Namibia: Reducing health inequity through commitment and innovation
Synergos Institute/Creative Commons
Namibia is one of the largest and least populated countries in Southern Africa. With an estimated population of 2.2 million living in an area the size of France, close to 50 percent of its citizens live in urban centers, resulting in a low population density in rural areas [1, 2].
After Namibia gained independence from South Africa in 1990, its healthcare delivery system reflected a traditional medical model, focused mainly on hospital-based and curative services . Health outcomes were generally poor, and income inequality in Namibia was extreme, as was inequity in access to health services [4, 5].
Commitment to care and equity
In response to the situation, the newly formed independent government of Namibia made a commitment to health as a fundamental human right, and to integrating racially divided communities into one health care system. Within a few years, the national leadership at the Ministry of Health and Social Services (MoHSS) began reforms to focus on transitioning to a system based on a central role for primary health care (PHC) [6, 7].
The prominence of PHC in these reforms is reflected in the vision of the MoHSS National Directorate for Primary Health Care Services "to translate and oversee the implementation of health policies and programs as an integral part of the health care delivery network based on the strategy and philosophy of primary health care" . This vision is being realized through both horizontal integration of public health and curative care services, as well as integration across multiple system levels from community health workers to health centers and district hospitals."
Additional efforts have been undertaken to integrate traditionally siloed programs such as HIV/AIDS, malaria, and tuberculosis into PHC. With the support of UNFPA, the MoHSS has remodeled PHC service delivery from a parallel, fragmented model towards a comprehensive, integrated, and patient-centered approach. For example, a pilot project conducted at Epako Clinic in Gobabis integrated sexual and reproductive health services with HIV services in a model known as “one nurse, one patient, one room.” Preliminary results suggest that this integration reduces patient waiting times, improves nurse productivity, and reduces stigma and discrimination against those seeking HIV-related services .
Reflecting this model of integration, primary health care in Namibia is centered on four pillars:
- Health promotion;
- Disease prevention;
- Curative services; and
- Rehabilitation services 
As the country began the transition towards a system focused on primary health care, Namibia faced the challenge of ensuring equitable and quality healthcare for all. It attempted to address inequity through strategies including the redistribution of health care resources based on measured differences in communities [3, 7, 9]. In order to provide effective PHC services, the healthcare reform included the decentralization of responsibilities and decision-making to the local communities . In 1994, thirteen regional health management teams were created to plan and manage all local PHC services and facilities [9, 10]. These teams were responsible for managing district health management teams as they sought to operationalize a primary care approach. This decentralization facilitated more equitable distribution of critical resources. For example, the regional health management team in the capital city of Windhoek used data to identify inequities in staffing related to increased demand and subsequently drove reallocation to poorer communities .
Mobile clinics and community outreach expand access
Recognizing the need for further action to reduce inequities in access to basic health services, a public-private partnership between the MoHSS, PharmAccess, and USAID SHOPS program implemented the Mister Sister mobile clinics in 2008 to enable better access in three rural regions . The clinics aim to improve geographic access and equity by targeting poor rural communities and other vulnerable populations, including pensioners, orphans and vulnerable children [11, 12]. The mobile clinics are designed to provide high-quality, person-centered care with a focus on comprehensiveness and continuity. Unlike traditional mobile clinic models which focus on acute care, the Mister Sister mobile clinics provide a range of services in line with the primary health care model, including routine immunizations, diagnosis and treatment of routine communicable diseases, management of minor trauma, testing and follow-up treatment for chronic diseases, voluntary counseling and testing for HIV, antenatal care, and health education [12, 14, 15]. Each mobile clinic includes a team comprised of a registered nurse, enrolled nurse, and a driver to help with administrative tasks. If a patient cannot be treated by the mobile clinic, they can be referred to the nearest public health facility. Recognizing the importance of being able to provide more comprehensive care for non-communicable diseases, Mister Sister plans to have a physician available in each clinic on a quarterly basis . The mobile clinics collaborate with rural employers and farmers to provide PHC to the targeted communities. The majority of local employers (80 percent) are willing to contribute to the financing of their employees’ health services, in part through these clinics .
The Mister Sister mobile clinics have had considerable success in expanding effective coverage, particularly for the most vulnerable. Within a group of children followed over time, statistically significant declines were seen:
- Anemia declined from 1.9 percent to 0.5 percent
- Incomplete immunizations fell from 6.5 percent to less than one percent
- Parasitic infections dropped from 16.9 percent to 0.2 percent.
Even more impressive improvements were seen among orphans: the rate of incomplete immunizations dropped from 25% to 0, and parasitic infections dropped from 22.7% to 0 .
Coordinated by regional health management teams, the MoHSS also provides community outreach services, including comprehensive medical outreach, eye campaigns, and clinic outreach services. Teams of doctors, dentists, and ophthalmic clinical officers visit primary care clinics in a district catchment area to expand access to these critical services. Additionally, primary care clinics conduct outreach activities within their home communities, including immunization, family planning, HIV rapid tests, antenatal care, and management of chronic diseases. New public private partnerships are also expanding access to services through outreach activities to rural communities with multidisciplinary teams of private and public doctors.
Health improvement results
Since independence, Namibia has shown a strong commitment to primary health care and achieved significant improvements in effective health coverage. Total health expenditure has increased from 6.2 percent of gross domestic product in the mid-1990s to 8.9 percent in 2014 .
Service delivery coverage has also improved. In 2013, 87 percent percent of women delivered in a facility, up from 75 percent in 2000, and 79 percent of children with diarrhea were treated with oral rehydration therapy or increased fluids . Namibia has made significant progress towards reducing preventable mortality, including:
- Under 5 mortality rate declined from 74 deaths per 1,000 live births in 1990 to 50 in 2013;
- Maternal mortality ratio declined from 320 deaths per 100,000 live births to an estimated 130 deaths per 100,000 live births over the same period ;
- Infant mortality decreased from 50 deaths per 1000 live births in 1990 to 35 deaths per 1000 live births in 2012 .
CDC Global/Creative Commons
Ongoing and emerging challenges
These improvements notwithstanding, Namibia still faces a number of challenges to providing equitable, person-centered primary health care. HIV prevalence is still the 6th highest in the world. Similar to many other countries, Namibia is now facing a growing burden of non-communicable disease, which accounted for 43 percent of deaths in 2014 . Reflecting its commitment to strengthening PHC, Namibia included measurements of blood pressure and fasting blood glucose for the first time in their most recent demographic and health survey . In the 2013 DHS, almost half of the population between the ages of 35 and 64 years (44 percent of women and 45 percent of men) had hypertension or were on medications for hypertension. Diabetes is also a growing challenge, with 7 percent of the population having elevated glucose or already taking medications .
Additionally, inequity remains a pressing challenge for Namibia overall. In 2010, Namibia had one of the highest income inequalities in the world , which is reflected in the lingering disparities in health access and outcomes seen across income groups, races, and geographic locations. For example, in 2013 18 percent of women in the lowest wealth quintile had an unmet need for family planning, compared to only 7 percent of women in the wealthiest quintile . Similarly, infant and under-five mortality rates in the wealthiest quintile in Namibia (22 deaths per 1,000 live births and 31 deaths per 1,000 live births, respectively) are less than half of that of the poorest wealth quintile (51 deaths per 1,000 live births and 67 deaths per 1,000 live births, respectively) .
Namibia has developed a vast health care system to meet the geographic spread of its population, which requires a focus on integration and coordination across its tiers. Namibia has four tiers in the public health system: 1150 outreach points, 309 health centers, 34 district hospitals, and four intermediate and referral hospitals. The growing health care demands are complicated by a workforce shortage, as well as gaps in management capacity [21, 22]. Reflecting human resource and other supply side shortages, the public sector is unable to respond to all needed care including specialized services. Some progress has been made through the creation of public-private models to increase the private sector coverage from its current level of 15 percent.
Notably, the Namibian government remains committed to ensuring universal access to primary health care for all its citizens. In the 2010-2020 National Health Policy Framework (NHPF) , the government of Namibia renewed its commitment to primary health care and the key principle that “All Namibians have the right to enjoy good health through access to primary care and referral level services according to need” . The NHFP set forth a strategy to expand and ensure equitable, quality PHC through a multi-sectoral, integrated model of delivery.
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