The Work of WHO in Namibia 2008-2013 Namibia A

The work of WHO in Namibia 2008-2013 Namibia A

WHO Cover page.indd 1 05/02/2014 19:36 B Namibia

The work of WHO in Namibia 2008-2013 C We can change the world and make it a better place. It is in your hands to make a difference. Nelson Mandela

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Printed in Namibia: John Meinert, 2014 Design and Layout: Imagine Design, 2014

D TABLE OF CONTENTS

Page

Acronyms and Abbreviations iii List of Tables and Figures vi Acknowledgements vii Foreword ix Executive Summary xi Introduction 1

1. THE CONTEXT 2

Geography and Climate 3 The People 4 The Economy 4 The Politics 5

2. HEALTH TRENDS 6

Mothers, Babies, Children and Adolescents 8 Major Communicable Diseases 10 Health Emergencies 11 Lifestyle and Health 12 The System and its Challenges 13 Working together for Better Health Outcomes 13 Partnerships 14

3. PROMOTING DEVELOPMENT 15

Achievements in Combatting Communicable Diseases 16 Progress in Reducing Lifestyle Diseases 20 Putting the Health of Mothers and Children First 22 Immunizing Every Child 24 Nutrition 25

4. FOSTERING HEALTH SECURITY 26

Are We Ready For Emergencies? 27 Preventing Disease Outbreaks 28 Water and Sanitation 29 Getting the Message Across 30

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5. STRENGTHENING HEALTH SYSTEMS 31

Governance 32 Human Resources – Developing the Health Workforce 34 Health Financing – Ensuring Sufficient Resources 36 Health Information – Taking Stock of Health Trends 37 Service Delivery – Getting Health Care to the People 37 Medical Products, Vaccines and Technologies – The Tools of the Trade 38

6. HARNESSING RESEARCH, INFORMATION AND EVIDENCE 39

Generating Evidence 40 Using Evidence for Policy Decision 40 Launch of the World Health Report 2008 41 Library Services 41 Country Health Portals 41

7. ENHANCING PARTNERSHIPS 42

Key Partners 43 Keeping Everyone on the Same Page 44 Resource Mobilization 45 Cross Border Collaboration 45 WHO Official Visits 46

8. IMPROVING PERFORMANCE 47

Human Resources 48 Office Location and Conditions 49 Finances 50 Steering the Agenda 50

9. THE WAY AHEAD 51

10. REFERENCES 53

ii ACRONYMS AND ABBREVIATIONS

ACs Assessed Contributions AFP Acute Flaccid Paralysis AFRO WHO Regional Office for Africa AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ART Antiretroviral Therapy ARV Antiretroviral AU African Union CCN Council of Churches in Namibia CCS Country Cooperation Strategy CDC Centers for Disease Control and Prevention CERF Central Emergency Response Fund CHS Catholic Health Services DAPP Society for Family Health, Development Aid People to People (DAPP) DG Director General DOTS Directly-Observed TB Treatment – Short Course Strategy e-MTCT Elimination of Mother-To-Child Transmission of HIV EDT Electronic Dispensing Tool EmOC Emergency Obstetric Care EmONC Emergency Obstetric and Newborn Care EPI Expanded Programme on Immunization EPR Emergency Preparedness and Response EU European Union EWI Early Warning Indicators FBO Faith-Based Organization GDP Gross Domestic Product GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GIVS Global Immunization Vision and Strategy GIZ Deutsche Gesellschaft für Internationale Zusammenarbeit (German Society for International Cooperation) GLP Global Learning Programme HIS Health Information System HIV Human Immunodeficiency Virus HIVDR HIV drug resistance HRH Human Resources for Health HSSR Health and Social Services Systems Review HTC Hospital Transfusion Committee IAEA International Atomic Energy Agency

iii IBBSS Integrated Biological and Behavioural Surveillance Survey IDSR Integrated Disease Surveillance and Response IMNCI Integrated Management of Newborn and Childhood Illness IMPAC Integrated Management of Pregnancy and Childbirth IST/ESA WHO Intercountry Team for East and Southern Africa JANS Joint Assessment of National Strategies KAP Knowledge, Attitudes and Practices MAMPA Monitoring Alcohol Marketing Practices in Africa MC Male Circumcision MDG Millennium Development Goal MDR-TB Multi Drug-Resistant Tuberculosis MMR Maternal Mortality Ratio MNCAH Maternal, Child and Adolescent Health MOHSS Ministry of Health and Social Services MSH Management Sciences for Health MTCT Mother-To-Child Transmission of HIV MTEF Mid Term Expenditure Framework MVA Motor Vehicle Accident Fund NABCOA Namibia Business Coalition on AIDS NaCCATuM Namibia Coordinating Committee for AIDS, Tuberculosis and Malaria NAEC National AIDS Executive Committee NAFIN Namibia Alliance for Improved Nutrition NAMAF Namibian Association of Medical Aid Funds NAMBTS Blood Transfusion Service of Namibia NANASO Namibia Network of AIDS Service Organizations NAPPA Namibia Planned Parenthood Association NBPr National Blood Programme NCD Non-Communicable Disease NDHS National Demographic and Health Survey NDHS+ National Demographic Health Survey Plus NDP National Development Plan NFP National Focal Point NGO Non-Governmental Organization NHA National Health Accounts NHFC Namibia Health Facility Census NID National Immunization Day NIP Namibia Institute of Pathology NLSA Nutrition Landscape Analysis

iv NPCS National Planning Commission Secretariat NRCS Namibia Red Cross Society NRSC National Road Safety Council NTLP National Tuberculosis and Leprosy Programme NVDCP National Vector-Borne Disease Control Programme OPV Oral Polio Vaccine PARMaCM Programme for Accelerating the Reduction of Maternal and Child Mortality PEP Post-Exposure Prophylaxis PEPFAR President’s Emergency Plan for AIDS Relief PHC Primary Health Care PITC Provider-Initiated Testing and Counselling PMDRC Policy and Management Development Review Committee PMTCT Prevention of Mother-To-Child Transmission of HIV RD Regional Director RED Reach Every District SACU Southern African Customs Union SADC Southern African Development Community SSC Social Security Commission STI Sexually-Transmitted Infection STOP Stop Transmission of Polio TB Tuberculosis TWG Technical Working Group UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNAM University of Namibia UNCT United Nations Country Team UNDAF United Nations Development Assistance Framework UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCs Voluntary Contributions VSO Voluntary Service Overseas WBW World Breastfeeding Week WCO WHO Country Office WFP World Food Program WHO World Health Organization WHS World Health Survey XDR-TB Extensively Drug Resistant TB

v LIST OF TABLES AND FIGURES

Page

Figure 1: Under five world wide mortality rate 8

Figure 2: World wide maternal mortality ratio 9

Figure 3: Estimated HIV and AIDS Incidence, Prevalence and Mortality, 1990-2015 10

Figure 4: Trends in notified DR-TB cases, 2007 - 2011 11

Figure 5: Trends of WHO estimated TB prevalence and incidence in Namibia, 1990–2011 18

Figure 6: Malaria burden in Namibia, 2001–2012 19

Figure 7: Motor Vehicle Accidents in Namibia 21

Figure 8: WCO Core Values 49

Figure 9: WCO Strategic Priorities, 2010-2015 50

vi ACKNOWLEDGEMENTS

Throughout the period 2008 to 2013, we have Honourable Minister of Health and Social Services consistently emphasized the importance of and his entire team at all levels. We are extremely partnerships. We have also translated our strong grateful for the conducive working environment, belief in the power of partnerships into concrete the excellent and productive collaboration, and the actions which led to significant improvement in our unwavering support to the work of WHO. collaboration with Government, Civil society, private sector, bilateral and multilateral partners in various We extend our deep gratitude to the teams at the fronts. WHO Country Office, Inter-Country, Regional Office and Headquarters. Without their collaboration, it Effective partnerships require constant dialogue and would have not been possible to provide technical information sharing, mutual respect, understanding, support to the Ministry of Health and Social Services shared values and principles toward common goals. and the Government of Namibia on its quest for a We have nurtured these principles, and enjoyed the better health for its people. fruits of smart partnerships. A special word of appreciation goes to late We sincerely thank all our partners for the immense Mr Moses Kuhanga, Senior driver of WHO Namibia support they have provided to WHO throughout who passed away in 2011. Moses was a very the years. Through such support, our work became competent, dedicated and committed driver. He easier and more relevant. We were able to do more discharged his responsibilities with diligence and with less, because we were complemented by other professionalism. More than a driver, Moses was a partners. great friend. He thought me a lot about Namibia, its people and history. We spent many and long hours Technical cooperation with the Government of together, traveling across this vast country. He cared Namibia, in particular with the Ministry of Health about his work, his colleagues and the Organization. and Social Services was at its best, thanks to the May his soul rest in eternal peace.

vii viii FOREWORD

As I write these words, there are less than 1,000 days economic growth and development and promotion to the end of 2015, the deadline for the achievement of of a more equitable distribution of wealth. Emphasis the Millennium Development Goals. These remaining is centred on strengthening health systems, in a clear 951 days should be effectively used to accelerate efforts recognition of the paramount importance of building towards achieving the goals, particularly those lagging solid foundations to deliver healthcare interventions. behind, Goals 4 and 5 on Reducing Child Mortality and Improving Maternal Health. The United Nations system has just launched its Partnership Agreement Framework with Namibia, Reaffirming what is known and widely recognized 2014-2018, aligned with the National Development within the health ranks, the Global Competitiveness Plan 4. Health is one of the four pillars of the Report 2013-2014 reminded us that in order to improve Partnership Agreement Framework, a clear indication its competitiveness, as in much of the region, Namibia of the importance that Government and stakeholders must do more in the areas of health and education. The attach to this area. Health systems, communicable country is ranked a low 123rd on the health sub-pillar and non-communicable diseases as well as maternal, (down five places), with high infant mortality and low newborn, adolescent and child health and nutrition are life expectancy—by far caused by the high rates of areas of focus. The National Development Plan 4 and communicable diseases. The Ministry of Health and the United Nations Partnership Agreement Framework Social Services, WHO and European Union’ ten million are both in alignment with and reflect the priorities of Euros Programme to accelerate the achievement of the MOHSS (National Health Policy 2010-2012) and the maternal and child health goals will go a long way in WHO Country Cooperation Strategy 2010-2015. addressing some of these challenges. This report intends to give readers a transversal As I write, the world is reflecting on what is generally snapshot of the efforts made and challenges faced by referred to as the Post 2015 Sustainable Development WHO in Namibia over the period 2008-2013, in our strive Goals, a strategic agenda building on the successes of to provide the Government in general and the Ministry the Millennium Development Goals, to ensure dignity, of Health and Social Services in particular with a world equity and prosperity to the peoples of the world, class strategic, technical and intellectual support. particularly the poorest; foster peace and security and improve health outcomes. As I end my tour of duty in Namibia, I hope that WHO and partners will pursue the ambitious yet achievable Also as I write these words, Namibia seems to be agenda of universal health coverage and continue to witnessing the end of a widespread drought. The work towards strengthening the health system, so that drought of 2012/2013, was caused by what was the best quality healthcare can be accessed by all in described as one of the driest rainy seasons on record. need, anywhere and everywhere in Namibia. Severe impact on food security and livelihoods was recorded and further impact is likely to continue to be I have enjoyed my six years in Namibia and am observed for several months to come, particularly on extremely thankful to the Government of Namibia and malnutrition and child mortality. The drought further all the partners for the immense support extended to fragilized the resilience and coping systems of the me and my team. Enjoy the reading! population, which had been severely compromised by repeated floods in previous years.

Namibia is well into the first year of implementation of its National Development Plan 4, 2012/13-2016/17 where Dr Magda Robalo Correia e Silva health features prominently as one of the enablers of WHO Representative

ix x EXECUTIVE SUMMARY

1. The Context

Namibia is an arid country, which has been seriously are road traffic injuries and fatalities, which are also affected by recurring droughts and floods in recent increasing. Ongoing demographic transition will years. With as much as 57.9% of the population dictate Namibia’s priorities over the next decades, as living in rural areas, vulnerability to such natural life expectancy and rural-urban migration increases, disasters, the risks of disease outbreaks and food and total fertility rates declines. shortages constitutes a real problem. Sanitation is also a serious concern, especially in rural areas and Communicable diseases are still a major public informal settlements. Namibia has a population of 2.1 health problem in Namibia, in particular HIV/AIDS million, sparsely distributed at a density of 2.5/sq km, and TB. The malaria burden has progressively been making access to improved services a challenge. reduced to the extent that it is no longer a major public health problem as its ranking has significantly In the political realm, Namibia enjoys a stable multi dropped on the list of top ten diseases. At 18.2% party democracy since independence in 1990. The prevalence among pregnant women, Namibia has country has also experienced economic growth one of the highest HIV prevalences in the world. over the years. However, Namibia’s gross domestic Spectrum modelling estimates HIV prevalence product (GDP) of US$12.81 billion, which places it in among people aged 15 and above at 12.8% in the Upper Middle Income category, masks significant 2013/2014. Estimates from the Global Tuberculosis poverty and one of the highest levels of social and Report 2013, indicates that tuberculosis incidence economic inequality in the world. The Government’s rate declined from 1,390 in 2005 to 867 in 2010, 723 Vision 2030 aims to transform Namibia into an in 2011 and 655 in 2012. It is estimated that 67% of the industrialized nation and redress income gaps population lives in malaria-affected areas. However, through a series of developmental processes. with an incidence rate of 6.7 per 1,000 population in 2010/11, Namibia is one of the few African countries 2. Health Trends which is ready to start the transition from malaria control to elimination. The years 2008-2013 saw Namibia undergo some key shifts in public health. At the beginning of this The health of mothers and children is a serious period, focus was changing from the emergency concern, as statistics on maternal and infant deaths, response to HIV/AIDS and Tuberculosis (TB) to and child malnutrition are alarming. The Maternal health systems strengthening and the integration Mortality Ratio (MMR) stood at 449 per 100,000 live of specific disease-related programmes into births in 2006/07; 29% of children were registered mainstream services. It is also becoming clear that as stunted, 8% as wasted, and 17% as underweight. health can no longer be dealt with in isolation, and These figures have brought the quality of antenatal, the country is turning its attention to the social, obstetric and child nutrition services under scrutiny. economic and environmental determinants of HIV prevalence among children is also a major health, such as access to decent housing, food, challenge, with 14,000 children estimated to be water, sanitation and lifestyles. Namibia is currently living with HIV. Other concerns around the health of undergoing a health transition, with communicable women and youth include high rates of unwanted diseases still highly prevalent but on the decline, and teenage pregnancies and unsafe abortions and non-communicable diseases such as cancer, among adolescents, and the high incidence of diabetes, cardiovascular diseases and hypertension gender-based violence in the country. on the rise. Mental illness is another concern, as

xi 3. Promoting Development part of this success story through our support to the National Vector-Borne Disease Control Programme Promoting health for development is top on the (NVDCP). WHO agenda, in recognition of the fact that poverty contributes to poor health, and poor health anchors We have supported the strong political commitment populations in poverty. Priority must be given to to addressing the emerging of diseases associated the improvement of health outcomes for poor, with unhealthy lifestyles, such as diabetes and disadvantaged and vulnerable groups, so that “All hypertension. Particular attention has been given the people of Namibia have equitable access to high to the generation of evidence, development of a quality and affordable health care services” (Vision strategy and policy document and capacity building 2030). We support the Government’s relentless of health workers to address the burden of non- efforts to achieve the health-related Millennium communicable diseases. We have made efforts Development Goals (MDGs), namely Goals 4, 5 to raise public awareness on the negative effects and 6: to reduce child mortality, improve maternal of smoking and excessive alcohol consumption, health, and combat HIV, malaria and other diseases, and supported development and enforcement respectively. These goals are cornerstones of WHO’s of relevant legislation. Other non-communicable overall health and development agenda. diseases, such as cancer and mental illness have also received our attention. We have worked closely with United Nations Agencies and other key development partners like the Centres for Disease Control and Prevention (CDC), United States Agency for International Development (USAID), President’s Emergency Plan for AIDS Relief (PEPFAR), German Society for International Development (GIZ) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to help the Ministry of Health and Social Services (MoHSS) address the dual epidemics of HIV and TB in Namibia. The results have been encouraging, in great part due to Practitioner-Initiated Testing and Counselling (PITC) and massive scale-up of anti- retro viral therapy (ART). We have also assisted in the improvement of surveillance and planning processes that the response requires, with a focus on HIV Drug Resistance (HIVDR) and treatment. With regard to TB, our assistance has focused on strategies to address multi-drug resistant TB (MDR- TB) and extensively-drug resistant TB (XDR-TB), as well as support for cross-border coordination and the revision of guidelines, policy development and planning.

Efforts to stem the scourge of malaria in northern Raising the profile of maternal and child health parts of the country have paid off, with Namibia now and mobilization of additional resources for this firmly on the path to pre-elimination by 2016 and important area have been a major priority for WHO elimination by 2020. We have been privileged to be a in Namibia in recent years. We have supported

xii the Ministry’s attempts to address high maternal, 5. Strengthening Health Systems newborn and child mortality rates, mainly through initiatives geared towards coordinating the various Despite the country’s economic ranking as an upper partners whose development and business activities middle-income country, the healthcare system still impact on the health of mothers and children. battles with challenges of striking inequality. In addition, we have trained healthcare workers in relevant skills, and supported immunization, Disease-oriented approaches have fuelled nutrition and growth monitoring activities. fragmentation and over-burdening of health workers, and left behind critical high-priority issues 4. Fostering Health Security that did not receive funding or adequate attention. Vertical systems for disease control contributed We provided technical assistance to the MOHSS to weakening the health system rather than in mitigating the impact of outbreaks of diseases strengthening it. such as cholera, meningitis and measles, and have contributed to strengthen Surveillance and Emergency Preparedness and Response (EPR) System, which has helped to avert major and widespread outbreaks.

This key item in the WHO international agenda aligns us fully with Government’s efforts to foster the health security of all Namibians. We have also assisted with broader technical and financial support to bolster the Ministry’s capacity for surveillance, data collection and analysis, laboratory diagnosis, disease prevention and control, and other aspects of emergency health. These capabilities are essential for Namibia’s implementation of WHO’s International Health Regulations (IHR) (2005), which will help the country to defend itself against disease outbreaks in the context of Integrated Disease Surveillance and Response (IDSR). Since it did not meet the criteria for full implementation by 2012, Namibia, along with other Member States, needs to redouble its efforts to build prevention and response Governance is one area in which we have systems. The country has made some strides in supported health systems strengthening. This this regard, such as the strengthened Expanded includes assistance for executing the 2008 Health Programme on Immunization (EPI) surveillance, and and Social Services Review (HSSR), as well as we have offered support along the way. the implementation of the recommendations that emanated from it. We also supported the Other health security activities in this reporting development of the Ministry’s Strategic Plan for period included support for the draft Health 2009-2013. Our second Country Cooperation Strategy Sector Plan of Action for Public Health Adaptation (CCS), which informs WHO operations in Namibia for to Climate Change, the revised National Health the period 2010-2015, was developed with reference Policy 2010-2020, and the National Policy on Health to this plan. Health Systems Strengthening is the Promotion. foundation of the Strategy. We have joined other

xiii partners to support the restructuring of the MoHSS, introduction of National Health Insurance in Namibia which is still under way, and have also prioritized and the Health Poverty Reduction and Economic support towards strengthening the Ministry’s Development Project. stewardship role and policy dialogue with multiple stakeholders within and across sectors, including the In line with our shared priorities for improved health private sector. information, we have facilitated the Ministry’s use of evidence in the review and development of an The withdrawal of human resources budget by array of norms, standards, policies, legislation, various key partners meant that the MoHSS must frameworks and guidelines. We have also partnered absorb staff assigned to specific programmes. We with the Ministry to upgrade its Health Information are providing assistance and guidance to the Ministry System (HIS), and have supported its preparations for the smooth transitioning of such staff to ensure for the National Demographic and Health Survey that they are used in the most efficient, effective and Plus (NDHS+). This NDHS+ will, for the first time in equitable way. We played a key role in strengthening Namibia’s history, contain an HIV/AIDS household the capacity of healthcare workers in Namibia, with survey. a focus on critical areas of health care such as Life Saving Skills, Emergency Obstetric and Newborn Service delivery is an obvious priority in health Care (LSS/EmONC), IDSR, growth monitoring and systems strengthening. Our support to the MoHSS nutrition, and immunization. We have also joined in this area included assistance for conducting the other partners in recommending the training and Namibia Health Facility Census (NHFC) in 2009 and deployment of community healthcare workers. The the development of the Essential District Health establishment of the Namibia School of Medicine in Package (EDHP). 2010 was a landmark event that will help to provide local health professionals who previously had to A well-functioning health system ensures equitable be trained outside the country. We were privileged access to essential medical products, vaccines and to have been part of the School’s development technologies of assured quality, safety, efficacy and process. cost effectiveness, as well as their scientifically sound and effective use. We have helped the MOHSS to In the area of health financing, we assisted the increase its capacity for the development of policies, MoHSS in producing the second (2001/02-2006/07) legislation, regulation and strategies; strengthening and third (2007/08-2008/09) National Health of the Namibia Blood Transfusion Services; improved Accounts (NHA). We were involved with two supply of medical gas; and inventory of medical projects aimed at reducing financial barriers to equipment. health services: feasibility processes for the possible

xiv 6. Harnessing Research, In collaboration with partners, we have provided Information and Evidence extensive technical support to the Ministry in the area of research, data gathering and the Evidence has always been an important factor in dissemination of information. Examples are the health management. Having reliable evidence on HIV Sentinel Surveys, the Health Facility Census, issues that compromise people’s health is crucial the provision of information booklets on the for setting relevant priorities, as well as identifying implementation of IHR (2005), monitoring of strategies for action and measuring results. HIV Early Warning Indicators (EWI) and HIV Drug Ultimately, evidence plays a key role in motivating Resistance, and the Survey on NCDs Risk Factors. the resource envelope for health initiatives. As the dynamics of health have become more complex, We have also assisted civil society and private sector our strategies for responding to them have been organizations in the area of research, information constantly adjusted. and evidence. These include the Namibian Planned Parenthood Association (NAPPA) and the Namibia The WHO Country Office (WCO) aspired and Network of AIDS Service Organizations (NANASO), succeeded in being at the forefront of health and among others. biomedical information in the country. We hosted the Namibian launch of the World Health Report 7. Enhancing Partnerships 2008, a document which critically reviews the way health care is organized, financed, and delivered in Tackling Namibia’s top health priorities requires rich and poor countries around the world, and sets a concerted and coordinated effort between a out a way to address inequalities in health care. We range of partners from different sectors, as well donated to the Namibia School of Medicine our as international development organizations, the library containing a comprehensive set of about private sector and civil society who play critical roles 4000 publications on diverse areas of health, a in the country’s health sector. With resources from powerful information resource that will provide traditional health donors diminishing, the need for students and health professionals much needed partner coordination in order to maximize efforts has information on health and health related areas. We never been more urgent. We must avoid duplication are also in the process of developing the Namibian of efforts, gaps in critical areas and ensure efficient pages of WHO’s two new on-line information portals utilization of resources. to assist health planning: the Country Health Policy Process (CHPP) and the African Health Observatory WHO leverages its convening power as a neutral (AHO). organization with nearly universal membership,

xv and a lead partner in the health sector, to bring WHO plays an important role in the coordination stakeholders together in the interest of health of health activities among United Nations (UN) development. In 2011, WHO established and chairs agencies in Namibia through bodies such as the the Health Development Partners Group, a gathering Joint UN Team on AIDS (UNAIDS). The United of international organizations and UN Agencies Nations Development Assistance Framework operating in the health sector in Namibia. The (UNDAF) 2006-2010/12, and the United Nations aim of the Health Development Partners Group Partnership Agreement Framework (UNPAF) 2014- is to facilitate greater coordination across the 2018 are important instruments guiding coherent, health sector, share information, maximize efforts, integrated programming and delivery among and enhance synergies and prevent duplication. This, it is by UN agencies in Namibia. WHO participated expected, will improve the quality and impact of the in the development and implementation of support provided to Government in general and the the former and played a leading role in the Ministry of Health and Social Services in particular. development of the latter, as the Chair of the Programme Development Team. In addition, we convene and participate in a wide range of technical working groups and advisory WHO is not a funding agency, but we do committees for specific programmes. mobilize funds from a variety of sources for the implementation of our Country Cooperation Strategy The MoHSS needs to take the lead in coordinating (CCS) and to provide catalytic financial support to partner’s efforts. We have therefore made it one the MOHSS and other partners. Over the years, we of our priorities to help the Ministry strengthen its have contributed to the development of several key stewardship role. The draft Donor Coordination proposals that have been submitted for funding Framework is an example of this work, and a key either directly or through the MOHSS. Two highlights instrument for harmonizing health activities in the of this work are the EU award of 10 million Euros country. We also facilitated regular cross-border for implementing the Programme for Accelerated collaboration between Namibia and Angola, for the Reduction of Maternal and Child Mortality prevention and control of various communicable (PARMaCM) and a series of successful proposals to diseases, such as malaria, polio, HIV/AIDS and TB. the Global Fund, which has disbursed a total of US$ 190,639,964 to Namibia since the beginning of its support in 2004.

xvi In February 2009, we were proud to host the first skills. Topics for training have included Gender official visit to Namibia of the WHO Regional Director Equality, Minute Taking, Time Management and (RD) for Africa, Dr Luis Sambo, and in April 2012, the Teamwork, Public Speaking and Media Skills, WHO Director General (DG) Dr Margaret Chan made and the Global Learning Programme, which her first visit to the country. Both visits boosted focused on the development of national health partnership relations with our various partners and policies, strategies and plans. We have also held the Government of Namibia. four staff retreat sessions in order to review the implementation of activities, plan the way ahead 8. Improving Performance and strengthen team spirit.

WHO plans its budget and activities through results- Our Country Cooperation Strategy is our based management processes, with clear expected main planning tool for the medium term. The results to measure performance, and undertakes implementation of the CCS’ strategic agenda is reforms aimed at improving efficiency and coordinated through biennial work plans, which effectiveness at country, regional and global levels. articulate the priority activities in the short term. Human resources play a critical role in the work Weekly meetings with technical staff serve as of WHO. The quality of the technical cooperation an important instrument to enhance internal we provide to Namibia depends on our ability to communication, information sharing and improve maximize our in-country expertise as well as in management and accountability. The operations reaching out and mobilizing our great organizational and support staff meetings on a bi-weekly basis are network. In the period 2008-2013, the WCO has aimed at sharing developments in their specific areas experienced adverse changing conditions in terms of work, review implementation, share information of staffing and financing. We have worked hard to and provide team guidance. All-staff meetings are make the most of our resources through regular held on a quarterly basis. Individual Performance introspection and realistic planning. Management and Development Plans are developed annually to ensure focus, performance-driven and We have promoted and supported a number of results-oriented actions by each staff member. in-country and external training and capacity Information technology platforms are used to building exercises for staff to update their technical enhance information sharing and communication. expertise and enhance knowledge and professional

xvii xviii INTRODUCTION

The world has witnessed some memorable events our efforts to meet the Ministry’s priorities, taking during the years covered by this report (2008-2013). into consideration agreed international and regional The global economic meltdown which has had a development goals and our comparative advantage. ripple effect on people’s lives in every corner of Our support has been mainly in the areas of 1) the world is one of them. Natural disasters have Strengthening the Health System; 2) Combatting rocked countries in every continent. In the area Priority Diseases; 3) Improving Maternal, Newborn, of health, the scale up of antiretrovirals (ARVs) Child and Adolescent Health; and 4) Promoting has helped to curb the ravages of HIV/AIDS on a a Safer and Healthier Environment. It should be global scale. The developing world is going through noted that, despite the various challenges, great an epidemiological, demographic and economic progress has been made in these areas, for which transition, leading to what is known as the rising of Namibia should be applauded. With the decline in the South. international donor funding for health, the Namibian Government has shown its commitment towards In this report we reflect on the strategic and technical taking on the costs and institutional development support the WHO Country Office (WCO) has provided involved, to secure a healthy future for all Namibians. to the Government of Namibia in particular to the Ministry of Health and Social Services (MOHSS) As we reflect on the past, we also take pause to between 2008 and 2013. The report reviews the consider the future. Making optimal use of limited challenges we have faced and the achievements we resources is more critical than ever. Ongoing have contributed to during this period. advances in information and technology give us expanded possibilities for gathering and using This report is structured around the six points evidence to improve health outcomes. Globalization of WHO’s agenda: Promoting Development; presents an opportunity to strengthen international Fostering Health Security; Strengthening Health collaboration on health matters and reduce the gap Systems; Harnessing Research, Information and between the haves and have nots. Evidence; Enhancing Partnerships; and Improving Performance. For health improvement to operate as a poverty- reduction strategy, health services must reach The Government of the Republic of Namibia is poor and underserved populations. While Namibia strongly committed to the improvement of the has made demonstrable progress in making health health of its citizens. The 2008 Health and Social services accessible, affordable and equitable, there Systems Review (HSSR) played an important role in are still considerable challenges in improving the outlining the health situation and paving the way for quality, effectiveness and efficiency of service the formulation of the Ministry’s five year Strategic delivery and reduce inequities in access to health Plan 2009-2013. care. The keys to success will be continued integration of health services in accordance with Our support during this time has been guided by the principles of Primary Health Care (PHC) and the first (2004-2007/09) and second (2010-2015) partnership across all sectors that impact on the Country Cooperation Strategies. We have aligned nation’s health.

1 1. THE CONTEXT

2 The health situation in any country is shaped by its geographic, environmental, social, demographic and economic context. Namibia is no exception. This sparsely populated, arid, developing nation faces specific challenges which impact the planning, organization and delivery of health services.

Geography and Climate

Situated on the south-western Atlantic coast of the African continent, Namibia borders Angola, Botswana, South Africa, Zambia and Zimbabwe. A large part of the country is covered by two deserts, the Namib to the West, and the Kalahari to the East.

The climate is mainly arid and semi‐arid with sparse and erratic rainfall. Environmental concerns include, among others, desertification, recurring drought and floods, depletion of natural resources, and decline of water Population size 2.1 million quality. Repeated drought and Rural population 65.3% floods have seriously affected Urban population 34.7% the food security of mainly rural Women and children 52% populations as successive harvests Population <15 years 40% have been destroyed. Annual Population 15-59 years 54% floods between 2009 and 2011 National population growth rate 1.4% led to severe water logging and Urban population growth rate 4-5% affected hundreds of thousands Life expectancy 62.3 of people. They also interrupted Households that are female headed 40.4% access to health care in affected Adult literacy rate 89% areas. The 2013 widespread drought has been severe. Food People in need of food assistance 74,000 security and livelihoods of rural Households with access to improved source of drinking water 93% communities have been seriously Rural population using unimproved sources of water 10% affected, to the extent that the Households using improved sanitation facilities 32% President of the Republic has Rural areas using improved sanitation facilities 17% declared a national state of Population density in informal/low income areas ≤50,000/sqkm emergency on 17 May 2013. National population density 2.7/sqkm

3 The People

The preliminary results of the 2011 census found Despite its small population, Namibia has a rich that the population of Namibia currently stands diversity of ethnic groups. at 2.1 million. Although the population increased more than eight times between 1921 and 2001, According to the World Food Programme (WFP), from 229,000 to 1,830,330 people, the growth rate although food availability at the national level is slowed to 2.6% per annum between 1991 and 2001, adequate, access to food is still a concern for an and further declined to 1.4% between 2001 and 2011. estimated 12-14 percent of the population. In 2013, This is thought to be caused by a reduction in fertility it was estimated that 463,581 people were food rates, which in turn is due to improved levels of insecure and 314,923 were moderately food insecure, education among young women and their increased as a result of the drought. participation in economic development. Population growth is mostly attributed to improved medical Latest United Nations Children’s Fund (UNICEF) care and immigration, as well as increased life figures estimates the percentage of households that expectancy. However, Namibia still has one of the have access to an improved source of drinking water lowest population densities in the world. at 93%. For sanitation, the figures are much lower with wide gaps between urban and rural areas. Only Namibia’s small population is spread over a wide 32% of households nationally use improved sanitation area, with the national population density estimated facilities, and in rural areas only 17% of the population at 2.5 people per square kilometre. Lack of fertile soil has access to improved sanitation facilities. and water are the main reasons for low population density in most parts of the country. The majority The Economy of inhabitants live in rural districts, often beyond the reach of road infrastructure and basic services, Namibia’s gross domestic product (GDP) grew from posing logistical problems for development. US$8.86 billion in 2009 to US$12.81 billion in 2012. According to the preliminary results of the The economic growth is largely due to growth in the Population and Housing Census of 2011, 57.9% of the sectors of mining, fisheries, large-scale farming and population lives in rural areas. high-end tourism. As a result, the World Bank has recategorized Namibia as an Upper Middle Income As in many other countries, rapid urbanization is Country (UMIC) in 2009. This means the country is occurring in Namibia, particularly in informal and no longer eligible for many concessional grants and low-income housing areas, where the population loans, and several donors have started scaling down density can reach up to 50,000 people per square their support. kilometre, which is very high if compared to the national average. This is partially linked to extensive However, Namibia’s GDP masks entrenched socio- migration for work in farms, mines and ports. The economic inequalities. In fact the country still has preliminary results of the Population and Housing one of the highest levels of income inequality in Census of 2011 indicates that there is significant the world with 39.6% of the population living in migration from rural to urban areas and that the urban population increased from 33% to 43% GDP: US$12.81 billion between 2001 and 2011. It is estimated that the urban Population living in poverty: 39.6% population growth rate has been around 4% to 5% Human Development Index: 0.608 over the past decades. Most young adults live in Human Development ranking: 128 out of 186 urban areas, with a significant number in informal settlements. poverty and high unemployment rates, especially among rural women. In 2012, Namibia had a Human Women and children constitute about 52% of Development Index of 0.608, ranking it of 128 Namibia’s population and 40.4% of households are (out of 186 countries with comparable data). This female headed. The country currently has a relatively is below the average of 0.64 for countries in the young population, with about 40% of people aged medium human development group and above the 15 years and below, and 54% aged 15 to 59 years old. average of 0.475 for countries in Sub-Saharan Africa. However, as life expectancy climbs, the country Economic inequality and the prevalence of poverty must prepare for an increasingly aging population. are considered to be both a cause of ill-health and

4 other challenges and a barrier to responses, as lower sitting President comes to an end in March 2015. income groups struggle to access services. During this reporting period, the Ministry of Health and Social Services implemented a programme from Vision 2030, which is implemented through a series the manifesto of the South West Africa People’s of National Development Plans, aims to transform Organization (SWAPO) led Government, the party Namibia into an industrialized nation and reverse which won the 2009 general elections with 75% of this legacy. the vote.

The Politics According to the World Governance Indicators, Namibia enjoys the second best position in Africa Namibia is a secular state, which has enjoyed a stable for Political Stability/Absence of Violence indicator. multiparty democracy based on the rule of law since On rule of law, Namibia scored 84, ranking sixth out gaining independence in 1990. National elections of 52 countries in the 2012 Ibrahim Index of African are due to occur in 2014, to elect a new President, Governance. The Southern African and African as the two constitutionally allowable terms of the scores are 63 and 48 respectively.

Namibia is blessed with a stable democratic political environment, which lays the foundation for effective planning and implementation of health and other development programmes. In view of the many environmental, demographic and economic challenges it is heartening to note the high-level political commitment to provision of equitable access to health services, as well as other developmental goals.

5 2. HEALTH TRENDS

6 In the period 2008-2013 Namibia continued to face serious health challenges: mothers and children are still dying during pregnancy and childbirth due to preventable causes; the dual HIV/AIDS and tuberculosis (TB) epidemic continues to affect a large portion of the population, and there is a significant prevalence of malnutrition among children aged less than five years. However, Namibia is also a country where malaria is under control; where life expectancy is increasing, the number of TB cases and deaths is decreasing, fewer babies are born infected with HIV, fewer new cases of HIV are recorded and the large majority of HIV/AIDS patients are under treatment. Government commitment and expenditure on health is relatively high and has been sustained; and partners are coming together to support Government in implementing health interventions that are better coordinated, effective and efficient.

The years 2008-2013 saw Namibia undergo some dynamics, together with the stabilization of the HIV key shifts in public health. Focus has changed from epidemic and an increase in lifestyle diseases, made the emergency response to HIV/AIDS and TB to the a focus on health risks such as obesity, smoking and integration of specific disease-related programmes alcohol use imperative. into mainstream services, and health systems strengthening. Alarming data on deaths among children as well as mothers during pregnancy or childbirth made It has become increasingly evident that health could these crucial priorities for Namibia. In August 2012, no longer be dealt with in isolation, and Namibia following several maternal and infant deaths a began to turn its attention to the social, economic Presidential Commission of Inquiry into the Public and environmental determinants of health, such as Health Sector was established. The Commission has access to food, water and sanitation. This broader presented its findings, which will accelerate ongoing perspective was triggered by a number of social reforms to public health services. trends, which have impacted the health situation in the country. These include growing urbanization The National Health Policy Framework 2010-2020 and informal settlement, and the continuing gap states the Government’s intention regarding access between rich and poor in the midst of overall to health care: “Health and social welfare services economic growth. With fertility rates on the decline will be affordable and the principle of equity and (standing at 3.15 births per woman in 2011) and life fairness will underpin the commitment expressed in expectancy increasing (from 61.0 in 2008 to 62.3 this policy framework; special attention will be given in 2011), Namibia’s health policy needed to address to vulnerable groups.” the prospect of an aging population. These social

7 Mothers, Babies, Children and in Namibia. Adolescents The WHO, UNICEF, UNFPA and The World Bank estimates of trends in maternal mortality indicates that there was no progress in reducing maternal The health and development of a nation is often mortality in Namibia during the period 1990 to 2010. measured by the level of women’s health as The report, released in 2012, estimated the maternal well as child survival, and development. Women mortality ratio at 200 per 100,000 live births. and children constitute more than 52% of the population in Namibia. It is estimated that children The situation is of particular concern given the fact who lose their mothers, are up to 10 times more that a large proportion of mothers are receiving likely to die prematurely than those who have not. antenatal care (ANC) and delivering at health Unfortunately in most African countries including facilities, so the quality of services has come under Namibia, the health indicators for women and scrutiny. The proportion of health facilities with children are worrisome. This is because more adequately skilled health workers to provide quality mothers are dying during childbirth and the rate of care during childbirth and the postnatal period is deaths in under-five-year-olds is not slowing quickly estimated at 42%. At the same time, spending on enough. maternal, child and adolescent health is inadequate and emergency obstetric care (EmOC) services are According to the latest Namibia Demographic and unevenly distributed. Health Survey (NDHS), the Maternal Mortality Ratio (MMR) nearly doubled to 449 per 100,000 live births Efforts are being made to build the capacity and during the period 1998 - 2007 from 271 per 100,000 skills of health workers to provide quality essential live births during the period 1991 - 2000. The majority services to mothers during pregnancy and after of maternal deaths are due to direct obstetric delivery. A Road Map for Accelerating the Reduction complications such as eclampsia, haemorrhage and of Maternal and Neonatal Morbidity and Mortality obstructed/prolonged labour. HIV/AIDS is estimated was developed in 2010 to guide government to be the leading indirect cause of maternal deaths and partners in achieving universal access to

Figure 1: Under five world wide mortality rate

Source: Levels and Trends in Child Mortality, 2012. Estimates developed by the UN Inter-Agency Group for Child Mortality Estimation, Report 2012

8 comprehensive quality maternal and neonatal health by many challenges including poor infrastructure care, and accelerate progress towards achieving the to access hard-to-reach areas, cold chain limitations Millennium Development Goals (MDGs). in remote areas and inadequate human resources, among others. Child malnutrition is very high. According to the NDHS 2006/07, approximately 29% of children are Around 90% of health facilities have treatment stunted. Wasting is at 8% and underweight registered guidelines for providing health services to children, at 17%. Infant and childcare is best provided through but all the items necessary to provide quality child a package of Integrated Management of Newborn health services are only available in less than half of and Childhood Illness (IMNCI), which has not yet health facilities that care for children. achieved a high enough coverage. A Nutrition Landscape Analysis to identify the readiness to HIV prevalence among children and the accelerate actions to reduce maternal and child disproportionate incidence among young females under-nutrition was undertaken in Namibia in 2012. is a major cause for concern. Over 90% of health It made recommendations for the scaling up of facilities provide Prevention of Mother-To-Child nutrition-related activities, focusing on policies, Transmission of HIV (PMTCT) services and the uptake legislation and guidelines; human resources; of ARV prophylaxis for PMTCT is reported to have nutrition promotion; information, surveillance and increased from 60% in 2004/05 to 96% in 2010/11. research, and calling for a well-coordinated multi- sectoral approach. Unwanted pregnancies and unsafe abortions are unacceptably high among adolescents. The Ministry Although the national routine immunization of Health and Social Services (MOHSS) estimates coverage is above 80%, rates vary between regions, that the number of teenage pregnancies increased with sub-optimal levels in several districts. The 2009 from 16% in 2006/7 to 17.3% in 2010/11. The Kavango Health Facility Census found that less than a third of Region registers the highest rate, 34% among 15 to health facilities providing immunization services have 19-year-olds. all the required equipment, and all the necessary items for infection control. The country is confronted Unmet needs for family planning are estimated to

Figure 2: World wide maternal mortality ratio

Source: Estimates of Maternal Mortality 1990-2010, WHO, UNICEF, UNFPA and The World Bank, 2012

9 be low (declining from 5% in 2000 to 3% in 2006/07), Estimates of Mother-To-Child Transmission rates with most facilities providing modern contraceptive point to a decrease from 6% to 4% at six weeks and services and counselling. from 18% to 14% at 18 months between 2009/10 and 2010/11. HIV prevalence dropped from 22% in 2002 Teenage pregnancies 17.3% to 18.2% in 2012 and there are encouraging signs of Syphilis prevalence rate 1.9% reduction of prevalence among young people aged Unmet needs for family planning 3% 15 to 24 years. According to the ANC Sentinel Survey, Females who have experienced physical the overall HIV prevalence among this age group was violence 40% 10.3% in 2010, compared to 15.2% in 2004. Reported cases of rape 2011 1,085 Significant progress has been made with regard to voluntary counselling and testing (VCT), the number In Namibia, it is estimated that 40% of females have of eligible patients on antiretroviral therapy (ART), experienced physical violence compared to 28% and the number of facilities providing ART services. of their male counterparts, according to a 2009 The World AIDS Report 2012, showed that access to study on Knowledge, Attitudes and Practices (KAP) HIV/AIDS treatment in Namibia is nearly universal conducted by the Ministry of Gender Equality and and over 80% of eligible people are receiving ART. Child Welfare. This high coverage is one of the highest in the African region and does not include patients being The 2011 National Crime Statistics showed that the treated in the private sector. Namibian police recorded 1,085 reported cases of rape and 277 attempted rape in the same year. In terms of prevention, there is a significant increase in reported condom use; however, much still needs Major Communicable Diseases to be done to reduce the number of new infections. Some of the identified drivers of the HIV epidemic in Communicable diseases remain a major public health Namibia are multiple and concurrent partnerships, problem in Namibia. Among them, HIV/AIDS, TB excessive alcohol use, intergenerational and and malaria deserve special attention, and these transactional sex. diseases are prioritized in the MOHSS Strategic Plan 2009‐2013. Namibia has one of the highest HIV Figure 3: Estimated HIV and AIDS Incidence, prevalences in the world and is one of the Sub- Prevalence and Mortality, 1990-2015 Saharan African countries most affected by the dual epidemic of HIV and TB. 25,000 250,000

20,000 200,000 Successful control of these major diseases requires cross‐border cooperation with neighbouring 15,000 150,000 countries in the context of the Southern African Development Community (SADC) Health Protocol, 10,000 100,000 AIDS Deaths) the implementation of World Health Organization and Children) (WHO) resolutions and recommendations, Number (New Infections & and scaling up of cost-effective interventions. 5,000 50,000 Number (HIV Positive Adults

Despite the challenges, the country has made 0 0 tremendous progress in curbing the impact of major communicable diseases in recent years. 1990/91 1993/94 1996/97 1999/00 2002/03 2005/06 2008/09 2011/12 2014/15 HIV New Infections (Primary Axis) The number of AIDS-orphaned children is estimated Annual AIDs Deaths (Primary Axis) HIV Positive Adults and Children (Secondary Axis) at about 75,000 and around 190,000 people are living with HIV. Annual AIDS-related deaths have decreased from 7,771 in 2008/09 to 5,047 in 2011/12. Source: MOHSS/UNAIDS HIV/AIDS epi-estimates

10 Tuberculosis

Although the number of notified TB cases continues to drop, the country still has one of the highest case notification rates in the world. HIV infection is the major driver of the current TB epidemic. It is estimated that 59% of TB patients tested HIV positive. The key approach for tuberculosis prevention and control is directly‐observed treatment short‐course (DOTS). New challenges are posed by the emergence of Multidrug resistant (MDR-TB) and extensively drug resistant (XDR-TB), the latter being virtually untreatable. The MOHSS has responded to these threats with decisive leadership and put in place a vigorous surveillance system and infection control measures. As a result, the number of registered Drug Resistant TB cases is progressively reducing. African Leaders Malaria Alliance (ALMA) Award presented Figure 4: Trends in notified DR-TB cases, 2007 - 2011 to His Excellency, Dr Hifikepunye Pohamba, the President of the Republic of Namibia, for quality leadership in 400 MDR-TB fighting malaria, 2013. 350 XDR-TB 300 PDR-TB 250 Total of malaria has declined significantly enough to 200 DR-TB lead national and international experts to consider 150 making the transition from control to elimination, Number of cases 100 and the country is currently in the process of 50 implementing malaria pre-elimination activities. 0 2007 2008 2009 2010 2011 MDR-TB 115 201 275 214 156 Health emergencies XDR-TB 3 20 17 8 2 PDR-TB 7 57 80 63 47 Total DR-TB 125 270 372 285 245 Namibia like other countries is experiencing an increase in frequency and severity of disasters. Source: MOHSS, National Tuberculosis and Leprosy Between 2008 and 2011, floods caused much Programme devastation in the most vulnerable northern regions of the country. These regions include Oshana, Ohangwena, Omusati, Oshikoto, Kunene, Malaria Kavango and Caprivi. The floods invariably caused impoverishment, food shortages due to the loss of Malaria is virtually confined to the northern part crops and livestock, and the destruction of roads of the country, where 57.9% of the population and bridges. lives. Despite limited human resources at all levels, Namibia has implemented a number of strategies Disease outbreaks have occurred during the period to curb the scourge of malaria. These include vector of this report. In most cases, these were confined control and prompt and effective case management. outbreaks of cholera and meningitis and a more The majority of health facilities provide malaria widespread outbreak of measles and Pandemic treatment services, have laboratory capacity Influenza (H1N1) 2009. for diagnosing malaria and first-line antimalarial medicines are available. As a result, the annual In 2012/2013, Namibia experienced one of the driest incidence of malaria, and the malaria mortality rate rainy season, with below normal cumulative rainfall have significantly dropped since 2000. Namibia is performance. This caused crop failure and an one of the few African countries where transmission extremely low agricultural production was observed.

11 middle-income countries where the highest burden of mortality due to NCDs among people aged under 60 years of age is recorded. It is estimated that by 2030, NCDs will become the most frequent cause of death in Africa.

In line with this trend, Namibia is currently undergoing a health transition, with communicable diseases still highly prevalent but on the decline, and non-communicable diseases such as cancer, diabetes, cardiovascular diseases and hypertension on the rise. Diabetes alone is emerging as one of the greatest threats to health in the country. Between July 2010 and July 2011, 3,650 new cases of the disease were recorded in the country’s public health facilities, as reported by the National Health Information System. The increasing burden of NCDs and conditions calls for significant measures to Amid the adversity, the sector discovered its mitigate their impact and stop the progression to a strengths and resilience. The health system larger public health problem. mobilized itself with the support from its partners, and the Government diverted valueable resources In most cases, NCDs are related to poor diet, lack of to confront the needs of affected populations. physical exercise, raised blood pressure and blood The response reached out to those affected by the glucose, and the harmful use of alcohol and tobacco. drought or cut off by water, provided medicines for Although there are a shortage of data on NCD longer periods to those chronically ill, continued to cases and risk factors, figures since 1992 show an immunize children, and assisted pregnant mothers increasing trend in overweight and obesity. to deliver their babies. Mental illnesses are a concern. As in most countries, In addition to the threat posed by flooding and mental health is sorely neglected in Namibia due drought, inadequate access to safe drinking water to limited availability of skilled health and social and sanitation, particularly in rural areas, posed a workers, and inadequate allocation of resources major health risk for disease outbreaks. within the sector. The approach to mental health is largely institution-oriented with much reduced focus Namibia is lagging behind in the implementation on prevention. of International Health Regulations (IHR) (2005), a legally binding international instrument to monitor, In addition, there is paucity of epidemiological data prevent and respond to public health risks and on mental illnesses in Namibia and its impact on emergencies of international concern. Although socio-economic development. Among the few data quite a number of regional and district staff have available are the results of the WHO World Health been trained in disease surveillance, there were Survey (WHS) for 2002/03, during which period still gaps in the areas of reporting surveillance 7% of respondents were reported to have been data. Some districts still submit weekly disease diagnosed with depression. Cases of suicide are surveillance reports late and the data are not also regularly reported. Mental health facilities are analyzed at district level to guide decision-making unequally distributed in Namibia, with the majority and response to disease outbreaks. of treatment facilities concentrated in urban areas.

Lifestyle and Health Another public health burden is posed by the high level of road traffic accidents and fatalities. The majority of It is now widely acknowledged that non- these deaths are preventable. In addition to the loss of communicable diseases (NCDs) are the number-one lives, hundreds more are left disabled and thrown into cause of death in the world, particularly in low and a spiral of physical and financial dependency.

12 The System and its challenges but places Namibia ahead of other SADC and African countries. Health Services and Facilities Key Challenges Health services in Namibia are provided through the public health sector and the private sector, which Major health challenges could be attributed to comprises for-profit and not-for-profit organizations. weaknesses in the health system, such as inadequacy Faith-based and civil society organizations play a in numbers and distribution of qualified staff, significant role in the implementation of health- unbalanced financing, limited integration of services, related programmes through community-based structural inefficiencies, and insufficient community interventions as well as patient care, treatment and outreach. support. The undertaking of the Health and Social Services The public sector provides health services to the Systems Review in 2008 and the subsequent majority of the population through an integrated development of the MOHSS Strategic Plan 2009- and decentralized system that includes 13 Regional 2013, laid the groundwork for a more responsive Management Teams and 34 District Health Teams. and quality-oriented healthcare system. As a result, Health facilities in Namibia are categorized into the MOHSS is currently working on several reforms, six levels: central referral hospital, intermediate such as the restructuring of the Ministry, systems hospitals, district hospitals, health centres, clinics integration, efficiency enhancements, reform of the and mobile clinics/outreach services. health information system and the implementation of a Health Extension Workers Strategy.

Namibia has seen the exit of several key development partners, and faces further reductions in international health funding in coming years. The MOHSS is therefore focussing on ways of mobilizing all potential sources of health financing, and better utilization of private sector services through Private Public Partnerships, along with improving efficiencies and fostering service integration.

Working Together for Better Health Outcomes

Financing Political Commitment

Funding for health in Namibia is provided by the Strong political commitment to health goals is public sector (government), private companies, exhibited at the highest level. Vision 2030 includes households and donors, with Government being the health as one of the top priorities of Government. major financier of the public health sector. Between The health sector has consistently benefited from a 2007/08 and 2012/13, government expenditure on large proportion of the national budget. health as part of overall government expenditure averaged a consistent 10%. The Fourth National Development Plan (NDP4) 2012/13 to 2016/17 emphasizes the centrality of a The Abuja Declaration sets the target for healthy population toward achieving economic government expenditure on health at 15% of total growth and development and acknowledges that government expenditure. Within the social sectors in health systems strengthening should be prioritized, Namibia, Health and Social Services is allocated the in order to better deal with health conditions, in largest portion of public spending after Education, particular Communicable and non-communicable receiving 10.5% of the total budget in 2012/2013. This diseases; reduce morbidity and mortality; and figure is short of the Abuja Declaration target of 15%, increase life expectancy.

13 ‘Quality of care is and will be a pivotal dimension of all health services.’ National Health Policy Framework, 2010-2020

Partnerships

WHO mainly provides technical support by availing also worked closely with the European Union, the technical experts to support the development and United States Agency for International Development implementation of policies, guidelines and standards, (USAID); Centres for Disease Control and Prevention as well as the training of health workers in order to (CDC), PEPFAR and GFATM, as well as the German strengthen the MOHSS’ capacities for the successful Society for International Cooperation (GIZ), the delivery of health interventions. Spanish Cooperation and the Embassy of Finland.

To maximize the reach and impact of our support, Collaboration with civil society was also critical we have partnered with several other bilateral and to our work. The Namibia Planned Parenthood multilateral partners, particularly agencies from the Association, Society for Family Health, Namibia United Nations System, namely the United Nations Network of AIDS Services Organizations, The Red Children’s Fund (UNICEF), the United Nations Cross and Rotary Clubs were some of the partners Populations Fund (UNFPA), and the United Nations with whom we worked closely together. Joint Programme on AIDS (UNAIDS). We have

“No child will be born with HIV and no woman will die while giving birth.” His Excellency the President of the Republic of Namibia Dr Hifikepunye Pohamba

(Launch of Elimination of Mother-To-Child Transmission global initiative, United Nations Millennium Development Goals Summit, New York, September 2010)

14 3. PROMOTING DEVELOPMENT

15 Promoting health for development is top on the WHO agenda, in recognition of the fact that poverty contributes to poor health, and poor health anchors populations in poverty. In order to unlock this vicious cycle of poverty and poor health, more resources than ever are being invested in health globally, and Namibia is no exception. Key targets for improved health outcomes in this context have been the triple threat of HIV, TB and malaria; the health of mothers and children and more recently the emerging lifestyle diseases.

The Government of the Republic of Namibia (GRN) supporting the MOHSS in the prevention and is working towards Vision 2030, a national long- control of Communicable and non-communicable term strategy for development across all sectors. diseases, with special focus on HIV/AIDS and TB, and The overall goal is to attain “A prosperous and diseases like malaria and polio that are targeted for industrialized Namibia, developed by her human elimination/eradication and lifestyle diseases. We resources, enjoying peace, harmony and political have also made ‘improving maternal, newborn, child stability” by the year 2030. It is obvious that a and adolescent health’ a strategic priority. healthy population is both a contributor towards the attainment of this vision, as well as part of the vision Achievements in Combatting itself. The Government is also working relentlessly to achieve the health-related MDGs, namely Goals 4, Communicable Diseases 5 and 6: to reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria and other During the period under reporting, HIV/AIDS and diseases, respectively. TB continued to be the major killers of Namibians. Therefore, Namibia’s health partners were firmly WHO’s commitment to development is directed by focused on the emergency response to the dual the ethical principle of equal access to health for all epidemics of HIV/AIDS and TB. The prevalence of members of society. This means giving priority to HIV/AIDS and TB both remained extremely high at improved health outcomes for poor, disadvantaged 18.2% (2012) and 729 per 100,000 population (2011) or vulnerable groups, which is also aligned with but have been declining. Namibia’s goal of ensuring that “All the people of Namibia have equitable access to high quality and HIV affordable health care services” (Vision 2030). Declines in critical indicators for HIV are encouraging We have participated in consultations and provided and it is thought that the epidemic has now technical and strategic inputs for the implementation stabilized. Overall, prevalence rates dropped from of the third and development of the fourth national 22% in 2002 to 18.2% in 2012. Reductions in HIV development plans (NDP 3 and 4), which have prevalence among young people aged 15 to 24 years guided multi-sectoral strategies towards Vision 2030 are a source of optimism. According to the ANC in this reporting period. Both plans identify health Sentinel Survey, the overall HIV prevalence among (HIV, more specifically for the third) as being a crucial this age group was 10.3% in 2010, compared to 15.2% enabler for the attainment of the country’s long- in 2004. These gains are largely due to the increasing term vision. focus on prevention and treatment.

As articulated in our current Country Cooperation The 2013 spectrum modelling estimates the HIV Strategy (CCS), we remained committed to prevalence at 12.8% in 2013/14 amongst people aged

16 15 years and above. HIV incidence is estimated to have declined sharply until 2010 and levelling off since then. The number of new infections has been decreasing, although there is an increase in new infections amongst young women, who also bears a disproportionate burden, compared to men.

We have supported advocacy for behaviour change and innovative prevention strategies, such as provider-initiated testing and counselling (PITC) and medical Male Circumcision. Together with other partners, we helped organize the country’s first Male Conference on HIV/AIDS, which saw the participation of men from a cross-section of sectors and industries.

We contributed to the development of the HIV/AIDS National Strategic Framework (2010/11-2014/15) and related Monitoring and Evaluation Results Framework, facilitating stakeholder consultations, and participating in reviewing proposed strategies and interventions. Other support we provided for HIV interventions include the revision of the Adolescent Health The massive scale up of ART in 2009 called for Guidelines in the context of Young People Living regular surveillance and monitoring of HIV drug with HIV/AIDS and technical and financial assistance resistance (HIVDR). We have supported the to the Namibia National Network of AIDS Service MOHSS in its efforts to prevent drug resistance. Organizations (NANASO) to strengthen its These include a number of studies and training coordinating capacity. Along with other United programmes aimed at identifying Early Warning Nations (UN) agencies and partners, we supported Indicators (EWI) for drug resistance, and patterns the MOHSS in developing a Strategic Plan for the of treatment adherence among patients. Other key Elimination of Mother-To-Child Transmission of HIV partners in these processes have been Management (e-MTCT), which was launched on 12 December 2012 Sciences for Health (MSH) and the National Institute at the commemoration of World AIDS Day. WCO of Pathology (NIP). HIVDR surveys are now being staff members participate regularly in the Joint UN carried out at three sentinel sites: Katutura State Team on AIDS (UNAIDS), as well as various technical Hospital, Oshakati Hospital and Rundu Hospital. advisory committees (TACs), and the Namibia Coordination Committee on HIV/AIDS, Tuberculosis Other surveillance processes we have supported and Malaria (NaCCATuM). are the Integrated Biological and Behavioural Surveillance Survey (IBBSS), which gathers data on From an observer status in important strategic fora key population groups, and the national HIV/AIDS in 2007, WHO has successfully managed to become database. a full member of bodies such as the National AIDS Executive Committee (NAEC) and NaCCATuM. As Concerns have been raised about the cost- members of the NaCCATuM, we have made available effectiveness of procedures for the testing of technical assistance and participated in the proposal ART patients. In response to these concerns, we development process for successive rounds of Global are actively taking part in the work of the Adult Fund awards. By the end of 2012, Namibia received a Treatment Working Group (TWG) to conduct a total of US$189,357,126 from GFATM for the country’s review based on the current WHO guidelines. coordinated response to HIV, TB and malaria.

17 Tuberculosis to harmonize guidelines for managing TB cases in the two countries. Tuberculosis (TB) incidence, prevalence and mortality has been declining in Namibia, although WHO facilitated a workshop to strengthen the it is unlikely that the country will achieve the MDG implementation of GFATM performance grants in target of halving TB burden by 2015 compared to the Phase I in Harare, Zimbabwe, with participation 1990 levels. from 19 countries, including Namibia. Following the workshop, Namibia developed a plan to improve The number of TB cases notified in 2011 was 11,924 negotiations on conditions of the grant, and build (all forms), a significantly lower notification when national-level capacity to oversee regional- and compared to the 16,156 cases notified in 2004. There district-level activities. has been an average annual rate of 5% decline over the past five years. In 2012, consultants from WHO and CDC provided the NTLP with technical support to assess its Figure 5: Trends of WHO estimated TB prevalence surveillance, monitoring and evaluation system. The and incidence in Namibia, 1990–2011 partners also sponsored the participation of three MOHSS staff members in a six-week intensive TB 1600 training course in Nairobi, Kenya. 1410 1400 TB Incidence TB Prevalence 1200 1380 Malaria 1000 800 905 675 729 600 Between 2008 and 2011, the incidence of malaria 400 had been reduced from 45.9 to 6.7 per 1,000 379 200 population, based on information collected by

Cases per 100,000 population 0 the health information system. This constitutes a 1990 1995 2000 2005 2009 2010 2011 massive reduction, which bears testimony to the Source: WHO Tuberculosis Reports success of the National Vectorborne Disease Control Programme (NVDCP) and efforts undertaken by the Our support to the TB programme mainly consisted Government of Namibia in cooperation with various on the provision of technical assistance to address partners, including WHO. The achievements of the drug resistance, revision of the TB Treatment and programme put Namibia firmly on the possible path Control Guidelines and the National TB Control Policy from malaria control to pre-elimination by 2016 and (both published in 2009), the facilitation of mid-term elimination by 2020. reviews, and the development of the Strategic Plan for TB, 2010-2015. We have extended support to the NVDCP in various forms, including improvements or indoor residual In 2009, WHO led a joint external review of the spraying and a malaria programme review, which Namibia TB Control Programme was undertaken. The resulted in the development of a new strategic plan aim of the review was to assess implementation of for the period 2010-2016. Health workers received the first generation medium term plan and provide training on malaria database management and recommendations for the development of the Environmental Health Officers were trained in second generation strategic plan. vector control and planning. We have also facilitated the revision of the National Malaria Policy, which We contributed technical inputs to meetings of the is crucial for the development of the programme TB-Leprosy Steering Committee, a forum established guidelines for malaria case management and to provide guidance to the National TB and Leprosy surveillance. Programme (NTLP), and serves as a platform for information and experience sharing by MOHSS staff We also supported regional interventions and and partner organizations. cross-border activities, including the Initiative of the Group of Eight Elimination Countries (E-8) involved A regional cross-border meeting between Namibia in malaria control and elimination, which was and Angola in February 2012 was held to discuss inaugurated in Windhoek in 2009 and is led by the mutual concerns, with support from WHO. One of Honourable Minister of Health, Dr Richard N. Kamwi. the recommendations of the meeting was the need

18 Figure 6: Malaria burden in Namibia, 2001–2012 Polio

Outpatient Malaria cases A major accomplishment in 2008 was the 600,000 certification of Namibia as polio-free. This was 400,000 achieved through high quality surveillance standards. 200,000 # of cases – However, continued efforts are made to maintain 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 this status. As part of the strategies for polio OPD 521 439 418 559 396 319 102 119 81,2 22,3 14,4 3,16 eradication, we have provided extensive technical

Malaria admissions support and some financial assistance to the MOHSS to improve and strengthen polio surveillance and 60,000 conduct annual National Immunization Days (NIDs), 40,000 20,000 with special attention to collaborative planning and # of cases – independent monitoring. 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Admissions 41,6 23,9 20,2 36,0 23,3 27,6 4,24 4,90 1,86 1,50 984 50 These events have been enhanced by the support of Malaria related deaths the Rotary Club of Windhoek, UNICEF and CDC. Two rounds of NIDs were successfully implemented 2,000 1,500 each year, with an estimated coverage between 1,000 94-97%. The country has now moved to sub-national # of cases 500 NIDs in at-risk districts.

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Deaths 1,74 1,03 1,09 1,73 1,13 612 181 174 64 45 36 4 Acute Flaccid Paralysis (AFP) is the most common sign of acute polio, and is an indicator that is Source: MOHSS, National Vector Disease Control used for surveillance of polio transmission. In Programme Namibia we support polio surveillance and data management, and continue to provide technical and World Malaria Day (25 April) was given an especially financial support to the meetings of the National high profile in 2012, as it coincided with the WHO Polio Expert Committee (NPEC) and the National Director General’s (DG’s) visit to Namibia. The Certification Committee (NCC). We also offer day was commemorated under the global theme: technical support for the Stop Transmission of Polio ‘Sustain gains. Save lives. Invest in Malaria’, and was (STOP) programme, including repeat training for attended by government officials and partners from new surveillance officers. In this reporting period national and regional levels. we have trained about 120 health workers on the RED approach, and an additional 57 on Vaccine Some of the major challenges identified during Management. annual programme reviews include the shortage of human resources, lack of proper orientation of regional and district staff towards malaria elimination, and poor communication between the national and regional level.

Other Communicable Diseases Leprosy

Namibia is among the African countries that have achieved the global elimination target of a prevalence of less than one leprosy case per 10,000 inhabitants. Namibia recorded 39 cases of leprosy in 2011, of which three were new cases.

Members of the African Region Polio Certification Commission meet with former President Dr Sam Nujoma

19 Progress in Reducing Lifestyle Namibia is taking a number of measures to reduce Diseases the underlying causes of NCDs, including the passing of the Tobacco Products Control Act by Parliament As in other developing countries, diseases that are and development and implementation of school associated with unhealthy lifestyles, such as diabetes health programmes. and hypertension, are on the increase in Namibia. Strong political commitment to addressing this issue Resources for combating NCDs are limited in the has been shown at a high level. country, and information is still inadequate, so targeted actions have been slow. Nevertheless, we In 2011, His Excellency the President of the Republic have contributed to the progress the Government Dr Hifikepunye Pohamba participated at the High- of Namibia has made to pro-actively anticipate Level Meeting of the General Assembly on the and stem the rise of NCDs. This support includes Prevention and Control of Non-Communicable our participation in the Committee on NCDs and Diseases and called upon WHO and other the development of the NCDs Strategy, as well as development partners to support NCDs programmes training of health professionals and assistance in in Namibia. The President expressed his commitment NCDs surveillance. NCDs data collection is included and determination to fight the emerging epidemic in the 2013 Demographic and Health Survey (DHS+), of non-communicable diseases in the country. The and we have supported the MOHSS in defining and resolution and political declaration adopted at the selecting NCDs-related questions and biomarkers for summit acknowledge the developmental impact of inclusion in the survey. As part of our commitment these diseases, if not tackled through a whole-of- to establishing a database on NCDs, our country and government and whole-of-society effort. regional offices provided assistance to conduct a second STEP Survey on risk factors associated with Opportunities for Addressing NCDs: NCDs in 2009. The STEP II Survey showed that the risk of high blood pressure increases with age in • Joint Programme on Cancer Control 2009 both men and women, and that 31% of people with • National Tobacco Products Control Act 2010 high blood pressure was not on medication. • Mental Health Bill 2010 • Fourth National Development Plan 2012/3-2016/7 Tobacco • Demographic and Health Survey (DHS+) 2013 • STEP Surveys Smoking is also a critical risk factor for lifestyle • UNPAF 2014-2018 diseases. We have therefore put emphasis on raising • Study on MAMPA public awareness on the negative effects of smoking • Alcohol Policy development on health. We played a key role in the development of the National Tobacco Products Control Bill , which More than ever, the Government recognizes that was enacted in 2010, and supported the promotion collective action on the determinants of health of a tobacco free environment and commemoration requires the contribution of non-health sectors. of World No Tobacco Days. The MOHSS intends to share knowledge in order to sensitize non-health sectors on the key determinants We have supported and facilitated Namibia’s of health and suggest effective strategies to combat participation at various international health fora them, in line with recommendations from the World to enhance the capacity of the country to meet Conference on Social Determinants of Health in Rio its commitments regarding the WHO Framework de Janeiro, October 2011 and other WHO resolutions. Convention on Tobacco Control (FCTC). This includes the protection of tobacco control policies from We have made some progress in implementing tobacco industry interference. interventions intended to tackle NCDs: strengthen surveillance, monitoring and research to establish Cancer disease patterns and trends; influence policy formulation, legislation and support planning Cancer is another non-communicable disease for non-communicable diseases and conditions; receiving increased attention in Namibia. In 2009, promote healthy lifestyles and strengthen primary WHO and the International Atomic Energy Agency prevention. (IAEA) launched a Joint Programme on Cancer

20 Control in developing countries, and in 2010 Namibia together nearly 40 delegates working in mental benefited from a joint mission composed of experts health and social services, comprised of Non- from IAEA, WHO Namibia, and an expert in nuclear Governmental Organizations (NGOs), Faith-Based medicine. The mission carried out a comprehensive Organizations (FBOs), private psychologists and needs analysis of the country’s cancer control representatives from other line Ministries such as the capacity and made recommendations relating to the Ministry of Labour. The outcome of the workshop coordination of NCDs activities and capacity building was the establishment of a Mental Health Action under the MOHSS Directorate of Atomic Energy and Forum and an agreement on the development of a Radiation Protection. multisectoral roadmap for scaling up mental health interventions. Following the workshop, a survey Cervical cancer is one of the most frequent cancers on the status of mental health in the country was among women. The MOHSS is determined to use conducted and a manual to educate health and social modern technology to improve and promote early workers about mental health was also developed. diagnosis and treatment. A situation analysis is being planned with support from WHO, with the aim of Road Safety developing a strategy for prevention and control. A major International Cervical and Breast Cancer Road accidents are one of the major causes of death Conference to be hosted by Namibia is planned for in Namibia. The average number of motor vehicle 2014, under the auspices of the First Lady of the accidents between 2009 and 2012 were 2,553, with Republic. WHO is an active member of the Task Force an average of 500 fatalities per year. It is reported preparing the Conference. that on a daily basis approximately two people lose their lives in a road accident. Alcohol Figure 7: Motor Vehicle Accidents in Namibia To address the growing problem of alcohol consumption in Namibia, a three days stakeholders’ Crashes 2009–2012 workshop was held in 2010 to review the draft Alcohol Policy. We played a technical and advisory role, and advocated for the adoption of measures to reduce the harmful use of alcohol in the country. The policy includes measures such as pricing, drunk- 1965 2689 2868 2689 driving policies, limiting advertising, age restrictions and limiting the availability of alcoholic beverages. 2009 2010 2011 2012 These measures are in line with WHO’s Global Strategy for reducing the harmful use of alcohol. Injuries 2009–2012 With support from WHO Regional Office for Africa (AFRO) and the Dutch Institute for Alcohol Policy (STAP), the WCO and the MOHSS provided technical assistance towards the implementation of the multicentric Study on Monitoring Alcohol 3538 5125 5659 4670 Marketing Practices in Africa (MAMPA), which was spearheaded by Blue Cross Namibia. The study aimed 2009 2010 2011 2012 to provide insight into the content, scale and impact of alcohol advertising in the participating countries. Fatalities 2009–2012

Mental Health

In order to address the many challenges in the area of mental health in Namibia, we assisted in the 525 539 492 470 development of a new Mental Health Bill in 2010 to enable effective implementation of the Mental 2009 2010 2011 2012 Health Policy. We also supported the MOHSS in hosting a stakeholder consultation, which brought Source: Motor Vehicle and Accident Fund

21 In addition to supporting for the development of this strategy document, we supported the development and production of promotional materials on the 5th Pillar (Post-Crash Response). The materials were used at the launch of the Emergency Medical Rescue Services Day that took place in 2012. Other tools launched on this day were the Medical Rescue Services Policy and Strategic Plan. Putting the Health of Mothers and Children First Why Are They Dying?

Maternal and child mortality trends have been a cause for concern and points towards the unlikelihood WHO provided support to the Government through of Namibia attaining MDGs 4 and 5 (Reduce Child the National Road Safety Council (NRSC) for the Mortality and Improve Maternal Health). Maternal adoption of the Global Plan of Action for Road mortality had almost doubled between the NDHS in Safety 2011-2020. The Global Plan provides an overall 2000 and 2006-07, despite very high rates of delivery framework for activities, grouped into five pillars: in health facilities and high ANC attendance. These findings called into question the quality of services 1. Building Road Safety Management Capacity provided. A review of EmOC services in 2005 revealed 2. Improving the Safety of Road Infrastructure and inadequate staff skills and equipment. At the same Broader Transport Networks time, spending on maternal, newborn, child and 3. Further Developing the Safety of Vehicles adolescent health (MNCAH) was declining. 4. Enhancing the Behaviour of Road Users 5. Improving Post-Crash Care Raising the profile of maternal and child health and mobilization of additional resources for this The WCO in collaboration with the NRSC, the important area have therefore been a priority for Motor Vehicle Accident Fund (MVA) and other WHO in Namibia with our key strategies being to stakeholders developed the Namibian Chapter of enhance the quality of focused antenatal care and the Decade of Action 2011-2020. The Namibia Postal promote the availability of emergency obstetric care Services (NamPost) launched a special stamp to services. commemorate this milestone. We supported the Landscape Analysis to Accelerate The Decade of Action for Road Safety 2011-2020 Actions to Improve Maternal and Child Nutrition in was launched in Namibia and globally in May 2011. Namibia, and the development of a child survival The plan calls for a collective and synergistic effort strategy. between governments, private sector, civil society, international agencies and other stakeholders, Planning for Success: the Road Map including road users, to curb the toll of death and disability caused by road traffic accidents. As with most public health issues, overcoming the obstacles to improved maternal and child health Namibia’s Road Safety Strategy focuses on requires a coordinated approach. In order to education and enforcement. The overall aim of facilitate this, we joined other partners in supporting the education component is to change mind-sets, the development of a Roadmap for Accelerating the attitudes and behaviours to create a deep-rooted Reduction of Maternal and Newborn Morbidity and culture of road safety among all road users. Another Mortality using the generic WHO roadmap template. pillar relates to enforcing compliance to legislation, regulations and standards in order to ensure To accelerate implementation of the Roadmap, behaviour change and prevent road traffic crashes which was launched in 2010, a resource mobilization and deaths. and advocacy toolkit was developed. Also, a national

22 Maternal, Perinatal and Neonatal Death Review maternal and child health. These efforts resulted in (MPNDR) Committee was set up to oversee the the EU award of 10 million Euros for implementing documentation of maternal and perinatal deaths the four years Programme for Accelerated Reduction and identify best practices to be shared, as well as of Maternal and Child Mortality (PARMaCM). These challenges and constraints to be addressed. We funds have been channelled through a Contribution supported the MPNDR Committee in developing Agreement with WHO. a medium-term plan to improve the quality of maternal and perineonatal health services as part EU awards Namibia 10 million of the response to the gaps identified during the 2012 review. This was followed by the development Euros for the Programme for of quick reference materials for managing major Accelerated Reduction of Maternal obstetric and neonatal complications, based on the WHO Integrated Management of Pregnancy and and Child Mortality (PARMaCM) Childbirth (IMPAC) documents. Building Skills Two major events in the 2009 health calendar made significant steps forward on the road to improved The scarcity of relevant skills among health staff, health for women and children. They were the is a critical obstacle to improved care for mothers launch of the Campaign to Accelerate the Reduction and children. This is why the CCS identified the of Maternal Mortality in Africa (CARMMA), with ‘strengthening of capacity to provide quality and patronage from the First Lady of the Republic of equitable emergency obstetric and newborn care Namibia, and the National Conference on Maternal services’ as a key strategy. We have supported and Child Health, both supported by WHO and other the training of health workers in Life Saving Skills, partners. These processes provided insights on Emergency Obstetric and Newborn Care (LSS/ how to address some of the most critical challenges EmONC). A total of 176 health workers were trained and offered the opportunity to establish strategic between 2009 and 2012. partnerships. The aim of the training was to facilitate the delivery Other ways in which we have provided support to of quality services to rural and disadvantaged the MOHSS in the area of maternal, newborn and women and newborns. MOHSS staff members have child health include assistance in the development been certified as trainers in LSS and have begun and revision of policies, norms, standards and job training independently. aids, in particular the guidelines on the Integrated Management of Adolescent and Adult Illnesses (IMAI) and associated community-training package and monitoring tools. Ten IMNCI facilitators have been oriented on the newly adapted IMNCI tools and guidelines, and they have subsequently trained 26 health workers on updated IMNCI case management.

The MOHSS appointed the First Lady of the Republic of Namibia as the Patron of Maternal and Child Health Agenda, to intensify advocacy and awareness creation towards improved maternal and child health.

Mobilizing Resources

In collaboration with other UN Agencies, the National Planning Commission and the MOHSS, high level meetings were held with partners and the PARMaCM, a partnership between the MOHSS, the EU diplomatic community, to advocate for support for and WHO

23 guidelines for the Syndromic Management of STIs and the Health Promoting School Initiative. In 2012, we contributed to the finalization of the draft 176 health workers trained in Sexual, Reproductive and Child Health Policy, and the Life Saving Skills, Emergency preparation of the 5th Africa Sexual, Reproductive Health and Rights Conference. At this conference, we Obstetric and Newborn Care presented a paper on ‘Socio-economic priorities and political leadership for sexual, reproductive health In addition, we continue to advocate for the and rights (SRHR) in Africa’ and moderated one of the allocation of adequate human and financial plenary sessions. We sponsored six members of the resources to maternal, newborn, child and Namibian Women’s Health Network, an NGO working adolescent health and nutrition services, as well as in the areas of sexual and reproductive health, to for increased scope of work of nurses and midwives attend the conference. This is expected to enhance for them to be able to manage EmONC. their capacity to deliver quality SRH services to their members and the community they are serving, Improving Access to Health Care and also to position SRH from the human rights perspective. One of the reasons why many women have been unable to access EmONC has been the lack of Immunizing Every Child affordable accommodation near health facilities, especially in rural areas. The need for maternity Immunization against major vaccine-preventable waiting homes was confirmed by an assessment diseases is a key element in the management of infant conducted by the MOHSS with support from various and child health in Namibia. We have been supporting partners including WHO. As a result, PARMaCM child immunization in Namibia through technical will support the construction and/or renovation of support and training. In 2012 we assisted in the four maternity waiting homes to facilitate access to finalization of the revised Expanded Programme on services for pregnant women and their newborns. Immunization (EPI) guidelines, which include effective strategies for new and underutilized vaccines. Four additional maternity waiting homes to be built in Namibia For measles control, we have been working with the NIP measles laboratory by providing technical Sexual and Reproductive Health support, equipment and reagents required for diagnosis of the disease and maintenance of It has been agreed that family planning must be accreditation standards. repositioned as a strategy to improve maternal health and ensure child survival in Namibia. Our In 2012, we supported a cross-border response to focus areas for support in this area included the the measles outbreak in the Engela district of the integration of reproductive health into HIV/AIDS, Ohangwena region and in the Angolan villages along and adolescent health interventions (CCS 2010-2015). the common border. As part of this process, we have supported the Namibian Planned Parenthood Association (NAPPA) In 2010 we provided support for an external review in developing IEC materials for young pregnant of the EPI, which was conducted with a view to woman on issues of family planning, HIV/AIDS and improving service delivery. We also contributed PMTCT. In addition we have contributed to the to inter-country meetings hosted by Namibia revision of the family planning training curriculum for to develop a comprehensive multi-year plan for Namibia, as well as the training of health workers on EPI, to boost the country’s efforts to effectively the new curriculum. implement quality routine immunization and surveillance activities at all levels. As a result, routine Another way in which we have assisted in the area immunization achieved national coverage of 83% in of sexual and reproductive health (SRH) has been 2010 and 95% in 2011. through funding and technical support for a study on the causes of Sexually Transmitted Infections We regularly provided technical and financial support (STIs); and support for the revision of the national to the MOHSS Epidemiology Division for conducting

24 EPI surveillance support visits to the regions and as an essential part of protecting, promoting and districts, at least twice a year. supporting breastfeeding. We have advocated Also in 2012 the WCO, with technical and financial strongly for messages on breastfeeding to be support from the WHO Inter-country Team for aligned to WHO’s revised PMTCT guidelines and East and Southern Africa (IST/ESA), supported the enhance the existing campaign on PMTCT and male MOHSS in conducting a Post-Measles Vaccination involvement, launched and led by the First Lady, with Campaign Coverage Survey among children aged support from the President of the Republic. 9-59 months, and a routine coverage survey among children aged 9-23 months. As part of our efforts to support the standardization of growth monitoring, we provided the MOHSS As a result of our role in continuous advocacy for with 80 copies of the new WHO growth standard immunization, two new vaccines – Pentavalent and training materials, age calculators and other training Hepatitis B – were introduced during the period materials. under review and two other vaccines against rotavirus and pneumococcal pneumonia are on the We also participate in the technical committee to verge of being introduced. advise and coordinate de-worming of school-age children, which was introduced in the second round We supported a rotavirus and paediatric bacterial of NIDs in 2012. De-worming is a way of achieving meningitis (PBM) mission to provide technical quick gains towards improved physical growth and support to the MOHSS and the NIP. Namibia cognitive development among children. is keen to be part of the rotavirus surveillance network and has the necessary infrastructure with Other nutrition activities that we have participated a well-equipped laboratory and highly competent in include the training of 22 health workers in personnel. the management of severe malnutrition in 2012, with support, funding and collaboration from the With the support of WHO and other partners, the FANTA-3/USAID project. MOHSS has procured doses of oral polio vaccine (OPV) and measles vaccine, and vitamin A capsules As part of strengthening coordination mechanisms and de-worming tablets, and distributed cold chain for IMNCH and nutrition, a Steering and equipment. The WHO guidelines for vitamin A management committee led by the Deputy supplementation were used to inform the review of Permanent Secretary was established by the MOHSS. Namibia’s guidelines. WHO is a member of the committee, which meets on a quarterly basis. A technical committee led by the Nutrition Director of Primary Health Care (PHC) and co-chaired by WHO and UNICEF meets on a monthly basis. Malnutrition continues to be a major underlying cause of death in the under-five age group, given the high levels of stunting and other forms of malnutrition reported.

In response to the crisis in child nutrition, the Government established the Namibia Alliance for Improved Nutrition (NAFIN). NAFIN brings together a wide range of stakeholders to galvanize and coordinate multi-sectoral support for nutrition programmes. WHO supports NAFIN meeting and activities.

We provided technical, media, and logistical support to the MoHSS for World Breastfeeding Week (WBW) celebrations, particularly in August 2011, under the Patronage of the Firs Lady of the Republic of In 2012, HE Mrs Graça Machel launched the Nutrition Namibia. The event focused on communication Landscape Analysis Summary Report in Parliament

25 4. Fostering Health Security

26 Health security is a shared responsibility demanding collective action between and within Governments, the private sector, civil society, media and communities, with the aim of preserving and protecting the health of the people. Health security can be threatened by epidemics, natural disasters, bioterrorism or emerging diseases. In the globalized world where we live today, the spread of diseases has been accelerated by travel and trade in goods and services between countries and continents. The Namibian Government is committed to reducing the vulnerability of its population to new, acute of rapidly spreading risks to their health, including those that threaten to cross international borders.

Ensure prompt and effective response to disasters’ • Surveillance, data collection and analysis is an objective in the Ministry of Health’s Strategic • Laboratory diagnosis Plan 2009-2013. Namibia has recently experienced • Training healthcare workers and Red Cross a number of emergencies related to climate volunteers change and environmental safety. These include droughts, floods and disease outbreaks. In keeping Are We Ready for Emergencies? with our mandate, we offered prompt technical and financial support to combat the outbreaks, Severe floods in 2008/09 and 2010 and one of the prevent further spread, and restore the health of worst droughts in 2013 are clear evidence that affected populations, as well to prevent the negative Namibia is increasingly prone to natural disasters. consequences of floods and drought. These events have underlined the need for better preparedness, WHO has played a key role in providing a wide range planning and coordination across a range of sectors, of technical support to the MOHSS to help prepare and the importance of attending to environmental for and respond to these natural disasters. This health as a preventative measure. support ranged from providing a rapid assessment of the affected regions to technical support for Helping the MOHSS to reduce the risk of surveillance, data collection and analysis, as well emergencies and disasters, included: as laboratory diagnosis. In addition, we deployed experts in the fields of epidemiology, disease • Supported updating guidelines on Integrated prevention and control, nutrition, public health, and Disease Surveillance and Response health emergency. In an effort to strengthen local • Adoption of International Health Regulations capacity, we held training sessions for healthcare (2005) workers and Red Cross volunteers to facilitate • Rapid assessment of flood-affected regions surveillance and reporting and the dissemination of • Flood action plan review and development health education messages, including the promotion • Review of contingency plans and simulation of sanitation measures and the prevention of • National Health Emergency Management diseases such as malaria, and diarrhoea. We also Committee meetings trained healthcare workers in managing the

27 outbreak of cholera in the Kunene region in 2008. Plan and Simulation exercise for the six flood-prone Another area of assistance was the procurement and regions. This activity assisted the regions in being distribution of medical supplies, including emergency better prepared to provide timely and effective health kits, medical supplies for diarrhoeal diseases, response to potential health hazards, especially water testing kits, malaria rapid diagnostic kits and disease outbreaks and other flood-related health insecticide-treated nets. These supplies were handed risks. over to the MOHSS ahead of the rainy season to equip the Ministry with the necessary capacity for Preventing Disease Outbreaks emergency preparedness and response. The country has registered a number of disease As part of our efforts during the period under outbreaks, such as cholera, measles, Influenza H1N1 review, we were able to mobilize funds from various (2009) and meningitis, during the period under partners and governments, such as the Government review. WHO has promptly provided technical of Finland, which disbursed 200,000 Euros, and the and material support to contain the outbreaks, in Central Emergency Response Fund (CERF), which collaboration with other partners, namely CDC, provided US$806,721. UNICEF and the Red Cross.

The purpose of the revised International Health Regulations (IHR) (2005) which came into force in 2007 is “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health”.

Unlike the 1969 IHR, which initially covered six quarantinable diseases, the IHR (2005) address all events that may constitute public health emergencies of international concern, and are binding to all WHO member states. Namibia has committed to implement these regulations in the context of Integrated Disease Surveillance and Response.

The Regulations stipulate that by the year 2012 all With support received from WHO and other UN member states are expected to have developed agencies, the Government of Namibia started the the minimum core public health capacities required development of the National Flood Preparedness, for the implementation of the regulations. Response and Mitigation Action Plan for the Unfortunately, Namibia and other member states did six flood-prone northern regions of Omusati, not achieve this milestone. Ohangwena, Oshana, Oshikoto, Kavango and Caprivi in 2009. Following these efforts, the National At a regional IHR (2005) stakeholders meeting held Disaster Risk Management Plan and Emergency in Lusaka, Zambia, these member states were urged Management Operational Procedures Manual were to fast track the implementation of the IHR (2005) launched in 2011. core capabilities, address identified gaps, and submit an implementation plan describing how they will In 2012, we collaborated with other UN agencies meet the requirements. and the MOHSS to update the Regional Contingency

28 Our main strategies for supporting the Ministry in this regard, as laid out in our current CCS, are to build core capacity for IHR (2005) requirements, and harmonize IDSR framework with IHR (2005). Despite not meeting the IHR (2005) milestone in 2012, it must be noted that substantial efforts have been made during the past five years, to strengthen Namibia’s capability to comply with the Regulations. These efforts consisted of, among others:

1. Sensitization workshops for regional and national staff members 2. Assessment of core public health capabilities in Karas, Erongo and Ohangwena 3. Development of an Action Plan to strengthen core capabilities to implement IHR (2005) 4. Inter-Country Meeting on Cross-Border Public Occupational Health and Safety Health Issues, between Angola, Congo, DRC, Namibia and Zambia In 2005, Namibia launched the Occupational Health 5. Revision and updating of Integrated Disease and Safety Policy. We supported the revision of the Surveillance and Response Framework, Guidelines National Health Policy 2010-2020, which also contains and Training modules to align with IHR (2005) updated strategies in the area of occupational 6. Strengthening Surveillance of Preventable health and safety and the training of public sector Diseases nurses from all 13 regions on occupational health and 7. Five-Year Strategic Plan for the Implementation medicine. of IHR (2005) and Revision of National Health Emergency Management Structures 8. Capacity development initiatives Water and Sanitation 9. Provision of guidelines and booklets on IHR (2005) and guidance for identifying A major obstacle to environmental health is the IHR National Focal Points inconsistent coverage of safe water and sanitation across the regions. In 2012, the Ministry of Climate Change and Public Health Agriculture, Water and Forestry hosted a Water Adaptation Investment Conference. The conference aimed at addressing the increasing demand and pressure The MOHSS, Ministry of Environment, City of on the country’s water resources and sanitation Windhoek and WCO held a consultative meeting facilities, opportunities to tackle the skill shortage on the draft Health Sector Plan of Action for Public in the water and sanitation sector, and the need to Health Adaptation to Climate Change in 2012. embark on research, development and innovation. Subsequently Namibia hosted an inter-country The CCS commits to complement the efforts of workshop to prepare national action plans for public the MOHSS and other partners by enhancing their health adaptation to climate change in Africa, with capacity to monitor the quality of drinking water the participation of 10 countries. The workshop and sanitation. It also pledges to collaborate with aimed at contributing to the identification and the Ministry of Education on implementing school management of public health risks related to climate initiatives on hygiene. change on a country-specific basis.

29 Getting the Message Across major milestone was achieved with the enactment of the Tobacco Products Control Act (Act No. 1 of 2010), One of the key findings of the Health and Social passed by Parliament and signed into law by H.E. the Services Review 2008 was the lack of a national President of the Republic of Namibia in 2010. strategy for health promotion and behaviour change communication and inadequate capacity to support Health Days interventions at national, regional and district levels. It was noted that there is no standardized training Apart from providing technical and programmatic and information, education and communication (IEC) support to the MOHSS in the area of health materials on various essential health issues, including promotion, we assisted with the commemoration of road accidents and non-communicable diseases. In major health days and weeks such as World Health addition, there is inadequate coordination of health Day, World AIDS Day, World Tuberculosis Day, promotion activities, which are undertaken by a World Blood Donor Day, World Breastfeeding Week, number of separate programmes. Healthy Lifestyles Day, World Oral Day, International Nurses Day, World Diabetes Day, and many more. WHO’s support for Health Promotion is guided by As a result of the efforts made, these days and three strategies in the current CCS: the concerns they raise are increasingly receiving national attention and recognition. • Advocate for multi-sectoral involvement in promoting healthy lifestyles Health Promoting Schools Initiative • Promote communities’ and individuals’ responsibility for own health Since the approval of a regional strategy for health • Disseminate information, evidence and best promotion by Ministers of Health in 2001, Namibia practices and advocate for action on social has been implementing the Health Promoting determinants of health Schools Initiative (HPSI), and remarkable progress has been made in some regions. While the National National Policy on Health Promotion Policy on School Health is predominantly based on the HPSI approach, the implementation of the In 2012, we supported the development of the Policy has been uncoordinated, with little support National Policy on Health Promotion. The Policy and guidance. In 2012, we provided technical outlines various strategies for reducing risk factors support at a national workshop on school health while improving health services to address the promotion. As a result, staff of the school health situation. The Policy calls for a whole-of-government programme was re-oriented and service providers approach, which is fundamental to addressing the were introduced to the HPSI in the regions. In crosscutting issues and underlying socio-economic addition, the guidelines for HPSI implementation determinants of health, such as the regulatory and related tools were revised. environment around alcohol and tobacco. Another

30 5. STRENGTHENING HEALTH SYSTEMS

31 Namibia can certainly be called ‘a country of contrasts’, not only in terms of its natural environment, but also in terms of its socio- economic make-up. Despite the country’s economic ranking as an upper middle-income country, the healthcare system still battles with challenges mainly derived from its colonial past. As a consequence, there is striking inequality in access to quality healthcare across the wealth spectrum. The Government is committed to eliminate this inbalance and achieve health for all. For health improvement to operate as a poverty-reduction strategy, health services must reach poor and underserved populations.

It will be impossible to achieve national and Governance international goals – including the MDGs – without greater and more effective investment in health Health and Social Services Review systems and services. While Namibia has made demonstrable progress in making health services Along with other partners, we provided support to accessible, affordable and equitable, there are the MOHSS for the execution of the 2008 Health and still considerable challenges in improving the Social Systems Review. The report on this exercise, quality, effectiveness and efficiency of service which was launched in 2009, carefully articulates the delivery. Disease-oriented approaches have fuelled state of affairs of the Namibian healthcare system. fragmentation and over-burdening of health The Review played a crucial role in shaping the way workers, and left behind critical high-priority forward for all actors in the health system, such as issues that did not receive adequate funding or ministries, civil society, the private sector and the attention. Vertical systems for disease control may donor community. have contributed to weakening the health system rather than strengthening it. In this section our The information obtained from the Review served major contributions are outlined along the ‘six to inform the MOHSS’s strategic planning process. health systems building blocks’ contained in the It presented a host of recommendations, some of WHO Health Systems Strengthening Framework: (1) which have already been implemented. We have Governance, (2) Human Resources Development, been able to provide technical and financial support (3) Health Financing, (4) Health Information Systems for the implementation of a number of the identified (HIS), (5) Service Delivery, and (6) Medical Products, priorities. Vaccines and Technologies.

32 MOHSS Strategic Plan 2009-2013 Aligning Approaches

Following the HSSR, the Ministry developed and In line with the strategic objective of the Ministry, we launched its Strategic Plan for 2009-2013. We included in the second CCS a key strategy: “Facilitate assisted with the development of the plan, which the use of evidence to improve the existing or prioritizes the following strategic areas: Service needed norms, standards, policies, legislation, Provision, Human Resources Management, frameworks and guidelines in accordance with the Infrastructure Development and Management, and Primary Health Care Strategy and approach, and Governance and Financial Management. In order to which are human rights based, gender responsive operationalize the plan, Directorates and Regional and equity oriented”. Consequently, a number of Management Teams (RMTs) were tasked to compile important policies, guidelines, legislative instruments management plans and score cards. and frameworks were either reviewed or developed during this period. These include the repeal of WCO Country Cooperation Strategy discriminatory clauses under the Immigration Law 2010-2015 and the drafting of the Human Tissues Act, the development of National Health Policy Framework In 2010, we launched our second Country 2010-2020, the Blood Transfusion Bill, the Policy on Cooperation Strategy, which informs our operations Male Circumcision for HIV Prevention, the National in Namibia for the period 2010-2015. The CCS was Policy on Health Promotion, and the National developed in close collaboration with the MOHSS Guidelines for Antiretroviral Therapy. The launch and partners, and is inspired by the priorities of of these instruments was often accompanied by the MOHSS Strategic Plan, among other national, capacity building, which we supported along with WHO and UN planning documents. Health Systems other partners. Strengthening is the foundation for the other four pillars of the Strategy (Combating Priority Diseases; Restructuring the MOHSS Improving Maternal, Newborn, Child and Adolescent Health, and Promoting a Safer and Healthier Another major activity that flowed from the HSSR, Environment). and which was prioritized in the Ministry’s Strategic Plan, was the need for the restructuring of the MOHSS. The findings and recommendations of the review triggered a renewed commitment towards the process of restructuring the health sector. The complexities and challenges in the health system have grown over the years, and have revealed that the structure has not been responsive to changing demands. The restructuring exercise has been extremely slow and it is still not completed. It is expected to contribute to eliminate duplications, reduce fragmentation, strengthen accountability, foster integration of services, and improve coordination and collaboration among programmes and services.

33 The exercise is being geared towards: have not only contributed to improving the planning and management of programmes and services, 1. Reviewing the existing organogram at various but have also strengthened the collaboration and levels, and clarifying linkages and reporting lines communication amongst actors in the health sector. 2. Clarifying functions and responsibilities of the However, there is a need to improve on the nature various departments, directorates and divisions and quality of such consultations. 3. Clarifying governance and service delivery mechanisms at the various levels In between the above mentioned meetings, there 4. Promoting a culture of accountability, and is no regular platform for information sharing, efficient and effective service delivery consultations and partners’ policy advice to the MOHSS. This dialogue takes place on a bilateral basis, WHO, UNICEF, and USAID have been key partners at the partner or MOHSS’s initiative and does not assisting the Ministry in the restructuring process. facilitate coordination of partner’s efforts in support We assigned a consultant to facilitate stakeholder to the Ministry. WHO supported a situation analysis consultations, review the MOHSS’s structure in of the health partner’s coordination environment in light of new policy and strategic orientations, and Namibia, with a view of informing the establishment propose a streamlined structure and functions that of a mechanism for regular information sharing and will guide the operations of the MOHSS. coordination. This process is still not completed and is further explained in the next chapter.

Strengthening the Coordinating Role of To mitigate the poor circulation and sharing of the MOHSS information as well as coordination of partners’ activities, WHO has established a “Health The 2008 HSSR found that there was a lack of Development Partners Group”, a monthly gathering overarching coordination of the various partners where health partners share information on their involved in the health sector. We have therefore activities and coordinate their support to the prioritized support towards strengthening the Ministry. Ministry’s stewardship role and policy dialogue with multiple stakeholders within and across sectors, Human Resources - Developing the including the private sector. The hosting of the Health Workforce Enlarged Ministerial Meeting, under the leadership of the Honourable Minister of Health and Social One of the major challenges Namibia has had to Services, is a tradition amongst the key actors in deal with since its independence in 1990 has been the health sector. The purpose of these meetings is the general shortage of healthcare workers, who to bring together all national, regional and district are essential for the provision of services. The 2008 senior staff and all key stakeholders in the health HSSR states that although Namibia’s health worker sector in order to: take stock of progress made capacity is 3 health workers per 1,000 population, during the year; identify challenges and propose which is above the recommended WHO standard solutions to address them; and, most importantly, of 2.5 per 1,000 people, there is a large disparity chart the way for the new fiscal year, following amongst the number of healthcare workers in the directives from the Minister of Health and Social public and private health sectors. In addition, the Services. We have always participated in these geographical distribution and reach of healthcare meetings, provided inputs into the topics reviewed, services has been a major problem. and extended insights about relevant regional and international initiatives and best practices in the area Producing Health Workers of health systems strengthening and beyond. Limited healthcare education exacerbated the Similarly, Primary Health Care Review and Planning challenges posed by the shortage of healthcare meetings between the MOHSS, UN agencies and professionals. For a long time after independence, other partners are held on an annual basis. At the only institution in the country responsible these meetings, the stakeholders undergo a review for the training of health professionals were the of agreed priorities and areas of support for the University of Namibia (UNAM) School of Nursing, previous and upcoming year. Meetings of this kind the Polytechnic of Namibia and the Ministry’s Health

34 Training Network. These institutions offered limited of human resources supported by donors, and qualifications, such as diplomas in Nursing, Social advises the Ministry on the smooth transitioning Work and Radiography. For other health-related of such staff to the MOHSS in order to ensure professionals, such as doctors, pharmacists, dentists, continuity of services. This process was required Namibia depended on training offered outside the as a result of the withdrawal of human resources country. budget by PEPFAR, and to some extent GFATM and other partners. The HRH Situation Analysis Over the years, various efforts have been made to involved comprehensive research to help provide a address the general shortage of healthcare workers complete picture of the health workforce situation in and professionals, in particular in the public health Namibia, support communications with and between sector. These efforts have not yet produced the policymakers and stakeholders, and facilitate cross- desired results but good progress has been made country comparisons. and is still underway. One positive step in the right direction was the establishment of the Namibia WHO has also provided support towards a School of Medicine in 2010. We were involved at national workforce situation analysis in view of the the start of discussions, and in collaboration with development of a Human Resources Policy and other partners played a key role in facilitating the Strategic Plan. These documents are available in a feasibility study, development of business plans and draft form and waiting stakeholder’s consultation recruitment of staff. before their finalization. The Human Resources Policy and Strategic Plan will help to ensure Planning the Workforce availability of sufficient health workers according to the country’s rising health needs. As a member of the Human Resources for Health (HRH) working group, under the Directorate of Building Capacity Special Programmes in the MOHSS, we are providing assistance and guidance to the Ministry to ensure We have played a key role in strengthening the that the absorption of staff (essentially in the area capacity of healthcare workers in Namibia, to of HIV/AIDS) previously employed by other partners ensure that they are kept up-to-date in their fields is guided by the Ministry’s long-term HRH plan. The of operation. A range of capacity development committee reviews the composition and distribution activities has been held in the form of short to

35 medium term training courses for MOHSS staff Keeping Track of Spending either in the country or elsewhere. These courses have focussed on critical areas of health care such The NHA analyzes national spending on health as disease prevention and control, maternal and in a country. They are an important tool that child health, surveillance, monitoring and evaluation, provides evidence on resource allocation and health health systems strengthening, HIV/AIDS, Tuberculosis, expenditure trends, and assist national authorities Malaria, Mental Health, Health Promotion and Health in planning, allocation and disbursement of financial Emergencies. A total of about 300 national staff resources in support to public health policies. benefited from capacity building activities outside Namibia in a form of short courses, workshops and In collaboration with other partners such as UNAIDS meetings, between 2009 and 2013. Similarly, several and USAID, we assisted the MOHSS in producing WHO experts have visited Namibia to provide the second (2001/02-2006/07) and third (2007/08- technical support in the various areas mentioned 2008/09) NHA. The third round was unique as for above. Between 2009 and 2013, a total of 221 missions the first time it included not only the NHA but also to Namibia were undertaken by WHO experts. the AIDS Resource Tracking Report (National AIDS Spending Assessment/NASA) and estimates of Health Financing – Ensuring subaccounts for Reproductive Health. Our support Sufficient Resources included training the core team members, data collection activities across the country, structuring In 2011 the 4th Joint Annual meeting of the African and analysis of the results and report writing. We Union (AU) Conference of Ministers of Economy also assisted with a National Health Accounts and Finance was held in Ethiopia. We facilitated sensitization workshop and financial resources for participation of senior MOHSS representatives and senior Ministry staff to attend the National Health decision-makers at the meeting, which reviewed Accounts Symposium in China in 2009. amongst others the progress AU countries had made towards the attainment of the Abuja target: National Health Insurance to allocate at least 15% of national budgets to the health sector. The WHO report on this conference We were able to provide further support to entitled ‘Ten Years On’, outlines the progress made the MOHSS in the inception phase of strategic by each country towards the target, and reveals that reflections on the National Health Insurance. The Namibia is making good progress compared to other National Social Security Commission (SSC), which Southern African Customs Union (SACU) countries. is mandated by the Social Security Act 34 of 1994, For the financial year 2012/2013, 11.2% of the national organized a stakeholder’s workshop aimed at budget has been allocated to health, placing Health exploring health insurance models and alternatives in the second position after Education. that could be suitable for Namibia. At the meeting, the experiences of other countries in this area, In the area of health financing, our current CCS sets such as Ethiopia, Ghana, Nigeria and South Africa out the following strategies: strengthen equitable, were shared and discussed. We took part in this evidence and results‐based resource allocation; USAID-supported workshop and provided financial promote sustainable financing and social protection support to the operationalization of the Namibia policies towards ensuring universal access to health National Health Insurance and Finance Technical care; institutionalize the National Health Accounts Advisory Committee, which will serve as an advisory (NHA); strengthen the capacity for domestic and committee to the SSC Board on issues related to the external resource mobilization. We have made good development of a National Health Insurance Scheme progress towards these commitments. in Namibia.

36 Tackling Poverty time was out-dated, inaccurate and not useful for adequate and timely health monitoring. We provided Another area in which we were able to support experts to perform a comprehensive review of the the MOHSS, this time in partnership with the available health indicators matrix, which included Government of Luxemburg, was the Health Poverty consultations with Ministry officials at national and Reduction and Economic Development Project. regional level, and other key stakeholders. Findings This three-year collaborative project focussed of the review revealed a host of weaknesses on the development of pro-health policies to in the system. The exercise also led to several reduce the financial barriers to health services, the improvements including the development of new reinforcement of donor coordination by the MOHSS indicators, definition of mechanisms and frequency and the National Planning Commission Secretariat for gathering and reporting of data. More clearly (NPCS), and the institutionalization of resource defined roles and responsibilities across the various tracking exercises. programmes at district, regional and national levels were also set out. Health Information – Taking Stock New Approach to Monitoring the Nation’s of Health Trends Health – the NDHS+ Health Information System We have supported the preparations for conducting the National Demographic and Health Survey Plus Over the years the MOHSS has shown greater (NDHS+), which will gather and analyse information appreciation and interest for the management of on key health indicators. This NDHS will, for the strategic health information. Some evidence of this first time in Namibia’s history, contain an HIV/AIDS is the recent review and upgrade of the Ministry’s household survey, collect data on NCDs risk factors Health Information System (HIS) and the ongoing and anemia. discussions around the restructuring of the Ministry, including the establishment of the Directorate for Health Information Systems. We have been a key Service Delivery – Getting Health partner in all these initiatives. Care to the People

We have assisted the Ministry in a number Availability of Facilities and Services of HIS-related areas, including the use of the standardized methodology recommended by There has been a significant increase in the coverage WHO for the national HIV Sentinel Surveys, and of a number of healthcare services in Namibia. the development of an updated Essential Health The public health system has a network of health Indicators framework. The existing framework at the facilities consisting of approximately 1,150 outreach

37 points, 260 clinics, 40 health centres, 30 district WHO has specifically supported review of the hospitals, 3 intermediate hospitals and 1 national Central Medical Stores management and logistics referral hospital, as well as various social welfare set-up; the establishment of a mechanism for regular service points. inventorying and audit of medical equipment and supplies and strengthening of the Namibia Blood We joined other partners in supporting the Namibia Transfusion Services and provision of medical gas to Health Facility Census (NHFC), which was conducted health facilities. in 2009. The aim of the NHFC was to describe the status of health facilities, the availability of specific Blood Safety client services in the areas of HIV/AIDS, TB, malaria and maternal and child health; the extent to which Through support initiated back in 2004, during the facilities are prepared to provide services; the type period under review a number of accomplishments of infrastructure, resources and support systems were registered, namely: available; and to what extent the service delivery process follows generally-accepted guidelines. • Development of Blood Safety Business Plan 2010- 2015 Essential Health Package • Capacity building at hospital level (blood transfusion banks) A component of the restructuring process of the • Establishment of National Quality System and MOHSS was the development of the Essential Hospital Transfusion Committees (HTCs) District Health Package (EDHP) and revision • Drafting of the Blood Transfusion Bill of national, regional and district management • Development of National Blood Programme structures. The EDHP was one of the strategic Waste Management Guidelines priority areas identified in the Ministry’s Strategic • Finalization of the Code of Ethics and Professional Plan 2009-2013. With our support, the Ministry was Conduct for the National Blood Programme able to seek ways to ensure that scarce resources • Production of a Monitoring and Evaluation Plan are best utilized by targeting essential, cost-effective for the National Blood Programme interventions that generate health benefits. The • Celebration of Annual World Blood Donor Days EDHP was initiated in 2011 and is still in draft form. It • Implementation of the Schools Peer Promoters is expected to provide standards for minimum health Programme services to be provided at any given health facility, • Testing of an electronic costing model for financial promoting equity and efficiency. sustainability of blood safety programme

Medical Products, Vaccines and Medical Gas Technologies – The Tools of the Trade We supported an assessment of medical gas (particularly oxygen) systems and supply in Namibia A well-functioning health system ensures equitable in 2010. This resulted in the development of plans for access to essential medical products, vaccines and the preventive maintenance programme, a quality technologies of assured quality, safety, efficacy assurance programme to prevent production and and cost effectiveness, as well as their scientifically supply of substandard medical gas products, and sound and effective use. In addition to assisting the development of a system for managing and in strengthening capacity for the development of monitoring the medical gas system by the MOHSS. policies, legislation, regulation and strategies for A tender document for the procurement of oxygen safe, uninterrupted, effective and equitable provision and other medical gases for MOHSS facilities was of medical products, vaccines and technologies, also produced.

38 6. HARNESSING RESEARCH, INFORMATION AND EVIDENCE

39 Evidence has always been an important factor in health management. Having reliable, strong and reproducible scientific evidence on health issues and interventions is critical for setting relevant priorities, as well as identifying strategies for action and measuring results. Ultimately, evidence plays a key role in motivating the resource envelope for health initiatives. As the dynamics of healthcare have become more complex, and policies and programmes have to be constantly adjusted, a renewed appreciation for evidence is displayed.

In consultation with leading experts, WHO generates • Health Facility Census authoritative health information for the setting of • Study on the major causes of STIs norms and standards, articulation of evidence-based • HIV Sentinel Surveys policy options, and monitoring of the evolving global • Monitoring of Early Warning Indicators (EWI) and health situation. During the period 2008-2013, we HIV Drug Resistance have assisted the MOHSS in various ways to ensure • Institutionalization of EWI Survey in Electronic that the country is afforded top quality expertise Dispensing Tool (EDT) to help review and, where necessary, develop • Survey on NCDs Risk Factors the necessary norms, standards, policies and • NDHS+ instruments to guide health strategies. Using Evidence for Policy Decision As an organization that values knowledge and information management, WHO is constantly WCO contribution to the development of national looking at innovative and effective ways to keep policies, strategies, guidelines, standards , plans and the public abreast of the latest information and reports included some of the following: developments in the health arena. Over the years, we have published and established a variety of useful • Revision of the Adolescent Health Guidelines in resources to enhance access to health information. the context of Young People Living with HIV/AIDS With the support received from WHO and other • Revision of the Health Promoting School Initiative partners, Namibia is increasing its capacity to analyze guidelines and use strategic information for decision-making • HRH Situation Analysis and Country Profile policy development and budget allocation. This • Revision of the IDSR technical guidelines and added intelligence is proving to be vital for managing alignment with IHR (2005) and staying ahead of the dynamic forces that • Revision of the EPI Guidelines influence the changing health situation. • Donor Coordination Situational Analysis • Country Analysis (UNCT) Generating Evidence • Ministry of Health Strategic Plan 2009-2013 • Second Medium-Term Strategic Plan for We have provided funding and/or technical support Tuberculosis and Leprosy 2010-2015 to the Ministry in the area of research, data • Nutrition Strategic Plan 2011-2015 gathering and the dissemination of information. • Strategic Plan for the Elimination of Mother to Some examples are given below: Child Transmission of HIV

40 • The National Strategy on the Reduction of Non- the four core PHC principles, namely: universal Communicable Diseases coverage, people-centred services, public policies • Child Survival Strategy and leadership. Subsequent World Health reports • The National Health Policy Framework 2010-2020 and other relevant WHO publications were widely • Policy on Male Circumcision for HIV Prevention disseminated throughout Namibia. • National Sexual Reproductive, Child Health and Nutrition Policy Library Services • National Policy on Health Promotion • Revision of the National Malaria Policy and The WCO aspires to be at the forefront of health and Malaria Guidelines to achieve Malaria pre- biomedical information in the country. Until 2012 we elimination by 2016 and elimination by 2020 housed on the UN House premises a library service, • Third Edition of the Namibia Guidelines for which aimed to provide all its visitors, in particular Antiretroviral Therapy health workers and other interested stakeholders, • Review of Vitamin A Supplementation Guidelines with access to the latest health, medical and • Review of ART Guidelines – Laboratory (Bio- development information resources. The library medical) Monitoring contained a comprehensive set of resources and • MDG reports by National Planning Commission information services on WHO-published information • Mid-Term Review of the 2nd National Strategic Plan in print and other media. Through a mailing list, for Tuberculosis and Leprosy 2010-2015 subscribers could receive regular literature on health, including training institutions, professionals and partner organizations. A full time librarian was available to orient and assist users. With reforms at UN House, and for cost effectiveness purposes, the library containing about 4,000 publications has been donated to the Namibia School of Medicine for close access and use by medical students. Country Health Portals

One of the key resources that once developed, can be accessed from the WHO’s online library, is the Country Health Policy Process (CHPP) and African Launch of the World Health Report Health Observatory (AHO) portals. These portals 2008 aim to provide regularly updated analytical health information to support cross-country comparisons To commemorate the 30th anniversary of the Alma- and the development and monitoring of national Ata International Conference on Primary Health health strategies, policies and plans. In essence, the Care held in 1978, WHO launched the World Health AHO and CHPP are a centralized one-stop portal Report 2008, ‘Primary Health Care – Now More Than for information sharing, which contain the latest Ever’. In Namibia, this report was launched by the research findings, partner reports and statistics, Honourable Minister of Health and Social Services, among other information. This initiative to harness Dr Richard N. Kamwi. This valuable information evidence, information and research was a joint source critically reviews the way health care is endeavor supported by the WHO Headquarters, organized, financed, and delivered in rich and poor the WHO Regional Office for Africa and the WCO. countries around the world, setting out a way Namibia’s pages are currently under construction, to address inequalities in health care. It outlines and some are already active.

41 7. ENHANCING PARTNERSHIPS

42 Namibia’s top health priorities, including among others strengthening health systems, maternal and child health, HIV/AIDS, TB, malaria, NCDs, emergency preparedness and response require a concerted effort between a range of partners from different sectors. Smart partnerships with various stakeholders from the public and private sector, civil society, bilateral and multilateral partners, particularly UN agencies were critical to the successes achieved in this reporting period.

WHO leverages its convening power as a neutral Key Partners organization with nearly universal membership, and lead partner in the health sector, to bring In the private and parastatal sectors, the Namibia stakeholders together in the interests of health Business Coalition on AIDS (NABCOA), the Namibian development. In Namibia we convene and Association of Medical Aid Funds (NAMAF), the participate in a wide range of working groups and Blood Transfusion Service of Namibia (NAMBTS) and activities in partnership with other stakeholders. the National Institute of Pathology (NIP) have made Underscoring the centrality of collaboration to our major contributions to health initiatives in Namibia. agenda, the theme of our Country Cooperation Strategy for Namibia 2010-2015 is ‘Together in Another important partner which has been critical Partnership’. Similarly, we have made it a priority to to the successes recorded is civil society, with its ‘Foster strategic partnerships and promote partner deep reach into communities. Organizations such coordination, harmonization and alignment, as well as NANASO, Namibia Red Cross Society (NRCS), as improved accountability’. Catholic Health Services (CHS), Voluntary Service Overseas (VSO) Namibia, The Council of Churches The multiple stakeholder survey, which informed the in Namibia (CCN), the Society for Family Health and development process of the CCS for Namibia 2010- Development Aid People to People (DAPP) manage 2015, showed that some key partners were unclear health facilities and/or implement a variety of health- about our mandate and role. We have attempted to related programmes including HIV/AIDS, TB and address this issue in part through the regular update malaria. of our page on the WHO’s website, press releases, mailshots, annual reports, dissemination of the CCS PEPFAR together with the USAID and CDC, and and technical publications, and the regular release GFATM have been the largest international of ‘Newsbreak’ to keep partners abreast of our development partners funding programmes in activities in the country. Increased awareness about Namibia over the last 10 years. Other significant our specific role and comparative advantage enabled development partners in health include GIZ and partners to collaborate more effectively with us and its affiliated agencies, EU, UNICEF, UNFPA, and the MOHSS. UNAIDS. Also active in the health sector are Spanish

43 Cooperation and the Embassy of Finland, and there TB-Leprosy Programme Steering Committee and is bilateral cooperation with Kenya, Nigeria, Zambia, HIV/AIDS Monitoring and Evaluation and other Zimbabwe and Cuba for the provision of health Committees, the National AIDS Executive Committee workers. (NAEC), and NaCCATuM. We have played an active role in these committee meetings and activities Keeping Everyone on the Same in order to coordinate our support to the MOHSS Page with that of other partners, avoid duplication and minimize fragmentation of programme Contributions from the different partners in health interventions. are critical to health development in the country and are gratefully received. In order to make the most We also initiated meetings of the Health of these contributions, it is important to minimize Development Partners Group (HDPG) in 2011. The overlapping roles, duplication of efforts, gaps in need for such a forum arose in the light of the critical area, and underutilization of resources. changing context in which health partners are operating. This has been shaped by trends such as Supporting the Stewardship Role of the the deepening financial crisis, diminishing resources MOHSS among traditional health donors, the World Bank revision of Namibia’s ranking to an upper middle- ‘Strengthening the stewardship role of the MOHSS’ income country, and MOHSS restructuring. The was prioritized by the Ministry in its Strategic Plan HDPG is expected to contribute to achieving better for 2009-2013. In line with this priority, we provided programmatic coherence, hence better results and technical support to the MOHSS in 2010 to design health outcomes. The members of the Group include a Donor Coordination Framework. Major findings UN agencies (WHO, UNICEF, UNFPA and UNAIDS), from the desk review revealed that Namibia has United States Government Agencies (PEPFAR, USAID in place guidelines and instruments for addressing and CDC), International Training and Education international agreements on aid effectiveness and Centre for Health (I-TECH), Programme Management harmonization in areas such as: organizational and Units (MOHSS/GFATM), the EU, GIZ, and Spanish institutional settings for coordination, monitoring Cooperation. However, challenges relating to and evaluation and participation of stakeholders; harmonization still persist. planning, budgeting and financial guidelines and procedures; resource mobilization strategy In March 2012, we assisted the MOHSS in convening principles; technical assistance management and a stakeholder consultation meeting, which brought financing modalities; and makes use of joint systems together nearly 40 participants from government through strategic planning, the Medium-Term agencies, embassies, academic institutions and NGOs. Expenditure Framework (MTEF), annual budgeting, The aim of the meeting was to garner stakeholder and monitoring and evaluation. The challenge is input regarding how to improve health sector for each sector to put the available instruments coordination for a more strategic approach to health into operation. At the Ministry level, there is a need in the spirit of the high-level international agreements for structures, functions and programmes to be signed by countries including Namibia. Partners harmonized to avoid duplication of efforts, maximize noted that new, innovative and better coordination effectiveness, and transition towards better-aligned mechanisms are needed to attain better health and effective cooperation in the health sector. outcomes and achieve the health-related MDGs for 2015, which are fast approaching. They called upon For specific programmes, several partnership fora, the MOHSS to host a follow-up meeting for further technical working groups and technical advisory development of coordination mechanisms. committees are in place, such as the National

44 UN Coordination Resource Mobilization

Within the United Nations System in Namibia, we WHO is not a funding agency, but we mobilize funds play a lead role in coordinating health activities, from a variety of sources for the implementation of ensuring harmonization of activities, thus the CCS strategic agenda and to provide technical strengthening the collaboration and coordination and catalytic financial support to the MOHSS. We with UN partners active in the health sector, and are a member of the resource mobilization technical streamlining and aligning their support to the advisory committee, which was convened for the MOHSS in particular and the Namibian Government first time by the MOHSS in 2012. Over the years, we in general. have contributed to the development of several key proposals that have been submitted for funding A tool aimed at greater harmonization of UN either directly or through the MOHSS. agencies is the United Nations Development Assistance Framework (UNDAF), which was initiated Resource mobilization efforts over the past years in 2006 and extended to 2012 and the just launched were especially geared towards improving maternal United Nations Partnership Agreement Framework and child health, as well as strengthening health (UNPAF), 2014-2018. The Frameworks aims to guide systems. One such effort resulted in the EU award joint programming among UN agencies working of 10 million Euros for implementing the PARMaCM. in Namibia to support the Government and civil These funds are channelled to the MOHSS through a society in reaching national economic and social Contribution Agreement with WHO. development goals, as stipulated in Vision 2030, National Development Plan 4, and the Millennium The Global Fund has been one of the largest Development Goals. The UNPAF is articulated financial sponsors of HIV, TB and malaria around four pillars: a) Institutional Environment; interventions in the country since 2004 and we have b) Education and Skills; c) Health and; d) Poverty consistently made available technical assistance Reduction. WHO was entrusted by the United for the Global Fund proposal development and Nations Country Team to be the Chair of the implementation process. As a result, a total of Programme Development Team, overseeing the US$ 190,639,964 has been disbursed to Namibia development and implementation of the UNPAF. since the start of support in 2004. In collaboration with other UN agencies, WHO will strive to maximize the great potential that UNPAF Cross Border Collaboration presents for joint planning and programming. We facilitate and participate in regular cross-border meetings aimed at fostering collaboration with neighbouring countries for the prevention and control of various communicable diseases, such as malaria, polio, HIV/AIDS and TB. For example, a regional cross-border meeting between Namibia and Angola was held with our support in February 2012. One of the issues highlighted by the regional and provincial staff at the meeting included the high number of drug-resistant TB cases and lack of harmonization of TB case management guidelines in UNPAF launched by Right Honourable Prime Minister, the two countries. Dr Hage Geingob

45 WHO Official Visits to Namibia. During her visit, Dr Chan met HE, the President of the Republic of Namibia Dr Hifikepunye WHO Regional Director (RD) for Africa, Pohamba and other high-ranking government Dr Luis Sambo officials. In his welcome to Dr Chan, the President thanked WHO for its support and contribution to the In February 2009, the first official visit to Namibia of progress noted in the country’s health sector. the WHO Regional Director (RD) for Africa, Dr Luis Sambo invigorated relations with the Government Dr Chan commended the Government of Namibia and key partners. Dr Sambo, hosted by the for the visionary leadership and commitment to Honourable Minister of Health and Social Services, health. “Namibia is a young country moving in smart Dr Richard Nchabi Kamwi, met high-level authorities, ways, in the right direction, especially with evidence- including the Right Honourable Prime Minister of based strategies for improving health. You have the Republic of Namibia, Nahas Angula, the Speaker accomplished a great deal already, especially in the of the National Assembly, Dr Theo-Ben Gurirab, the past decade, and you aspire, in well-articulated, long- United Nations Resident Coordinator and the United term plans, to do a great deal more.” She further Nations Country Team. called for improved collaboration and coordination with and among development partners, civil society, During the visit, Dr Sambo commended Namibia and public-private partnerships to come up with for putting health high on the development agenda innovative ways to mobilize resources within the and reiterated WHO’s unwavering support to country in order to ensure sustainable health gains. the Government in tackling the country’s health challenges. Dr Sambo also visited the northern Dr Chan urged the Government to direct more regions of Omusati, Ohangwena, Kunene and resources to maternal and child health, nutrition, and Kavango, where he was able to meet with Regional NCDs. To this end she also underlined the importance Health Management teams (RMTs) and observe first of strengthening the HIS to provide the evidence hand the challenges confronting the health system. necessary for improved decision-making and health financing, and pledged support from WHO staff WHO Director General (DG) in the country, as well as at the regional and head Dr Margaret Chan offices. Addressing the Namibian Parliament, she said: “You have the focus right. Poverty and poor In April 2012, the WHO Director General (DG) health go hand-in-hand. They are the iron fist that Dr Margareth Chan made her first official visit puts the brakes on development.”

46 8. IMPROVING PERFORMANCE

47 WHO plans its activities and budget through results-based management processes, with clear expected results to measure performance, and undertakes reforms aimed at improving efficiency and effectiveness at country, regional and global levels. We aim to ensure that our strongest asset - our people - work in an environment that is motivating and rewarding.

In the period 2008-2013, the WCO has experienced Since WHO’s main function is to provide technical changing conditions in terms of staffing and support and cooperation, human resources play financing. We have worked hard to make the most a critical role in its work at country level. During of our resources through regular introspection the reporting period, we have been grappling with and realistic planning. The quality of the assistance various challenges in this area. Inadequate funding we provide to Namibia depends on our ability to and shortage of local expertise are some of the key maximize our in-country expertise and mobilize our factors that dictate the human resources pattern in great organizational network. the office.

Human Resources Performance Improvement and Capacity Strengthening Staff Complement Gender Training The WHO Representative (WR) heads the office In order to strengthen the integration of gender and is assisted by eight technical officers (five issues into WHO’s work at country level, a training internationals and three nationals) and ten support on gender was organized for WHO staff in 2008, and staff. When needed, short-term consultants are facilitated by the UN Country Team (UNCT) Gender brought in to complement the work of the team on Adviser. The training was an introduction to gender the ground. and gender equality, and focused on the meaning, principles and related concepts of gender equality.

48 The goal of gender equality is that ‘The Human During our 2009 retreat, we articulated our Rights of women, girls, boys and men are equally core values and developed a new organizational promoted and protected.’ Protecting human rights structure to increase effectiveness and efficiency. and gender equality must be seen as central in all The organizational structure has evolved with time aspects of society. At WHO we fully support this and was adjusted to the needs and priorities of the principle and strive to promote gender equality in moment and availability of resources. order to create a just and balanced society where women and men, girls and boys enjoy opportunities Figure 8: WCO Core Values and rights on an equal basis. At WHO Namibia we ... Skills Training In 2009, the SWOT analysis that informed the development of the 2010-2015 CCS for the WCO in Namibia identified the need for additional support each professional training. A training and development TEAM WORKother needs assessment was subsequently carried out, which resulted in the establishment of a staff are responsible development plan and the engagement of a local and hardworking

service provider to offer a number of training COMMITMENT

courses in 2009, namely Minute Taking, Time trustworthy and are accountable are

Management and Teamwork, Public Speaking and INTEGRITY Media Skills

Global Learning Programme

PROACTIVE

and creative and In 2012 a team of four WCO staff attended the flexible are Global Learning Programme (GLP) workshop. The relate to others in workshop focused on national health policies, a clear and caring way strategies and plans in the context of the Paris COMMUNICATION Declaration on aid effectiveness, and its principles of country ownership, harmonization, alignment, focus on results and mutual accountability. One of the tools that was presented was the Joint Assessment of National Strategies (JANS), which can be used Office Location and Conditions before and after developing a plan. The workshop was an excellent forum for better understanding The WHO Country Office is located in the purpose- of the processes for developing national health built UN House situated in Klein Windhoek, one policies and strategies, and communicating the of the upmarket suburbs of the Namibian capital, WHO mandate, values and core functions, WHO Windhoek. The office has a modern appeal and staff roles in the national health policy and strategy complies with essential UN System Security development processes. requirements. Most staff members work from this office and have access to the necessary IT equipment Staff Retreats and infrastructure, adequate office furniture and In this reporting period we held four staff retreats supplies. Digital phones are used and the office in order to review performance, plan the way ahead telephone system is linked to the WHO regional and foster team spirit. Staff retreats presents an and headquarters internal telephone systems. For opportunity to enhance team relationships and this purpose the Global Private Network and local for staff reflection on their own performance and area networks have been updated. A storeroom, contributions to team performance. For each boardroom, kitchen and toilet facilities are available. retreat, the specific objectives are identified by the Other physical resources include a shared video staff, in relation to the Office’s internal development conferencing room and a multipurpose centre to processes as well as the country’s health agenda. host large gatherings.

49 Finances The 2010-2015 CCS was the result of an extensive and inclusive process, which included a systematic The extent to which we are able to support health analysis of policy documents, interviews and development in Namibia and achieve our strategic interactions with multiple stakeholders in health. agenda is dependent on finances sourced from WHO The strategic direction was defined by considering Assessed Contributions (ACs) (quota contributions WHO’s comparative advantage in relation to national of member states and miscellaneous income) and health priorities. It took into consideration agreed Voluntary Contributions (VCs) from donor partners. international, regional and local development goals. From 2008 to 2009, the Country Office experienced a slight increase in funding. However, the 2010- The four pillars of the CCS are: Strengthening 2011 bienniums saw a 3% decrease in Assessed the Health System; Combatting Priority Diseases; Contributions, and this trend continued into 2012 and Improving Maternal, Newborn, Child and Adolescent 2013. The predictability of voluntary contributions Health, and Promoting a Safer and Healthier has been a challenge due to restrictions and Environment. The first strategic priority lays the conditions, and the global financial crisis and foundation for all the others. recession have negatively affected the size of these contributions. Figure 9: WCO Strategic Priorities, 2010-2015 Steering the Agenda Medium-Term Planning Improved Country Cooperation Strategies are the established health medium-term planning tools for WHO strategic outcomes agenda at country level. The development of each CCS aims at achieving greater relevance, alignment and focus in the determination of priorities, effective Improving Promoting a Combatting achievement of objectives and greater efficiency maternal, safer and priority in the use of resources allocated for WHO country newborn and healthier diseases activities. child health environment

To date, the work of the WCO was guided by two CCSs: the first covered the period 2004–2007 and Strengthening the Health System was developed through a participatory process that mobilized the three levels of WHO, national Coordination and Implementation authorities and its partners. It enabled the WCO to better plan its interventions using a results-based The implementation of the strategic agenda is approach and an improved management process. guided and coordinated through biennial work plans, which articulate the priority activities in the A review of the implementation of the first CCS, short term. which informed the development of the second, revealed that WHO made considerable achievements Weekly meetings of technical staff serve as in the area of health systems improvement and the an important instrument to enhance internal prevention of communicable diseases. However, communication and information sharing and give objectives were not fully met in some strategic guidance. Bi-weekly meetings of operations and priority areas, such as non-communicable diseases, support staff are held to share developments maternal and child health, and health promotion. and provide guidance in their specific areas of This was largely attributed to lack of funding, work. All staff meetings are held on a quarterly inadequate human resources at the country level, basis. Individual Performance Management and and changes in prioritization on the part of MOHSS. Development Plans are developed annually to ensure The unfinished agenda was incorporated in the focus, performance-driven and results-oriented second CCS. actions by each staff member.

50 9. THE WAY AHEAD

51 The Post 2015 Agenda for Sustainable Development

Namibia is committed to achieving the Millennium Development Goals by 2015. The National Planning Commission in collaboration with the MOHSS, other line Ministries and development partners has been regularly monitoring progress towards the achievement of the health, health related MDGs 1, 3, 4, 5, 6 and 8; and other MDGs.

WHO has taken part in the national and international stocktaking meetings that are coordinated by the National Planning Commission. According to the information available, the country has achieved MDG 8, has achieved most MDG 1 and MDG 3 targets, is effectively addressing MDG 6, and is not on track to achieve MDGs 4 and 5 due to persistently high rates of maternal mortality and stagnating child mortality.

With less than 1000 days left for the achievement of the targets, we should be proud of the progress made thus far and gear efforts towards sustaining the gains.

Namibia is a country which enjoys peace, democracy and the rule of law. The goal of equitable social and economic development is achievable. Quality healthcare for all is possible.

We should advocate for the inclusion of health goals in the Post 2015 Agenda, to ensure consolidation of gains and improved health outcomes, a foundation of sustainable development.

52 REFERENCES

53 - National Planning Commission. (April 2012) Namib- - MoHSS. September 2012. Landscape Analysis to ia 2011 Population and Housing Census. Windhoek: Accelerate Actions to Improve Maternal and Child Republic of Namibia Nutrition in Namibia. Windhoek: Republic of Na- mibia. - National Planning Commission. (April 2012) Namib- ia 2011 Population and Housing Census. Windhoek: - Ministry of Health and Social Services (MoHSS) Republic of Namibia [Namibia] and ICF Macro. 2010. Namibia Health Facility Census 2009. Windhoek, Namibia. MoHSS - National Planning Commission. (April 2012) Namib- and ICF Macro. ia 2011 Population and Housing Census. Windhoek: Republic of Namibia - Ministry of Health and Social Services (MoHSS) [Namibia] and ICF Macro. 2010. Namibia Health - National Planning Commission. (April 2012) Namib- Facility Census 2009. Windhoek, Namibia. MoHSS ia 2011 Population and Housing Census. Windhoek: and ICF Macro. Republic of Namibia INDICATOR - Ministry of Health and Social Services (MoHSS) - World Food Program. (October 2012) Food Secu- [Namibia] and Macro International Inc. 2008. rity in Namibia. http://www.wfp.org/countries/ Namibia Demographic and Health Survey 2006-07. namibia/food-security. Accessed July 2013 Windhoek, Namibia and Calverton, Maryland, - UNICEF. Namibia Statistics. http://www.unicef.org/ USA: MoHSS and Macro International Inc. infobycountry/namibia_statistics.html. Accessed - UNAIDS. Climbing against gender-based violence: July 2013 A quest for dignity, equality and justice (25 April - World Bank (2012) Namibia GDP http://search. 2013) http://www.unaids.org/en/resources/press- worldbank.org/data?qterm=Namibia+GDP&lan- centre/featurestories/2013/april/20130425namibia. guage=EN&format. Accessed August 2013 Accessed July 2013 - UNAIDS. Namibia. https://www.unaids.org/en/re- - UNDP. Namibia Country Profile: Human Develop- gionscountries/countries/namibia/. Accessed July ment Indicators. http://hdrstats.undp.org/en/coun- 2013 tries/profiles/NAM.html. Accessed July 2013 - MOHSS. (2012). Report on the 2010 National HIV - UNDP. Namibia Country Profile: Human Develop- Sentinel Survey. Windhoek: Republic of Namibia. ment Indicators. http://hdrstats.undp.org/en/countries/profiles/NAM.html. Accessed July 2013 - WHO. (2010). Second Generation WHO Country Cooperation Strategy, 2010-2015, Namibia. Brazza- - MOHSS. (July 2010). National Health Policy Frame- ville, Republic of Congo: WHO Regional Office for work 2010-2020. Windhoek: MOHSS. Africa. - UN Inter-agency Group for Child Mortality Estima- - MOHSS. (December 2010). Namibia Health and tion. (2010). Levels & Trends in Child Mortality. HIV/AIDS Resource Tracking 2007/08 & 2008/09. - Ministry of Health and Social Services (MoHSS) Windhoek: MOHSS. [Namibia] and Macro International Inc. 2008. - Ministry of Health and Social Services (MoHSS) Namibia Demographic and Health Survey 2006-07. [Namibia] and ICF Macro. (2010). Namibia Health Windhoek, Namibia and Calverton, Maryland, Facility Census 2009. Windhoek, Namibia. MoHSS USA: MoHSS and Macro International Inc. and ICF Macro. - MOHSS. (July 2010). National Health Policy Frame- - WHO. (2010). Second Generation WHO Country work 2010-2020. Windhoek: MOHSS. Cooperation Strategy, 2010-2015, Namibia. Brazza-

54 ville, Republic of Congo: WHO Regional Office for - MOHSS. (December 2010). Namibia Health and Africa. HIV/AIDS Resource Tracking 2007/08 & 2008/09. Windhoek: MOHSS. - MOHSS. (2011). National Technical Guidelines for In- tegrated Disease Surveillance and Response, Second - MOHSS. (2008). Report on the 2008 National HIV Edition. Windhoek: Republic of Namibia. Sentinel Survey. Windhoek: Republic of Namibia. - WHO Namibia. (2011). Quarterly Report July-Sep- - National Planning Commission. (September 2008) tember 2011. Windhoek: WHO Namibia. 2nd Millennium Development Goals Report 2008. - Ministry of Health and Social Services (MoHSS) Windhoek: Republic of Namibia. [Namibia] and Macro International Inc. 2008. - CCM Request for Renewal to GFATM (19 February Namibia Demographic and Health Survey 2006-07. 2013) Windhoek, Namibia and Calverton, Maryland, USA: MoHSS and Macro International Inc. - GFATM. (18 July 2013) Investing in Namibia. http:// portfolio.theglobalfund.org/en/Country/Index/ - WHO Namibia. (2011). Quarterly Report July-Sep- tember 2011. Windhoek: WHO Namibia. NAM. Accessed July 2013 - Ministry of Health and Social Services (MoHSS) - WHO. (2012). 2011 Annual Report. Windhoek: WHO [Namibia] and ICF Macro. (2010). Namibia Health Namibia. Facility Census 2009. Windhoek, Namibia. MoHSS - GFATM. Namibia and the Global Fund Sign and ICF Macro. US$100 Million Grant Agreement. http://www. - Ministry of Health and Social Services (MoHSS) theglobalfund.org/en/mediacenter/newsreleas- [Namibia] and ICF Macro. (2010). Namibia Health es/2013-07-09_Namibia_and_the_Global_Fund_ Facility Census 2009. Windhoek, Namibia. MoHSS Sign_USD_100_Million_Grant_Agreement/. and ICF Macro. Accessed July 2013 - WHO. (2010). Second Generation WHO Country - Republic of Namibia. September 2012. Landscape Cooperation Strategy, 2010-2015, Namibia. Brazza- Analysis to Accelerate Actions to Improve Ma- ville, Republic of Congo: WHO Regional Office for ternal and Child Nutrition in Namibia. Windhoek, Africa. Namibia. MoHSS. - MOHSS. (July 2010). National Health Policy Frame- - Republic of Namibia. February 2009. MOHSS Stra- work 2010-2020. Windhoek: MOHSS. tegic Plan 2009-2013. Windhoek, Namibia. MoHSS. - MOHSS. (2008). Health and Social Services System - Directorate Disaster Risk Management. (13 July Review. Windhoek: MOHSS. 2009) Report on the 2009 Flood Disaster Re- sponse. Windhoek: Republic of Namibia. - MOHSS. (December 2010). Namibia Health and HIV/AIDS Resource Tracking 2007/08 & 2008/09. - Directorate Disaster Risk Management. (Novem- Windhoek: MOHSS. ber 2011) Report on National Response to the 2011 - Government of the Republic of Namibia. (2012). Flood Disaster. Windhoek: Republic of Namibia. Appropriation Act 2012 - Informal Settlement Communities & the Shack - National Planning Commission. Fourth National Dwellers Federation of Namibia. (March 2009). Development Plan 2012/13-2016/17. Windhoek: Re- Profile Of Informal Settlements In Namibia. Wind- public of Namibia. hoek: Community Land Information Program (Clip).

55 - WHO. (2011). The Abuja Declaration: Ten Years On. WHO. - http://www.who.int/healthsystems/publications/ abuja_report_aug_2011.pdf (accessed 11 Novem- ber 2012). - Republic of Namibia. 2008-2012. Estimates of Rev- enue and Expenditure. Windhoek: Ministry of Fi- nance.

- MOHSS. (2008). Health and Social Services System Review. Windhoek: MOHSS. - MOHSS. (2008). Health and Social Services System Review. Windhoek: MOHSS. - GFATM. (14 August 2013) Namibia disbursements. http://portfolio.theglobalfund.org/en/Country/In- dex/NAM. Accessed August 2013

- WHO Namibia. (25 April 2012) http://www.afro. who.int/en/namibia/press-materials/item/4580-who- director-general-dr-margaret-chan-makes-first-visit- to-namibia.html. Accessed August 2013

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