CHAPTER 1

INTRODUCTION

1.1 Geography, History, and Economy

Geography

Namibia has a surface area of 824,295 km2 and ranks as Africa's fifteenth largest country. It is located in the southwestem part of the continent and shares borders with Angola and Zambia on the north, Zimbabwe at the eastem end of the Caprivi Strip, Botswana to the east, and South Africa in the south and southeast.

Geographically, Namibia is divided into three major regions, the Namib Desert, the Central Plateau and the Kalahari Desert. The Namib Desert is in the westem part of the country, stretching approximately 1,400 km along the Atlantic coast. Its width varies between 97 and 160 kin. Despite the barrenness of the Namib, it is endowed with rich mineral deposits. The Central Plateau, which forms part of the Central African Plateau, lies between the two deserts. The plateau, comprising over 50 percent of the total land area of Namibia, stretches from the northern to the southern border. It is the most fertile area in the country and most suitable for human settlement. To some extent this area is suitable for cattle-raising and crop cultivation. The mountain ranges of the plateau are endowed with rich mineral deposits. The Kalahari is a semi-desert covering the southeastern part of the country; it consists mainly of terrestrial sands and limestones. Unlike the Namib Desert, vegetation grows in the Kalahari. The northern parts of the Kalahari are most suited to cultivation, while the southem part is suitable for sheep-raising and the eastern part is suitable for cattle, goats and to lesser extent, sheep.

Rainfall is the main factor influencing the climate of Namibia. The average annual rainfall for the country is only 270 mm and 92 percent of the land is categorised as extremely arid (22 percent), arid (33 percent) or semi-arid (37 percent), while the remainder is sub-humid.

History

On 21 March 1990, following the successful implementation of United Nations General Assembly Resolution 435, Namibia became the 1ast colony in Africa to attain its independence after more than 100 years of colonialism.

Designated South West Africa, it was a German colony from 1884 until World War I. The territory was invaded and occupied by the Union of South Africa during the war, and then became the responsibility of the League of Nations. In 1920, the mandate of Namibia was handed over to South Africa under category "C" status, in which South Africa was expected to promote to the utmost the material and moral well-being and social progress of the inhabitants of the territory. To the contrary, the government of South Africa pursued a policy of exploitation and armexation of the territory. Following the refusal by the United Nations Assembly in 1946 to allow South Africa to incorporate the territory into its union, the South African government declared it would administer the territory without United Nations jurisdiction and shortly afterwards began to introduce its apartheid system. In 1971 the lntemational Court of Justice declared South Africa's occupation of Namibia illegal. Following the recommendations of the apartheid-oriented Odendaal Commission in 1964, Namibia was divided into a number of ethnic "homelands," which made up forty percent of the land in Namibia. Forty-four percent was reserved for whites, and the remaining 16 percent consisted of game reserves, diamond mining areas, etc.

In the early 20th century, Namibians fought bloody wars against the German occupation (e.g., Nama and Herero wars). In 1960, the South West Africa People's Organisation (SWAPO), under the leadership of Sam Nujoma, was established and led the liberation struggle against the South African oppressors. Guerilla warfare took place from 1966 until independence, principally in northern Namibia. Thousands of Namibians fled to camps in Angola, Botswana, and Zambia. In tile seventies and eighties, the warfare increased, resulting in an estimated 10,000 civilian deaths.

After independence in March 1990, Namibia set about redesigning the national infrastructure, administrative bodies, and basic services. The Government of the Republic of Namibia operates under a multi-party system. There is an executive branch comprised of the President and Cabinet, and a legislalive branch made up of the National Assembly.

The country is divided into 13 regions and the election of Regional Councils took place in 1992. The Ministry of Health and Social Services administers four health regions, which were used in the Namibia Demographic and Health Survey. The Northwest health region includes Oshana, Omusati, Ohanguena, and Oshikoto regions; the Northeast health region includes Okavango and Caprivi; the Central health region comprises Kunene, Otjozondjupa, Erongo and Omaheke; and the South region includes Khomas, Hardap and Karas regions.

Economy

Namibia is one of the wealthier, more resource-rich countries on the continent. It is the fifth largest mineral producer in Africa and its fishing grounds are among the richest in the world. However, the national economy inherited by the Namibian government is fragile, dependent, and has an over-extended public sector. In its own interest, Namibia has decided to stay in the South African Customs Union and it still operates in the Rand Monetary Area and Bank of Namibia System. Namibia's economy is heavily dependent on a few prim ary commodity exports--diamonds, uranium, copper, other base metals, lead and mercury and livestock, followed by the Karakul (Persian lamb) pelt industry. The balance is made up by fish, manufactured products, and the tourist industry. Mining accounts for about two-thirds of all export earnings. Namibia depends on South Africa for about 75 percent of all imports.

The majority of the population are dependent for their livelihood on livestock, i.e. cattle, sheep, goats and pigs. Per capita income varies greatly. The gross domestic product (GDP) was estimated at US$100 per year in mral areas, US$305 in the semi-urban areas, and US$580 in Katutura (a former black residential area in Windhoek, the capital city), while the annual GDP for whites was estimated at US$14,650 (UNICEF, 1990).

1.2 Population

The last comprehensive population census, which was conducted in October 1991, reported a total population of 1,401,711 with an annual growth rate of 3 percent (Central Statistical Office, 1992). Despite the small size of its population, Namibia has a rich diversity of ethnic groups including Ovambo, Herero, Nama, Damara, Kavango, Caprivians, San, Twana, and Whites, Coloureds and Basters.

2 The population of Namibia is concentrated in the northern part of the country (60 percent); the south is least populated (7 percent); and the remainder are in the central part of the country. As a consequence of the apartheid policy, which reserved nearly 60 percent of the land for whites (who constituted less than 10 percent of the total population), ethnic distinctions were reinforced and different subgroups were encouraged to live in separate regions and, in urban areas, in separate localities. The majority of the black population is now concentrated in restricted rural areas, previously called "homelands."

Overall, about one-third of the population lives in urban areas (in 57 "towns"), while 67 percent live in rural areas, including communal areas and commercial farms. At less than two persons per square kilometre, population density for the country as a whole is low. However, there are substantial regional differences in population density. For instance, Oshakati and Ondangwa districts in Northwest region exceed 11 persons per square kilometre.

1.3 Population and Family Planning Policies and Programmes

Although population growth has been considerable during the last decade, the Government of the Republic of Namibia has yet to formulate an explicit population policy. However, population issues have received some attention, and different sectors of the govemment have come to realise the intersectoral impact of population issues, and of the importance of integrating population issues into a holistic planning perspective. Several surveys and needs assessment missions have indicated the need for information and understanding on the relationship between population and development, and a need for organised and coordinated population/health information, education and communication activities.

Although family planning services in Namibia are underdeveloped and far from meeting the needs of the population, 191 (79 percent) of the 242 health facilities are providing family planning services. However, there are substantial differences in the availability and accessibility of family planning services. In the Northwest region, where nearly 50 percent of the population resides, only 43 percent of the health facilities are providing such services.

One of the major components of primary health care (PHC) in the Ministry's Development Programme is the Maternal and Child Health/Family Planning (MCH/FP) programme. Its tasks, as stipulated in the draft policy, include:

The promotion and improvement of MCH/FP services at all levels where such services are provided; To increase knowledge and access to family planning services, especially for distant communities; Identification of high-risk groups among pregnant women, mothers, and children, and to provide appropriate intervention; and To decrease morbidity and mortality associated with pregnancy.

1.4 Health Priorities and Programmes

Namibia inherited a health structure that was segregated along racial lines and based entirely on curative health services. The administrative structure for delivery of health services was based on the Representative Authorities proclamation of 1980 (Proclamation AG8 of 1980), which created a two-tier system, resulting in an unequal allocation of resources and services. The ethnic-based second-tier was poody funded and administrators could not raise the necessary income to provide basic health care services. As a result, there were large inequalities in the delivery of health care services in the country.

3 Shortly after independence, major changes occurred in all sectors, many of which have been restructured to meet the challenges facing the new nation in the post-apartheid era. The Government of Namibia declared its commitment to the equitable distribution of resources and to equity of access to basic services for those who are socially or economically disadvantaged (i.e., the impoverished and underprivileged).

The Ministry of Health and Social Services has adopted a "Primary Health Care" (PHC) strategy for achieving health for all Namibians. Its objective is to attain this goal for women and children in the 1990s. The PHC approach is used to guide the restructuring of the health sector in an independent Namibia. The Ministry of Health and Social Services has, in particular, made progress in streamlining and restructuring what was a curative-based health system to be a more community oriented system. The Minister of Health and Social Services has described this policy in the document "Towards Achieving Health for All Namibians" (Ministry of Health and Social Services, 1992). The National PHC/Community-based Health Care Guidelines were announced on February 22, 1992 by the President of the Republic. This gave the Ministry of Health and Social Services a mandate to design, develop and implement programmes which focus on promotion of health at the community level. The PHC guidelines also provide a solid base for decentralised planning and intersectoral collaboration with joint identification and prioritisation of needs at the community level by all sectors. Health regions were now able to plan and prioritise programmes according to their immediate needs. The Ministry of Health and Social Services also emphasised other PHC components:

Immunisation against the major infectious diseases, i.e., poliomyelitis, diphtheria, tuberculosis, measles, tetanus and whooping cough; Maternal and child health care, which encompasses family planning; The promotion of proper nutrition, a safe water supply, and basic sanitation to secure an environment conducive to the well-being of all Namibians; and Education and training regarding prevailing health problems in communities, as well as prevention and control measures.

During restructuring of the Ministry of Health and Social Services many national health programmes came into being, namely, Mother and Child Health and Family Planning Programme (MCH/FP), Expanded Programme on lmmunisation (EPI), Control of Diarrhoeal Diseases (CDD), Acute Respiratory Infections (AR1), lnlormation, Education and Communication (IEC), National AIDS Control Programme (NACP), National Nutrition Improvement Programme (NIP), School/Adolescent Health Programme, National Malaria Control Programme, Tuberculosis Control Programme, Rehabilitation Programme, National Vector-borne Diseases Control Programme, National Tuberculosis Control Programme, and Health Training Programme.

1.5 Objectives and Organisation of the Survey

Objectives

The Namibia Demographic and Health Survey (NDHS) is a national sample survey of women of reproductive age designed to collect data on mortality and fertility, socioeconomic characteristics, marriage patterns, breastfeeding, use of contraception, immunisation of children, accessibility to health and family planning services, treatment of children during episodes of illness, and the nutritional status of women and children.

More specifically, the objectives of NDHS are:

To collect data at the national level which will allow the calculation of demographic rates, particularly fertility rates and child mortality rates, and maternal mortality rates;

4 To analyse the direct and indirect factors which determine levels and trends in fertility and childhood mortality, Indicators of fertility and mortality are important in planning for social and economic development;

To measure the level of contraceptive knowledge and practice by method, region, and urban/rural residence;

To collect reliable data on family health: immunisations, prevalence and treatment of diarrhoea and other diseases among children under five, antenatal visits, assistance at delivery and breastfeeding;

• To measure the nutritional status of children under five and of their mothers using anthropometric measurements (principally height and weight).

Organisation

The Namibia Demographic and Health Survey was conducted by the Ministry of Health and Social Services, with the assistance of the Central Statistical Office of the National Planning Commission. The survey was funded by the World Bank through a grant from the Government of Japan and the Namibian Government. Technical support was provided by Macro International Inc., located in Columbia, Maryland, USA. Questionnaires

Two questionnaires were used in the main tieldwork for the NDHS: the household questionnaire and the individual questionnaire. The two questionnaires were adapted from the DHS model B questionnaire, which was designed for use in countries with low contraceptive prevalence. The questionnaires were developed in English, and then translated into five of the major Namibian languages: Oshiwambo, Herero, Lozi, Kwangali, and Afrikaans. English versions of the questionnaires are reproduced in Appendix E.

All usual members and visitors in the selected households were listed on the household questionnaire. For each person listed, information was collected on age, sex, education, and relationship to the head of household. The household questionnaire was used to identify women eligible for the individual questionnaire.

The individual questionnaire was administered to women age 15-49 who spent the night preceding the household interview in the selected household. Information in the following areas was obtained during the individual interview:

1. Background characteristics of the respondent 2. Health services utilisation and availability 3. Reproductive behaviour and intentions 4. Knowledge and use of contraception 5. Breastfeeding, health, and vaccination status of children 6. Marriage 7. Fertility preferences 8. Husband's background and woman's work 9. Height and weight of children under five and their mothers 10. Causes of death in childhood 11. Maternal mortality Sample

The sample for the NDHS was designed to be nationally representative. The design involved a two- stage stratified sample which is self-weighting within each of the three health regions for which estimates of fertility and mortality were required--Northwest, Northeast, and the combined Central/South region. In order to have a sufficient number of cases for analysis, oversampling was necessary for the Northeast region, which has only 14.8 percent of the population. Therefore, the sample was not allocated proportionally across regions and is not completely self-weighting.

In the first stage of sampling, a total of 175 sampling points were selected from the 1991 census frame with probability proportional to size. The sample points corresponded to enumeration areas, and the measure of size used in the selection process was the number of households in the census enumeration areas. Lists of household heads for the selected enumeration areas were then obtained from the census office and the sample households were selected from these lists. A more detailed description of the sample design is presented in Appendix B.

Fieldwork

The NDHS field staff consisted of Table 1.1 Result of the household and individual interviews seven teams, each composed of four female interviewers, one female editor, and one Number of households,number of interviews, and response rates, male or female supervisor. The interviewers Namibia 1992 and editors were newly recruited for the survey, while supervisors were from the Ministry of Health and Social Services. Result Urban Rural Total Fieldwork was conducted from July to November 1992. The persons involved in Households sampled 1642 3364 5006 the survey are listed in Appendix A. A Households found 1501 3011 4512 more complete description of the fieldwork Households interviewed 1350 2751 4101 is presented in Appendix B. Household response rate 89.9 91.4 90.9

Table 1.1 is a summary of results Eligible women 2057 3790 5847 from the household and the individual Eligiblewomen interviewed 1891 3530 5421 interviews. A total of 5,006 households Eligiblewomen response rate 91.9 93A 92.7 were selected; of these,4,101 were success- fully interviewed. The shortfall is largely due to households being absent. This includes nine clusters not interviewed in Northeast region. One team in this region had experienced multiple problems and lagged considerably behind the other teams. In the interviewed households 5,847 eligible women were identified and 5,421 were successfully interviewed, for a response rate of 93 percent. More detailed information on the reasons for nonresponse are given in Appendix Table B.2.

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