, inclusion, and the idea of “health without borders” now appear frequently in global public health debates. However, across much of sub-Saharan Africa, these aspirations often collide with the everyday realities of how policy is implemented. Governments may commit to universal access, but institutional routines, administrative rules, and professional hierarchies continue to shape who is reached in practice. These tensions become most visible during periods of strain, when systems must prioritise, ration, and decide quickly. In Botswana, recent public health challenges have brought these issues into sharper focus. Using Botswana as a central case, this paper examines how institutional arrangements influence inclusion in public health responses, while drawing cautious comparisons with similar settings in the region. This paper adopts an institutional and political economy perspective, drawing on policy documents, official reports, and published research from Botswana and selected sub-Saharan African countries. Rather than assessing individual programmes, the analysis focuses on how legal mandates, bureaucratic routines, and decision-making cultures shape public health action over time. Attention is paid to moments of fiscal pressure, emergency response, and donor transition, when institutional choices tend to narrow and their consequences for marginalised populations become more pronounced. The analysis suggests that exclusion in public health rarely stems from explicit policy intent. More often, it arises through routine practices: rigid eligibility criteria, fragmented accountability, weak inter-sectoral coordination, and governance cultures that prioritise institutional protection over adaptation. These patterns intensify during crises, when speed and control are valued and participation by affected communities is often sidelined. As a result, groups already facing social or economic disadvantage experience reduced access, limited voice, and greater exposure to health risks. Botswana’s experience reflects wider regional patterns. Inclusive public health is limited less by stated commitments than by how institutions exercise authority, value knowledge, and learn under pressure over time.