Analytical summary - Health system outcomes
Health services in Namibia are provided through the public health sector (government) and the private sector, which comprises for-profit and non-for-profit organizations. The public system provides services to the majority of the population and is predominantly funded through general taxation while the private health care system, which provides either comprehensive or partial health care coverage, is funded largely through employee and employer contributions. (MoHSS, 2008)
Public funds are the largest financier of curative care – inpatient and outpatient – while donors are the largest financier of public health programmes, though Namibia faces reduced international health funding in coming years. Household contributions are low and are also on the decline, showing that the population is largely protected from the burden of health costs. (MoHSS, December 2010)
According to the latest NHA data series, approximately 50% of the health total health budget is awarded to MoHSS public and mission hospitals, health centres and clinics. Only 4% of the budget is directed to PHC programmes despite the Government’s commitment to the national PHC strategy. However, this low expenditure is an underestimation, as hospitals and health centres also undertake PHC activities. (MoHSS, December 2010)
The MoHSS allocates a budget to each regional management team and referral hospitals for provision of health care to a geographically defined population. Until 2001, budgets were allocated according to historical criteria which perpetuated the deprivation of the most needy regions. After 2001, the Ministry has been considering the implementation of needs-based resource allocation formulae with a view to developing an equitable funding system through a task team.
This process has been delayed by unfilled critical senior management posts in the Ministry , but some progress has been made. As stated in the National Health Policy Framework 2010-2020, “Health and social welfare services will be affordable and the principle of equity and fairness will underpin the commitment expressed in this policy framework; special attention will be given to vulnerable groups.” (MoHSS, July 2010) The latest National Health Accounts (NHA) 2007/2008-2008/2009, aim to facilitate improved resource allocation and efficiency within the health sector.
In response to challenges caused by one of the highest HIV/AIDS, TB and malaria prevalence rates in the world, which saw the country’s life expectancy reduce from 60 in the early 1990s to 49 in 2009, the Ministry’s overall goal, as articulated in its Strategic Plan 2009-2013, is to ‘Increase life expectancy from 49 years to 55 years by 2013’. (MoHSS, February 2009) This target has already been surpassed, with life expectancy in Namibia currently estimated at 62 (UNICEF).
Some of the country’s major achievements since independence in 1990 have been the restructuring and re-orientation of the health sector in line with the Primary Health Care (PHC) approach, which brought health services closer to the population; the highly successful roll-out of antiretroviral therapy (ART) from 2002; the stabilization HIV/AIDS prevalence rates - dropping from 22% in 2002 to 18.8 in 2010 (MoHSS, November 2010) - and the eradication of malaria, with Namibia now on track for elimination. (MoHSS and UNAIDS, June 2011; MoHSS, 2008). TB has also shown a significant decline in recent years.
However, more is needed to bring the burden of these priority diseases to a level where they will not constitute a major public health problem in the country. In addition, non-communicable diseases (NCDs) are emerging as important causes of morbidity and mortality. Although community-based survey data on NCDs is limited, health facility statistics indicate hypertension, diabetes and cancer as important health problems among adults. Also, Namibia is not on track to achieve the MDG 4 target of reducing the under-five mortality rate by two thirds, between 1990 and 2015. There is an urgent need for improved maternal, neonatal and infant care, which have now become high priorities for the Government. (WHO Namibia, 2011).
According to the National Health Policy Framework 2010-2020, ‘Quality of care is and will be a pivotal dimension of all health services’. Despite favourable consumer surveys (MoHSS, 2008) the MoHSS recognises that service quality must be improved at all levels, especially in primary health care, obstetric care and ambulance services (MoHSS, July 2010). The referral system is weak and there are equipment shortages, and as a result there is no continuity of care, largely due to lack of transport. Outreach and mobile services are not functioning optimally for the same reason. (WHO, 2010)
There is notable dissatisfaction with attitudes of staff, opening hours of facilities, language barriers and lack of access for people with disabilities. (MoHSS, 2008) While quality of care is generally accepted to be much higher in private facilities, no specific data is available.
A 2004 study of the technical efficiency of public sector district hospitals revealed significant amounts of inefficiency that are attributable to both pure technical and scale inefficiency and the possibility of reaping substantial efficiency gains. It pointed to the need for efficiency measures to be instituted and pursued vigorously in order to redress past inequities in access to healthcare. (MoHSS, 2004) Another study is required in order to assess progress on the implementation of these measures.
As identified in the 2008 Health and Social Systems Review (HSSR) and the 2006/07 Namibia Demographic and Health Survey (NDHS), major health challenges such as increasing maternal mortality could be attributed to certain weaknesses in the health system, such as:
- inadequate human resources and institutional capacity gaps at leadership level;
- lack of stewardship and coordination of multiple partners;
- duplication of structures and functions at all levels;
- multiple information systems;
- limited integration of programmes and interventions;
- outdated policies and strategies for linkages between formal structures and communities. (WHO, 2010).
The MOHSS is committed to improvements in all these areas and is currently working on several reforms, such as: restructuring the MoHSS; systems integration; improved NHA; and implementing the Health Extension Workers Strategy.