Namibia - Health sector note

 69986 Namibia Health Sector Note (P110113) May 22, 2010 Health, Nutrition and Population Southern Africa Country Department I Africa Region  Abbreviations and Acronyms ARV - Antiretroviral (drugs) ART - Antiretroviral Therapy BCC - Behavior Change Communication CBHC - Community-Based Health Care CMO - Chief Medical Officer CSO - Civil Society Organizations DMO - District Medical Officer DOTS - Directly Observed Therapy, Short Course GDP - Gross Domestic Product GP - General Practitioner HBC - Home-Based Care HH - Household(s) HR - Human Resources (for Health) IEC - Information, Education, Communication IFMIS - Integrated Financial Management Information System IMR - Infant Mortality Rate IT - Information Technology MCH - Maternal and Child Health MGYS - Ministry of Gender, Youth and Sports MHSS - Ministry of Health and Social Services MICs - Middle Income Countries MLG - Ministry of Local Government MMR - Maternal Mortality Ratio NCD - Non-Communicable Disease(s) Nemlist - Namibia Essential Medicines List NGO - Non-Governmental Organization(s) OPE - Out-of-Pocket Expenditures ORS - Oral Rehydration Salts OVC - Orphans and Vulnerable Children PHC - Primary Health Care PPP - Public/Private Partnership RN - Registered Nurse SACU - Southern Africa Customs Union SSA - Sub-Saharan Africa SW - Social Work or Social Worker(s) SWIS - Social Welfare Information System U5 - Under five (children) USAID - United States Agency for International Development TB - Tuberculosis THE - Total Health Expenditures WB - World Bank WHO - World Health Organization ii  Table of Contents Abbreviations and Acronyms .......................................................................................................... ii Table of Contents ........................................................................................................................... iii List of Tables.................................................................................................................................. iv List of Figures ..................................................................................................................................v Introduction .................................................................................................................................. viii Executive Summary ........................................................................................................................ x Chapter 1: Sociodemographic and Economic Background............................................................ 1 Chapter 2: Health Sector Expenditure Trends................................................................................ 6 Chapter 3: Health Sector Structure and Overview ....................................................................... 13 Chapter 4: HIV/AIDS................................................................................................................... 23 Chapter 5: Tuberculosis................................................................................................................ 30 Chapter 6: Malaria........................................................................................................................ 34 Chapter 7: Maternal and Child Health.......................................................................................... 37 Chapter 8: Namibia's Comparative Health Sector Performance .................................................. 49 Chapter 9: Possible Areas Where the World Bank Could Provide Technical Support ................ 69 Annexes ......................................................................................................................................... 71 References ..................................................................................................................................... 72 Map................................................................................................................................................ 75 iii  List of Tables Table 1: Regional differences in poverty related indicators .............................................. 4 Table 2: Health sector financing by program (N$)............................................................. 7 Table 3: Sector allocations of total public expenditure (percent), 2005/06 – 2008/09...... 7 Table 4: Percentage share of sources of health sector funding, 2000-2005....................... 8 Table 5: Financing agents to the health sector, 2001/02 – 2006/07................................... 9 Table 6: Internally Generated Revenues in MHSS (in '000 N$), 2001/02 - 2006/07........ 9 Table 7: Health expenditure per capita, 2001-2005 (US$) .............................................. 10 Table 8: Development Partners and Funds (N$‘000) ...................................................... 10 Table 9: Share of health in total external assistance, 2001-2005..................................... 11 Table 10: Expenditure by category shares, percent (N$ million) .................................... 11 Table 11: Health Expenditures by Category, in Percent, 2001/02 to 2006/07 ................ 12 Table 12: Numbers of people per doctor, registered nurse and hospital bed in public health facilities in 2000..................................................................................................... 15 Table 13: The number of health facilities attending to different numbers of people each day..................................................................................................................................... 16 Table 14: The average number of outpatients aged 5 and over reported for the 10 most frequent conditions each year, and the percentage that these made up of all new visits, 1995-1999 ......................................................................................................................... 17 Table 15: The average number of outpatients aged 5 and under reported for the 10 most frequent conditions each year, and the percentage that these made up of all new visits, 1995-1999 ......................................................................................................................... 17 Table 16: The average number of inpatients aged 13 and over admitted for the 10 most frequent conditions each year, and the percentage that these made up of all admissions, 1995-1999 ......................................................................................................................... 18 Table 17: The average number of inpatients under the age of 13 admitted for the 10 most frequent conditions each year, and the percentage that these made up of all admissions, 1995-1999 ......................................................................................................................... 18 Table 18: Causes of death, 1995-1999 (number and percentages),1995-1999................ 19 Table 19: Number of Staff Who Left the Health Workforce, by Reason, 2007 .............. 20 Table 20: Tuberculosis in SACU Countries, 2008. ......................................................... 30 Table 21: Utilization of antenatal care services, by Region ............................................ 40 Table 22: Infant and Under-5 Mortality Rates (Per 1,000 Live Births) in Countries in Southern Africa, 1990 and 2006 ....................................................................................... 44 Table 23: Infant and Under-5 Mortality Rates (Per 1,000 Live Births) in Countries in Southern Africa, 1990 and 2006 ....................................................................................... 49 Table 24: Percent of Children with Symptoms of Illness in the Last 2 Weeks in Selected Countries in Sub-Saharan Africa, 2000s........................................................................... 50 Table 25: Percent of Children Provided with Selected Child Health Services in Countries in Southern Africa, 2000-2006 ......................................................................................... 54 iv  List of Figures Figure 1: Percentages of the population in different age cohorts, 1960-2000 .................... 1 Figure 2: Gini coefficient for selected countries................................................................. 3 Figure 3: HDI in relation to GNI per capita and Gini-coefficient ..................................... 5 Figure 4: Government allocation to health and social welfare as a percentage of total Government expenditure, 2001/01 – 2007/08 .................................................................... 7 Figure 5: The organization and lines of responsibility in the MHSS .............................. 14 Figure 6: Main types of disability in Namibia, by sex (numbers), 2007 ......................... 21 Figure 7: Adult HIV Prevalence & Number of People living with HIV/AIDS (1990- 2007) ................................................................................................................................. 23 Figure 8: HIV Prevalence Rate Among Pregnant Women in Namibia, 1992-2006........ 27 Figure 9: Life expectancy at birth in Southern African Countries (1950-2010).............. 28 Figure 10: GDP per capita and life expectancy ............................................................... 29 Figure 11: NTP budget line items, 2009.......................................................................... 32 Figure 12: Maternal Mortality Ratio (Per 100,000 Live Births), 1990-2006 and 2005... 37 Figure 13: Direct causes of maternal death, 2005............................................................ 37 Figure 14: Percent births delivered by caesarean section, by Region............................. 38 Figure 15: Percent of Pregnant Women Receiving Antenatal Care in Countries in Southern Africa, 2000-2006.............................................................................................. 39 Figure 16: Percent of Pregnant Women Receiving Antenatal Care in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 39 Figure 17: Percent of births attended by skilled staffed in Southern African countries, 1990 and 2006................................................................................................................... 40 Figure 18: Percentage of births assisted by SBAs, by income ........................................ 41 Figure 19: Use of postnatal care, 2009 ............................................................................ 42 Figure 20: Total fertility rate (number of births per woman) in countries in Southern Africa, 1990 and 2006....................................................................................................... 42 Figure 21: Adolescent pregnancy and education ............................................................. 43 Figure 22: Percent contraceptive prevalence rate in countries in Southern Africa, 2000- 2006................................................................................................................................... 43 Figure 23: IMR and U5 MR............................................................................................. 44 Figure 24: Distribution of U5 deaths by age cohort ........................................................ 44 Figure 25: Determinants of mortality, neonatal and under 5 years.................................. 45 Figure 26: Percent children (aged 12-23 months) receiving all basic vaccinations ........ 46 Figure 27: Nutritional status of children by age .............................................................. 47 Figure 28: Percent of children born with low birth weight.............................................. 48 Figure 29: Percent of Households Consuming Iodized Salt and Percent of Children 6-59 Months Receiving Vitamin A Supplementation in Countries in Southern Africa, 2000s 48 Figure 30: Life expectancy at birth (in years) in countries in Southern Africa, 1990 and 2006................................................................................................................................... 49 Figure 31: Maternal Mortality Ratio (Per 100,000 Live Births), 1990-2006 and 2005... 50 Figure 32: Total fertility rate (number of births per women) in countries in Southern Africa, 1990 and 2006....................................................................................................... 50 v Figure 33: Adolescent Fertility Rate (Number of Births Per 1,000 Women Ages 15-19) in Countries in Southern Africa, 1990 and 2006 .............................................................. 51 Figure 34: Percent Prevalence of Undernourishment in the Population in Countries in Southern Africa, 1990-92 and 2002-04 ............................................................................ 51 Figure 35: Percent of Children Under Five Who Are Malnourished in Countries in Southern Africa, 2000-06.................................................................................................. 52 Figure 36: Percent of the Population with Access to Improved Water Source in Countries in Southern Africa, 1990 and 2004 ................................................................................... 52 Figure 37: Percent of the Population with Access to Improved Sanitation Facilities in Countries in Southern Africa, 1990 and 2004 .................................................................. 52 Figure 38: Percent Prevalence of Diabetes (Population Ages 20-79) in Countries in Southern Africa, 2007....................................................................................................... 53 Figure 39: Per Capita Recorded Alcohol Consumption (in Liters of Pure Alcohol) Among Adults 15 Years and Above in Countries in Southern Africa, 2003.................... 53 Figure 40: Percent of Households Consuming Iodized Salt and Percent of Children 6-59 Months Receiving Vitamin A Supplementation in Countries in Southern Africa, 2000s 54 Figure 41: Percent Contraceptive Prevalence Rate (Married Women Ages 15-49) in Countries in Southern Africa, 2000-2006 ......................................................................... 54 Figure 42: Percent of Pregnant Women Receiving Antenatal Care in Countries in Southern Africa, 2000-2006.............................................................................................. 55 Figure 43: Percent of Births Attended by Skilled Staff in Countries in Southern Africa, 1990 and 2006................................................................................................................... 55 Figure 44: Per Capita Total Health Expenditure (US$ at Official Exchange Rate), 1998- 2003................................................................................................................................... 56 Figure 45: Percent Share of Total Health Expenditure to GDP in Countries in Southern Africa, 1999 and 2003....................................................................................................... 56 Figure 46: Percent Shares of Government and Private+Household Health Expenditure to Total Health Expenditure in Countries in Southern Africa, 2003 .................................... 57 Figure 47: Percent share of Government health expenditure to total Government expenditure in countries in Southern Africa, 1999 and 2003 ........................................... 57 Figure 48: Percent share of prepaid and risk-pooling plans to private health expenditure in countries in Southern Africa, 1999 and 2003 ............................................................... 57 Figure 49: Percent Share of Out-of-Pocket Expenditure to Private Health Expenditure in countries in Southern Africa, 1999 and 2003 ................................................................... 58 Figure 50: Percent share of external health resources to total health expenditure in countries in Southern Africa, 1999 and 2003 ................................................................... 58 Figure 51: Percent of GDP Spent on Social Assistance in Selected sub-Saharan African Countries, 2000s ............................................................................................................... 59 Figure 52: Density per 1,000 population of key health workforce cadres in selected countries in Eastern and Southern Africa, 2004 ............................................................... 59 Figure 53: Hospital beds per 10,000 population in selected Sub-Saharan African countries, 2000s ................................................................................................................ 61 Figure 54: Care-Seeking Behavior of the Poorest Quintile of the Population in Selected Countries in Sub-Saharan Africa (Percent)....................................................................... 61 Figure 55: Percent of survey respondents in selected countries in Sub-Saharan Africa who found health facitilies too expensive, 2000s ............................................................. 62 vi Figure 56: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Found Health Facilities Lacked Medicines, 2000s .................................................. 63 Figure 57: Percent of survey respondents in selected countries in Sub-Saharan Africa who experienced lack of health staff attention or respect, 2000s ..................................... 63 Figure 58: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Doctor Absenteeism, 2000s ................................................................ 64 Figure 59: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Long Wait at the Health Facility, 2000s ............................................. 64 Figure 60: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Found Health Facilities in Poor Condition, 2000s ................................................... 65 Figure 61: Percent of Survey Respondents in Selected Countries in Sub-Saharan Africa Who Experienced Health Facilities Demanded Illegal Payments, 2000s......................... 65 Figure 62: Percent Prevalence of Child Malnutrition in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ...................... 66 Figure 63: Percent of Children Who are Immunized Against Measles in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 67 Figure 64: Percent of Pregnant Women Receiving Antenatal Care in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 67 Figure 65: Percent of Births Attended by a Skilled Health Staff in the Poorest and Richest Household Quintiles in Selected Countries in Sub-Saharan Africa, 2000s ......... 67 vii  Introduction This report responds to the Government of Namibia's request to provide technical support in conducting a health sector review as part of the updating of the Health Sector Strategic Plan. Following the process agreed upon under the World Bank's Interim Strategy for Namibia, the Government submitted to the Bank a prioritized list of requests compiled from the various ministries. The requests from the Ministry of Health and Social Services (MHSS) were presented to the Bank during the February 2008 mission by the newly appointed Permanent Secretary. The most urgent need was support to the planned health sector review. The report benefited from missions undertaken by the Bank's team to Namibia in 2008 and 2009. The first mission occurred from May 19-21 when the Bank team travelled to Swakopmund to participate in the Health System Review Data Analysis Workshop at the Alte Brucke Resort and Conference Center. The second mission occurred from June 9-13 when the Bank team travelled to Windhoek to participate in the national conference to present the draft health sector review and initiate work on the strategic planning exercise at the NamPower Convention Center. The final missions took place during 2009, during which the Bank’s health team also participated in the post-flood assessments of health infrastructure. The preparation of this report largely followed to the MHSS timeline to undertake a comprehensive review and analysis of the country's health and social welfare system, including specific reviews of the following policy documents: (a) the Health policy Framework of 1998; (b) the Primary Health Care Approach and Strategy; and (c) Developmental Social Welfare Approach and Strategy. The various components of the review include governance, human resources, finance, services provision, and infrastructure. Several data-gathering and analytical activities are being done, including key informant interviews with district, regional, and national stakeholders; focus group discussions; exit interviews with patients; and health facility checklists. These activities began in February 2008 and concluded on June 12, 2008 when the Draft Report was presented in a national workshop at the NamPower Convention Center in Windhoek, as noted above. Role of the World Bank - Discussions with MHSS officials1 indicated that the World Bank is well placed to provide selected specific technical inputs in the drafting of the strategy and planning documents for both health and social welfare. The Government's interest included the following roles for the World Bank team: International benchmarking of Namibia's sector performance vis-à-vis other countries in the region, and other middle income countries. Sharing good international practices in the areas of health planning (e.g., health service packages, cost-effective interventions), social welfare (e.g., cash and other transfers, targeting of recipients), institutional reforms (e.g., public/private partnerships in health, hospital autonomy), decentralization (which services should be devolved to local authorities and which to be retained by central authorities), utilities pricing (e.g., rural 1 Key MHSS staff involved in these consultations included Ms. Celine Usiko (Chief of Planning and Human Resources, MHSS) and Dr. Vincent Orinda, chief technical consultant of the MHSS review and strategic planning exercise viii  water, health services), and general public expenditure management (e.g., budget allocation and execution). Peer reviewing draft documents. Providing practical recommendations both in terms of technical substance and the processes and sequencing of activities. To respond to these technical assistance requests, a World Bank team was formally constituted consisting of Sheila Dutta, Oscar Picazo, Eugenia Marinova, and Barry Kistnasamy. The team prepared this report. ix  Executive Summary The World Bank’s involvement with the health sector in Namibia is at a nascent stage (no previous health sector projects nor analytic work). The preparation of this report responded to the Ministry of Health and Social Services (MHSS) request for technical support in conducting a health sector review as part of their overall exercise of updating of the draft Health Sector Strategic Plan. The MHSS was particularly interested in an assessment which would provide informal benchmarking of Namibia’s health sector progress, in comparison with other lower middle-income countries, both regionally and globally. In responding to this request, the World Bank team developed the report in a manner which would enable this document to potentially serve as a background chapter for a proposed health sector public expenditure review, which would enable a more advanced stage of health sector analysis. As a result, the focus of this analytic work was to, first, conduct a sectoral assessment that could serve as a stepping stone for subsequent analytic work (e.g. Public Expenditure Review) and, second, to enable the Bank team to become more familiar with the structure and context of the Namibian health sector (in addition to issues surrounding data collection and accessibility). Given the early stage of the Bank’s health sector engagement in Namibia would have precluded the effective delivery of a full Country Status Report (CSR), the team agreed on the preparation of a Health Sector Note. The content of the Health Sector Note is structured as follows. Chapter 1 presents an overview of the sociodemographic and economic status of Namibia, in addition to a summary of its development progress and challenges in the health sector. Chapter 2 examines health expenditure trends since independence, with focus on internally-generated revenues in the sector, as well as health development assistance. Chapter 3 provides an overview of the structure of the Namibian public health system, including an examination of trends in access and utilization of health services and human resource management. Chapter 4 addresses the magnitude and impacts of Namibia’s HIV/AIDS epidemic. Chapter 5 examines the epidemiology of tuberculosis in Namibia, including an assessment of the TB/HIV co-epidemic. Chapter 6 reviews the impact of malaria on morbidity and mortality in Namibia. Chapter 7 summarizes the status of maternal and child health and includes a review of antenatal and post-natal care, in addition to reproductive health. Chapter 8 examines Namibia's health sector performance in the context of other Southern African countries and, more broadly, other middle income countries. This chapter was prepared in response to the MHSS’ interest in this type of informal regional benchmarking and addresses the following aspects of the health sector: health outcomes, risk factors, health service coverage, health system indicators, people's experiences in health facilities, and inequities in health. Chapter 9 concludes the Health Sector Note with a prioritized list of possible areas of future World Bank support including health sector governance, human resource, and public-private partnerships. x  Chapter 1: Sociodemographic and Economic Background A. Sociodemographic background 1. Namibia’s population was estimated to be 1.89 million by 2000. Given the country’s surface area of 823,700 km2, this yields a mean population density of slightly over 2 people per km2. In addition, Namibia’s population is distributed very unevenly across the country. Large areas of the country, particularly along the South Atlantic coast, are completely uninhabited and many other areas remain very sparsely populated. It is estimated that Namibia’s population has grown by about eight times since its first census in 1921, which enumerated a population of 229,000. It is estimated that Namibia’s population will continue increasing to 2.25 million by 2010 and 2.60 million by the year 2020. The annual rate of increase, however, is expected to decline from 3.0 percent to about 1.5 percent between 2010 and 2020, largely due to the impact of the HIV/AIDS epidemic and declining national fertility rates. Namibians are of diverse ethnic origins. The principal ethnic groups are the Ovambo, Kavango, Herero/Himba, Damara, Colored (including Rehoboth Baster), White (Afrikaner, German, English, and Portuguese), Nama, Caprivian, San, and Tswana. While the Ovambo comprise about half of Namibia's population, the San are generally assumed to have been the earliest inhabitants of the region. 2. There is considerable migration in Namibia, at present, both by people entering the country and by people moving from rural to urban areas. Accurate data on the numbers of immigrants are not available, although it is clear that many Angolans have moved to northern Namibia over recent years. More detailed information is available regarding rural-urban population movements within Namibia itself. It is estimated that the proportion of the national population living in urban areas has increased, over the past 100 years, from virtually 0 percent in 1901 to 39 percent by 2001. It is anticipated that over 80 percent of Namibia’s population may be living in towns/urban centers by the year 2020. 3. A comparison of population data for 1960, 1970, 1991 and 2000 indicates that, interestingly, age cohort proportions have remained largely constant over the past 40 years (Figure 1). There has been a slight reduction in the proportion of 0 to 4 year-olds and a minor increase in the percentage of 5-14 year-olds, but few other significant variations in population structure during this period. People under the age of 15 years continue to constitute about 45 percent of the total population. Figure 1: Percentages of the population in different age cohorts, 1960-2000 1  Source: MOHSS, 2008. 4. Declining fertility rates are, in addition to the impacts of HIV/AIDS, are the most significant demographic changes to have occurred in Namibia in recent decades. The national fertility rate has dropped by almost 2 between 1991 - 2000 (from 6.1 children in 1991 to 4.2 children in 2000). Much of the decrease is due to the greater involvement of women in the cash/formal economy and improved levels of education. An analysis by the Ministry of Health and Social Services (MHSS) indicated that women who attended secondary school produced progressively smaller families the higher the grade they completed. Urban-rural disparities in fertility continue to be evident. Women in rural areas have an average of 5.1 children, two children more than mothers in urban areas (urban fertility rate of 3.1 children in 2000). 5. While Namibia has achieved major gains in reducing mortality among children over the past 10 years, life expectancy unfortunately has worsened. The HIV/AIDS epidemic has caused a dramatic decline in life expectancy. The overall life expectancy in 1991 was 61 years. By 2000, the MHSS estimated that this figure had declined to 43 years. While there were significant declines in life expectancy in all regions, the biggest reductions have been in Hardap, Caprivi, Oshikoto and Omusat – unsurprisingly, the regions most heavily impacted by HIV/AIDS. The overall impact of the HIV/AIDS epidemic is further discussed in Chapter 4. B. Economic background 6. As noted in the Interim Strategy Note2 (2007), Namibia is a small open economy which is closely linked to South Africa. With a 2006 per capita income of about US$3,000, Namibia is classified as a lower middle-income country (LMIC). At independence, Namibia inherited a functioning physical infrastructure and a market economy, in addition to rich mineral resources and a relatively strong public administration. Government has put these assets to good use to produce almost two decades of economic growth and political stability. However, the social and economic imbalances of the apartheid system also left Namibia with a highly dualistic society. The structure of the economy has made job creation and poverty reduction difficult, and income inequality remains very high. 7. Namibia has experienced steady growth, moderate inflation, strong external surpluses and low indebtedness over the past several years as a result of generally prudent fiscal policies, a stable political environment, a fairly developed infrastructure, and a strong legal and regulatory environment. Economic growth since independence has been good, if somewhat volatile, averaging 4.3 percent per annum, and sufficient to increase per capita income in most years. Much of the recent volatility in growth can be traced to spurts in diamond production in 2004 and 2006. 8. Overall, the economy is dominated by the service sector, public and private, which accounts for around 60 percent of overall output. GDP growth peaked at 14 percent in 2002 and has averaged about 9 percent since this time. Efforts to diversify the economy have not been successful for a number of reasons, including the generally low level of education in the labor force, insufficient technological sophistication, limited domestic investment, and Namibia’s proximity to the much larger South African economy. 2 Namibia Interim Strategy Note (2007). The World Bank, Washington, D.C. 2 9. The generally good growth and macroeconomic picture is overshadowed by three worrying and related features of the economy: the lingering high levels of poverty; high unemployment; and the country's unequal distribution of wealth and income. While poverty has declined since independence, it remains high at 27 percent. Unemployment, at nearly one-third of the labor force, is a major cause of poverty. Namibia's income distribution, as illustrated by its Gini coefficient of 0.60, remains among the highest in the world (Figure 2). Figure 2: Gini coefficient for selected countries Source: World Bank, Namibia Interim Strategy Note (2007) 10. The post-independence Government identified poverty alleviation, reduction of income inequality, job creation and sustainable economic growth as the main four national development objectives. The means selected to achieve this was to prioritize expenditure in the social sectors – in particular health and education. As a result, the education and health sectors have traditionally received the highest budget allocations in the years since independence. 11. In response to the current global economic slow-down, the Namibia government has adopted a more expansionary fiscal policy stance, aimed at “weathering the storm.