69986 Namibia Health Sector Note (P110113) May 22, 2010 Health, Nutrition and Population Southern Africa Country Department I Africa Region Abbreviations and Acronyms ARV - Antiretroviral (drugs) ART - Antiretroviral Therapy BCC - Behavior Change Communication CBHC - Community-Based Health Care CMO - Chief Medical Officer CSO - Civil Society Organizations DMO - District Medical Officer DOTS - Directly Observed Therapy, Short Course GDP - Gross Domestic Product GP - General Practitioner HBC - Home-Based Care HH - Household(s) HR - Human Resources (for Health) IEC - Information, Education, Communication IFMIS - Integrated Financial Management Information System IMR - Infant Mortality Rate IT - Information Technology MCH - Maternal and Child Health MGYS - Ministry of Gender, Youth and Sports MHSS - Ministry of Health and Social Services MICs - Middle Income Countries MLG - Ministry of Local Government MMR - Maternal Mortality Ratio NCD - Non-Communicable Disease(s) Nemlist - Namibia Essential Medicines List NGO - Non-Governmental Organization(s) OPE - Out-of-Pocket Expenditures ORS - Oral Rehydration Salts OVC - Orphans and Vulnerable Children PHC - Primary Health Care PPP - Public/Private Partnership RN - Registered Nurse SACU - Southern Africa Customs Union SSA - Sub-Saharan Africa SW - Social Work or Social Worker(s) SWIS - Social Welfare Information System U5 - Under five (children) USAID - United States Agency for International Development TB - Tuberculosis THE - Total Health Expenditures WB - World Bank WHO - World Health Organization ii Table of Contents Abbreviations and Acronyms .......................................................................................................... ii Table of Contents ........................................................................................................................... iii List of Tables.................................................................................................................................. iv List of Figures ..................................................................................................................................v Introduction .................................................................................................................................. viii Executive Summary ........................................................................................................................ x Chapter 1: Sociodemographic and Economic Background............................................................ 1 Chapter 2: Health Sector Expenditure Trends................................................................................ 6 Chapter 3: Health Sector Structure and Overview ....................................................................... 13 Chapter 4: HIV/AIDS................................................................................................................... 23 Chapter 5: Tuberculosis................................................................................................................ 30 Chapter 6: Malaria........................................................................................................................ 34 Chapter 7: Maternal and Child Health.......................................................................................... 37 Chapter 8: Namibia's Comparative Health Sector Performance .................................................. 49 Chapter 9: Possible Areas Where the World Bank Could Provide Technical Support ................ 69 Annexes ......................................................................................................................................... 71 References ..................................................................................................................................... 72 Map................................................................................................................................................ 75 iii List of Tables Table 1: Regional differences in poverty related indicators .............................................. 4 Table 2: Health sector financing by program (N$)............................................................. 7 Table 3: Sector allocations of total public expenditure (percent), 2005/06 – 2008/09...... 7 Table 4: Percentage share of sources of health sector funding, 2000-2005....................... 8 Table 5: Financing agents to the health sector, 2001/02 – 2006/07................................... 9 Table 6: Internally Generated Revenues in MHSS (in '000 N$), 2001/02 - 2006/07........ 9 Table 7: Health expenditure per capita, 2001-2005 (US$) .............................................. 10 Table 8: Development Partners and Funds (N$‘000) ...................................................... 10 Table 9: Share of health in total external assistance, 2001-2005..................................... 11 Table 10: Expenditure by category shares, percent (N$ million) .................................... 11 Table 11: Health Expenditures by Category, in Percent, 2001/02 to 2006/07 ................ 12 Table 12: Numbers of people per doctor, registered nurse and hospital bed in public health facilities in 2000..................................................................................................... 15 Table 13: The number of health facilities attending to different numbers of people each day..................................................................................................................................... 16 Table 14: The average number of outpatients aged 5 and over reported for the 10 most frequent conditions each year, and the percentage that these made up of all new visits, 1995-1999 ......................................................................................................................... 17 Table 15: The average number of outpatients aged 5 and under reported for the 10 most frequent conditions each year, and the percentage that these made up of all new visits, 1995-1999 ......................................................................................................................... 17 Table 16: The average number of inpatients aged 13 and over admitted for the 10 most frequent conditions each year, and the percentage that these made up of all admissions, 1995-1999 ......................................................................................................................... 18 Table 17: The average number of inpatients under the age of 13 admitted for the 10 most frequent conditions each year, and the percentage that these made up of all admissions, 1995-1999 ......................................................................................................................... 18 Table 18: Causes of death, 1995-1999 (number and percentages),1995-1999................ 19 Table 19: Number of Staff Who Left the Health Workforce, by Reason, 2007 .............. 20 Table 20: Tuberculosis in SACU Countries, 2008. ......................................................... 30 Table 21: Utilization of antenatal care services, by Region ............................................ 40 Table 22: Infant and Under-5 Mortality Rates (Per 1,000 Live Births) in Countries in Southern Africa, 1990 and 2006 ....................................................................................... 44 Table 23: Infant and Under-5 Mortality Rates (Per 1,000 Live Births) in Countries in Southern Africa, 1990 and 2006 ....................................................................................... 49 Table 24: Percent of Children with Symptoms of Illness in the Last 2 Weeks in Selected Countries in Sub-Saharan Africa, 2000s........................................................................... 50 Table 25: Percent of Children Provided with Selected Child Health Services in Countries in Southern Africa, 2000-2006 ......................................................................................... 54 iv List of Figures Figure 1: Percentages of the population in different age cohorts, 1960-2000 .................... 1 Figure 2: Gini coefficient for selected countries................................................................. 3 Figure 3: HDI in relation to GNI per capita and Gini-coefficient ..................................... 5 Figure 4: Government allocation to health and social welfare as a percentage of total Government expenditure, 2001/01 – 2007/08 .................................................................... 7 Figure 5: The organization and lines of responsibility in the MHSS .............................. 14 Figure 6: Main types of disability in Namibia, by sex (numbers), 2007 ......................... 21 Figure 7: Adult HIV Prevalence & Number of People living with HIV/AIDS (1990- 2007) ................................................................................................................................. 23 Figure 8: HIV Prevalence Rate Among Pregnant Women in Namibia, 1992-2006........ 27 Figure 9: Life expectancy at birth in Southern African Countries (1950-2010).............. 28 Figure 10: GDP per capita and life expectancy ............................................................... 29 Figure 11: NTP budget line items, 2009.......................................................................... 32 Figure 12: Maternal Mortality Ratio (Per 100,000 Live Births), 1990-2006 and 2005... 37 Figure 13: Direct causes of maternal death, 2005............................................................ 37 Figure 14: Percent births delivered by caesarean section, by Region............................. 38 Figure 15: Percent of Pregnant Women Receiving Antenatal Care in Countries in Southern Africa, 2000-2006.............................................................................................. 39 Figure 16: Percent of Pregnant Women Receiving Antenatal Care in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 39 Figure 17: Percent of births attended by skilled staffed in Southern African countries, 1990 and 2006................................................................................................................... 40 Figure 18: Percentage of births assisted by SBAs, by income ........................................ 41 Figure 19: Use of postnatal care, 2009 ............................................................................ 42 Figure 20: Total fertility rate (number of births per woman) in countries in Southern Africa, 1990 and 2006....................................................................................................... 42 Figure 21: Adolescent pregnancy and education ............................................................. 43 Figure 22: Percent contraceptive prevalence rate in countries in Southern Africa, 2000- 2006................................................................................................................................... 43 Figure 23: IMR and U5 MR............................................................................................. 44 Figure 24: Distribution of U5 deaths by age cohort ........................................................ 44 Figure 25: Determinants of mortality, neonatal and under 5 years.................................. 45 Figure 26: Percent children (aged 12-23 months) receiving all basic vaccinations ........ 46 Figure 27: Nutritional status of children by age .............................................................. 47 Figure 28: Percent of children born with low birth weight.............................................. 48 Figure 29: Percent of Households Consuming Iodized Salt and Percent of Children 6-59 Months Receiving Vitamin A Supplementation in Countries in Southern Africa, 2000s 48 Figure 30: Life expectancy at birth (in years) in countries in Southern Africa, 1990 and 2006................................................................................................................................... 49 Figure 31: Maternal Mortality Ratio (Per 100,000 Live Births), 1990-2006 and 2005... 50 Figure 32: Total fertility rate (number of births per women) in countries in Southern Africa, 1990 and 2006....................................................................................................... 50 v Figure 33: Adolescent Fertility Rate (Number of Births Per 1,000 Women Ages 15-19) in Countries in Southern Africa, 1990 and 2006 .............................................................. 51 Figure 34: Percent Prevalence of Undernourishment in the Population in Countries in Southern Africa, 1990-92 and 2002-04 ............................................................................ 51 Figure 35: Percent of Children Under Five Who Are Malnourished in Countries in Southern Africa, 2000-06.................................................................................................. 52 Figure 36: Percent of the Population with Access to Improved Water Source in Countries in Southern Africa, 1990 and 2004 ................................................................................... 52 Figure 37: Percent of the Population with Access to Improved Sanitation Facilities in Countries in Southern Africa, 1990 and 2004 .................................................................. 52 Figure 38: Percent Prevalence of Diabetes (Population Ages 20-79) in Countries in Southern Africa, 2007....................................................................................................... 53 Figure 39: Per Capita Recorded Alcohol Consumption (in Liters of Pure Alcohol) Among Adults 15 Years and Above in Countries in Southern Africa, 2003.................... 53 Figure 40: Percent of Households Consuming Iodized Salt and Percent of Children 6-59 Months Receiving Vitamin A Supplementation in Countries in Southern Africa, 2000s 54 Figure 41: Percent Contraceptive Prevalence Rate (Married Women Ages 15-49) in Countries in Southern Africa, 2000-2006 ......................................................................... 54 Figure 42: Percent of Pregnant Women Receiving Antenatal Care in Countries in Southern Africa, 2000-2006.............................................................................................. 55 Figure 43: Percent of Births Attended by Skilled Staff in Countries in Southern Africa, 1990 and 2006................................................................................................................... 55 Figure 44: Per Capita Total Health Expenditure (US$ at Official Exchange Rate), 1998- 2003................................................................................................................................... 56 Figure 45: Percent Share of Total Health Expenditure to GDP in Countries in Southern Africa, 1999 and 2003....................................................................................................... 56 Figure 46: Percent Shares of Government and Private+Household Health Expenditure to Total Health Expenditure in Countries in Southern Africa, 2003 .................................... 57 Figure 47: Percent share of Government health expenditure to total Government expenditure in countries in Southern Africa, 1999 and 2003 ........................................... 57 Figure 48: Percent share of prepaid and risk-pooling plans to private health expenditure in countries in Southern Africa, 1999 and 2003 ............................................................... 57 Figure 49: Percent Share of Out-of-Pocket Expenditure to Private Health Expenditure in countries in Southern Africa, 1999 and 2003 ................................................................... 58 Figure 50: Percent share of external health resources to total health expenditure in countries in Southern Africa, 1999 and 2003 ................................................................... 58 Figure 51: Percent of GDP Spent on Social Assistance in Selected sub-Saharan African Countries, 2000s ............................................................................................................... 59 Figure 52: Density per 1,000 population of key health workforce cadres in selected countries in Eastern and Southern Africa, 2004 ............................................................... 59 Figure 53: Hospital beds per 10,000 population in selected Sub-Saharan African countries, 2000s ................................................................................................................ 61 Figure 54: Care-Seeking Behavior of the Poorest Quintile of the Population in Selected Countries in Sub-Saharan Africa (Percent)....................................................................... 61 Figure 55: Percent of survey respondents in selected countries in Sub-Saharan Africa who found health facitilies too expensive, 2000s ............................................................. 62 vi Figure 56: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Found Health Facilities Lacked Medicines, 2000s .................................................. 63 Figure 57: Percent of survey respondents in selected countries in Sub-Saharan Africa who experienced lack of health staff attention or respect, 2000s ..................................... 63 Figure 58: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Doctor Absenteeism, 2000s ................................................................ 64 Figure 59: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Long Wait at the Health Facility, 2000s ............................................. 64 Figure 60: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Found Health Facilities in Poor Condition, 2000s ................................................... 65 Figure 61: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Health Facilities Demanded Illegal Payments, 2000s......................... 65 Figure 62: Percent Prevalence of Child Malnutrition in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ...................... 66 Figure 63: Percent of Children Who are Immunized Against Measles in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 67 Figure 64: Percent of Pregnant Women Receiving Antenatal Care in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 67 Figure 65: Percent of Births Attended by a Skilled Health Staff in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 67 vii Introduction This report responds to the Government of Namibia's request to provide technical support in conducting a health sector review as part of the updating of the Health Sector Strategic Plan. Following the process agreed upon under the World Bank's Interim Strategy for Namibia, the Government submitted to the Bank a prioritized list of requests compiled from the various ministries. The requests from the Ministry of Health and Social Services (MHSS) were presented to the Bank during the February 2008 mission by the newly appointed Permanent Secretary. The most urgent need was support to the planned health sector review. The report benefited from missions undertaken by the Bank's team to Namibia in 2008 and 2009. The first mission occurred from May 19-21 when the Bank team travelled to Swakopmund to participate in the Health System Review Data Analysis Workshop at the Alte Brucke Resort and Conference Center. The second mission occurred from June 9-13 when the Bank team travelled to Windhoek to participate in the national conference to present the draft health sector review and initiate work on the strategic planning exercise at the NamPower Convention Center. The final missions took place during 2009, during which the Bank’s health team also participated in the post-flood assessments of health infrastructure. The preparation of this report largely followed to the MHSS timeline to undertake a comprehensive review and analysis of the country's health and social welfare system, including specific reviews of the following policy documents: (a) the Health policy Framework of 1998; (b) the Primary Health Care Approach and Strategy; and (c) Developmental Social Welfare Approach and Strategy. The various components of the review include governance, human resources, finance, services provision, and infrastructure. Several data-gathering and analytical activities are being done, including key informant interviews with district, regional, and national stakeholders; focus group discussions; exit interviews with patients; and health facility checklists. These activities began in February 2008 and concluded on June 12, 2008 when the Draft Report was presented in a national workshop at the NamPower Convention Center in Windhoek, as noted above. Role of the World Bank - Discussions with MHSS officials1 indicated that the World Bank is well placed to provide selected specific technical inputs in the drafting of the strategy and planning documents for both health and social welfare. The Government's interest included the following roles for the World Bank team: International benchmarking of Namibia's sector performance vis-à-vis other countries in the region, and other middle income countries. Sharing good international practices in the areas of health planning (e.g., health service packages, cost-effective interventions), social welfare (e.g., cash and other transfers, targeting of recipients), institutional reforms (e.g., public/private partnerships in health, hospital autonomy), decentralization (which services should be devolved to local authorities and which to be retained by central authorities), utilities pricing (e.g., rural 1 Key MHSS staff involved in these consultations included Ms. Celine Usiko (Chief of Planning and Human Resources, MHSS) and Dr. Vincent Orinda, chief technical consultant of the MHSS review and strategic planning exercise viii water, health services), and general public expenditure management (e.g., budget allocation and execution). Peer reviewing draft documents. Providing practical recommendations both in terms of technical substance and the processes and sequencing of activities. To respond to these technical assistance requests, a World Bank team was formally constituted consisting of Sheila Dutta, Oscar Picazo, Eugenia Marinova, and Barry Kistnasamy. The team prepared this report. ix Executive Summary The World Bank’s involvement with the health sector in Namibia is at a nascent stage (no previous health sector projects nor analytic work). The preparation of this report responded to the Ministry of Health and Social Services (MHSS) request for technical support in conducting a health sector review as part of their overall exercise of updating of the draft Health Sector Strategic Plan. The MHSS was particularly interested in an assessment which would provide informal benchmarking of Namibia’s health sector progress, in comparison with other lower middle-income countries, both regionally and globally. In responding to this request, the World Bank team developed the report in a manner which would enable this document to potentially serve as a background chapter for a proposed health sector public expenditure review, which would enable a more advanced stage of health sector analysis. As a result, the focus of this analytic work was to, first, conduct a sectoral assessment that could serve as a stepping stone for subsequent analytic work (e.g. Public Expenditure Review) and, second, to enable the Bank team to become more familiar with the structure and context of the Namibian health sector (in addition to issues surrounding data collection and accessibility). Given the early stage of the Bank’s health sector engagement in Namibia would have precluded the effective delivery of a full Country Status Report (CSR), the team agreed on the preparation of a Health Sector Note. The content of the Health Sector Note is structured as follows. Chapter 1 presents an overview of the sociodemographic and economic status of Namibia, in addition to a summary of its development progress and challenges in the health sector. Chapter 2 examines health expenditure trends since independence, with focus on internally-generated revenues in the sector, as well as health development assistance. Chapter 3 provides an overview of the structure of the Namibian public health system, including an examination of trends in access and utilization of health services and human resource management. Chapter 4 addresses the magnitude and impacts of Namibia’s HIV/AIDS epidemic. Chapter 5 examines the epidemiology of tuberculosis in Namibia, including an assessment of the TB/HIV co-epidemic. Chapter 6 reviews the impact of malaria on morbidity and mortality in Namibia. Chapter 7 summarizes the status of maternal and child health and includes a review of antenatal and post-natal care, in addition to reproductive health. Chapter 8 examines Namibia's health sector performance in the context of other Southern African countries and, more broadly, other middle income countries. This chapter was prepared in response to the MHSS’ interest in this type of informal regional benchmarking and addresses the following aspects of the health sector: health outcomes, risk factors, health service coverage, health system indicators, people's experiences in health facilities, and inequities in health. Chapter 9 concludes the Health Sector Note with a prioritized list of possible areas of future World Bank support including health sector governance, human resource, and public-private partnerships. x Chapter 1: Sociodemographic and Economic Background A. Sociodemographic background 1. Namibia’s population was estimated to be 1.89 million by 2000. Given the country’s surface area of 823,700 km2, this yields a mean population density of slightly over 2 people per km2. In addition, Namibia’s population is distributed very unevenly across the country. Large areas of the country, particularly along the South Atlantic coast, are completely uninhabited and many other areas remain very sparsely populated. It is estimated that Namibia’s population has grown by about eight times since its first census in 1921, which enumerated a population of 229,000. It is estimated that Namibia’s population will continue increasing to 2.25 million by 2010 and 2.60 million by the year 2020. The annual rate of increase, however, is expected to decline from 3.0 percent to about 1.5 percent between 2010 and 2020, largely due to the impact of the HIV/AIDS epidemic and declining national fertility rates. Namibians are of diverse ethnic origins. The principal ethnic groups are the Ovambo, Kavango, Herero/Himba, Damara, Colored (including Rehoboth Baster), White (Afrikaner, German, English, and Portuguese), Nama, Caprivian, San, and Tswana. While the Ovambo comprise about half of Namibia's population, the San are generally assumed to have been the earliest inhabitants of the region. 2. There is considerable migration in Namibia, at present, both by people entering the country and by people moving from rural to urban areas. Accurate data on the numbers of immigrants are not available, although it is clear that many Angolans have moved to northern Namibia over recent years. More detailed information is available regarding rural-urban population movements within Namibia itself. It is estimated that the proportion of the national population living in urban areas has increased, over the past 100 years, from virtually 0 percent in 1901 to 39 percent by 2001. It is anticipated that over 80 percent of Namibia’s population may be living in towns/urban centers by the year 2020. 3. A comparison of population data for 1960, 1970, 1991 and 2000 indicates that, interestingly, age cohort proportions have remained largely constant over the past 40 years (Figure 1). There has been a slight reduction in the proportion of 0 to 4 year-olds and a minor increase in the percentage of 5-14 year-olds, but few other significant variations in population structure during this period. People under the age of 15 years continue to constitute about 45 percent of the total population. Figure 1: Percentages of the population in different age cohorts, 1960-2000 1 Source: MOHSS, 2008. 4. Declining fertility rates are, in addition to the impacts of HIV/AIDS, are the most significant demographic changes to have occurred in Namibia in recent decades. The national fertility rate has dropped by almost 2 between 1991 - 2000 (from 6.1 children in 1991 to 4.2 children in 2000). Much of the decrease is due to the greater involvement of women in the cash/formal economy and improved levels of education. An analysis by the Ministry of Health and Social Services (MHSS) indicated that women who attended secondary school produced progressively smaller families the higher the grade they completed. Urban-rural disparities in fertility continue to be evident. Women in rural areas have an average of 5.1 children, two children more than mothers in urban areas (urban fertility rate of 3.1 children in 2000). 5. While Namibia has achieved major gains in reducing mortality among children over the past 10 years, life expectancy unfortunately has worsened. The HIV/AIDS epidemic has caused a dramatic decline in life expectancy. The overall life expectancy in 1991 was 61 years. By 2000, the MHSS estimated that this figure had declined to 43 years. While there were significant declines in life expectancy in all regions, the biggest reductions have been in Hardap, Caprivi, Oshikoto and Omusat – unsurprisingly, the regions most heavily impacted by HIV/AIDS. The overall impact of the HIV/AIDS epidemic is further discussed in Chapter 4. B. Economic background 6. As noted in the Interim Strategy Note2 (2007), Namibia is a small open economy which is closely linked to South Africa. With a 2006 per capita income of about US$3,000, Namibia is classified as a lower middle-income country (LMIC). At independence, Namibia inherited a functioning physical infrastructure and a market economy, in addition to rich mineral resources and a relatively strong public administration. Government has put these assets to good use to produce almost two decades of economic growth and political stability. However, the social and economic imbalances of the apartheid system also left Namibia with a highly dualistic society. The structure of the economy has made job creation and poverty reduction difficult, and income inequality remains very high. 7. Namibia has experienced steady growth, moderate inflation, strong external surpluses and low indebtedness over the past several years as a result of generally prudent fiscal policies, a stable political environment, a fairly developed infrastructure, and a strong legal and regulatory environment. Economic growth since independence has been good, if somewhat volatile, averaging 4.3 percent per annum, and sufficient to increase per capita income in most years. Much of the recent volatility in growth can be traced to spurts in diamond production in 2004 and 2006. 8. Overall, the economy is dominated by the service sector, public and private, which accounts for around 60 percent of overall output. GDP growth peaked at 14 percent in 2002 and has averaged about 9 percent since this time. Efforts to diversify the economy have not been successful for a number of reasons, including the generally low level of education in the labor force, insufficient technological sophistication, limited domestic investment, and Namibia’s proximity to the much larger South African economy. 2 Namibia Interim Strategy Note (2007). The World Bank, Washington, D.C. 2 9. The generally good growth and macroeconomic picture is overshadowed by three worrying and related features of the economy: the lingering high levels of poverty; high unemployment; and the country's unequal distribution of wealth and income. While poverty has declined since independence, it remains high at 27 percent. Unemployment, at nearly one-third of the labor force, is a major cause of poverty. Namibia's income distribution, as illustrated by its Gini coefficient of 0.60, remains among the highest in the world (Figure 2). Figure 2: Gini coefficient for selected countries Source: World Bank, Namibia Interim Strategy Note (2007) 10. The post-independence Government identified poverty alleviation, reduction of income inequality, job creation and sustainable economic growth as the main four national development objectives. The means selected to achieve this was to prioritize expenditure in the social sectors – in particular health and education. As a result, the education and health sectors have traditionally received the highest budget allocations in the years since independence. 11. In response to the current global economic slow-down, the Namibia government has adopted a more expansionary fiscal policy stance, aimed at “weathering the storm.� A budget deficit of nearly 5 percent is envisaged for the next fiscal year. However, Government remains committed to the social sectors, including health and education, which remain among the largest recipients of the total budget. It, is therefore, not envisaged that there will be a disruption in the provision of social services due to the global economic crisis, for at least the short-term. 12. Total revenue and grants to Government are projected to scale down to N$21.1 billion in 2010/11 from N$21.8 billion in 2009/10. The decline is expected to be broad based reflected in lower revenues from tax on profits and income, tax on domestic goods and services as well as that on international trade. The decline is expected from reduced economic activity due to the global economic downturn and its concomitant impact on the Namibian economy. Although economic activity is expected to improve beyond 2010/11, revenue shortfalls due to the anticipated decline in SACU revenue will continue to present a risk for the overall budget, including health sector expenditures. 3 C. Development Progress and Challenges 13. Namibia has made substantial progress in addressing some of the structural problems resulting from the dual economy it inherited at independence. Access to basic education has become more equitable and primary health care coverage is more widespread. The Government’s commitment to the social sectors is evident in the fact that it is among the top 10 countries worldwide in share of GDP spent on education, and second only to South Africa on the African continent in per capita expenditures on health. 14. Country-wide immunization campaigns, coupled with parallel strengthening of the overall public health infrastructure, yielded a significant reduction in the infant mortality rate between 1990 and 2005 (from 60 to 43 per 1,000 live births). The Government has improved access to education, safe water, and sanitation, although substantial variation in coverage exists across the country (Table 1). Namibia is one of very few countries in Sub- Saharan Africa that maintains a social safety net for the elderly, disabled, orphans and vulnerable children, and war veterans. Namibia also has a Social Security Act which supports maternity leave, sick leave, and medical benefits. Table 1: Regional differences in poverty related indicators REGION Median yrs % HHs with % HHs with %HH within % women of school access to improved not the lowest currently completed improved source shared sanitation wealth quintile employed of water facility Caprivi 5.4 85.9% 8.2% 48.8% 40.3% Erongo 8.2 94.9% 52.9% 0.0% 63.4% Hardap 5.9 94.7% 46.8% 0.2% 39.4% Karas 7.1 93.9% 52.1% 0.4% 51.5% Kavango 3.4 69.1% 11.6% 46.3% 34.5% Khomas 9.1 98.5% 62.0% 0.0% 56.5% Kunene 2.3 77.6% 21.7% 25.5% 34.4% Ohangwena 4.2 86.9% 5.4% 37.7% 27.6% Omaheke 4.3 96.1% 22.7% 1.7% 36.4% Omusati 5.2 65.2% 14.3% 32.9% 39.9% Oshana 6.4 97.0% 29.6% 12.4% 48.4% Oshikoto 5.1 85.2% 31.9% 29.2% 42.8% Otjozondjupa 5.1 96.6% 42.8% 2.7% 37.8% Source: DHS, 2006/07 15. These efforts and the previously noted strong economic performance, unfortunately, have not been commensurate with improvements in Namibia’s overall Human Development Index (HDI), as can be illustrated in Figure 3. There was a significant divergence between the per capita GNI and HDI between 2000-2005, as per capita GNI increased by 55.2 percent while the HDI declined significantly. In addition to HIV/AIDS, other factors that have limited HDI improvements are the continued high income inequality and lack of access to basic services including adequate sanitation in rural areas. In 1995, the HDI stood at 0.698 before falling to 0.657 in 2000, and it further declined to 0.650 by 2005. 4 Figure 3: HDI in relation to GNI per capita and Gini-coefficient Source: National account-Namibia CBS (GNI) United Nations (HDI), 2009 16. The 2009 HDI estimate was 0.686, indicating progressive, modest improvements in recent years. Namibia's human development indices yield a ranking of 128 out of 182 countries surveyed in the 2009 Human Development Report. Although Namibia is on track to meet some of the Millennium Development Goals (environment, gender equality), it will be challenged to meet poverty, education, and health – and especially HIV/AIDS – targets (Annex 2). 5 Chapter 2: Health Sector Expenditure Trends A. Background 17. As noted in the previous chapter, upon independence in 1990, the Government of Namibia prioritized expenditures on health and education in order to address both poverty and the highly skewed income distribution. The education and health sectors received the highest budget allocations over the years. However, as noted in the 2007 Public Expenditure Tracking Survey, it was soon evident that high public expenditure would not automatically conform to high quality service delivery3. Studies conducted in other countries indicate that, in fact, budget allocation is a poor predictor when used as an indicator of the quality of public services provision.4 18. According to World Bank data, Namibia spends about 5 percent of GDP on public health services, which is more than many other African countries. However, the outcomes of this substantial health sector investment remain uneven. For example, the share of children immunized against DPT and measles is lower than in most of the countries that spend less than Namibia, and has even declined in 2001. In contrast, infant and under five mortality rates in Namibia have improved more rapidly than many other countries. Such contrasts in health sector performance are further discussed in Chapter 3. 19. Calculations by the World Health Organization, ranked Namibia 189th of 191 countries in terms of health sector’s performance, as measured using disability-adjusted life expectancy, and 168th in terms of overall performance of the health sector5. At the same time, Namibia ranks 66th based on per capita health expenditure. This large discrepancy in ranking indicates that other countries with less spending per capita have achieved a higher “level of health.� Given the above, in recent years, Government has been placing greater emphasis on the more efficient use of social sector resources, in parallel with ensuring continued adequate sector allocations. B. Total and Government expenditure 20. In response to the above challenges, targets of the “Medium Term Expenditure Framework for 2009/10 to 2011/12� set targets, include the following: (1) improve TB cure rate by 2011 to 85 percent from 75 percent in 2006/07; (2) reduce HIV prevalence rate by 25 percent from 14.2 percent amongst the age groups aged 15 to 24 years of age; and reduce malaria fatality cases by 26 percent by 2011. The health budget is further allocated into the four main programs, namely tertiary health care, regional and district health services, disease control and social development. 21. As noted in Table 2, the program on regional and district health services accounts for the largest share of total expenditure followed by that for tertiary health care. Regional and district health program’s expenditure increased sharply from N$0.811 million in 2006/07 to N$1.5 million in 2009/10, while expenditures for tertiary health care increased from N$0.55 million to N$0.92 million. 3 Schade & Ashipala, 2007. 4 Dehn, Reinikka , & Svensson, 2003. 5 WHO, 2000. 6 Table 2: Health sector financing by program (N$) 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 Tertiary health care 545 739 702 526 805 951 918 087 871 266 891 911 Regional and district health 810 884 933 482 1 283 243 1 461 137 1 529 565 1 616 821 services Disease control 22 598 29 650 20 298 16 885 20 633 18 502 Social development 16 770 17 285 21 381 18 478 18 419 19 882 Total 1 395 991 1 682 916 2 130 873 2 414 587 2 439 883 2 547 116 Source: MTEF 2009/10 to 2011/12 22. With respect to overall government expenditure on health (as a percent of total public spending), the share declined from 13.2 percent in 2001 to 10.1 percent in 2005 (Figure 4). Figure 4: Government allocation to health and social welfare as a percentage of total Government expenditure, 2001/01 – 2007/08 Source: MHSS 23. Over the period 2005/06-2008/09, the total budget expenditure’s share for health remained almost constant at around 10 percent of the national budget. This trend is expected to continue through 2011/2012, as indicated in Table 3. This expenditure trend parallels that of the education sector, which has similarly remained constant, but relatively higher at 20 percent of national budget. Table 3: Sector allocations of total public expenditure (percent), 2005/06 – 2008/09 Actual Estimates Projections 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 7 General 31.3 28 26.7 34.8 30.3 29.1 27.1 Government Services General public 12.7 11.1 10 15.7 12.2 10.8 9.1 services Defense 9.5 9 9.5 10.6 10 10.1 10 Public order and 9.1 7.9 7.2 8.6 8 8.1 8 safety Community/Social 49.9 48.4 46 48 47.5 47.6 48.9 Services Education 20.0 22.2 20.9 19.9 18.6 19.2 19.5 Health 9.9 8.9 9.5 9.4 9.6 9.0 9.4 All other 20.0 17.3 15.7 18.6 19.4 19.4 19.9 Economic Services 9.8 17 17.6 11.3 12.9 12.2 12.8 Expenditure not 9 6.6 9.7 5.9 9.3 11.1 11.2 classified TOTAL 100 100 100 100 100 100 100 EXPENDITURE Source: Ministry of Finance & Bank of Namibia (2009) 24. The health sector has been and continues to be financed by Government, private sources and funds from external development partners. As noted in Table 4, government has been the largest source of funding, though declining over time. Similarly, the private sector’s share of the total sources of funds has been reducing in recent years. However, there has been increased financing from external development partners over this period, from 3.7 percent to a 19.7 percent, as will be discussed subsequently. Table 4: Percentage share of sources of health sector funding, 2000-2005 2000 2001 2002 2003 2004 2005 Government 66.4 64.5 61.3 61.2 59.1 54.7 Private 29.9 30.4 30.4 27.6 26.5 25.6 External 3.7 5.1 8.4 11.2 14.4 19.7 Total 100 100 100 100 100 100 Source: Health and Social Services System Review 2008 8 25. As noted in Table 5 (below), total financing to the health sector increased from N$1.9 billion in 2001/02 to N$3.9 billion in 2006/07, with both donor and private insurance accounting for the largest increase. Table 5: Financing agents to the health sector, 2001/02 – 2006/07 2001/02 2006/07 Government 1 055 730 913 1 641 597 829 Public insurance 321 127 930 614 222 886 Private insurance 373 967 669 842 723 230 Total insurance 695 095 599 1 456 946 116 Out of pocket 57 491 032 126 080 880 Companies 16 693 706 29 545 265 Donors 28 943 658 635 670 045 Total 1 853 954 908 3 889 840 136 Source: Health and Social Services System Review, 2008 C. Internally generated revenues in the health sector 26. MHSS health facilities generate as much as N$37.2 million a year from user fees for health services as well as ambulance fees, meal fees, and mortuary fees (Table 6). However, the absence of a national policy for fee retention at the point of service means that these revenues are returned to the Ministry of Finance. These user fees differ between clinics, health centers, and hospitals, and also by type of patients (private and state patients). The fees range from N$4 (clinic visits) to N$30 (national referral center) for state outpatients, and between N$2 and N$15 for follow-up visits. According to exit interviews, patients' access to services is constrained by the perceived high cost of access to care (user fees, as well as opportunity costs) and lack of transport. The long distances arising from the size of the country raises the out-of-pocket transport costs of patients. Table 6: Internally Generated Revenues in MHSS (in '000 N$), 2001/02 - 2006/07 Source 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 Health 12,598 19,263 27,349 23,225 28,206 28,289 services Ambulance 17 34 81 39 32 34 fees Total 22,122 26,962 38,139 31,274 34,864 37,173 27. Per capita health expenditure increased from US$126 in 2001 to US$165 in 2005, which yields an improvement of 10.5 percent, on average, over this period. Table 7 (below) presents this data in comparison with other SACU countries, in addition to regional averages. 9 Table 7: Health expenditure per capita, 2001-2005 (US$) 2001 2002 2003 2004 2005 Average % ∆ Botswana 143 180 277 387 431 32.7 Namibia 126 108 163 200 165 10.5 South Africa 216 198 296 385 437 21.2 Swaziland 70 57 114 144 146 27.3 Sub Saharan Africa 29 30 36 44 49 14.3 Source: World Bank, World Development Indicators, 2008 D. Health development assistance 28. As previously noted, Namibia receives development assistance in health, from a number of external development partners (Table 8). Development assistance allocated to health amounted to N$220.9 million in 2006/07 and was estimated to rise to N$345.9 million by 2009/10. Table 8: Development Partners and Funds (N$‘000) 2006/07 2007/08 2008/09 2009/10 WHO 4 284 4 284 15 590 15 590 Chinese Medical team 2 000 2 500 2 800 3 000 Health Unlimited 379 3 989 3 785 3 539 UNFPA 4 356 8 400 8 900 10 000 UNICEF 11 610 5 320 10 760 12 202 VSO 1 835 1 276 2 129 2 285 Czech TV Foundation 1 830 1 700 904 0 EU/EC 5 179 8 414 0 0 German Development Services 0 5 500 5 500 0 Cestas (Italy) 1 632 1 632 0 0 KFW/GITEC (Nasoma) 9 948 6 317 4 350 0 Global Fund Program 35 832 163 717 148 298 TBC Bristol-Myers-Squibb (BMS) 7 046 3 202 0 0 USAID/PEPFAR 127 115 115 920 133 700 133 700 10 Medicos del Mundo 3 612 4 267 4 481 5 304 GTZ 4 000 13 400 6 800 6 800 Total 220 858 349 839 347 997 345 994 Source: Medium Term Framework. 29. The largest source of funding during 2006/07 was the USAID with a share of 58 percent followed by the Global Fund with 16 percent. However, by the following year, the share of the Global Fund had risen to 46.8 percent while that for the USAID had reduced to 33.4 percent. Namibia’s share of external assistance to health has been increasing steadily, rising to 13.5 percent in 2001 from 2.7 percent in 2005, as noted in Table 9 (below). Table 9: Share of health in total external assistance, 2001-2005 2001 2002 2003 2004 2005 Botswana 0.5 0.5 1.9 2.0 4.0 Namibia 2.7 4.8 5.3 7.3 13.5 South Africa 0.2 0.4 0.3 0.5 0.5 Swaziland 1.6 1.9 2.7 3.9 5.6 Source: World Bank, World Development Indicators, 2008 E. Health expenditure allocation 30. Health expenditure for the period from 2001/02 to 2006/07 has been increasing in absolute terms, although only rising on average by 0.1 percentage over this period, implying that there has not been significant rise in expenditure year-on-year. Personnel expenditure’s share of the total expenditure has been the largest, increasing from a share of 38.7 percent in 2001/02 to 56.9 percent in 2006/07 (Table 10). Table 10: Expenditure by category shares, percent (N$ million) 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 Personnel 38.7 40.5 39.4 39.9 56.2 56.9 Goods and other services 24.7 23.9 22.5 21.3 26.2 24.6 Subsidies 30.7 29.2 31.7 33.6 10.8 11.2 Assets 0.9 0.8 1.4 1.3 0.7 1.3 Capital formation 5.0 5.6 5.0 3.9 6.1 6.0 Expenditure (N$’million) 1 354.1 1 508.4 1 689.7 1 759.0 1 334.9 1 358.3 Source: Source: Health and Social Services System Review 2008 11 31. In terms of use of health sector funding by service type, community health services (district hospitals, health centres, clinics and outreach points) increased from 40.1 percent (of total expenditure ) in 2001/02, to 54.8 percent. Specialized health services increased, over this period, from 27.6 percent to 34.4 percent (Table 11). According to the MTEF, expenditure on tertiary services is expected to rise from N$0.87 million in 2010/11 to N$0.89 million in 2011/12, and the regional and district health services is envisaged to increase over the same period from N$1.5 billion to N$1.6 billion. Spending in primary health care remains low. Spending in social welfare services rose steadily until the mid-2000s (to as much as 27.3 percent in 2004/05). However, the transfer of some key social welfare functions to other ministries (and therefore the requisite allocation) makes it difficult to trace actual spending on this budget item since 2005/06. Table 11: Health Expenditures by Category, in Percent, 2001/02 to 2006/07 Category 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 Primary Health 1.1 1.1 1.2 1.3 1.8 1.9 Care Community 40.1 42.2 40.4 39.4 54.1 54.8 health services Specialized 27.6 27.8 27.5 27.0 36.3 34.4 health services Social welfare 26.7 24.0 25.9 27.3 1.1 0.8 services Total 100.0 100.0 100.0 100.0 100.0 100.0 Source: Source: Health and Social Services System Review 2008 12 Chapter 3: Health Sector Structure and Overview A. Historic trends in health service delivery 32. The first formal health services in Namibia were established in the 1890s, and consisted of a field hospital for German soldiers in Windhoek and a hospital in Swakopmund. Several clinics in northern Namibia were subsequently established, between 1902 and 1908, by the Finnish Missionary Society. 33. The MHSS notes that four trends characterized the development of health services over the next 100 years, until independence in 19906. First was the obvious increase in the number of facilities and other services. For example, the number of doctors in Namibia rose from 9 in 1907, to 43 in 1948, 130 in 1966, 324 in 1991, to about 600 in 2001. The second trend was the increasing support given to mission facilities by the South West African administration. This also meant that the administration could increasingly influence these facilities. By 1966, all running costs of the mission health services were subsidized by the government. 34. A third feature was, unsurprisingly, the huge disparities between health services provided for the white and for black populations. Compared with the number of people, many more and better-quality services were available to whites than blacks. The disparities had many consequences, one example being that many more black children died at an early age. As a result, infant mortality rates were five to six times higher among the black population than the white population between 1960 and 1981. 35. Fourth, health services concentrated heavily on curative services, which were largely provided in well-equipped hospitals in urban areas. Very little focus was traditionally placed on rural/community health, disease prevention, the promotion of good nutrition, or educational programs. The great majority of Namibians, therefore, spent most of the past 100 years lacking most primary health care services. B. Structure of health services 36. Since independence, Government has strongly supported the provision of primary health care, with a predominant focus on community health, preventative measures and on treatments that can be provided relatively easily, inexpensively, and quickly. Most primary health care is delivered through outreach points, clinics, health centers and district hospitals. More serious health conditions are generally referred to and treated at higher (secondary and tertiary) levels. Health centers and district hospitals offer secondary level care, while the most specialized and tertiary level care is offered at the main referral hospitals in Rundu, Oshakati, and Windhoek. This hierarchy allows for different facilities to be staffed and equipped appropriately to provide different kinds of health services. 37. There are two principal levels of management of public health - the national MHSS head office in Windhoek and the regional management. The head office consists of the ministerial 6 MHSS, 2008. 13 offices, the offices of the Permanent Secretary and Deputy Permanent Secretary, and two departments. One of these departments is responsible for Social Services, Policy Development and Resource Management. The other department is in charge of Health Care Services, which is further divided into two directorates: one for Primary Health Care and one for Tertiary Health Care (Figure 5). Figure 5: The organization and lines of responsibility in the MHSS 38. In general, the head office is responsible for policy formulation, strategic planning, legislation and regulation, monitoring and overall coordination. The Deputy Permanent Secretary is responsible for a Regional Co-ordination Unit, which provides direction for the regional level of management. The regional level is responsible for policy implementation and the provision of services. Until recently, four directorates administered public health services in the country, and the directorates were divided into 34 health districts. The system of regional management is soon to be further decentralized to the 13 political regions, where MHSS Regional Management Teams will manage health and social services within each region in close collaboration with its Regional Council. C. Health care access and utilization 39. There has been a substantial increase in the number of hospitals and clinics since independence. In 1981, there were only 98 public health facilities, compared to the 317 public hospitals, health centers and clinics in 2001. This growth has been concentrated on clinics since the number of public hospitals actually decreased from 57 in 1990 to 36 hospitals in 2001. 40. Despite these substantial infrastructure investments, some populations in remote areas still have limited access to health facilities. Challenges regarding access are most severe in Omaheke and Kunene, where less than half the people are close to a clinic or hospital. Access is somewhat better in Otjozondjupa and Oshikoto, with about two-thirds of people being within 10 km of health facilities. All the other regions provide coverage for about 80 percent or more of the population. Of all people in Namibia, about 80 percent or 1.51 million people live within 10 km of a public health facility. 41. There are also substantial differences in access to staff and hospital beds in the 13 regions (Table 12). The best staff allocations are in Khomas and Oshana, given that these regions both have large referral hospitals that are staffed to serve both people in these two regions and referrals from other regions. Ohangwena and Omaheke constitute the regions with the worst staff 14 allocations. For Namibia as a whole, there are about 7,500 people per public service doctor, and 950 people per registered nurse. 42. Khomas, Oshana, Karas and Kavango are best equipped with hospital beds in relation to the number of people in each region. The allocation of beds in these four regions is roughly three times more generous than in Ohangwena and Omusati, where each hospital bed serves a population of more than 400 people. Nationally, there are 271 people per hospital bed. In addition to doctors and registered nurses serving in public health services, there were approximately 370 doctors and specialists in private practice in 2000. Over two-thirds of them were in Windhoek. Table 12: Numbers of people per doctor, registered nurse and hospital bed in public health facilities in 2000 Source: MOHSS, 2008. D. Access to safe water and sanitation 43. About 77 percent of all households in Namibia had access to safe sources of water in 2000. Almost all households (98 percent) living in urban areas had access to safe water, whereas only 67 percent of rural homes had safe water. The great majority of households using unsafe water were in northern, rural areas. Water drawn from open wells (oshanas), which are shared with livestock, remain the primary source of unhygienic water in Kunene, Omusati, Oshana, Oshikoto and Ohangwena. 44. The Okavango, Zambesi, Kwando and Chobe Rivers are the major sources of unsafe water in Kavango and Caprivi. In the southern regions, by contrast, the great majority of people in rural areas use safe water pumped from underground. Approximately 41 percent of all Namibian households have adequate sanitation, although a substantial urban-rural discrepancy is evident (i.e. 85 percent of urban households versus 19 percent of rural households have adequate 15 sanitation). The MHSS estimates that over 1.1 million people do not have adequate sanitary facilities in Namibia7. E. Utilization of health services 45. Studies by the MHSS examining the efficient use of health services indicate that each person visited a clinic as an outpatient 1.5 times on average per year during 1995-19998. The figure is high compared to many African countries, where there are often less than 0.5 visits per year on average. There is a great deal of variation in the number of people that clinics treat each day. A recent MHSS assessment indicated that thirty-four clinics (14 percent of all clinics) attended to more than 50 people each day, on average, 106 (44 percent) were visited by between 15-50 people per day, and 103 clinics (42 percent) had less than 15 people each day. There was a similar high degree of variation in rates of attendance at health centers, as summarized in Table 13. Table 13: The number of health facilities attending to different numbers of people each day Patients per day Clinics Health Centers Less than 15 patients 103 4 15-50 patients 106 15 More than 50 patients 34 12 Source: MHSS, 2008. 46. Many of the clinics that are little used are in sparsely populated areas, such as in Kunene and south of the Okavango River. However, others are in areas where large numbers of people live. This is true in the north-central regions and especially so in Caprivi, where very many clinics attend to fewer than 15 people each day, on average. The high proportion and distribution of under-utilized clinics suggest that there may be too many health facilities in certain areas. However, this assessment did not also examine quality of care issues in health facilities in these diverse locations. 47. A 2008 MHSS analysis of bed occupancy showed that resources at some hospitals are used much more intensively than at others. In this national assessment, eleven wards (adult and pediatric) recorded bed occupancy rates of less than 40%. In contrast, 17 other wards had their beds occupied for more than 80% of the time and are over-utilized. In hospitals, children spend an average of 5.9 days in pediatric wards, while adult patients remained in hospital for an average of 8.6 days. Mothers spend an average of 3.1 days in maternity wards. TB patients may spend up to two months in hospital, and the growing number of TB and AIDS patients has contributed to an increase the average length of time spent in hospital. For example, the average length of stay by adults in hospitals in Ohangwena increased from 9.7 days in 1995 to 11.2 days in 1999. F. Disease burden 48. An MHSS assessment of all outpatient visits from 1995-1999 indicated that a relatively small number of diseases account for the great majority of outpatient cases. Among outpatients aged 5 and over, the ten most frequent diseases accounted for 83 percent of all new visits. The four most common conditions (acute respiratory infections; ear,nose and throat diseases; malaria 7 MHSS, 2008. 8 This refers to new visits only, each visit being for a different reason or treatment. 16 and muscular and skeletal diseases) constituted nearly half (48 percent) of all new cases (Table 14). Table 14: The average number of outpatients aged 5 and over reported for the 10 most frequent conditions each year, and the percentage that these made up of all new visits, 1995-1999 Source: MHSS, 2008. 49. The ten-most common diseases among children under 5 years made up an even greater proportion of all outpatients. An estimated 97 percent of all new visits were for these ten conditions, as noted in Table 15. The four most prevalent conditions accounted for over two- thirds (69 percent) of all new cases. These were acute respiratory infections, malaria, diarrhea, and ear, nose and throat diseases. Over one out of every five children (under five years) treated as outpatient was diagnosed as having an acute respiratory infection. Table 15: The average number of outpatients aged 5 and under reported for the 10 most frequent conditions each year, and the percentage that these made up of all new visits, 1995-1999 Source: MHSS, 2008. G. Inpatients 50. In public hospitals, inpatients are divided into those aged 13 and older, who are treated in adult wards, and those that are younger than 13 years, who are admitted into child or pediatric 17 wards. The older age group made up 68 percent of all inpatients, while 32 percent of inpatients were below the age of 13. Tables 16 and 17 list the ten diseases for which most inpatients aged 13 and over and children below 13 years were admitted. There was a much greater range of diseases among inpatients than outpatients. For patients of 13 years and over (Table 16), the top 10 conditions comprised 65 percent of all admissions, and the top four diseases (malaria, genitourinary diseases, injuries and other gastrointestinal diseases) accounted for only 35 percent of all admissions. Table 16: The average number of inpatients aged 13 and over admitted for the 10 most frequent conditions each year, and the percentage that these made up of all admissions, 1995-1999 Source: MHSS, 2008. 51. For children under 13 years (Table 17) , the top 10 conditions accounted for 75 percent of all admissions, while the main four (malaria, diarrhea, pneumonia and injuries) made up 51% of all admissions. Malaria is especially prevalent among children with almost one out of every four inpatients being hospitalized for this disease. Malaria is the most important cause of admission in the northern regions of Caprivi, Kavango, Ohangwena, Oshana, Oshikoto, Omusati and Kunene. Table 17: The average number of inpatients under the age of 13 admitted for the 10 most frequent conditions each year, and the percentage that these made up of all admissions, 1995-1999 Source: MHSS, 2008. 18 52. A high proportion of inpatients are referred from one hospital to another, especially for surgical treatment. Most surgical activities are conducted at the major referral hospitals in Windhoek and Oshakati, particularly for major procedures. Of all major operations, 34 percent were done at the Windhoek Central Hospital, 21 percent at the Katutura Hospital, and 14 percent took place at Oshakati Hospital. Of all minor operations, 17 percent were done at the Windhoek Central Hospital, 18 percent at the Katutura Hospital and 12 percent at the Oshakati Hospital. The rest of the of the 31 percent of all major and 51 percent of all minor operations took place in the other 31 public hospitals. H. Mortality 53. A total of 41,598 deaths were reported in public hospitals and health centers between 1995 and 1999. The ten-most frequent causes of death are listed in the next table, and these 10 causes made up 76 percent of all deaths over this period. The high percentage of deaths due to AIDS indicates that almost one out of every five deaths was due to this disease. The actual impact of AIDS was most probably even higher, since a substantial proportion of deaths attributed to TB, acute respiratory infections, and some other infectious and parasitic diseases were probably also a result of advanced HIV infection. The number of AIDS deaths increased over four times between 1995 and 1999 (from 632 deaths in 1995 to 2,756 deaths in 1999). Table 18: Causes of death, 1995-1999 (number and percentages),1995-1999 Source: MHSS, 2008. I. Human resources for health 54. Namibia provides reasonable pay to its health workers compared to other countries in the region. Results of informal surveys indicate that respondents felt secure in their jobs, and also noted opportunities for further studies, either in local training institutions or if not, training programs with other countries. However, it has been noted that the current staff establishment is outdated relative to the current and expected burden of disease of the country. The long process of recruitment for government positions through the Public Service Commission, as well as the protracted process of issuing work permits to foreign nationals, also contributes to the HR shortage. It is estimated that 60 percent of health workers are in the civil service and the remaining 40 percent are in the private sector. 55. The health and social welfare system is facing a major crisis in human resources, especially district hospitals. Staff inadequacy is generalized, but particularly severe for doctors, 19 nurses (RN), pharmacists, dental therapists, and social workers. The shortage of doctors occurs primarily because Namibia does not have a medical school and therefore has to rely on South Africa for the training of Namibians. The availability of foreign doctors is constrained by the long recruitment process arising from the protracted approval and delays in the release of work permits9. Finally, Namibia is facing increasing movement of Namibian doctors - mostly medical officers and specialists - to the private sector. The human resource shortage is also being artificially worsened by staff resigning from their post only so that they can get receive their pension benefits under the Government and Industry Pension Fund (GIPF) and after receiving it, apply back to their old posts. 56. Namibia has limited training capacity for health workers. In addition, it possesses a serious training supply-side constraint: the pool of high school graduates with adequate sciences and mathematics background to meet entrance requirements for tertiary education in the health sciences (medicine, nursing, pharmacy, medical technology, etc.) is very limited. South Africa has indicated that it can no longer be relied upon to be the source of training for Namibian medical students. As a result, the Namibian Government is considering the establishment of a medical school attached to the University of Namibia. J. Human resource management 57. As noted in Table 19, key cadres of health workers have high attrition rates for the following reasons: (a) The abolition of the deprivation package for rural areas in 1995 resulted in fewer people willing to work in these remote places. (b) The disparity of salary scales/grades in some job categories pushes some health workers, especially those in professional categories, to quit the public sector. (c) Staff suffer from low motivation due to high workload arising from the high vacancy rates and the increasing morbidity due to HIV/AIDS and other diseases. High losses are occurring particularly for doctors, pharmacists, dentists, radiographers, and social workers. Dual service of doctors and social workers is allowed through the "remunerative work outside civil service" policy, with this system managed by the Medical Superintendent. Table 19: Number of Staff Who Left the Health Workforce, by Reason, 2007 Reasons No. of Staff Percent Resignation 226 51 Death 77 17 Retirement 88 20 Transfer to other government job 22 5 Expiration of work contract 0 0 Medical discharge 20 5 Dismissal 8 2 Total 441 100 Source: MHSS, 2007 9 It normally takes 3-4 months to approve a foreign worker application. However, according to the Ministy of Home Affairs, delays occur because of incomplete application forms and lack of computerization. The Immigration Selection Board consisting of the Permanent Secretary of each ministry or his/her deputy meets every Thursday to look at the applications, but sometimes there is no quorum, thus delaying the process further. The MHA is in the process of computerizing the application and approval process, and this is expected to shorten the period of getting foreign health workers into the country. 20 K. Social welfare services 58. The main categories of disability in Namibia are shown in Figure 6. To address these needs, the key social welfare services provided by Government include support to the elderly, disabled, victims of family abuse, and recovering drug/substance abuse patients. Social Welfare services are provided by an array of institutions, namely: the Social Welfare Directorate and Primary Health Care Rehabilitation Services of the MHSS, the Child Welfare Services which has been transferred to the Ministry of Gender and Child Welfare, the Ministry of Labor and Social Security, and Veterans Affairs. Figure 6: Main types of disability in Namibia, by sex (numbers), 2007 Source: MHSS, 2007 L. Additional challenges 59. Organizational structures: At the central level, current structures are not aligned to enhance performance. Duplication of functions are obvious in the separate directorates for the following: (a) Human Resource Management and Human Resource Development, (b) disability prevention and disability rehabilitation, (c) facility planning and facility management, (d) logistics and general services, and (e) overlapping donor coordination done by the Policy and Planning and Special Programs directorates. Additionally, there is inadequate coordination of various (new) vertical programs at the national level, as seen in the following: (a) primary health care and HIV/AIDS, with the latter tending to attract most management attention and financial resources; (b) nutrition, CBHC, and health promotion which exist as programs at the national level but have no regional and district level mechanisms for their implementation. In general, there are no clear structures in communities for promotive and preventive health as the current system ends at health facilities. 60. Social welfare: The responsibility for social welfare services is spread thinly across different ministries including the MHSS, the Ministry of Labor and Social Welfare (MLSW), the Ministry of Gender Equality and Child Welfare (MGECW). Within MHSS itself, responsibility for social welfare is diffuse. Thus, some are arguing for the unification of all social welfare services under a single ministry. At the local level, the rules and functions of regions and districts remain unclear, resulting in overlaps and duplications in functions. There has also been delay in the decentralization of services to the regional councils. 21 61. Information systems: The information system is not unified and harmonized. Stand- alone "sub-systems" are managed by different divisions, each with its own IT system and language. The health information system remains highly centralized. 62. Intersectoral collaboration: The increasing frequency of natural disasters (flooding) and health epidemics (cholera) requires a stronger emergency response through intersectoral collaboration. There is no policy and implementation plan at this time on emergencies. Other sectors that need to work with MHSS include the Ministries of Education for school health; Local Governments; Information and Broadcasting for public health announcements and information, education and communication (IEC) campaigns; and Gender and Child Welfare for issues dealing with orphans and vulnerable children. Interesectoral collaboration is particularly weak at the regional level. Despite well-meaning intentions, meetings on health and social welfare within the Regional Development Councils are infrequent due to lack of time. 22 Chapter 4: HIV/AIDS A. Status of the epidemic 63. Namibia has the fifth highest HIV/AIDS prevalence in the world, after Swaziland, Botswana, Lesotho, and South Africa. Namibia’s first AIDS case was reported in 1986. Since then, overall adult HIV/AIDS prevalence increased from 4% in 1992 to 22% in 2002. There has 10 been a recent reported decrease in prevalence to 17.8% according to 2008 ANC survey , (15.4% estimated adult HIV prevalence in 2007/08 using Estimation and Projections Package11). However, the epidemic remains a very serious challenge with towns in the Caprivi region in the north-east reaching disturbingly high prevalence estimated at 31.7 percent. The majority of those infected have been young adults – 25 percent of all Namibians with HIV/AIDS in 2000 were between the ages of 25 and 29. Figure 7: Adult HIV Prevalence & Number of People living with HIV/AIDS (1990-2007) Source: UNAIDS/WHO, 2008. 64. The Namibian epidemic is heterogeneous in nature. Infection rates in northern Namibia are generally higher than in the south, but there are lower infection rates in Kavango than in the other densely populated northern regions. The 2008 ANC survey indicates that the epidemic appears to be concentrated in four main pockets where mobile populations are likely to take temporary residence such as mining centers, tourist areas, commercial centers, and border points. There is no difference in prevalence rates among urban and rural women, however the prevalence among urban women aged 20-24 is slightly higher. 65. HIV/AIDS presents a substantial additional challenge to the health sector. The number of AIDS inpatients increased almost four times between 1995 and 1999 in the country as a whole, and 10 times over the same period in Omusati and Ohangwena. This epidemic has been exacerbated by an extremely high TB incidence (765 per 100,000 in 2006, with several regions 10 http://www.healthnet.org.na/statistics/2008%20HIV%20Sentinel%20brochure.pdf 11 Estimates and Projection of the Impact of HIV/AIDS in Namibia, Ministry of Health and Social Services, June 2008 23 reporting rates of over 1000 per 100,000). Given its significance, the TB epidemic will be discussed further in the subsequent chapter. 66. The number of AIDS deaths each year at government hospitals increased from 86 in 1992 to just under 2,700 deaths in 1999. AIDS caused over 25 percent of all deaths recorded in health facilities in 1999, and it is now the leading cause of death in Namibia. Most deaths occurred in the 30 - 34 age group for women whereas the majority of deaths among men were between the ages of 35 and 39. The number of orphans is rapidly rising with a total of 85,000 households 12 with a single or double parent orphan aged 0-17 years . B. Drivers of the Namibian Epidemic 67. Multiple and concurrent partnerships are likely contributing to the rapid spread of HIV throughout the country. In 2006, 16 percent of sexually active men and 3 percent of sexually active women reported more than one partner over the previous 12 months (NDHS 2006). Several local studies also have recorded high levels of concurrent partnerships throughout Namibia13, although nationally representative data are not available (NDHS 2006; VCT data). 68. Intergenerational sex exposes adolescents and young adults to partners who, by virtue of their age and longer sexual history, are more likely to be HIV positive. Among women age 15 to 24, 7 percent of single women and 26 percent of married women have a partner 10 or more years older (NDHS 2006). Intergenerational sex in Namibia is associated with higher levels of sexually transmitted infections (STIs) and with a greater likelihood of having multiple partners (NDHS, 2006). Intergenerational relationships introduce the virus into the younger cohort, where it quickly spreads as a result of rapid partner turnover and common concurrent partnerships (especially among young men). 69. Pervasive alcohol abuse and low levels of HIV risk-perception serve to foster multiple and concurrent partnerships, and may discourage consistent condom use (NDHS 2006). Nationally, 78 percent of men and 62 percent of women used a condom at last sex with a nonmarital noncohabiting partner (NDHS 2006). In Caprivi and Kavango, regions facing the worst of the epidemic, condom use is the lowest in the nation (NDHS 2006). Furthermore, low levels of male circumcision are reported in some of the areas with the highest HIV prevalence, namely Caprivi, Ohangwena, Omusati and Oshikoto. 70. Over the years there has been a steady decline in marital or cohabiting relationships (NDHS, 1992, 2000, and 2006). In 2006, approximately 1 in 3 Namibians ages 35 to 39 had never married or cohabitated with anyone. For women, never marrying or cohabiting was associated with having a greater number of sexual partners over one’s lifetime (NDHS 2006). In most African countries one of the strongest predictors of HIV infection is the number of lifetime sexual partners. 71. Transactional sex appears to be common in many parts of Namibia, although research that quantifies this practice is lacking. In this context of widespread poverty and limited employment opportunities, sexual intercourse has become a commodity freely traded for goods 12 Based on data in Namibia Household and Income Expenditure Survey 2003-2004, reported in A Review of Poverty and Inequality in Namibia, October 2008, Central Bureau of Statistics, National Planning Commission 13 Parker & Connolly 2007 & 2008. 24 and services by men and women (Mufune 2003). Women are particularly vulnerable to transactional sex, since many remain economically dependent on men. 72. High levels of population mobility also accelerate the spread of HIV. Namibia serves as a corridor for much traffic to and from Southern Africa, receiving migrants from the highest prevalence countries in the world (particularly through the Caprivi Region). Also, Namibia’s reliance on the mining and fishing industry, as well as on seasonal agricultural production, requires regular internal population displacement. Travel away from home is associated with an increase in multiple partnerships in Namibia (NDHS 2006). 73. The evidence strongly suggests that young women are at highest risk of acquiring HIV infection. Recent projections estimate that nearly half (44 percent) of new infections over the next 5 years will occur among 15 to 24 year olds; 77 percent of these will occur in young women. These women are most likely infected early in their sexual life by their first or second partner14. It appears that the risk for many women stems from their choice of partner rather from their own behavior. Only 27 percent of women aged 15 to 49 reported more than two partners in their lifetime, and multiple partnerships were not a risk factor for HIV infection among female VCT clients. C. Government Response 74. HIV/AIDS features prominently in the key policy documents: the National Development Plans (NDP-3 is currently under implementation), the Poverty Reduction Strategy and the overarching national guide - Namibia Vision 2030 – and is seen as one of the key constraints to Namibia’s development. The Government has launched an intensive campaign captured in the National Strategic Plan on HIV/AIDS and the (associated) Medium Term Plans (MTP), the Third of which was launched in April 2004, and will be completed in 2010. The overarching goal of MTP 3 is “the reduction in incidence of HIV infections to below epidemic threshold.� 75. The strategic results that the plan will try to achieve are: people affected and infected by AIDS should enjoy equal rights; reduced new HIV infections and other sexually transmitted infections (STIs); all people living with HIV/AIDS (PLWHA) have access to cost-effective and quality treatment and support services; strengthened capacity of local responses to mitigate socio- economic impacts of AIDS; and effective management structures, capacity and skills for quality implementation of the strategies and plans. The plan contains five major components that are designed to achieve the targets set above: enabling environment; prevention; access to treatment, care and support; impact mitigation; and integrated and coordinated program management at all levels. 76. Management of the national HIV/AIDS response is organized at the following levels: • The National AIDS Committee (NAC) is the highest policy decision-making body and is attended by Cabinet ministers and Regional governors; • The National Multi-Sectoral AIDS Coordination Committee (NAMACOC) provides leadership for multi-sectoral and regional implementation and is at Permanent Secretary level including equivalent local level officials; 14 VCT data, NDHS 2006; UNICEF 2006 25 • The National AIDS Executive Committee (NAEC) provides technical leadership and is responsible for coordinating the detailed implementation of multi-sectoral responses ; • The National AIDS Coordination Program (NACOP) under the Directorate for Special Programs of the Ministry of Health and Social Services is the technical body working with NAEC; the Sectoral Steering Committees involves all key actors working in that sector and is responsible for the implementation of sector-specific interventions; • The Regional AIDS Coordinating Committee (RACOC) in each Region coordinates activities among government and civil society interventions and between national and regional institutions. 77. MTP 3 takes a “results-based� multisectoral management approach to achieving nationally and internationally agreed targets, and gives a prominent role to non-governmental organizations, private sector companies, professional associations, academia, etc. It recognizes the important role that the private sector will play in HIV prevention and AIDS treatment for company employees, their families and in general private sector mobilization against the epidemic. All Government departments have developed strategies and allocated resources for workplace programs, clearly specified in the medium term expenditure framework15. D. Prevention efforts 78. The predominant mode of transmission is through heterosexual intercourse, and prenatal transmission. The most recent Demographic and Health Survey16 (2006-2007) provides detailed information on HIV trends. While knowledge of the disease is almost universal (99 percent for both men and women ages 15-49) there is not noticeable behavior change commensurate with the 17 reported high levels of information. There are still misconceptions about HIV especially among the less educated people, in the Caprivi and Kunene regions. 79. Stigma and discrimination about HIV while decreasing is still a major obstacle for people to get tested and adhere to therapy. Prevention in terms of condom use is reportedly most frequent among women aged 15-19 which is most probably the reason for a sharp decline in prevalence for that age group. At the same time older women are less consistent in condom use. An encouraging trend among younger people is delayed first sex with a sharper decline among men age 15-19 years, from 31 percent to 19 percent compared to the 2000 DHS. 80. Government has placed much emphasis on scaling-up HIV counseling and testing. By end-2004, all 34 hospitals and about 178 health facilities were providing PMTCT services with 88% of pregnant women accepting HIV tests. Sexually transmitted diseases (STIs) still pose a major challenge and rank 8th among reasons for all hospital consultations.18 In 1995, the government introduced Syndromic Management as an intervention measure for STI control. 15 Namibia Medium Term Expenditure Framework for 2008/09-2010/11; http://www.mof.gov.na 16 Namibia, Demographic and Health Survey 2006-07, Ministry of Health and Social Services, Macro International Inc, August 2008 17 Common misconceptions are: a healthy looking person cannot be HIV-positive; mosquitoes transmit HIV; sharing food with an HIV-positive person exposes you to the disease, etc. 18 Namibia Demographic and Health Survey 2006-07 26 However, due to lack of human resources and capacity implementation has not been very successful, including the training of health personnel providing STI services. 81. Based on the DHS 2006-07 data, 7 percent of women and 4 percent of men age 15-49 self-reported having an STI and symptoms of STI in the past 12 months. Interestingly, the lowest self-reporting on STIs comes from the Caprivi region which has the highest HIV prevalence, which may be indicative of under-reporting for variety of reasons. The 2008 Antenatal survey indicates alarmingly high syphilis prevalence rates of 17.9 percent in some parts of the country showing that unprotected sex is still very common. Figure 8: HIV Prevalence Rate Among Pregnant Women in Namibia, 1992-2006 Source: MOHSS E. Treatment 82. The growth in government health expenditures and financial support from the Global Fund and PEPFAR have enabled the authorities to speed up the roll out of ARVs. The MTP-3 projected an outcome of 30,000 people on HAART by 200919. Namibia has done exceptionally well in its program and has been recognized for its rapid expansion of ART that is estimated to currently cover 88% of those who need treatment. As of end Feb 2009, there were 59,500 people on ARVs. An estimated 50,000 are expected to be put on in the near future, depending on whether they meet the criteria of having a CD4 count of 200 or lower20. 83. According to the study on the impact of HIV/AIDS using the Estimation and Projects Package (EPP) the number of people in need of ART will further increase by 2012/13 (the Namibia Spectrum model estimates that a total of 69,500 were in need of ART by end-March 2008, and it projects that the number will reach 114,500 by March 2013). This effort in providing life-saving medication to a large percentage of the population is a major achievement. However, its sustainability is crucial, particularly at this crossroad of response to HIV, and the global financial and economic crisis that might impact the funding of programs. F. Development and demographic impact of HIV 19 The cost of ARV per person per year is estimated at NS$1,512 (about US$180) for the 1st regimen. That amount does not include consultations, administration, hospitalization, etc. 20 The ART-initiation criteria for pregnant women is aCD4 count of 250 (or lower). 27 84. HIV and HIV-related health complications pose the most serious development challenge to Namibia, and the negative impact on all sectors of the economy has been felt and it will continue to considerably affect the country’s progress in the near future. One of the most immediate aspects of the impact of the epidemic is the increase in mortality and the corresponding decrease in life expectancy. HIV/AIDS has resulted in high levels of mortality and has eroded the gains from improved primary health care21. AIDS accounts for up to half of all mortality and is the dominant cause of deaths among young adults in the Southern African hyper epidemic MICs22. As a consequence, life expectancy has dropped dramatically (Figure 1). 85. In Namibia it is estimated the losses in life expectancy accounted for 17 years, reversing the gains in life expectancy achieved in the 1950s. Based on preliminary data, Figure 9 also illustrates some estimates of the impact of increasing availability of antiretroviral therapy – while it increases life expectancy of people living with HIV, the HIV/AIDS continues to have a large impact on life expectancy even where treatment coverage rates are high. Figure 9: Life expectancy at birth in Southern African Countries (1950-2010) Source: United Nations Population Division, 2007, “World Population Prospects: The 2006 Revision Population Database� (New York: United Nations). 86. Figure 10 adds a cross-country perspective relating life expectancy and GDP per capita for low- and middle-income countries. It shows that Namibia, compared to countries with similar income levels, has levels of life expectancy that are about 20 years lower. Figure 10 also indicates that levels of life expectancy in middle-income in Southern Africa countries are as low as levels normally attained by low-income countries.23 21 Population Projections 2001-2031, National and Regional Figures, Central Bureau of Statitistics, National Planning Commission, January 2006, ISBN 0-8697-676-7 22 For example, the United Nations Population Division (2007; World Population Prospects: The 2006 Revision) estimates that crude mortality in Swaziland in 2000-05 was 1.7 percent, which compares to 0.7 percent for a scenario excluding the impact of HIV/AIDS. For the population between ages 15 and 49, estimated mortality is 1.8 percent, representing a 6-fold increase compared to a “no-AIDS� scenario. 23 Figure 2 shows several countries with life expectancy as similarly low as the SACU countries. These are countries which recently have experienced very large gains in GDP associated with oil revenues (e.g., Angola, Gabon, Equatorial Guinea), and where other development indicators have not improved in line with the fast gains in GDP per capita. 28 Figure 10: GDP per capita and life expectancy Figure 2. GDP per C apita and Life Expectancy, 134 Low- and Middle-Income C ountries 80 Life expectancy at birth, 70 2000-05 (Years) 60 Namibia 50 South Africa Swaziland Botswana 40 Lesotho 30 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 GDP per capita, US$ at PPP, 2005 Source: IMF, World Economic Outlook Database (2008) for GDP per capita, and UN Population Division (2007) for life expectancy. 87. The reversals in key health indicators, such as life expectancy, and their immediate consequences (losses of family members, increasing number of orphans, increasing dependency ratios) as a result of HIV/AIDS has profound implications on the macroeconomic level, for public services, especially the delivery of health services. It is estimated that the indirect cost (added to the direct cost of medical care) meant a loss of over N$ 8 billion (US$ 1 billion) to the Namibian economy by 2001, or 20% of GDP. In addition to the macroeconomic impact HIV/AIDS has more direct and more severe impacts on living standards, arising from the increased risks to life and health and their economic consequences. 88. Namibia is facing considerable challenges in terms of sustaining the response to HIV/AIDS. The numbers of new infections remains very high (even though available indicators suggest that incidence may have peaked), suggesting that the challenges described above, in terms of the macroeconomic impact of HIV/AIDS, the very high numbers of orphans, and the scale of the response to HIV/AIDS, are going to persist for years to come. Moreover, the costs of treatment programs are likely to escalate over the coming years, as increasing numbers of people living with HIV/AIDS are projected to reach a stage of the disease at which they require treatment, and as an increasing number of patients currently receiving treatment are projected to require far more expensive (second-line) drugs. 29 Chapter 5: Tuberculosis A Epidemiology of tuberculosis in Namibia 89. Namibia has the fourth highest TB incidence in the world after Swaziland, South Africa, and Djibouti. Since 1990, the incidence of TB has increased 261 percent, with the highest rates in Walvis Bay, north-eastern Otjozondjupa, and part of Ohangwena, as well as around Bagani and near Tsumeb. The TB death rate in Namibia is 96/100,000 population which is higher than Botswana (91/100,000), Lesotho (88/100,000), DRC (84/100,000), Tanzania (66/100,000) and the continental average (83/100,000).24 While TB case detection (83%) and treatment success (75%) are better than many in the region and have progressed as a result of commendable TB Program efforts, unpacking this data establishes that for every 100 infectious TB patients in Namibia, only 62 are being found and successfully treated by the health system.25 90. Namibia’s commitment to Directly Observed Therapy, Short- Course (DOTS) has led to a decline in the case notification rate by 6.5 percent per year for the past 3 years although the number of cases of re-treatment has been increasing.26 Despite this, Namibia continues to face an increasing co-epidemic of HIV/AIDS and TB, which is exacerbated by increasing rates of Multi- Drug Resistant and Extensively Drug-Resistant (MDR/XDR) tuberculosis. The following table compares Namibia’s TB epidemiology with other Southern Africa Customs Union (SACU) countries and with the continental average: Table 20: Tuberculosis in SACU Countries, 2008. B. TB/HIV co-epidemic 91. A high proportion of TB patients are HIV positive (national average 59 percent but as high as 72 percent in some districts) with most accessing appropriate HIV care and treatment but 24 WHO Global TB Report 2008 25 This is calculated by taking the proportion detected (83%) and multiplying that proportion by the treatment success rate (75%): 100 x 0.83 x 0.75 = 62 26 CDC: “Report of the MDR and XDR-TB Mission Visit�, 23-29 October 2008, p.3 30 not HIV prevention services27. For example, in the first half of 2008, 72 percent of all TB patients were tested for HIV. While this represents good progress in attacking the co-epidemic from the TB side, opportunities are being missed from the HIV side to prevent and diagnose TB in those accessing services for HIV care and treatment. Given this dual epidemic context, numbers of TB cases and deaths increased dramatically between 1995 and 1999, with much of the increase being due to the rising numbers of people with HIV/ AIDS. 92. The number of inpatients with tuberculosis rose 27 percent from 1995 to 1999, while the number of deaths increased by 64% over the same period. These increases were due to the rising number of TB cases among patients aged 13 and over. The number of children under 13 with TB in hospitals remaining fairly even at about 1,300 to 1,400 each year. The majority of people who died of TB during 1995-1999 were elderly. The disease is, in fact, a leading cause of death among older people, especially elderly men. Many of the deaths of people between the ages of 20 and 50 were associated with HIV/AIDS. Just over 5% of all deaths were children under 5. 93. The ‘3-Is’ of Intensified case finding, Isoniazid preventive therapy (IPT), and Infection control, which are the foundation of HIV-side efforts to reduce the burden of TB in PLWHA, remain areas in need of improvement in the Namibian health system. For example, TB screening is not yet standard practice at HIV testing and counseling (HTC) centers e.g. VCT, PMTCT, STI clinics, nor is it routinely reported.28 IPT is being implemented, which is noteworthy, however the proportion of those eligible versus being treated is not known. 94. Infection control for TB in health care and congregate settings is an issue of major concern. In an era of increasing TB drug-resistance, the risk that PLWHA (in addition to HIV- negative patients) may acquiring TB infection as a result of contact with the health system is very real. While awareness of the issue is high, there is no systematic planning for scaling-up of TB- IC in all health facilities. Many facilities lack written TB-IC plans, have limited isolation facilities for infectious TB patients, and have poor TB-IC practices.29 C. Multi Drug-Resistant and Extensively Drug Resistant (MDR and XDR) TB 95. The threat of an epidemic of drug-resistant TB cases is very real in Namibia. The first XDR-TB cases were detected in 2008 and since that time, there are 201 confirmed MDR-TB and 23 confirmed XDR-TB cases.30 The actual number of cases is likely higher and increasing. Some consequences of this emerging threat to the health sector may include: • Efficiency: Reduced efficiency of health sector expenditures in HIV/AIDS as PLWHA are especially vulnerable and die quickly without adequate treatment when co-infected. • Access: More patients with MDR/XDR-TB will result in an increased burden on the health system e.g. hospitals, HR etc. as they require treatment for 18-24 months to be cured vs. the 6 months of treatment for ‘regular’ (drug-susceptible) TB. Health systems limitations may lead to problems of access to diagnosis and treatment for increased volumes of MDR/XDR- TB patients. 27 Namibia External NTCP Review, Executive Summary, 28 February, 2009 28 Van Gorkom, Jeroen “Report on a visit to Namibia� Report #4, 17-28 November 2008, KNCV, p.6 29 Namibia External NTCP Review, Executive Summary, 28 February, 2009, p.5 30 Ministry of Health and Social Services, National TB Control Policy, 2009, p.4 31 • Quality: Treatment outcomes for patients with MDR/XDR-TB are much lower than those for patients with drug-susceptible TB. Increased levels of MDR/XDR-TB in the population will result in poorer health outcomes (higher mortality, morbidity, and transmission) • Global Public Goods Dimensions: Given the cross-border movement of populations, a higher concentration of MDR/XDR-TB cases will facilitate the spread of TB drug-resistance throughout the region e.g. (Angola, Botswana, Zambia, Zimbabwe etc.) • Cost: Increased burden on health sector budget given the high cost of MDR / XDR-TB treatment 96. The NTP budget graph for 2009 illustrates the high cost of addressing MDR/XDR-TB. It also underlines the urgency of strengthening the regular TB control program in order to reduce the number of MDR/XDR-TB cases being created and to manage the escalating costs of addressing TB drug-resistance in the future. Figure 11: NTP budget line items, 2009 Source: WHO Global TB Report 2009, Namibia Country Profile 97. One particular area of concern that indicates an elevated risk of spreading drug-resistant TB throughout the country is the poor treatment outcomes for previously treated cases. Currently, only 65 percent of re-treatment cases are successfully treated due to a high case fatality (10 percent), very high treatment failure (13 percent), and default rate (7 percent).31 This group is among the main contributor to MDR-TB cases and to manage the problem, it will be critical for Namibia to improve results for this group. D. Opportunities to strengthen the response 98. The following opportunities to strengthen the national TB response are noted: a) Enhance collaboration with the private sector and other non-health sectors: The program review in February 2009 found that there was limited involvement of the private sector in TB control activities and that no other sector other than health had a plan for TB control.32 A multi-sectoral approach to controlling the spread of TB drug-resistance would increase the speed of diagnosis thereby interrupting transmission, and lead to 31 Van Gorkom, Jeroen “Report on a visit to Namibia� Report #4, 17-28 November 2008, KNCV, p.4 32 Namibia External NTCP Review, Executive Summary, 28 February, 2009, p.6 32 increases in access and quality for vulnerable groups i.e. prisoners, migrant populations etc. b) Build on the advanced laboratory network to bolster the regional response: Namibia deserves credit for its high quality laboratory network – managed largely by the National Institute of Pathology (NIP), a parastatal that provides lab services throughout Namibia. All MDR-TB specimens are sent to South Africa (MRC) for second line drug sensitivity testing (SL DST), as there is currently no capacity for this in-country. By strengthening the lab network not only in terms of efficiency but also in terms of reduced diagnostic turn-around-time for patients, enhanced case-finding activities (e.g. contact-tracing etc.), and support for specimen transport (possibly via private sector contracting arrangements) – treatment outcomes could be improved for people with TB. c) Increased volumes of tests for drug-resistant TB will have cost implications on government budgets and therefore working out a payment mechanism that optimizes efficiency may reduce budgetary pressure. The possibility of Namibia becoming a center of excellence in terms of MDR and XDR-TB diagnosis may provide regional benefits to surrounding countries in terms of increasing the speed of diagnosis, building cross-border collaboration and response to mobile population groups d) Apply systematic contact-tracing among priority groups: Given the high costs of treating MDR and XDR-TB, the additional cost required to boost active case-finding strategies for example, systematic contact tracing would be a good investment. Given the higher likelihood of MDR/XDR-TB cases occurring in the households of those with confirmed MDR/XDR-TB – it should be a matter of routine that all household members should be screened for TB. Every additional case detected early and put on treatment is one less infectious case amplifying the spread of the disease. Given the long distances in Namibia and dispersed population, this will be challenging; however, it is necessary to begin to proactively manage the epidemic. 33 Chapter 6: Malaria A. Epidemiology of malaria in Namibia 99. Malaria remains a major public health problem in Namibia and is the leading cause of illness and death among under-five year old children and the third leading cause among adults. The vast majority of cases of malaria are in northern Namibia, where most people live and infection rates are highest. It is possible that more than half the population is infected on average each year in the most risky areas around Katima Mulilo, along the Kavango River and near Ruacana. The malaria prevention and control goal in Namibia is to achieve 50 percent reduction in malaria burden by 2010. 100. Approximately, 1,620,183 people (almost 70 percent of the population) live in malaria endemic areas33. Nine out of the 13 administrative regions and 22 of the 34 health districts in the northwestern, central and northeastern part of the country are endemic for malaria. Annually, an average of 400,000 outpatient, 30,000 inpatient cases and 1,000 deaths are reported nationwide due to malaria. The incidence of the disease varies from region to region, with an average of 242/1000 for the whole country in the year 2003. The malaria mortality rate varied between 14/100,000 and 95/100,000 during the years 1996 and 2003 with an average of 43/100 000 population. P.falciparum constitutes up to 98 percent of the cases and 2 percent due to P. vivax. 101. Rates of infection peak about two months after much of the summer rain has fallen each year. The annual peaks are much clearer and predictable in Katima Mulilo and Rundu where the seasonal rains fall at much the same time every year. In the north-central regions around Oshakati, by contrast, the timing of rainfall is much more variable and seasonal outbreaks of malaria occur earlier in some years and later in others. Infection rates change during the year, starting earliest in Caprivi because that region receives rain before other areas. The disease then spreads west and south from December onwards, so that the number of cases is greatest in March, April and May in regions such as Kunene, Omaheke and Omusati. 102. An average of over 357,000 people were treated each year as outpatients between 1995 and 1999, and an average of about 26,000 people (7 percent) were admitted as inpatients. However, many people also die each year and an average of 518 deaths due to malaria were reported each year (people that died outside health facilities are not included in this figure). The number of deaths amounted to about 2 percent of the more serious cases of malaria where people were admitted as inpatients. Of all deaths recorded between 1995 and 1999, 6 percent were due to malaria. Malaria places a substantial burden on all health facilities, accounting for 18 percent of all new outpatients and 15 percent of all inpatients. Demands on health services are obviously much greater in regions where malaria is most prevalent. Thus, malaria accounted for 38 percent of all inpatients in Kavango and 30 percent of inpatients in Caprivi. These are averages over five years, but the burden on health services is much greater in years when rates of infection are higher. 33 MHSS, 2008. 34 103. The predominantly seasonal nature of malaria transmission in Namibia confers little or no immunity against the disease. As a result, all ages are affected while an average of 68,048 pregnant women and 226,826 young children being at greater risk of severe disease. Malaria epidemics occur periodically, e.g. in 1990, 1996, 1997, 2000 and 2001, when environmental conditions (such as high rainfall) are optimal and can cause high levels of morbidity and mortality among all age groups. As a result, the national program has been implementing a comprehensive malaria control strategy to reduce the impact of this disease. B. Government response 104. Malaria control in Namibia is planned and implemented by the MHSS’ National Vector- Borne Disease Control Program (NVDCP) which is under the Directorate of Special Programs. Operational activities are mainly implemented by the Regional Management Teams and District Coordinating Committees. Malaria diagnosis and treatment services are delivered through all public and private health facilities, while In-door Residual Spraying is conducted through house- to-house operations by NVDCP. Insecticide-treated nets (ITNs) for vulnerable population groups are distributed free of charge through public health facilities. Nets targeted for the general population living in malaria endemic areas are made available through different community based and non-governmental organizations and the private sector, at cost. 105. Key strategies employed by the NVDCP are case management, vector control (largely through indoor residual house spraying, IRHS); personal protection (ITNs); surveillance and epidemic preparedness, detection and response; IEC and social mobilization and operation research. These are described in more detail in the National Malaria Policy and Five-Year Malaria Strategic Plan. IRHS has been carried out in most malaria endemic areas since 1960s with very good results. The insecticides used for IRHS are DDT and deltamethrine. As in other southern African countries, IRHS is done during the months of October-January every year preceding the main malaria transmission season that follows the rains. 106. The malaria control program has been monitoring the efficacy of antimalarial drugs every 2 years over the last 8-10 years. A study carried out in 2004 in three sentinel sites established that the efficacy of the first line drug, chloroquine, has declined markedly beyond the acceptable limit of 25% Treatment Failure (Source: MoHSS, 2004). In addition, the efficacy of sulphadoxine pyrimethamine declined (9-28 percent treatment failure) to some extent. This necessitated the extensive revision of the Malaria Policy which was launched on 25th April 2005. The policy has adopted Artemether lumefantrine as the first line medicine for malaria, despite the increased cost implications. 107. Government is providing the vast majority of the program budget for malaria control. On average, government spends around US$7.1 million annually. The contribution from partners is quite limited. World Health Organization contributes about US$ 100,000 annually while contributions from UNICEF, JICA and other partners are small and irregular. In the second round Global Fund, the program has secured around US$ 4 million, with additional resources secured as part of the country’s successful Round 6 TB proposal. 108. While government and its partners reasonably address most of the program components, the recent change in the malaria treatment policy from a cheaper to a much more expensive medicine and the introduction of expensive malaria Rapid Diagnostic Tests put a substantial increased burden on the available resources for malaria control. 35 109. Namibia is among the signatories of the Abuja Declaration on Roll Back Malaria, 2000 and the Millennium Development Goals. It has endorsed the commitment of African Heads of State and Government and the international community to reduce malaria morbidity and mortality by half by the year 2010. The country has made strides in achieving the mid-term Abuja Targets (2005) in increasing the coverage in ITN, and IPT and access to malaria treatment and prevention. 36 Chapter 7: Maternal and Child Health A. Maternal Health 110. While access to health services by pregnant women in Namibia is high (81 percent of pregnant women were assisted by skilled birth attendants and 70 percent of pregnant women received at least four antenatal clinic check-ups in 2006/07), the rising trend in maternal mortality34 in Namibia is worrying. The Maternal Mortality Ratio (MMR) rose rapidly from 271 deaths in 100,000 live births in the 2000 to 449 deaths in 100,000 live births in 2006 (Figure 12). Figure 12: Maternal Mortality Ratio (Per 100,000 Live Births), 1990-2006 and 2005 Note: 1990-2006 data are national estimates while 2005 data re modeled estimates. Source: World Bank, World Development Indicators, 2008 111. According to the MHSS, the direct causes of death are severe pre-eclampsia and eclampsia (33.3 percent) followed by obstructed and prolonged labour (25 percent), hemorrhage (25 percent), post-partum sepsis (8.3 percent) and complications emanating from abortion (8.3 percent). Figure 13: Direct causes of maternal death, 2005 34 A maternal death is any death that occurs during pregnancy, childbirth, or during the two months after the birth or termination of pregnancy. 37 Source: WHO, 2009 112. In Namibia, indirect causes of maternal death, which refers to conditions that are aggravated by pregnancy but do not necessarily lead to death, include sexually transmitted infections (STIs), HIV and AIDS as well as malaria. In 2006, 18 percent of pregnant women in Namibia tested HIV-positive, with prevalence highest amongst 30-34 year olds (27.2 percent) and 35-39 year olds (26 percent). The DHS shows that about 80,000 people were treated for new STIs in the 2005-06 fiscal year. Namibia has experienced a heavy STI burden that ranks 8th amongst all hospital consultations (DHS 2006/07). 113. With regards to malaria, 11 percent of pregnant women age 15-49 slept under a net the night before the DHS survey in 2006 and 9% slept under an ever treated net or an ITN. Mosquito net usage among pregnant women is higher in rural areas (13 percent) than in urban areas (7 percent). 30 percent of all pregnant women took an anti-malarial drug to prevent malaria and most of these women (28%) took Sulphadoxine/ pyrimethamine (SP). One in five pregnant women (20 percent) received SP/Fansidar during an antenatal care visit, and half of these women received two more doses of SP/Fansidar during an antenatal care visit. 114. One probable cause for the increasing MMR in Namibia is the lack of health facilities which can treat emergencies during labor. Though Namibia has four comprehensive emergency obstetric care (CEmoC) facilities which meet the WHO standard for sufficient access to obstetric care35, these are concentrated in the central regions of Windhoek (2), Otjiwarongo (1) and Oshakati (1). There are no basic emergency obstetric care (BEmoC) facilities in Namibia and most obstetric emergencies are performed in the four CEmoC facilities. The highly populated northern areas do not have either BEmoC or CEmoC facilities. This uneven distribution of services for obstetric emergencies is reflected in the distribution of cesarean sections, which seem to be concentrated within areas where CEmoC facilities are available. The uneven distribution of emergency obstetric care is reflected in the caesarean section rate which is 13 percent for the country as a whole. However, most cesearean sections were conducted in Khomas (26 percent of all deliveries in the region), Erongo (23.4 percent) and Omaheke (18.8 percent), while Caprivi and Kunene were considerable lower at 2.2 percent and 3.5 percent, respectively (Figure 14). Figure 14: Percent births delivered by caesarean section, by Region 35 According to WHO guidelines for sufficient access to obstetric care, four BEmoC and one CEmoC facility needs to be operational for every 500,000 people. 38 Source: WHO, 2009 B. Antenatal Care 115. While 95 percent of pregnant women received antenatal care from a health professional for their most recent birth in the five years preceding the survey (16 percent from a doctor and 79 percent from a nurse/midwife), only 1 percent of pregnant women received antenatal care from a traditional birth attendant (TBA). Over 70 percent of pregnant women received at least four ANC checkups. Compared to other Southern African countries, Namibia is only second to Botswana in ANC attendance rates. On average, however, pregnant women start later with ANC visits, with the median duration of pregnancy for the first antenatal care visit of 4.7 months. Younger women, and women who are pregnant with their first child tend to seek ANC care more than older women or women who already have children. Figure 15: Percent of Pregnant Women Receiving Antenatal Care in Countries in Southern Africa, 2000- 2006 Source: World Bank, World Development Indicators, 2008 Figure 16: Percent of Pregnant Women Receiving Antenatal Care in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s 39 Source: World Bank, Socioeconomic Differences in Health, Nutrition and Population: Cross Country Report, 2007 116. While 95% women receive ANC care from a skilled birth attendant (either a doctor, nurse or midwife), some differences below are worth noting. Firstly, within the Kunene region, about 10% of women are still receiving ANC care from a traditional birth attendant compared to an average of 1% in total for the country. Also interesting to note, is in central regions, more women seek ANC care from doctors compared to other regions (e.g 38.3% of women in Khomas seek care from doctors compared to 2.9% of women in Caprivi). As noted in the 2006/2007 DHS, a greater proportion of the wealthiest quintile (96%) access ANC services compared to the poorest quintile (81%). Table 21: Utilization of antenatal care services, by Region REGION % women aged % women aged 15- % women aged 15- 15-49 receiving 49 receiving ANC 49 receiving ANC ANC from a from a from a traditional doctor nurse/midwife birth attendant Caprivi 2.9% 90.8% 1.4% Erongo 23.4% 69.5% 0.2% Hardap 22.1% 73.4% 0.0% Karas 23.1% 75.6% 0.0% Kavango 9.5% 82.2% 0.6% Khomas 38.3% 58.5% 0.4% Kunene 8.7% 72.6% 10.1% Ohangwena 1.9% 93.8% 2.0% Omaheke 18.0% 73.5% 1.1% Omusati 7.1% 89.8% 1.0% Oshana 7.4% 91.1% 0.0% Oshikoto 4.3% 91.0% 0.0% Otjozondjupa 25.3% 68.1% 0.0% Source: DHS 2006/07 C. Delivery 117. While the percentage of deliveries assisted by skilled birth attendants (SBA) is reported to be 81% in the 2006/07 Demographic and Health Survey (DHS), there are disparities in terms of educational attainment and wealth characteristics of women in labor as well as regional differences which need to be considered36. Almost one in five births (19%) were delivered at home. 76% of births were delivered in a public facility and 5% were delivered in a private facility. Figure 17: Percent of births attended by skilled staffed in Southern African countries, 1990 and 2006 36 WHO Maternal and Child Health in Namibia, May World Health Organization 2009 40 Source: World Bank, World Development Indicators, 2008 118. While 94 percent of births in urban areas were assisted by skilled birth attendants (SBAs), in rural areas the number was 73 percent. There also seems to be regional differences with areas such as Kunene, in the north west of the country showing a 54 percent utilization of SBAs, whereas the central region of Khomas has a 95 percent utilization of SBAs. There is a strong association between mother’s education and place of delivery. About half the births among uneducated mothers were delivered in a health facility compared with almost all the births among mothers with secondary and higher education. In terms of income, almost 98 percent of the richest quintile was assisted by SBAs as shown below, while only about 60 percent of the poorest quintile was assisted by SBAs. Figure 18: Percentage of births assisted by SBAs, by income Source: World Health Organization, 2009 D. Postnatal Care 119. Postnatal care treats complications arising from the delivery and provides the mother with information on how to care for herself and her child. There are several factors which influence whether a woman accesses postnatal care and if so, the timeliness of utilization of these services. These include, a women’s place of residence (urban versus rural), region she lives in, educational attainment and household wealth. 73 percent of women in urban areas received postnatal care within 48 hours of the birth compared with 59 percent of women in rural areas. Regional utilization of timely postnatal care ranges from 40 percent among women in Kavango to 81 percent in Erongo and Oshana regions. 41 Figure 19: Use of postnatal care, 2009 Source: WHO, 2009 120. 44 percent of women with no education received timely postnatal care, compared with 70 percent of women with at least some secondary education. Similarly, 49 percent of women in the lowest wealth quintile received timely postnatal care within 48 hours compared with more than 76% in the highest wealth quintile. E. Reproductive Health 121. Namibia is a middle performer compared to other counties in terms of total fertility rate (TFR). The total fertility rate37 from the 2006/07 DHS is 3.6, with significant regional differences (TFR for Khomas is 2.6 and Omaheke 5.1) as illustrated in Figure 20. Figure 20: Total fertility rate (number of births per woman) in countries in Southern Africa, 1990 and 2006 Source: World Bank, World Development Indicators, 2008 122. Adolescent pregnancies are high considering that 15 percent of women aged 15-19 have begun childbearing (they are either pregnant with their first child or already delivered a live birth). Adolescent pregnancies are strongly correlated with a mother’s educational attainment, household wealth and regional location. 37 TFR is the number of children a woman would have by the end of her childbearing years if she were to pass through those years bearing children at the currently observed age-specific rates. 42 123. In terms of regions, the highest percentage of women aged 15-19 years who have begun childbearing is found in the Kavango region (34 percent) followed by Kunene (30.5 percent) and Caprivi (29.7 percent) and the lowest percentage is found in the Khomas region (approximately 5 percent). With regards to income, 22.4 percent of the 15-19 year old women who have begun child bearing come from the lowest wealth quintile, while only 4.8 percent come from the health wealth quintile. In addition, 58 percent of women aged 15-19 years who have begun child bearing had no education while only 6 percent who have completed secondary school were pregnant. Figure 21: Adolescent pregnancy and education Source: WHO, 2009 124. The use of modern contraceptive methods amongst women during 2006/07 was at 46 percent with injectibles the preferred method of contraception (17.1 percent) followed by male condoms (17 percent). Unmet demand for contraceptives is about 10 percent according to the DHS 2006/07. Sexually active women in urban areas are more likely to use modern contraceptives (74 percent) than rural women (55 percent). Contraceptive use increases with women’s level of education; 37 percent among sexually active women with no education use modern contraceptives compared to 79 percent among women who completed secondary education. Figure 22: Percent contraceptive prevalence rate in countries in Southern Africa, 2000-2006 Source: World Bank, World Development Indicators, 2008 F. Newborn, Infant, and Child Health 43 125. As indicated below, aside from Nambia, infant mortality rate (IMR)38 and Under-5 mortality rate39 (U5 mortality) rose in several countries in Southern Africa between the period 1990-2006. Namibia is somewhat of an anomaly in the region with declining IMR and U5 mortality from 60 to 46 and 81 to 69 per 1000 live births respectively between 1990 and 2006 (DHS, 2004). However, the rate of reduction in IMR and U5 mortality has slowed since 2000 as shown in the graph below. Table 22: Infant and Under-5 Mortality Rates (Per 1,000 Live Births) in Countries in Southern Africa, 1990 and 2006 Country Infant Mortality Rate Under-5 Mortality Rate 1990 2006 1990 2006 Angola 154 154 260 260 Botswana 45 90 58 124 Lesotho 81 102 101 132 Namibia 60 45 86 61 South Africa 45 56 60 69 Swaziland 78 112 110 164 SSA 109 94 184 157 MICs 43 26 56 33 Source: World Bank, World Development Indicators, 2008 Figure 23: IMR and U5 MR Source: WHO, 2009 126. The Inter-Agency Child Mortality Estimation Group (IACMEG) estimates that three- quarters of all under five year old deaths in Namibia occur during the first year of life, as shown below. Neonatal40 deaths account for 3 percent of the total and 26 percent of U5 deaths occur between the second and fifth years of age. Figure 24: Distribution of U5 deaths by age cohort 38 Infant mortality is defined as the probability of dying before the first birthday 39 Under five mortality is defined as the probability of dying between birth and the fifth birthday 40 40 Neonatal mortality is defined as the probability of dying within the first month of life 44 Source: WHO, 2009 127. The determinants of U5 mortality include the mother’s educational attainment, household income levels and a child’s place of residence. Children born to mothers with no education have a higher probability of dying before age five (78 deaths per 1,000 births) than those born to mothers who completed secondary school (27 deaths per 1,000 births). Children born to mothers in the lowest wealth quintile are three times more likely to die before their fifth birthday than those born to mothers in the highest wealth quintile. Figure 25: Determinants of mortality, neonatal and under 5 years Source: WHO, 2009 128. According to the WHO, of an estimated 1200 neonatal deaths surveyed in 2006, 39 percent of deaths were due to preterm births and a quarter due to asphyxia. This indicates that the greatest risk to children immediately after birth results from complications originating during pregnancy and delivery. A further 17 percent were caused by severe infections including pneumonia and sepsis, and 2 percent due to neonatal tetanus and diarrhea. After the neonatal period, more than half of children died due to HIV/AIDS related illnesses. G. Immunization 129. Universal immunization of children against the six vaccine-preventable diseases (namely tuberculosis, diphtheria, whooping cough (pertussis), tetanus, polio, and measles) is crucial to reducing infant and child mortality. According to the guidelines developed by the World Health Organization, children are considered fully vaccinated when they have received a vaccination 45 against tuberculosis (BCG), three doses each of the DPT and polio vaccines, and a measles vaccination by 12 months of age. 130. At the time of the 2006/07 DHS, 69 percent of children age 12-23 months had been fully vaccinated in Namibia. 84% of children age 12-23 months received the measles vaccination. Coverage for those who have received the third dose of DPT and polio is lower (83 percent and 79 percent, respectively). There are substantial differences in the coverage of immunization by region, educational attainment of mothers and household wealth. 131. The percentage of children fully immunized ranges from 35 percent in Kunene to 81 percent in Omusati as shown in the graph below. An estimated 44 percent of children of mothers with no education are fully immunized, compared with 86 percent of children of mothers with at least some secondary education. Similarly, 59 percent of children of mothers from the lowest wealth quintile are fully immunized, compared with 82 percent of children of mothers from the highest wealth quintile. Figure 26: Percent children (aged 12-23 months) receiving all basic vaccinations Source: DHS, 2006 H. Nutrition 132. The Namibia DHS used the following criteria to classify children who are underweight, wasted or stunted. Stunting reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illness. Children whose height-for-age Z-score was below minus two standard deviations (-2 SD) were considered short for their age (stunted) and are chronically malnourished. Children who were below minus three standard deviations (-3 SD) were considered severely stunted. 133. Wasting represents the failure to receive adequate nutrition and may be the result of inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose Z-scores were below minus two standard deviations were considered thin (wasted) and acutely malnourished; below minus three standard deviations (-3 SD) were considered severely wasted. . 46 134. Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age was below minus two standard deviations (-2 SD) were classified as underweight. 135. The DHS of 2006/07 reports that about 30 percent of children under age five are stunted and 10 percent are severely stunted. An estimated 8 percent of children under five are wasted and 2 percent are severely wasted (Figure 27). The weight- for-age indicator shows that 17 percent of children under five are underweight and 4 percent are severely underweight. At the same time, 4 percent of Namibian children are overweight or obese. Figure 27: Nutritional status of children by age Nutritional Status of Children by Age 40 38 35 36 32 30 30 27 25 Percent 20 19 19 20 17 18 17 15 16 14 11 12 10 9 10 9 7 6 7 5 5 5 0 <6 6-8 9-11 12-17 18-23 24-35 36-47 48-59 Age in months Stunting Wasting Underweight Source: DHS, 2006/07 136. The graph above indicates that stunting increases by age of a child, particularly after age 1, with its peak at 38 percent for the age group 28-23 months. Birth weight is an important determinant of nutritional status of children. Stunting is higher among children reported as very small at birth (47 percent) than children described as small (39 percent), average or larger (26 percent) in size at birth. Rural children are more stunted (31 percent) than urban children (24 percent). The percentage of children stunted decreases with increasing level of mother’s education and with increasing household wealth (wealth quintile). 137. A worrying issue in terms of child health in Namibia, is the increasing number of children who are born with low birth weight. Newborns weighing less than 2,500 grams are considered low birth weight (LBW) according to WHO standards. 47 Figure 28: Percent of children born with low birth weight Percent of Children Born with Low Birth Weight 16 14 % of babies weighing less than 2.5kg 12 10 8 6 4 2 0 1992 2000 2006/07 Source: WHO, 2009 138. In terms of interventions to improve child nutrition, 52 percent of children age 6-59 months received micronutrient vitamin A and 63 percent received foods rich in iron in 2006/07. A significantly higher proportion of urban children (72 percent) than rural children received iron- rich foods (58 percent), as shown in Figure 29. Figure 29: Percent of Households Consuming Iodized Salt and Percent of Children 6-59 Months Receiving Vitamin A Supplementation in Countries in Southern Africa, 2000s Source: World Bank, World Development Indicators, 2008; Namibia DHS 2006/07) 48 Chapter 8: Namibia's Comparative Health Sector Performance 139. This chapter examines Namibia's health sector performance in the context of other Southern African countries and, more broadly, other middle income countries (MICs). The MHSS indicated a particular interest in this type of informal regional benchmarking. The succeeding seven sections present the following aspects of the health sector: Section A - health outcomes; Section B - risk factors; Section C - health service coverage; Section D - health system indicators; Section E - people's experiences in health facilities; and Section F - inequities in health. A. Health Outcomes 140. In general, Namibia has better health outcomes than its neighboring countries - Figures 1 to and Tables 2 and 3 compare the health outcomes of Namibia relative to other countries in Southern Africa and middle-income countries (MICs) in general: Namibia has better life expectancy at birth in the region. It also has the lowest infant and under-five mortality rates. It has the lowest percentage of children with symptoms of diarrhea and fever. Namibia is a middle performer in terms of total fertility rate and adolescent fertility rate. The worrying problem is maternal mortality. While Namibia showed a respectable maternal mortality ratio (MMR) in the 1990s, MMR has risen rapidly in 2006. Figure 30: Life expectancy at birth (in years) in countries in Southern Africa, 1990 and 2006 Source: World Bank, World Development Indicators, 2008 Table 23: Infant and Under-5 Mortality Rates (Per 1,000 Live Births) in Countries in Southern Africa, 1990 and 2006 Country Infant Mortality Rate Under-5 Mortality Rate 1990 2006 1990 2006 Angola 154 154 260 260 Botswana 45 90 58 124 Lesotho 81 102 101 132 Namibia 60 45 86 61 South Africa 45 56 60 69 Swaziland 78 112 110 164 49 SSA 109 94 184 157 MICs 43 26 56 33 Source: World Bank, World Development Indicators, 2008 Table 24: Percent of Children with Symptoms of Illness in the Last 2 Weeks in Selected Countries in Sub- Saharan Africa, 2000s Country Diarrhea Fever Acute Respiratory Infection Kenya 16.4 40.7 18.4 Lesotho 14.5 25.6 18.8 Madagascar 27.1 32.2 23.9 Malawi 17.6 41.6 26.7 Mozambique 14.5 26.7 9.8 Namibia 12.0 19.4 17.7 South Africa 13.2 n.a. 19.3 Tanzania 12.6 24.5 8.1 Uganda 19.6 43.9 22.5 Zambia 21.2 43.1 14.6 Zimbabwe 13.9 25.8 15.8 SSA average 19.7 34.4 16.2 Source: World Bank, Socioeconomic Differences in Health, Nutrition and Population, 2007 Figure 31: Maternal Mortality Ratio (Per 100,000 Live Births), 1990-2006 and 2005 Note: 1990-2006 data are national estimates while 2005 data re modeled estimates. Source: World Bank, World Development Indicators, 2008 Figure 32: Total fertility rate (number of births per women) in countries in Southern Africa, 1990 and 2006 Source: World Bank, World Development Indicators, 2008 50 Figure 33: Adolescent Fertility Rate (Number of Births Per 1,000 Women Ages 15-19) in Countries in Southern Africa, 1990 and 2006 Source: World Bank, World Development Indicators, 2008 B. Risk Factors 141. Among the major risk factors for which data are available, Namibia performs poorly in the area of sanitation; in all other risk factors, it occupies a middle position among countries in the region - Nutrition – Figures 5 and 6 show indicators of undernourishment and malnutrition in Southern Africa; Namibia turns in a middle performance on both indicators. Water and sanitation – While Namibia has a respectable coverage of population access to safe water (Figure 7), its coverage of households with improved sanitation facilities is the worst in comparator countries (Figure 8). Diabetes – Namibia’s prevalence of diabetes is lower than South Africa’s and Botswana’s (Figure 11). Alcohol consumption - Alcohol consumption is also lower than that of the two neighboring countries (Figure 12). Figure 34: Percent Prevalence of Undernourishment in the Population in Countries in Southern Africa, 1990-92 and 2002-04 Source: World Bank, World Development Indicators, 2008 51 Figure 35: Percent of Children Under Five Who Are Malnourished in Countries in Southern Africa, 2000- 06 Source: World Bank, World Development Indicators, 2008 Figure 36: Percent of the Population with Access to Improved Water Source in Countries in Southern Africa, 1990 and 2004 Source: World Bank, World Development Indicators, 2008 Figure 37: Percent of the Population with Access to Improved Sanitation Facilities in Countries in Southern Africa, 1990 and 2004 Source: World Bank, World Development Indicators, 2008 52 Figure 38: Percent Prevalence of Diabetes (Population Ages 20-79) in Countries in Southern Africa, 2007 Source: World Bank, World Development Indicators, 2008 Figure 39: Per Capita Recorded Alcohol Consumption (in Liters of Pure Alcohol) Among Adults 15 Years and Above in Countries in Southern Africa, 2003 Source: WHO, World Health Statistics, 2005 C. Health Service Coverage 142. Namibia’s coverage of key health services is mixed - Coverage of child health services are on the low side (Table 4) but food fortification (with iodized salt) and consumption of Vitamin A among children is quite good (Figure 14). Contraceptive prevalence rate among married women 15-49 is a middling 48 percent, lower than Swaziland and South Africa and MICs as a whole (Figure 15). The proportion of pregnant women receiving antenatal care (91 percent) is at par with other Southern African countries and MICs (Figure 16), but the proportion of births attended by a skilled staff (76 percent) can stand improvement (Figure 17). 53 Table 25: Percent of Children Provided with Selected Child Health Services in Countries in Southern Africa, 2000-2006 Country Immunization rate Children Children w/ Children Children with Measles DPT3 with ARI diarrhea sleeping fever taken to a receiving under receiving provider ORS and treated antimalarial continuous bednets drugs feeding Angola 48 44 58 32 2.3 63.0 Botswana 90 97 14 7 … … Lesotho 85 83 59 53 … … Namibia 63 74 53 39 3.4 14.4 Swaziland 57 68 60 24 0.1 25.5 S. Africa 85 99 … … … … SSA 71 72 … … … 34.5 MICs 91 91 … … … … Source: World Bank, World Development Indicators, 2008 Figure 40: Percent of Households Consuming Iodized Salt and Percent of Children 6-59 Months Receiving Vitamin A Supplementation in Countries in Southern Africa, 2000s Source: World Bank, World Development Indicators, 2008 Figure 41: Percent Contraceptive Prevalence Rate (Married Women Ages 15-49) in Countries in Southern Africa, 2000-2006 75 60 48 44 44 37 22 6 Angola SSA Lesotho Botswana Namibia Swaziland S. Africa MICs 54 Source: World Bank, World Development Indicators, 2008 Source: World Bank, World Development Indicators, 2008 Figure 42: Percent of Pregnant Women Receiving Antenatal Care in Countries in Southern Africa, 2000- 2006 Source: World Bank, World Development Indicators, 2008 Figure 43: Percent of Births Attended by Skilled Staff in Countries in Southern Africa, 1990 and 2006 Source: World Bank, World Development Indicators, 2008 D. Health Systems 143. Namibia’s level of financing to the health sector is quite high - Namibia has the third highest per capita spending on health care (US$145 in 2003) in Southern Africa, eclipsed only by South Africa and Botswana (Figure 19). This has been a consistent trend since the 1990s. Similarly, the share of helth expenditures to total GDP is also high although declining (Figure 20). Health spending comes largely from the government (70 percent). The share of government health expenditures to total health expenditures is also high (Figure 22). Most of the private health expenditures come from prepaid and risk-pooling plans (Figure 23). As a result, the share of out-of-pocket spending is rather low (Figure 24). However, 55 for those without health insurance coverage – like most of the poor – out-of-pocket spending may very well be high. The share of external resources to total health expenditures is still low (5.3 percent). Figure 44: Per Capita Total Health Expenditure (US$ at Official Exchange Rate), 1998-2003 Source: WHO Source: WHO, 2006 Figure 45: Percent Share of Total Health Expenditure to GDP in Countries in Southern Africa, 1999 and 2003 Source: WHO 56 Figure 46: Percent Shares of Government and Private+Household Health Expenditure to Total Health Expenditure in Countries in Southern Africa, 2003 Source: WHO Figure 47: Percent share of Government health expenditure to total Government expenditure in countries in Southern Africa, 1999 and 2003 Figure 47. Percent Share of Government Health Expenditure to Total Government Expenditure in Countries in Southern Africa, 1999 and 2003 Source: WHO Figure 48: Percent share of prepaid and risk-pooling plans to private health expenditure in countries in Southern Africa, 1999 and 2003 57 Source: WHO Figure 49: Percent Share of Out-of-Pocket Expenditure to Private Health Expenditure in countries in Southern Africa, 1999 and 2003 Source: WHO Figure 50: Percent share of external health resources to total health expenditure in countries in Southern Africa, 1999 and 2003 58 Source: WHO Figure 51: Percent of GDP Spent on Social Assistance in Selected sub-Saharan African Countries, 2000s Source: World Bank 144. While Namibia’s health sector is facing a crisis in the availability of health workers especially in government facilities, the density per 1,000 population of key health workforce is actually quite high relative to other countries in the region (Figure 27). The problem seems to be the high proportion on personnel not directly involved in service delivery (i.e., administration and support). 145. Hospital beds per 10,000 population (at 33) is also quite high by regional standards (Figure 28). Figure 52: Density per 1,000 population of key health workforce cadres in selected countries in Eastern and Southern Africa, 2004 59 Source: WHO/AFRO HRH Observatory 60 Figure 53: Hospital beds per 10,000 population in selected Sub-Saharan African countries, 2000s Figure 53: Hospital Beds Per 10,000 Population in Selected Sub-Saharan African Countries, 2000s Sources: World Health Statistics; Swaziland MOHSW; Namibia MHSS 146. Namibia may be unique in the region in that most of the poorest people are accommodated in government health facilities (Figure 29), unlike other countries where the poor also seek care in private facilities. Figure 54: Care-Seeking Behavior of the Poorest Quintile of the Population in Selected Countries in Sub- Saharan Africa (Percent) Source: Marek, Tonia, et al., Trends and Opportunities in Public/Private Partnerships to Improve Health Service Delivery in Africa. World Bank Human Development, Africa Region. 61 E. People's Experiences in Health Facilities 147. Namibia still performs poorly in many aspects of health services - Based on country surveys of Afrobarometer, African health facilities are not up to par with their citizens’ expectations, in general. If the 11 countries for which survey data are available (Figures 30 to 36) are ranged from “worst� to “best� performance across a range of factors, and if proportion above the median is considered “bad�, the factors that make Namibia weak are: poor condition of health facilities, illegal payments from patients, expensive care, long waiting time, lack of staff attention, and doctor absenteeism. More than half (56.3) of Namibians found health facilities in poor condition, the second highest proportion among comparator countries, and next only to Zambia (Figure 35). More than a third (39.8 percent) of Namibians experienced demands for illegal payments in health facilities More than half (57.3 percent) of Namibians found health facilities too expensive (Figure 31). Five out of six (83.0 percent) of Namibians reported experiencing long queues at the health facility, one of the highest rates among comparator countries, and exceeded only by three countries (Figure 34). About two-thirds (64.3 percent) of Namibian’s also experienced lack of health staff attention or respect (Figure 32). More than half (59.4 percent) of Namibians experienced doctor absenteeism in a clinic. This is not as severe as the situation in five other comparator countries where, as in Zimbabwe and Zambia, five out of six patients experienced doctor absenteeism (Figure 33). 148. The only factor where Namibia performed above the median is drug availability - About two-thirds (65.4 percent) of Namibians found health facilities lacked medicines (Figure 31), but the situation is not as bad as in five other comparator countries. Figure 55: Percent of survey respondents in selected countries in Sub-Saharan Africa who found health facitilies too expensive, 2000s 62 Source: Afrobarometer Figure 56: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Found Health Facilities Lacked Medicines, 2000s Source: Afrobarometer Figure 57: Percent of survey respondents in selected countries in Sub-Saharan Africa who experienced lack of health staff attention or respect, 2000s 63 Source: Afrobarometer Figure 58: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Doctor Absenteeism, 2000s Source: Afrobarometer Figure 59: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Long Wait at the Health Facility, 2000s 64 Figure 60: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Found Health Facilities in Poor Condition, 2000s Source: Afrobarometer Figure 61: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Health Facilities Demanded Illegal Payments, 2000s 65 F. Inequities in Health 149. Namibia needs to focus more in widening the access to child nutrition and skilled health attendance at birth which are the two services that has the largest disparity in coverage and outcome (Figures 37 to 40). Figure 62: Percent Prevalence of Child Malnutrition in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s Source: World Bank, Socioeconomic Differences in Health, Nutrition and Population: Cross Country Report, 2007 66 Figure 63: Percent of Children Who are Immunized Against Measles in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s Source: World Bank, Socioeconomic Differences in Health, Nutrition and Population: Cross Country Report, 2007 Figure 64: Percent of Pregnant Women Receiving Antenatal Care in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s Source: World Bank, Socioeconomic Differences in Health, Nutrition and Population: Cross Country Report, 2007 Figure 65: Percent of Births Attended by a Skilled Health Staff in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s 67 Source: World Bank, Socioeconomic Differences in Health, Nutrition and Population: Cross Country Report, 2007 68 Chapter 9: Possible Areas Where the World Bank Could Provide Technical Support 150. The possible areas of support by the World Bank could be prioritized around the following areas – governance, human resource planning, and public-private partnerships. Regional and international good practice would be drawn upon to assist the MHSS in its deliberations on the various policy options outlined below. A. Governance 151. Governance: As indicated in the previous chapters, various policies (and legislation) may need updating to enable the MHSS to provide effective and efficient health and social services that are influenced by demographic, epidemiological and technology change as well as the increased expectation of the citizens of Namibia. Technical inputs on the policy and legislative changes could be supported by the World Bank. In addition, the issue of norms and standards for health facilities would be important to address. Sector performance could be benchmarked and the recommendations used by managers and the community to identify areas of good and poor performance and the necessary improvements. The World Bank could provide technical assistance in such a policy and programmatic review. B. Human resources in the health sector 152. Human resources for health: There is an acute shortage of trained human resources in Namibia, especially in the areas of medicine, pharmacy, managerial and technical areas, such as, epidemiology, biostatistics, health policy and planning, and health economics. At a primary health care level, approximately 90% of expenditure is on personnel with about 70% being spent on personnel at the hospital level. Challenges facing policy makers with regard to the development of human resources include the development of support mechanisms necessary for the development of human resources, development of a comprehensive plan for human resources development, addressing the maldistribution of health personnel, ensuring optimal utilization of available personnel, and introduction of measures to ensure that those trained remain in service. 153. The World Bank could support a strategic approach to human resources planning in health that would consider the following areas of work. Policy & legal framework o Public service framework (government-wide systems versus the special needs of the MHSS) o Recruitment and accreditation of personnel o Education Ministry inputs o Research support o Other ministries, departments and agencies would that have an influence on the MHSS such as Police – medico-legal and forensic services and Public Works – infrastructural development. Health Professional Training: 69 Namibia has implemented a two year internship program for graduate medical doctors in line with a similar approach in South Africa. The World Bank could support a human resource review for the MHSS as well as the policy options and interventions for health professional training in Namibia. C. Public-Private Interactions 154. Public Private Interactions: Public private interactions (PPIs) potentially allow for greater engagement of the public and private sectors in supporting the goals of the MHSS towards universal access. The World Bank could provide support to the MHSS to enable it and other stakeholders in Namibia to develop an understanding of the process and possible instruments to engage the private sector in the provision of health services, learn from other country experiences and challenges in public-private partnerships for health, and to conduct a planning exercises to engage the private sector in meeting the MHSS health sector objectives 155. A workshop with MHSS staff could be a possible first step in expanding the dialogue on PPPs. The workshop could cover trends in private provision of health services, regional perspectives and emerging issues; “market� analysis of the health sector and private sector; Government’s role as steward versus provider; contracting for health services; financing mechanisms to engage the private sector; and implementation challenges to engaging private providers. 70 Annexes Namibia: Millenium Development Goals 71 References Afrobarometer (various years). 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