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Comprehensive Analytical Profile: Namibia

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This analytical profile provides a health situation analysis of the Namibia and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to Country Context
2. Health Status and Trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
LocationNamibia.gif

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Statistical profile
Introduction to Country Context

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 of Africa’s largest deserts: the Namib to the west and the Kalahari to the east.

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Africa Namibia map.png

The climate is mainly arid and semi‐arid with sparse and erratic rainfall. Environmental concerns include desertification, recurring drought and floods, depletion of natural resources, loss of biodiversity, decline of water quality, pollution from solid and domestic waste, and aquatic acidification. Repeated drought and floods have seriously affected the food security of mainly rural populations as successive harvests have been destroyed.

Floods in 2009 and 2010 led to severe water-logging and affected over 300 000 people.[1] According to the Food and Agricultural Organization of the United Nations and the World Food Programme Crops, livestock and food security assessment mission to Namibia,163 000 people in the north‐eastern and central regions of the country are food insecure.

Nationally, 92% of households have access to an improved source of drinking water, but 12% of the rural population obtains water from unimproved sources.[2]

According to the latest United Nations Children's Fund figures, only 17% of rural households do not use improved sanitation facilities.[2]

References

  1. Disaster assistance: Namibia. United States Agency for International Development
  2. 2.0 2.1 Namibia statistics. United Nations Children's Fund
Health Status and Trends

The health status of Namibia has been heavily impacted by the HIV/AIDS epidemic and negatively affected by the country’s unequal socioeconomic development. The top 10 causes of death are currently AIDS, diarrhoea, pneumonia, pulmonary tuberculosis, health failure, other respiratory system ailments, anaemia, malnutrition, stroke and malaria.

The Ministry of Health and Social Services has prioritized the implementation of three health Millennium Development Goals, namely goals 4, 5, and 6: to reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria and other diseases, respectively.[1]

The 2001 Population and Housing Census showed a dramatic drop in life expectancy in Namibia since the previous census in 1991 – from 59 to 48 for men, and 63 to 50 for women. The main reason for this drop, as was the case in many countries in the WHO African Region, was the HIV epidemic.[2] Thanks to the concerted HIV response, as well as other health initiatives, Namibia has already exceeded its 2012 target as set by NDP 3 (ensure that life expectancy is 51 years); according to latest figures, life expectancy in Namibia is currently estimated at 62 years.[3]

Progress
Progress on SDGs
The Health System
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)

Leadership and governance

At independence, Namibia inherited a fragmented health system based on racial segregation and marked by a concentration of infrastructure and services in urban areas. Since independence in 1990, a number of health sector reforms have taken place, including 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 health system still faces challenges due to persisting inequities as well as the scattered nature of the Namibian population, with consequent difficulties in geographical access to health facilities. Structural and systemic issues within the Ministry of Health and Social Services (MoHSS) are also hampering the effective and equitable provision of health services.

Namibia has a pluralistic health system in which the MoHSS serves about 85% of the population, and the private sector serves the other 15%. There are 1150 outreach points, 309 clinics and health centres, 29 district hospitals and 4 intermediate and referral hospitals. One problem that needs to be addressed is that referral hospitals are not autonomous (MoHSS, July 2010).

Community ownership and participation

The National Health Policy Framework 2010-2020 states that “All Namibians will be encouraged and empowered to actively participate in activities which promote good health and prevent ill health at individual, family and community level, hence complementing the health and social welfare services. The public system will provide an enabling environment for this to happen through supporting community health.”

Literacy rates in Namibia overall appear to be high (MoHSS and Macro, August 2008). However, regional and district disparities exist and health literacy levels among the population appear to remain low as a whole, as evidenced by inadequate maternal and child nutrition and increasingly high non-communicable disease figures, among others. Although the causes of these problems are partly socio-economic, health education plays a key role.

General health promotion is inadequate with no national strategy, poor coordination and capacity gaps all levels. (MoHSS, 2008) Health promotion is a priority for the MoHSS, and behaviour change communication has become mainstream on the back of HIV and AIDS strategies.

Partnerships for health development

Partner coordination in Namibia is governed by the Partnership Policy of 2005. The Ministry of Health and Social Services (MoHSS) plays a stewardship role in the health sector. Currently, donor coordination in the MoHSS is facilitated by a subdivision: Development Cooperation (SDC) within the division Policy and Planning, directorate: Human Resources Development, Policy & Planning (HRD, P&P) as well as subdivision: Resource Mobilisation and Development Coordination in the Directorate Special Programmes.

HIV, malaria and TB interventions are coordinated by the Directorate of Special Programmes (DSP) Overall, there is inadequate coordination between the various vertical programmes involving partner agencies, as evident in the parallel management of HIV/AIDS and other Primary Health Care programmes . (MoHSS, 2008)

Health information, research, evidence and knowledge
Health financing system

The budget for the Ministry of Health and Social services (MoHSS) as the provider of public health services is established within the annual government budget and Medium-Term Expenditure Framework (MTEF). The budgeting process in the Ministry involves all levels at national, regional and district, to ensure that the budget allocations match priorities at the specific levels. Planning and budgeting are done in separate entities in the MoHSS and need to be brought together.

The Ministry of Finance (MoF) has introduced an integrated financial management system (IFMS), which has the potential to de-concentrate access to this system but, unexpectedly, it has made it more cumbersome for the regions to access funds as the system is not yet established in the regions. Funds Distribution Certificate (FDC) holders (regions and directorates at central MoHSS) control their budget allocations and are the key actors involved in planning and budgeting. Accountability, financial and programme, still leaves much to be desired and needs to be streamlined with routine procedures in place. (MoHSS, July 2010)

Service delivery

The MoHSS is the main implementer and provider of public health services with a four tier system: outreach points (1150) clinics and health centres (309), district hospitals (29) and intermediate and referral hospitals (4). Faith-based organisations operate services for the MoHSS on an outsourcing basis. The private sector is sizeable, with 844 private health facilities registered with MOHSS.

These include 13 hospitals, 75 clinics and 8 health centres, mainly in urban areas of Erongo and Khomas regions. 72% of doctors in Namibia are in the private sector and a little less than 50% of registered nurses. The public sector cannot currently adequately respond to the needs for certain referral level specialised services so the MoHSS is looking into introducing new services and technology through the public-private partnership model. (MoHSS, July 2010)

The 13 regions have Regional Management Teams (RMTs), which are responsible for the translation, implementation and management of the public health system in the respective regions, including the hospitals. There has been some de-concentration of planning and management functions to the regions and the districts. The health district is coordinated by the DCC.

Health workforce

Namibia faces a human resource crisis in the public health sector, which is characterised by a shortage of health professionals, high vacancy rates for all categories of staff, high attrition rates (mostly due to resignations), lack of a human resources retention strategy, staff burn‐out (and incomplete implementation of the Employee Assistance Programme) and inadequate capacity at local health academic institutions to produce the required number of needed health workers.

In the public health system, Human Resource Management comes under the Directorate of Human Resources and General Services whereas Human Resource Development is in the Directorate of Policy Planning and Human Resource Development.

The MOHSS has a Long-Term Human Resource (HR) strategic framework forecasting the future needs and supply of required staff in the country for a period of thirty years (1997- 2027). Subsequently, a Medium-Term Human Resources Plan (1997-2007) and Five-year Human Resource Development Plans (2000-2005; 2008-2012) were developed to serve as guidelines for HR planning.

Medical products, vaccines, infrastructures and equipment

The Pharmaceutical Services Division of the MoHSS comprises of the Office of the Deputy Director and three sub-divisions, namely Pharmaceutical Control and Inspection (PC&I), National Medicines Policy Co-ordination (NMPC) and Central Medical Stores (CMS). The CMS serves as the Ministry's central agency for procurement, storage and distribution of essential medicines and vaccines, and related clinical supplies for the public health sector. (MoHSS, 2008)

The roll out of ART services to all districts in Namibia has put increased pressure on the Central Medical Stores in terms of staff and storage space. (MoHSS, July 2010)

The National Drug Policy of 1998 provides comprehensive guidelines and regulations for public and private pharmaceutical sectors in line with WHO recommendations on national drug policies. This policy is currently under revision. Medicines procured, stored and distributed are those approved by the Ministry and are specified in the Namibian Essential Medicines List (Nemlist). (WHO, 2010)

General country health policies

Overview of major policy reforms The Namibia health and social services sector since independence was guided by the Policy Statement of 1990 and the 1998 Policy Framework. The National Health Policy Framework 2010-2020 was developed to keep pace with changes in the health sector and is aligned to the National Development Plan 3, the Ministry of Health and Social Services Strategic Plan 2009–2013, and the Millennium Development Goals. (MoHSS, July 2010)

The main reform initiatives that have taken place since independence include the restructuring and re-orientation of the health sector in line with the Primary Health Care (PHC) approach; the shift in orientation of social services from curative and remedial social work to a developmental approach with emphasis on prevention of social ills and empowerment of individuals, groups, and communities; the performance improvement of the civil service through the establishment of the Wages and Salaries Commission (WASCOM) and the introduction of the Public Service Charter; the broadening of health financing options through the introduction of user-fees policy at all facilities; and the introduction of the principle of managed competition in the area of buying-in support services. (MoHSS, 2008)

Universal coverage

The public and private not‐for‐profit health‐care system serves 85% of the Namibian population and is accessed by the lower income population. The private for‐profit health‐care system serves the remaining 15% of the population, consisting of the middle and high income groups.

Organizational framework of universal coverage

Overview of main actors and arrangements related to universal coverage

The 2008 HSSR recommended a feasibility study for universal coverage (free health services through universal insurance scheme), which is one of the principles of the government’s Primary Health Care approach to public health.

Specific Programmes and Services
HIV/AIDS

Over the past 20 years the HIV epidemic in Namibia has negatively impacted on health and development indicators, and will remain a major challenge for the next 10 to 20 years. Although the number of new HIV infections (incidence) has begun to decline, HIV prevalence in Namibia has stabilised at a high level and continues to burden the health care system, to fuel new infections and to pose serious developmental challenges.

The epidemic impacts both directly and indirectly on the well-being of the vast majority of the population, the performance of the formal and informal economy, the capacity of public and private sectors to provide services, and the attainment of all MDGs (Millennium Development Goals). The primary responsibility for facing the challenges of HIV and AIDS in Namibia lies with the Directorate of Special Programmes of the Ministry of Health and Social Services, working in co-operation with other ministries and initiatives.

Tuberculosis

In 2007 Namibia was the country with the fifth highest incidence of TB (WHO, 2009), the epidemic being fuelled by the generalized HIV/AIDS epidemic in the country. The case notification rate (CNR) and absolute number of TB cases have been on a downward trend since 2005, with a major (10%) reduction observed between 2007 and 2008. (MoHSS, 2010)TB prevalence gradually decreased from 1,287 per 100,000 in 1990 to 603 per 100,000 in 2010. (WHO, 2011)

The Government of Namibia has consistently provided high quality first- and second-line medicines for TB treatment, which are provided free of charge. Eight out of every ten health-care facilities offer diagnostic services for TB, though some regions have better coverage than others and the quality of service varies from place to place. (MoHSS, 2009HFC) Infection control is another area where significant efforts have been made to reduce the burden of the disease in the country. The recently adopted Second Medium Term Strategic Plan 2010-2015 aims to reduce TB prevalence to 50% of 1990 levels by 2015. (MoHSS, 2010SPTBL)

Currently less than half of funding for TB treatment, care and prevention comes from domestic sources (WHO, 2011); it is clear that Namibia needs to work towards taking a greater share of the responsibility for maintaining, improving and extending these programmes.

Malaria

The arid regions of Erongo, Hardap, Khomas and Karas are considered free of malaria transmission and almost risk-free. Some risk exists in the southern regions, but it is uncertain whether the cases reported in these areas are imported or locally acquired. The areas of high transmission and population density are located along the northern border of the country. (MoHSS, December 2010)

In 2008 there were 128,531 (62/1,000) reported outpatient malaria cases and 5,233 (0.9/1,000) inpatient cases. A total of 199 deaths were reported in the same year. (HMIS data of August 2010) Transmission risk is currently estimated between 15% in low risk areas and 55% in high risk areas. (MoHSS, December 2010)

The National Vector-borne Diseases Control Programme (NVDCP) was introduced in 1991 and supported by the National Policy and Strategy for Malaria Control in 1995 (MoHSS, 1995). In 2006 a policy of parasitological diagnosis using Rapid Diagnosis tests (RDTs) was introduced.

Immunization and vaccines development

TB remains a serious concern in Namibia, which has one of the highest case notification rates in the world. However, the number of TB cases notified has dropped from 16,156 in 2004 to 13,332 cases in 2009 (WHO Namibia, 2010; MoHSS, December 2010). The diseases that are targeted for elimination and eradication include polio, measles, neonatal tetanus and malaria.

Namibia has already achieved the elimination of neonatal tetanus and measles and is recognized by the African Regional Certification Commission (ARCC) as a polio‐free country. (WHO, 2010) Notwithstanding these gains, Namibia has experienced a number of epidemics in recent years, such as cholera, crimean congo haemorrhagic fever, influenza H1N1 (2009), measles, meningococcal meningitis, polio and rift valley fever. (MoHSS, 2011)

Immunisation against the major infectious diseases is one of the eight elements of the PHC approach that has been adopted by the MoHSS. The Expanded Programme on Immunization (EPI) within the Ministry of Health and Social Services (MOHSS) was formally established in June 1990, 3 months after independence. The programme aims to achieve and maintain vaccine coverage above 90% for all antigens (namely tuberculosis, diphtheria, whooping cough (pertussis), tetanus, polio, and measles) in every district with a dropout rate of less than 5% by the year 2010 and beyond, sustain the elimination of neonatal tetanus, poliomyelitis measles by the year 2010 and beyond.

Child and adolescent health

Infant mortality declined from 71 deaths per 1,000 live births in 1980 to 45 in 2006. The same trend is observed in the under-five mortality rate, which is 61 deaths per 1,000 live births. (Inter-Agency Child Mortality Estimation Group (IACMEG), 2009; MoHSS and Macro, August 2008). Although acute respiratory infections are among the leading causes of morbidity and mortality in children under-five, not enough has been done to improve the management of acute respiratory infections.

The MOHSS essential indicators report of 2006/07 show that diarrhoea (29%), pneumonia (29%) and HIV/AIDS (8%) are the major causes of infant mortality. The same three conditions are the leading cause of child mortality (age 1 to under5 years) with diarrhoea causing 35% of reported deaths and pneumonia and HIV/AIDS causing 24% and 8% of reported deaths respectively. The high prevalence of diarrhoea is largely due to poor sanitation and hygiene practices especially in some regions such as Caprivi, Kavango and Ohangwena. Community based treatment for pneumonia has not yet been introduced in Namibia. (MoHSS, 2008)

Concerns around adolescent health focus on STIs (including HIV), alcohol and substance abuse, and mental health, but specific data is lacking.

Maternal and newborn health

Women’s health has come to the fore in the nation’s health agenda most recently due to concerns over maternal health. The maternal mortality ratio is on the increase (almost doubling between 1992 and 2007) despite increased delivery at health facilities, indicating weaknesses in the quality of services.

The DHS of 2006/2007 shows that the perinatal mortality rate was 29 per 1,000 pregnancies. The overall rate of stillbirths is below 10 in 1,000 pregnancies, while early neonatal mortality lies at 20 deaths in 1,000 pregnancies. (MoHSS and Macro, August 2008) Infant mortality declined from 71 deaths per 1,000 live births in 1980 to 45 in 2006. The same trend is observed in the under-five mortality rate, which is 61 deaths per 1,000 live births. This is a marked improvement from the 1980 level of 108 deaths per 1,000 live births (Inter-Agency Child Mortality Estimation Group (IACMEG), 2009).

However, according to the DHS 2006/2007 data, there is a slight upwards trend in infant and under-five mortality as compared to 2000 (38 to 46 and 62 to 69 respectively) which poses a significant challenge. The reduction in the under-five mortality rate, which is expected to be 42 deaths in 1,000 live births, is not sufficient to meet the MDG target of 29 per 1,000 live births by 2015.

Gender and women's health

Women’s health has come to the fore in the nation’s health agenda most recently due to concerns over maternal health. The maternal mortality ratio is on the increase (almost doubling between 1992 and 2007) and the nutrition and overall health of pregnant women appears to be impacting on the under‐five mortality rate in general, and newborn mortality in particular, which are not decreasing fast enough to meet MDG 4.

These trends occur in a context of increased delivery at health facilities, indicating challenges in the quality of services. At the same time, spending on maternal, child and adolescent health is declining and emergency obstetric care coverage is very low and inequitable. A 2005/06 EmOC Assessment Report found that only four out of 34 hospitals provided comprehensive EmOC. (MoHSS and Macro, August 2008)

The primary direct causes of maternal mortality in Namibia are severe eclampsia (33%), haemorrhage (25%) and obstructed or prolonged labour (25%). The most common direct obstetric complication treated in Namibia in 2006 was obstructed or prolonged labour (38%). According to the MoHSS, HIV/AIDS is the leading indirect cause of maternal mortality in health facilities, accounting for 37% of total mortality. Other causes include malaria, tuberculosis, meningitis and pneumonia. (MoHSS, 2010)

Epidemic and pandemic-prone diseases

The diseases that are targeted for elimination and eradication include polio, measles, neonatal tetanus and malaria. Namibia has already achieved the elimination of neonatal tetanus and is recognized by the African Regional Certification Commission (ARCC) as a polio‐free country. (WHO, 2010) The malaria mortality rate declined drastically from 96.5 per 100,000 population in 2000 to 8.4 per 100,000 population in 2008 (WHO Namibia, 2010).

Although malaria is virtually confined to the northern part of the country, with approximately 67% of the population living in malaria‐endemic areas it is still one of the leading causes of death among under‐five children and adults in Namibia. (WHO, 2010)

However, the annual incidence and mortality rate due to malaria has dropped since 2000. A total of 199 deaths were reported in 2008, compared to 679 in 2000 (HMIS data as of August 2010 (MoHSS, December 2010)).

Neglected tropical diseases

Despite Namibia having reached the leprosy elimination target of less than one case per 10,000 inhabitants nationally, there are still pockets of the disease, particularly in Caprivi and Kavango regions. Following a WHO-supported assessment in 2009, four new cases were identified, adding to the 22 cases reported in 2007 and 2008. Training workshops and a review meeting were conducted to target Kavango and Caprivi. (MoHSS, NTLP Annual Report 2010) There is no data on the disease burden of other neglected tropical diseases in Namibia.

Schistosomiasis and soil-transmitted helminthesHelminths poses a serious health problem in the northern regions particularly in Caprivi, Kavango and Omusati regions. It is likely that 14% of the population are infected, with many more at risk of infection. According to the study done in the affected regions in 2000 and 2001, the prevalence of schistosomiasis in Namibia ranges from 17% - 100% in Kavango, 0% -54% in Caprivi and Omusati regions.

The rates of anaemia among pregnant women are highest in these regions where soiltransmittedsoil transmitted helminthesHelminths and schistosomiasis are endemic. These areas are also associated with the highest rates of growth retardation among children. The school population also suffers from worm and other parasitic diseases such as schistosomiasis. These results warrant attention as a public health problem. (MoHSS, July 2010)

Non-communicable diseases and conditions

Evidence shows that NCD’s, long thought to be the burden of high-income populations, are affecting more low-and middle-income countries, including Namibia. According to the demographic health survey series, non-communicable diseases (NCDs) such as cancer, diabetes, cardiovascular diseases and chronic respiratory illnesses are among the top 10 diseases and top 15 causes of death in Namibia. Diabetes alone is emerging as one of the greatest threats to health.

Between July 2010 and July 2011, 3,650 new cases of the disease were recorded in the country’s public health facilities. To date, the major focus of health interventions in Namibia has been on communicable diseases, but in response to prevalence figures the health sector has now made the prevention of NCDs a priority. An integrated multi-sectoral NCD Task Force under the leadership of the MoHSS is now in place an NCD strategy is under development.

Reducing risk factors is being pursued as one of the best ways to prevent chronic diseases. The National Policy on Health Promotion, which is currently being drafted, outlines ways for reducing risk factors while improving health services to address the situation. The policy calls for a ‘whole-government’ approach, which is fundamental to addressing the crosscutting issues and underlying socio-economic determinants of health, such as the regulatory environment around alcohol and tobacco.

Key Determinants
Risk factors for health

The main risk factors for health in Namibia include alcohol consumption, tobacco use, unhealthy or nutrient deficient diets, escalating overweight and obesity, sedentary lifestyles, risky sexual behaviour and inadequate hygiene.

Evidence shows that non-communicable diseases (NCDs) such as cancer, diabetes, cardiovascular diseases and chronic respiratory illnesses, long thought to be the burden of high-income populations, are affecting more low- and middle-income countries, including Namibia. According to the demographic health surveys, NCDs are among the top 10 diseases and top 15 causes of death in Namibia. Health facility-based data indicate hypertension and diabetes as the first and second causes of disability among adults respectively.

The 2008 estimated prevalence of raised blood pressure was 43.4%. HMIS data are used for surveillance of blood pressure, blood glucose and cholesterol measurements. To date, the major focus of health interventions has been on strengthening the prevention and control of communicable diseases, with little attention paid to noncommunicable diseases (NCDs) and their associated risk factors, such as tobacco use, poor diet and unhealthy lifestyles. In 2010, an NCDs Committee was established to advocate, mobilize resources and plan for NCDs prevention and control programmes.

The physical environment

The environment influences our health in many ways - through exposures to physical, chemical and biological risk factors, and through related changes in our behaviour in response to those factors. With increased globalization, climate change, increased population mobility, Namibia’s physical environment is being affected and so too is the health of its citizens.

Data on the urban environment is sparse. There are two major urban areas, namely the capital city, Windhoek and the centre of the fishing industry, Walvis Bay. According to the National Population Census of 2001, Windhoek’s total population was estimated at 233,529 people, which accounted for about 39% of Namibia’s total urban population at that time. (City of Windhoek, August 2011) W

hile urbanization brings along development and other good opportunities, it is associated with health challenges such as overcrowding, pollution, poor sanitation, unhealthy lifestyles and all these contribute to poor health for the citizens. In Namibia, children from the poorest urban quintile are 2.7 times more likely to die before the age of 5 than children from the wealthiest urban quintile, and 5 times more likely to be chronically malnourished. They are also more likely to be malnourished than children from rural areas. (WHO Urban Health Profile)

Food safety and nutrition

Namibia’s potential for agriculture is severely limited due to climatic and soil factors. The main food crops grown in Namibia are millet and maize. Other food crops include ground nuts, maize, wheat and sunflowers. During the past five years agricultural output has been seriously constrained by recurring drought, floods, locusts, insects and worm invasions.

The main agricultural output in Namibia is livestock (mainly beef cattle, sheep and goats) which is produced on commercial and communal farms. (FAO, 2008) The Ministry of Agriculture, Water and Forestry (MAWF) is implementing initiatives geared to improving food production, including the diversification of crop production to bring about improved nutritional status in the country. These initiatives include projects such as Green Scheme, National Horticulture Development Initiative, Dry-land Crop Production for grain producers and Strategic Food Reserve Facilities (silos). (MoHSS, 2011)

Detailed data on common food intake patterns in Namibia is sparse and information is mainly based on popular knowledge. It is believed that meals mostly consist of maize meal or mahangu (millet) which is prepared as porridge or thick paste. This is usually accompanied by fish or meat and few people consume legumes.

Social determinants

It is widely understood that the health is of a nation is heavily influenced by the social and economic conditions in which people are born, grow, live, work and age. In Namibia, gross inequalities in social and physical living conditions result in widely varying health indicators for different segments of the population. For the majority of the population, enjoying good health is inhibited by low income, lack of education, inadequate sanitation and water supply, and social problems such as gender-based violence.

Namibia is a vast country but is sparsely populated with 2.8 persons per square km. The majority of the population lives in rural areas, often beyond the reach of road infrastructure and basic social services including water, sanitation, food and health care. Almost two-thirds of the population reside in the four northern regions and less than one-tenth lives in the south. There are significant differences in average living standard indicators between urban and rural areas. For example, two thirds of the population have non-improved household sanitation facilities (mostly in rural or peri-urban areas) and nearly 27% of rural households require 30 minutes or longer to obtain drinking water. Inadequate sanitation and water provision is directly linked to increased health risks.



References
  1. Windhoek, Government of Namibia, Ministry of Health and Social Services, 2010
  2. Namibia Demographic and Health Survey 2006-07 (pdf 2.6Mb). Windhoek, Ministry of Health and Social Services; and Calverton, Maryland, Macro International, 2008
  3. United Nations Children's Fund