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Issues and challenges - Progress on the Health-Related MDGs

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MDG 1 :

The causes and effects of poverty are extensive, complex and multifaceted. The challenges faced by Namibia in responding to poverty lie mainly in the implementation of existing policies, plans and strategies as Namibia has created an enabling policy environment for poverty alleviation. The test now is to make programmes work on the ground and in areas where the needs are urgent and concentrated. Serious attention, therefore, needs to be paid to those regions with the highest poverty and inequality levels, rural areas, female-headed households, children, the disabled and pockets within well-off regions such as informal settlements in urban settings. This section highlights key challenges and recommends interventions that would realistically support acceleration of MDG 1 implementation for the remaining period until the end of 2015. The recommendations would need consideration within the frameworks of NDP 4 and respective sectoral plans, and in conjunction with recommendations made for the remaining seven MDGs.

Challenges Interventions to expedite MDG implementation
Food insecurity and malnutrition at household level have a negative effect on overall development, most specifically for children.
  • Raise awareness of household food security programmes
  • Food aid in the form of drought relief food or food-for-work should be directed to the most vulnerable first
  • Scale up the school feeding programme to provide for all children and not only OVC
  • Raise budget allocations for food production programmes, such as the Green Scheme and Dry Land Agricultural Programme
  • Continue to raise awareness of the most appropriate breastfeeding practices and improved nutrition for children and their mothers
  • Raise awareness about the importance of consuming fortified foods
  • De-worm all children between 1 and 5 years of age
Namibia has a long-standing and well-established social grant system but the distribution of the number of grants and amounts paid per person are still relatively low. The coverage of social grants is affected by inefficient budgets, but also the inability of eligible persons to gain access to such grants. Additionally, poverty stricken children who are not classified as orphans and many extremely poor households are not covered by current social grants.
  • Speed up the registration and issuing of vital documents to enhance access to social grants
  • “More social workers are needed and they need to be freed up from administrative work in order to focus on child protection issues” (NDP 4:63)
  • Expand the social grant system to include children in poor and severely poor households
  • Social grants should be increased annually as inflation increases and the increments need to be higher than inflation because the individual payments are small in number
  • Reconsider the commencement of the Basic Income Grant (BIG)
Ongoing corruption and mismanagement of public funds are serious challenges, given that theft of public funds takes away resources geared towards development of the nation, especially the poor.
  • Implement the Zero Tolerance for Corruption strategy more effectively
Strategies need to be designed in such a fashion that beneficiaries of poverty reduction programmes are active participants in their own development. Programmes and projects need to be designed in such a fashion that they do not increase dependency on government and other external support, but enhance self-sufficiency.


MDG4:

Several road maps have been developed and workshops facilitated to accelerate the reduction of child mortality in the country’s effort to reach MDG 4 by 2015. These have resulted in the design of strategies and the current implementation of a number of initiatives. Some of the key challenges and a set of recommendations towards expediting implementation and improving Namibia’s chances of achieving this Goal within the remaining two year period are outlined below. The overall recommendation is based on the need for the public health sector to become more proactive in its responses.

Challenges Interventions to expedite MDG implementation
The state of health infrastructures is such that there is a public outcry for improvement in buildings, equipment, water, sanitation, electricity and other facilities
  • Urgent attention needs to be paid to the condition of infrastructure in public hospitals, health centres and clinics
  • An increased budget allocation is needed for regular maintenance of health infrastructure but such funds need to be well used, starting with a tendering process that is efficient and provides value for money
  • Increase the number of maternal waiting homes near major hospitals
While generally a good quality service is provided, some ineffective and inefficient management of health service provision at national, regional, district and local levels has contributed to lower quality health provision, especially as it relates to child health. This includes management of staff shortages.
  • Strengthen the capacity of health management teams to plan, manage, implement, monitor and evaluate
  • An in-depth assessment is needed to determine the qualifications of health managers, with recommendations to strengthen overall management
  • Strengthen the Reproductive and Child Health sub-division
  • Enhance the capacity of personnel and infrastructure to provide AFHS
  • Strengthen follow-up mechanisms, including tracking of mothers and children through the health system
Lack of basic skills among some nurses to prevent child mortality, noting that a large proportion of newborn deaths is preventable. In addition, the undesirable attitude of some health personnel towards patients, discourage some from seeking medical support unless absolutely necessary.
  • In-service training needs to be strengthened
  • Self-assessment tools that are already in place need to be utilised
Referral systems are weakened by poor communication between health service providers and patients, and lack of transportation to referral health facilities
  • Establish community health committees and emergency committees to support access to health facilities and referrals
  • Such committees need to establish appropriate communication and transportation mechanisms relevant to an area and based on local resources
  • Roll out the Community Health Extension Officer programme currently being piloted in five regions
Difficult access to health services, especially for severely poor and marginalised groups
  • Planning for infrastructure development needs to be based on current and projected future geographical distribution of people
  • Sufficient allocation of public funds needs to be allocated to infrastructure development
  • All health service providers need to be informed about the exemption of OVC so that is applied consistently
  • The exemption needs to be revised to include the severely poor as well, especially as some OVC are better off than some severely poor
  • Community Health Committees need to be established to improve access through better coordinated transportation and communication with health service providers
Low awareness of maternal and child health, especially in remote and poor areas, contributes to higher mortality rates in such regions.
  • Promote maternal and child healthcare
  • Promotion of the involvement of the entire family in maternal and child health, especially involvement of males
  • Develop and disseminate culturally sensitive information, education and communication (IEC) materials on child health, prenatal care, postnatal care, PMTCT and family planning
  • A rights-based approach to awareness raising is needed, ensuring that parents know their own and their children’s health rights
  • Continue to raise awareness of the importance of child immunisation
  • Expand health extension workers services to all thirteen regions to bridge the gap between facilities and the communities needing access
Illegal and unsafe abortions and baby-dumping contribute to increased child and maternal mortality.
  • Raise awareness about abortions and baby-dumping, while current legislation is reviewed to decrease unsafe abortions and baby dumping
The existing M&E system is not used optimally to plan for child health.
  • Strengthen the M&E of the Health Management Information System (HMIS) to make data more frequently available
  • Capacitate health professionals and administrators to apply available data from HMIS

MDG5:

Namibia needs to continue with the implementation of the above-mentioned Road Map with the aim of ensuring a continuum of care connected by effective referral links and supported by adequate skills, supplies, equipment, drugs and transportation. The challenges outlined and recommendations made here are also relevant to the child mortality goal (MDG 4).

Challenges Interventions to expedite MDG implementation
The human resource challenges include shortage of skilled health workers, high attrition, language barriers between patients and some health professionals, and shortage of basic lifesaving skills among nurses.
  • Design a health professional human resources development plan
  • Improve retention of health professionals with strategies such as scarce skills allowance, rural hardship allowance, and staff housing especially in rural areas
  • Accelerate training of all health workers, and design a long-term training plan
  • Build capacity of all categories of reproductive health service providers, including traditional birth attendants, nurses, midwives, etc.
Essential medicines including ergometrine, oxytocin, MgSO4 and others are unavailable at lower levels of healthcare delivery.
  • Ensure the availability and maintenance of essential medicines and equipment at all MCH centers
Health infrastructure is not appropriate to providing all required services.
  • Design clinics that cater appropriately for all health needs
  • Expand maternal waiting rooms
Slow implementation of decentralisation.
  • Speed up the decentralisation and devolution of power to regions and districts, with appropriate budget allocation
Community outreach is challenged by limited male involvement, weak referral systems and the difficulty of maintaining momentum.
  • Strengthen male involvement in sexual and reproductive health
  • Strengthen the already established AFHSs, Namibia Planned Parenthood Association, Multi-Purpose Youth Centres, etc., which provide a wide range of reproductive health services
  • Expand access to midwifery care in the community and use midwives as an avenue for awareness raising
  • Raise the level of family planning uptake, especially long-term methods, and continue reducing the prevalence of unmet need for contraceptives
  • Improve the referral system for responding to maternal emergencies
  • Institutionalise regular monitoring and evaluation at all levels of the healthcare delivery system
Monitoring and evaluation
  • Emphasise the routine collection and processing of data on process indicators for monitoring progress towards maternal mortality reduction, in the context of Namibia’s Road Map for Accelerating the Reduction of Maternal and Neonatal Morbidity and Mortality, using indicators set out in the Road Map and the Neonatal Health HMIS

MDG6:

Namibia is currently preparing the NSF mid-term review which will look at current progress, key successes, and challenges, and make recommendations for prioritised interventions based on lessons learned. It is essential for all stakeholders to focus on the recommendations from the mid-term review as this will pave the way for expediting achievement of the targets set in the NSF, but also other commitments such as the MDGs and UNGA Political Declaration targets from 2011. It is assumed that high impact interventions for prevention, treatment care and support for key, marginalised and severely poor population groups will be prioritised for scale-up. Furthermore, it will be important to manage strategically the integration of HIV into broader sexual and reproductive health and overall primary healthcare without jeopardising the progress and gains that have been made.


Challenges Interventions to expedite MDG implementation
While extensive progress has been made with provision of ART, care and support, challenges remain with adherence, effectiveness of treatment due to inadequate nutrition for PLHIV who are on treatment, staff shortages, inadequate capacity of CSOs, and community outreach.
  • Strengthen task shifting/sharing by increasing numbers of IMAI trained nurses with knowledge and skills to initiate ART
  • Use of point-of-care diagnostics needs to be expanded
  • Enhance scale-up towards increased geographical coverage to health centres and larger clinics
  • Continue with quality improvement activities, enhancing adherence to treatment and improving retention in care
  • Strengthen capacity of CSOs to deliver adherence support, such as an umbrella body for PLHIV organisations
Key challenges experienced by the PMTCT programme include slow roll-out of PMTCT Prongs 1 and 2, HIV and infant feeding, effective implementation of PMTCT Option B+, quality of services and adherence of clients to PMTCT services.
  • Expand PMTCT to remaining health facilities with ANC facilities
  • Intensify efforts set for elimination of MTCT by 2015/16
  • Improve quality of service for each of the four PMTCT prongs as well as critical enablers and synergies
  • Special focus on “undeserved and most at risk populations”, such as PLHIV, sero-discordant couples, adolescents and rural populations (MOHSS, 2013:16)
  • Build community systems critical for PMTCT performance in collaboration with CSOs
  • Roll out implementation of the national HIV and infant feeding guidelines
Slow uptake of voluntary medical male circumcision (VMMC) with a coverage of 21 percent in 2008.
  • Expedite implementation of the National Policy on Male Circumcision for HIV Prevention of 2010
  • Finalise the VMMC Draft Strategy and Implementation Plan to operationalise the policy
Although Namibia has a generalised epidemic, key populations (MSM, commercial sex workers, prisoners) are significant drivers of the epidemic due to stigma and discrimination, high risk behaviours, and poor access to services.
  • Continue with current prevention, treatment, and care and support interventions for MSM, CSWs and prisoners
Due to Namibia’s upper-middle income country status, donor funding is decreasing.
  • The sustainability plan needs to be finalised and put into action to ensure increased efficiencies and effectiveness in the national response, and sufficient funds to keep the existing momentum in the country’s HIV response
  • This is especially important for civil society contribution to the response
  • Integrate investment approaches based on clear evidence of greatest impact
  • Strengthen cost effectiveness and efficiency
Namibia has a functional M&E framework but there is high staff turn-over and inefficient use of available staff, the quality of data collected is poor and there is a lack of HIV population based survey and programme evaluations to provide evidence for programme design, planning, implementation and M&E.
  • Provide more attractive incentives for qualified M&E officers to remain in regions, for example, performance award incentives such as M&E Officer of the Year with a prize that could include additional training, a scholarship or money
  • Triangulation and verification measurements need to be strengthened at all levels
  • Carry out HIV population based bio-behavioural surveys
  • Surveys need to be carried out to inform the NSF, MDGs and 2011 UN Political Declaration

The main challenges facing the NVDCP are unsustainable financial, logistical and technical support, especially in malaria zones 1 and 2. Below are key the challenges and sets of recommendations, which complement the Malaria Strategic Plan (2010-2016) and should be used as a guide to accelerating implementation.

Challenges Interventions to expedite MDG implementation
Shortage of staff at national, regional, district and health facility levels, and lack of training of all health workers in case management and diagnosis.
  • Accelerate the proposed restructuring process for NVDCP specifically, including Malaria Elimination Officers
  • Employ additional spray operators
  • Expand annual training in case management and diagnosis to all health workers
Information challenges, including lack of a proper GIS for malaria specifically, no effective information management system for malaria, poor reporting from regions, and no active surveillance system.
  • Purchase GIS hardware and provide most appropriate training via internal technical support
  • Establish, with the support of HMIS, an effective information management system for malaria
  • Establish an active surveillance system
Absence of annually updated Malaria Epidemic Preparedness Plan.
  • Annual updates of the malaria preparedness plan, especially for district levels
Expiration of ITNs delivered more than three years ago.
  • Expand and strengthen the procurement and distribution of insecticide-treated nets
  • Establish a procurement and supply management system
Limited IEC materials at regional, district and community levels
  • Design standardised clinical algorithms (procedures) and posters for health workers
  • Design, produce and disseminate IEC materials that are age, sex and culturally appropriate
Shortage of community support programmes.
  • Health extension workers could take on some of the community mobilisation tasks
  • Continue with national advocacy days
  • Appoint a focal person responsible for health promotion and communication
  • Harmonise malaria messages developed by different partners
  • Improve awareness raising on risk perception and prevention methods
  • Improve awareness of appropriate ways of using nets
Logistical challenges overall, but most specifically for spraying activities.
  • Strengthen logistical support in relation to transportation and supervision
Lack of cross-border initiatives with Zambia, Botswana, Angola and Zimbabwe.
  • Establish other cross-border initiatives similar to the Trans-Kunene Malaria Initiative

Although NTLP has laid a strong foundation for TB control in Namibia, innovative interventions are needed to reach targets such as reducing TB cases notified for all forms of TB to 299 or less per 100 000 population. Innovation will also be needed to keep the momentum for other TB related targets already met, such as 85 percent of TB cases treated successfully, and reducing the death rate associated with TB to four by the year 2015. Therefore, the implementation of the Medium Term Plan (MTP) II for TB and Leprosy (2010-2015) is essential. Below are some challenges and recommendations, which are complementary to the MTP II.


Challenges Interventions to expedite MDG implementation
Inadequate institutional and human resource capacity (including specialists), and high staff turnover.
  • The Public Commission needs to create a position at hospitals specifically catering for TB
  • Import specialist health skills, while Namibians are being capacitated
  • Reintroduce the bush allowance for those working in remote areas
  • Get laboratories to provide surveillance as well as clinical functions such as diagnosis
Limited TB workplace safety measures for health workers.
  • Provide adequate ventilation in wards and other areas
  • Provide appropriate infrastructure to protect those not infected (including nurses) from becoming infected
Inadequate health infrastructure and equipment to offer effective services.
  • Construct appropriate health facilities that are responsive to current health needs
  • Build accommodation for healthcare providers at each health facility, especially in remote rural areas
IEC materials are mostly confined to health facilities and not in the community.
  • Urgently roll out Community Based Health Care Extension (currently at pilot stage in Kavango and Kunene)
  • Continue to mobilise and involve CBOs and NGOs, while Government should seek avenues to support CSOs financially
  • Training needs to be provided to Community Health Committees
Suboptimal functional collaboration between TB and HIV programmes.
  • Strengthen coordination of responses between TB, HIV and other vector diseases
Poor accessibility of TB diagnostic services and DOTs observers due to distance from clinics.
  • Bring medical care closer to the people with innovative strategies such as the use of Community Health Extension Workers
Unaddressed social factors, such as poverty, unemployment, overcrowding, smoking, silicosis, alcoholism, overcrowding and unemployment.
  • Apply recommendations under MDGs 1, 2 and 3