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Private Sector Lessons for Better Health Delivery Time to take leadership in the fight to end TB CElebrities United to fight against TB Taking the fight to Tuberculosis namibia Health sector Defies All Odds
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Private Sector Lessons for Better Health Delivery Maurice Diamond is the group commercial director and global private-public partnership expert at crown agents. He has advised numerous clients on the formulation of innovative and effective ppp solutions since the mid-1990s. Here he explores how public private partnerships can fundamentally improve the health system throughout africa.
crown agents is an international development specialist that partners with leaders across the world to make profound and lasting changes to systems and people. They have offices in 33 countries and work on projects in over 100 countries. Their expertise in financial services, consultancy and supply chain enables governments to increase prosperity, reduce poverty and strengthen health systems.
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hile the last decade has seen healthcare improvements in many African countries, numerous challenges persist that keep the continent off track for achieving many health-related Millennium Development Goals. Despite progress, governments still struggle to deliver healthcare to the most vulnerable populations and the most remote places. This means that the use of innovative approaches is crucial to improving health outcomes in Africa. As one of many interventions used to strengthen health delivery in Africa, public private partnerships (PPPs) can be a lifeline for governments seeking to bolster inefficient and under-resourced health systems. While PPPs are most commonly considered as a solution for running large hospitals, the model is well-utilized to improve the wider health care system, and supply chain management can be a highly effective use of private sector participation and best practices. In Africa, where there is increased interest in the private sector playing a bigger role to help governments meet socio-economic needs, these partnerships can deliver the innovation and capacity necessary for strengthening health systems. Forming PPPs that capitalize on the skills of the private sector can also strengthen
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parts of the system for which governments lack the expertise to be competitive, such as central medical stores (CMS) or transport systems. By privatizing transport, for example, governments offload the logistical burden of reaching remote areas to private companies with a wealth of experience in managing deliveries. Outsourcing these services frees governments to focus instead on services they have the resources to tackle – while also improving delivery outcomes.
Stronger supply chains Private sector input can be particularly useful in transforming a country’s medical supply chain, including warehousing and distribution. By incorporating best commercial practices, the private sector can help transform systems plagued by stock-outs, expired medicines and unreliable delivery into organized and demand-led operations that save the lives of people dependent on medicines or health products. This will only be successful, however, if the most appropriate PPP model is implemented. An important consideration in planning PPP models for health systems is allowing the government to retain responsibility for delivering services to the people, albeit with private sector inputs. The World Health Organization, while recognizing
clear benefits for governments working with the private sector in areas of health delivery, warns that not all areas of health systems are appropriate for privatization. Considering this, there are many forms that a PPP can take within the health system in order for the partnership to produce the best results for all stakeholders. PPPs take several basic forms, including private investment with the expectation of a reasonable return (investment PPPs); private investment for the sake of social good, otherwise known as corporate social impact (developmental PPPs) and hybrid versions of the two. Each of these models can be applied to managing health supply chains, with private companies, NGOs, or social enterprises taking ownership of one specific element of the health system. While the government ideally should continue to be held responsible for healthcare delivery, areas such as warehousing, distribution and transportation are often made more effective in the hands of the commercial sector.
decide whether they will pick and choose contractors for each element, or allow one contractor to handle hiring of companies to handle each element. Regardless of the PPP and management models chosen, there must always be a common first step for a successful overhaul of services: evaluating what has gone wrong while under public management and determining how the process will run better under private control.
Not all areas of health systems are appropriate for privatization.
The next choice to be considered is which pieces of a health system are to be outsourced. When using PPPs for central medical stores (CMS), for example, a government has the option to outsource single elements of the system (such as truck fleets or equipment maintenance) or to outsource the overall management of the CMS to a private contractor. In the latter example, the government must then Corporate Africa
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Tailored for Success A partnership with Crown Agents recently helped the government of Zambia revitalize their Medical Stores Limited (MSL) after many years of struggling to reliably store and deliver medicines and health commodities. The country-specific project has transformed MSL into a more efficient model with measurable impact, and different countryspecific models are currently being adopted in Botswana and elsewhere. Fixing the broken system began with the crucial first step of identifying problem areas and working with the government to implement a plan to address them. Before, MSL was plagued with stock-outs, slow delivery times, low employee morale and an out-dated operating system. Crown Agents helped the government mediate staff issues with regular appraisals, pay scales and pension plans to boost job satisfaction, and achieved significant cost savings with monthly stock reports. Major improvements to infrastructure, equipment and IT systems helped keep drugs usable longer, improved delivery time on distribution and streamlined the entire ordering process. The results of the partnership have been considerable for Zambia. Distribution costs have dropped by 32 per cent, stock availability has doubled and 95 per cent
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of all orders are delivered on time. In addition, nearly all development partners now route their commodities through MSL, creating a single coordinated logistics operation and producing better outcomes for patients reliant on medicines and health commodities in the country. Other private enterprises have targeted smaller aspects of the heath supply chain with measurable impact, such as addressing only the most difficult final leg of delivery to actual patients, known as the ‘last mile’. Cola Life, a non-profit organization founded by a former UK aid worker, uses innovative
Private sector input can be particularly useful in transforming a country’s medical supply chain.
packaging to include critical medicine in Coca Cola crates being distributed to otherwise unreachable parts of rural subSaharan Africa. Currently being trialed in Zambia, the model capitalizes on the soda company’s incomparable reach of distribution and uses the well-established system to deliver oral rehydration packs to pharmacies that otherwise would lack these simple but life-saving kits. Riders for Health is another example of a PPP intervention using private expertise and innovative methods to deliver care. Founded by motorcycle enthusiasts, the social enterprise supports last-mile deliveries by providing vehicle maintenance for fleets maneuvering the difficult terrain that can complicate health delivery. By maintaining vehicles and training drivers, they allow ministries of health, NGOs and other groups to complete the last mile of delivery without wasting resources on those areas in which they have no expertise. Now operating in seven countries in sub-Saharan Africa, the group proves that success can often be more readily achieved through local projects that are smaller, simpler and deliver greater impact dollar-for-dollar than larger investment-dependent projects.
Regardless of the specific form it takes, the PPP model tailored for its local environment has the potential to revitalize national health supply chains and deliver the significant improvements required of languishing health systems. While local partnerships must be formed with the utmost care in order to empower governments to treat their people, the crucial work of a well-formed PPP that brings medicine and health commodities to sick and dying people is invaluable.
There are many forms that a PPP can take within the health system.
With fewer than 1,000 days until the MDGs expire, using innovative approaches is increasingly necessary to come closer to achieving goals and saving more lives.
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Time to take leadership in the fight to end TB Dr Mario raviglione is the director of the Global TB program at the World Health organization. Here he discusses the economic and political priorities that must take precedent in order to eradicate the threat of TB.
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uberculosis (TB) is an ancient disease that holds the world to ransom. It takes 1.4 million lives and afflicts 9 million people every year. Significant progress has been made in the fight against tb by nations, the World Health Organization (WHO) and other partners, and 51 million people have successfully been treated between 1995 and 2011, with 20 million lives saved. However, the disease still has the potential to affect millions of lives, despite the fact that it is totally preventable. The BRICS countries, who are most affected by TB, must lead the fight against the disease. There are many priorities in the fight against TB. Firstly, there is need for increased resources for TB care and control, both economically and politically. WHO and the Global Fund have identified a gap of US$ 1.6 billion in annual international support for the fight against TB in 118 low and middleincome countries on top of an estimated US$ 3.2 billion that could be provided by the countries themselves. Filling this gap could enable full treatment for 17 million TB and multidrug-resistant TB patients and save six million lives between 2014 and 2016. It is
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There is urgent need for a shorter and simpler drug therapy for people with drug-susceptible TB.
projected that domestic contributions could cover the bulk (over 65 per cent) of financing required for TB care and control in these 118 countries, equivalent to US$ 3.2 billion. This will require that TB funding increases in line with economic growth and increased political commitment especially in countries that currently underperform in comparison to their ability to pay. The BRICS have developed from resource-poor countries to prospering nations, and should have the ability to tackle the disease as well as contributing to combating the disease in poorer nations. They need to recognize the urgency of utilizing their country’s resource wealth into sustainable investments for health.
With regard to TB vaccines, there is no effective pre-exposure or post-exposure vaccine yet available for TB today.
Secondly, success in ending the TB pandemic cannot be achieved without advances in research and development. Progress in new diagnostic tools for TB came as late as December 2010 when WHO endorsed a rapid test for TB- xpert mtb/rif, which could provide an accurate diagnosis for many patients in about 100 minutes. Â This test is now available in 83 low and middle-income countries and its adoption
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has accelerated significantly since its endorsement. Furthermore, for the first time in over 40 years, a new TB drug – Bedaquiline – is available for the treatment of MDR-TB, and was granted accelerated approval by the United States Food and Drug Administration in December 2012. WHO issued interim guidance on the safe use of Bedaquiline to treat MDRTB in June 2013. There is urgent need for a shorter and simpler drug therapy for people with drug-susceptible TB. People with drugresistant TB need a more efficacious, fully oral, shorter, less toxic and safer therapy. There are also no child-friendly TB treatment options. There is no effective pre-exposure or post-exposure vaccine yet available for TB today. Progress in the past decade means that it is possible that at least one new vaccine may be licensed by 2020. Without progress in research we cannot hope to succeed in eliminating TB. The Delhi Communiqué, signed recently by the health ministers of BRICS, is an excellent step in this direction. The communiqué highlights the necessity of cooperation among the BRICS countries for enhancing capacity and infrastructure; building consortia for research; and supporting innovation to develop and try out new tools. 10
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There is no effective pre-exposure or post-exposure vaccine yet available for TB today.
The translation of this communiqué into action could serve as a launch-pad for research for tb elimination. Thirdly, a psychological paradigm shift is required. TB has drifted away from the public’s awareness. While multidrug-resistant TB has been in the media limelight, TB overall has been largely forgotten, especially in the developed world. With globalization, TB has no barriers – it is no longer confined to poorer countries. The disease can be transmitted by coughing and sneezing. BRICS countries, with their experience in the fight against TB, can build awareness to renew global commitment to end this pandemic. It is vital that the threat of TB is contained and eliminated. None of us can afford to walk away from TB or leave it to others. We need determined leadership especially from the BRICS countries that are most affected by the disease and who have the capacity to truly turn the tide against it, to take a stand and strengthen international cooperation to eliminate the threat of TB forever.
Without progress in research we cannot hope to succeed in eliminating TB.
Celebrities Unite to Fight Against TB The World Health Organization is utilizing national and international celebrities to raise awareness and lobby for preventative TB funding. Corporate Africa’s Patrick Lee describes the work being done by the ‘Champions Against Tuberculosis’ campaign.
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uberculosis is the second most common cause of death from infectious disease on Earth, second to HIV/ AIDS. In 2011, 8.7 million people fell ill with TB, and 1.4 million of these people died. Over 95 per cent of TB deaths occur in low and middle income countries and research conducted by the World Health Organization (WHO) in 2010 found that there are around 10 million children who have been orphaned due to TB deaths among parents. Perhaps most shockingly, it is estimated that approximately one third of the world’s population (around two billion people) is infected with latent TB. Despite these overwhelming statistics, public awareness of the disease is still fairly low. This is because of the staggeringly high rate of illness being localized to predominantly developing nations, while simultaneously TB rates in developed nations are at an all-time low. Champions Against Tuberculosis is a campaign run by WHO, the objective of which is to raise public awareness about the threat of TB and consequently motivate the general public, politicians and decision makers into funding preventative programs and donating aid. The biggest problem in preventing TB
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is not the inability to treat the illness; rather, it is a lack of funding and social stigma directed at TB sufferers.
Raising awareness In order to achieve this goal, Champions Against Tuberculosis use celebrities and campaigns that vary depending on national context and the needs of a particular country. By utilizing the publicity enjoyed by their “champions”, the campaign aims to act as a conduit of information from sources such as health ministries and government officials. Ultimately, by raising public awareness and creating a high-profile media campaign on the issue of TB, Champions Against Tuberculosis hopes to help form partnerships between local governments, businesses and nongovernmental organizations. The campaign therefore effectively utilizes both personal and professional networks in order to stimulate policy change, raise funds and connect professional networks. In their primary objective of raising public perception, the campaign uses a number of techniques depending on their target audience. For
example, in order to educate children and parents about the dangers of TB, the campaign has published comic books to be distributed throughout schools and publicity events. This publication has been boosted by the involvement of football superstar Luis Figo, and its title – Luis Figo and the Tuberculosis Cup – exemplifies how the content uses the language of football and the star profile of its protagonist in order to educate children as to the dangers of TB. This comic has been published in 11 languages, and is available in schools, public events and at football training sessions for children. Similarly, the organization targets young adults and teenagers through social media, film and music campaigns, using national and international celebrities as a voice. In a global environment where people are constantly saturated by marketing, maintaining a single presence can be very challenging. The campaign addresses this problem by utilizing a variety of different media. Ghanaian pop singer Obour, for example, composed a song on TB awareness and later made a documentary which aired nationally highlighting the fight against TB. International pop star Craig
David has helped to raise awareness by creating a link to TB websites on his Facebook page. In India, actors such as Deepak Raj Giri and Deepa Shree Niraula have visited prisons (where due to close confinement TB rates are exceptionally high). Jordanian actress Rania Ismail is another example of a celebrity using her profile to raise publicity through plays and speeches at events in schools, prisons and orphanages. One of the key messages conveyed in their publicity campaign is that TB affects those who are most at risk in society. Lack of health care and information on the disease mean that the most vulnerable in society are most at risk from TB. For example, homeless people, the very poor, migrants, slum dwellers, minority groups and prison populations. TB is the leading killer of people infected with HIV; causing one quarter of all HIV related deaths. Depending on the most vulnerable in a particular country, Champions Against Tuberculosis will utilize their significant public profile in different ways. The best example of this has been the workshops, programs and fundraising events in
Indian prisons engineered and propagated by Indian film and television stars.
Influencing politicians It is another objective of Champions Against Tuberculosis to involve and influence government ministers, policy makers and decision makers. The belief is that political advocacy will help in developing agendas, funding and possible changes in policies aimed at reducing tuberculosis. Sustained engagement between the campaigners and ministers will ensure that governments will have the most relevant statistics and information required to make the best policy decisions regarding TB. WHO have, for example, recently made policy recommendations on how TB action should be specific for each national context. The Champions are excellent in terms of conveying this message, and helping to raise funds in order to propagate it. Furthermore, through extensive campaigning and activities in forums against TB, Champions often have excellent contacts and constituents who, via the Champions, have their voice heard at a governmental level.
Due to the stigmatism of sufferers of TB, many people do not consult a doctor even when displaying symptoms of the illness. This is an understandable fear sufferers have, due to the neglect and ostracism they face from their local communities. By using positive media campaigns headed by popular figures, Champions Against Tuberculosis aim to fight this prejudice against TB patients. Champions are well respected, popular figures within particular communities, often national celebrities ranging from television and film stars, to music icons and sports personalities. The publicity that these figures can generate is a powerful tool in both raising awareness of TB, reducing social stigma, and in influencing public opinion and decision makers into funding preventative TB projects and research.
Over 95 per cent of TB deaths occur in low and middle income countries. Corporate Africa
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Taking the Fight to Tuberculosis At the height of her success as a television personality, Gerry Elsdon was diagnosed with tuberculosis. She soon realized the stigmatism that TB patients in Africa have to suffer. Having beaten the illness, Gerry worked as Secretary General to the Red Cross in South Africa. In this exclusive interview with Corporate Africa, she speaks about her reaction to contracting TB and how it affected her life. What was your first reaction to your diagnosis of TB? It brought great sadness and confusion. The sadness was because I was attempting to conceive at the time, and since the TB was found in the lining of my womb we would have to delay our ‘baby project’. I was confused because I had no symptoms whatsoever. No weight loss, fatigue, coughing and definitely no loss of appetite. I knew absolutely nothing about TB at the time. My mother broke down when we told her, first because she had heard that people die from TB and secondly because she thought it was hereditary. I looked for a second opinion, and to my relief the tests were negative for TB. I mentioned the misdiagnosis to a physician friend and I was thrown back into my abyss: He had practiced in rural villages around South Africa and treated many women who had TB in the womb. He was the first person to speak to me about non-pulmonary TB, found outside of the lungs. He insisted I begin treatment for mainstream TB. I did a nine month course of vitamins and antibiotics, between six and eight pills a day. Empowered with information about TB, its symptoms, the knowledge that South Africa was the fourth highest burdened country in the world and understanding the consequences of compliance 14
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and non-compliance, I was able to go through my treatment without fear or anxiety. After nine months of treatment a biopsy of the womb confirmed success of my treatment. Unfortunately the damage to the lining of my womb was severe and I will never conceive a child. It was the stigma and the discrimination I read about that angered and motivated me into becoming a social activist. Can you describe the stigmatism attached to TB? Where does it come from, and how does it manifest itself? The stigma originates from the extremely high percentage of people living with HIV in the world. Years ago there was the distinct impression that only people living with HIV suffered from TB. It is still believed in some circles that HIV and TB are caused by sexual behavior. Husbands still abandon wives who display symptoms of TB without having themselves checked out. The similarity of the symptoms of untreated TB and those of full blown HIV did not allay talk and stigma either. The lack of knowledge of TB is what causes the greatest stigmatism. You would stay at the bedside of someone with cancer or heart disease or diabetes, but the person infected by airborne bacteria is ostracized.
Do you feel that your status as a celebrity was compromised by your plight with TB? I chose to visit a public clinic for my treatment. Doctors in the private health care system have very little knowledge on TB. They don’t see many cases and misdiagnoses are rife. They diagnose and treat patients for influenza, bronchitis, lung disease and suggest invasive surgery before even considering TB. I have always been a celebrity. I was born in the township and have stood on the soapbox in defense and for the protection of the people of South Africa on many occasions. I wanted to experience what they experience. It was when one of the nursing sisters asked for an autograph that I realized that information about TB status may go viral, that I too may be stigmatized. For the first time I was concerned that people may say I was HIV positive (a sign of my own fear of stigma and discrimination), that my career may be compromised. I had to pre-empt this and so I went public and chose to share my story. My ex-husband was infuriated: “What would people say!” he asked. Deep inside I knew I was doing the right thing. I had a responsibility to speak for those who could not speak for
themselves. The stigma had to be dealt with and I was in a position to do so. One journalist wrote that I was using TB to boost my career. If that were true I should fire my entire PR team, I thought. A local talk radio host questioned whether I was HIV positive and using TB to hide my true status. A friend or two took a wide berth when we were in the shopping mall but my resolve was strengthened when ordinary people would stop me to express how empowered they felt to talk about their status based on my story. If I would do it unashamedly so could they. One woman used the magazine story as an educational tool: telling people that TB was not a death sentence and that with treatment and compliance they could live a long TB free live. The television interviews came streaming in. Do you feel the treatment you received as a TB patient has since improved? Do you feel it could be improved further? Heck yes it can be improved! Six to eight pills a day is not pleasant. The treatment has not changed in decades.
And research on how to change this is on-going. I hope for a shorter term of treatment also, six to nine months of treatment is a long time and once people feel better they drop their treatment and noncompliance could be fatal. I am overjoyed by the introduction of the GeneXpert machine which can diagnose TB within two hours instead of two weeks. Sadly, not many poor countries can afford this system and are completely reliant on foreign aid which after the recent recession has been difficult to access. The challenge is now to get medication at the speed at which the GeneXpert can diagnose patients and
Employers offer no counseling to the TB sufferer. since we cannot afford the infrastructural expansion of our TB clinics we cannot house patients desperately in need of in-patient care.
Do you feel that part of the problem with TB’s mortality rate is that people are afraid of seeking help, or are maybe ignorant as to the symptoms of TB? If so, why, and what can be done to change this? As I said before sometimes it’s misdiagnosis. But yes, there needs to be better access to information about TB no matter which continent or society you live in. TB receives 10 per cent of the budget of HIV and yet a vast amount of people living with HIV die of TB. I find this despicable. In recent years the relationships between those working in TB and HIV have been improved but they must improve further. What do you feel is the single biggest challenge in fighting TB? There are as many people who are not HIV positive but who are diagnosed with TB as there are who are HIV positive. It’s a message that must be emphasized. TB patients suffer no matter what; and their lifestyles and illnesses are impacted by TB. It preys on the vulnerable:
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For the first time I was concerned that people may say I was HIV positive, a sign of my own fear of stigma and discrimination, that my career may be compromised.
older people and children, anyone whose immune systems may be compromised. Those with poor or malnourished diets are vulnerable. Sufferers have been known to lose their jobs because they have to visit the clinic on a monthly basis. Employers offer no counseling to TB sufferer. Can you describe the work the Red Cross does in fighting TB, and your role within this? Furthermore, do you feel more could be done by government in fighting TB? If the South African Government allocated more funds to TB we could possibly do more. However I must add that the small team in the Department of Health is highly efficient, hardworking and dedicated to the task of eradicating TB in our lifetime. I am very proud of my alignment to government. The South African Red Cross offers home-based care to those living with HIV and TB. We administer treatment to the bedridden so as to ensure compliance to treatment. We ensure that food parcels are delivered to them. We counsel sufferers and offer support where needed. 16
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What is your specific role with the Champions Against Tuberculosis campaign? This is an advocacy role I take very serious. The Champions are encouraged to highlight the need for treatment, compliance and knowledge to the communities in their various countries and to network amongst leaders and decision makers how and where possible. I do talks in the corporate sector and on government health day. I seem to have become the television go-to-girl on behalf of our government, telling the human interest story while the Minister of Health, Dr. Aaron Motsoaledi, tackles the technical and medical questions. We sit on panels together and we make a good team. He is knowledgeable and passionate about the issue. Do you feel that Africa and other countries can look at the all-time low TB rates in other parts of the developed world, and eventually hope to emulate these statistics? In other words, what are your hopes for eradicating TB?
It is well known how infuriated and frustrated I have become about complacency in our sector. A Fact: Other parts of the developing world do not have the HIV rate of the African continent. With more infections come more fatalities. Funders and organizations focused on HIV need to admit the severe impact TB has on people and ensure that their clients receive treatment. Tunnel vision is a killer! Do you think more could done politically, and by private investors, in order to fight TB? As with any cause and particularly something like TB which is ravaging our country, there has to be political will. TB should not be an issue only highlighted during the month of March, which is TB month. And yes more health and safety officers in the corporate sector need to be trained and exposed to the information available to better understand and advise workers on their next steps. Sometimes this is of more value than any amount of money given to campaigns.
If it is true that those most at risk from TB are those most at risk in society – the very poor, slum dwellers, illiterate people – then does this not mean something needs to be done that is greater than a media campaign, as for these people, the media is often inaccessible? Yes! In South Africa we attempt to get as many food parcels to sufferers as possible. One of our problems is that the people delivering are as poor as the people receiving it. It feels as though the pain and humiliation just never ends. Access to clean water and health care is still a problem in some parts of our country. And water and sanitation programs are few and far between. We attempt to teach that ventilation is an imperative to prevent the spread of TB but when you don’t have a window in your shack this advice is pointless. According to WHO policy recommendations on TB, a country should have a control model for TB, at provincial, regional and district levels. These strategies should cater
for the countries specific situation, for example, TB prevalence, HIV prevalence, multi drug resistant TB prevalence. What is the health policy toward TB in South Africa at the moment? We sit on the board of the WHO Stop TB Partnership. We adhere to all of the standards and policies recommended by WHO. We have developed twinning programs between the TB and HIV departments in our Ministry of Health. Regular information is passed on to the WHO. Can you describe working with TB sufferers? It is so humbling; each patient is more courageous than the other. Most have the understanding that within three months of starting their medications they will be non-infectious. The most impressive are the people I meet when they are first diagnosed, when they are ill: I hold a timid skinny hand, massage the loose skin until its warm,
and try to be comforting. I ask them that for the sake of family and friends to hang in there; complete the treatment and I assure them that God and I are watching. I often promise to return and when I do, I find that same sufferer, full-bodied, radiating life and looking forward to the future. It is a wonderful sight. At this point, however, it becomes important to celebrate but moreover, to preach compliance to treatment. It’s so easy to stop a course of antibiotics when you are feeling on top of your game. But every patient must be warned that with non-compliance, they could find themselves right back where it all started.
Namibia health sector defies all odds For a young democratic state that attained its independence in 1990, the Namibian health sector is working at a level that far exceeds global expectations according to Farai Diza, Corporate Africa Southern Africa Correspondent. Namibia was recently elected to serve on the Executive Board of the World Health Organization (WHO). The Minister of Health and Social Services, Dr Richard Nchabi Kamwi, joined 33 other individuals designated by member states to offer technical expertise to the board for the next three years. The Health Ministry’s Deputy Permanent Secretary, Dr Norbert Foster, has been designated as an alternate member. Namibia will also serve on the General Committee of the World Health Assembly (WHA). It is the first time that Namibia has served on the General Committee and the Namibian health minister praised the work that has been done in developing the health sector: “The fact that Namibia has been considered for election to the board two times during my state of office demonstrates the confidence the international community has in the country following its exemplary health indicators. The election to the board is both exciting and challenging. I will take it up with caution due to the immense challenges facing the WHO, such as Africa’s immense problems with disease, where HIV/ AIDS, TB and malaria remain a challenge that is bedeveling the continent,” said Dr Kamwi. Despite the remarkable growth that has developed throughout peri-urban and rural areas, major challenges have in the past threatened to derail the progress. These emanate from the HIV/ AIDS pandemic and the spread of malaria mostly throughout the northern parts of the country, where the majority of Namibia’s population is situated. The ubiquitous monetary constraints remain a major obstacle.
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So how has the Namibian health sector managed to attract global fame resulting in its Ministry being elected into the WHO and WHA boards?
Focusing on health Since the country’s independence in 1990 the Namibian government, through the Ministry of Health and Social Services, has focused on providing preventative care and on expanding its services to Namibians throughout the country. The Ministry of Health, headed by Dr Richard Kamwi, receives one of the highest budget allocations of any department in the Namibian government. The Ministry was presented with US$ 525 million in the 2013/2014 budget. This is a significant increase compared to the US$ 340 billion that was allocated to the same ministry in the 2012/2013 budget. “Increased funding is provided to the health sector to improve health facilities and to bring health services closer to the people.
The Ministry of Health, headed by Dr Kamwi, receives one of the highest budget allocations of any ministry in the Namibian government.
Funding focuses on strengthening disease control and prevention through clinical health care service programs, improvement of health care facilities, and recruitment of personnel and sustaining program activities, which were previously funded by donors,” said Finance Minister Saraah Kuugongelwa-Amadhila, when she tabled the annual budget. Relying mostly on foreign medical practitioners predominantly from Zimbabwe, South Africa and Nigeria, Namibia undoubtedly has one of the best patient to doctor ratios in Africa with one doctor for every 10,062 people. Statistically, this figure is remarkable in comparison with ratios from other Sub Saharan and West African states. The bed ratio is estimated at 0.27 per 1000 people in all of the country’s thirteen geological regions, which is the third best in Africa after South Africa and Nigeria. Namibia has 248 clinics, 37 health centers and 47 hospitals. Most of the health establishments are located in the northern parts of the country as well as larger towns where most of the population live. Some clinics and hospitals have outreach points that health workers periodically visit to provide health care services. Over the past ten years the government has committed itself to health, and health facilities have more than tripled, increasing from 98 to 335. Consequently 80 per cent of the population now lives within ten kilometers of a clinic. This leaves 20 per cent of more than 300,000 people in remote areas, particularly in Omaheke and Kunene regions, without ready access to health services. Disappointingly, many of the newly established clinics are under utilized with half of them serving less than 15 people a day.
Training Namibia is one of the many countries in Africa experiencing human resource challenges in the health sector, especially a shortage of qualified nurses. Most nurses are trained at the University of Namibia as well as in regional training centers operating under the auspices of the Ministry of Health and Social Services. The majority of Namibian born doctors are trained outside the country, mostly at South African Universities, and also in Europe and China. The trend has changed slightly since the establishment of the Unam School of Medicine in 2010. Due to a shortage of critical skills it is estimated that more than half of practicing doctors in Namibia are expatriates. Although the Unam School of Medicine has been providing health training over the years, the institution has not been able to train sufficient health care professionals to satisfy the growing demand both in the public and private health sectors. Furthermore, the presidential inquiry into the health sector reported that the graduates from Unam do not have practical experience. Dr Kamwi said that his ministry is closely working with the university in order to produce a better health team that will have a positive impact in hospitals and clinics. “The Health Ministry is complimenting the efforts that are being done by Unam”, according to Dr Kamwi. We have decided to start a three year diploma course for midwives at three health training centers in Keetmanshoop, Windhoek and Rundu. In addition, the ministry intends to work closely with the International University Corporate Africa
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Despite the remarkable growth that has developed throughout peri-urban and rural areas, major challenges have in the past threatened to derail the progress
of Management (IUM) and the Welwitschia University in South Africa to also train registered nurses and midwives in the near future, to help address the acute shortage of health workers in the country. “I am indeed pleased to see that locals are taking up the challenges to supplement the efforts of the government. However, the recruitment of foreign professionals remains an interim measure that aims to respond to the increasing health care needs of Namibians,” said Dr. Kamwi. Access to clean water and sanitation remains a major challenge owing to the country’s populace and size, arid climate and widely dispersed population. The provision of water and sanitation has improved since independence and continuous efforts are being made to further improve these services. Poor sanitation and clean water supplies have often led to outbreaks of disease in small shanty settlements that are scattered across major cities due to the lack of proper adequate housing. A team of more than 10,000 health workers and medical employees are at the forefront of providing healthcare services in Namibia, with this figure made up of both locals and expatriates.
The malaria situation has been worsened in recent years due to abnormally high rainfall and flooding. 20
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HIV/AIDS HIV/AIDS poses a serious challenge to Namibia’s public health system. Namibia is ranked fifth worldwide for the prevalence of HIV/AIDS, which currently stands at 17.8 per cent – meaning that close to 20 per cent of the population is living with the virus. The Ministry of Health and Social Services allocates 20 per cent of its budgetary allocation towards HIV and AIDS programs. However, the recent withdrawal of Global Funds due to Namibia being reclassified as an upper middle income country has put a strain on the ministry and the health service system in general. A number of HIV counseling and testing centers have been closed down, while almost 50 per cent of available hospital beds are occupied by HIV and AIDS patients putting a severe strain on health care workers and medical staff. A vast number of other government departments have joined in the fight against HIV/ AIDS which is claiming lives on a daily basis. For example, the Minister of Regional and Local Government, Housing and Rural Development, Major General Charles Namholo has called on civil society organizations to stand together and fight HIV and AIDS. “Our government has initiated a decentralization program across the country to respond to the problems of centralized systems. Decentralization is about participation, diversity, efficiency and conflict resolution. It will benefit regional councils and local authorities to take appropriate action in terms of planning coordination and management in the fight against HIV and AIDS. We need to empower our people at grassroots level and enable
them to make decisions on matters that affect their lives and livelihoods. This goal can only be reached if the entire country embraces the slogan of One Namibia, One Nation,” explained Namholo. Namholo added that despite the progress made by his ministry, the HIV/ AIDS prevalence rate is still very high in Namibia and it is the responsibility of every Namibian to bring it down to single digit figures. He also called on stakeholders to come up with new operational approaches that would enable all regions to achieve their goals. “The government response to HIV/AIDS requires a strong and wide partnership to make a difference. I would like to thank the United States government through USAID for actively supporting the ministry in strengthening regional and local responses to HIV/AIDS. The partnership between the ministry and USAID has grown tremendously in realizing our government’s efforts and commitment to making Namibia free from HIV and AIDS,” he said.
Fighting illness
Malaria also poses a serious challenge to the health ministry, particularly in the northern regions of Namibia close to the Angolan border.
The malaria situation has been worsened in recent years due to abnormally high rainfall and flooding which has displaced thousands of people from their homes. On a positive note, a campaign run by the ministry, in conjunction with other international organizations, to combat the spread of malaria is yielding positive results. Unam, together with other universities, is currently conducting research on using traditional medicine in the treatment of malaria. Both the public sector, which provides services to the majority of the population and is predominantly funded through general taxation, and the private health sector are positively contributing to improve health in Namibia. According to the latest data that was presented by the Namibia National Health Accounts, approximately 50 per cent of the total health budget is awarded to the Ministry of Health and Social Services public and mission hospitals, health centers and clinics. Only four per cent is directed to Primary Health Care programs. With such financial mechanisms in place, TB has shown a significant decline over the last couple of years.
Limited community based data surveys have indicated hypertension, diabetes and cancer as important health care problems among adults. The government is now broadening its health data collection in order to come up with a more formidable and diversified data table. The Ministry of Health and Social Services is conducting its forth Demographic Health Survey that will cost cost the government over US$ 2 million. The main objective of the 2013 Demographic Health Survey is to collect population based data to support the monitoring and evaluation of the needs of the health sector as well as providing data to assess key indicators in other sectors. The survey, set to be carried out over the next four months, saw 28 teams deployed in various parts of the country to interview men, women and children in throughout communities. “It is expected that the survey will yield estimates of key indicators by regions, urban and rural, and selected demographic and social economic groups. The survey is important because it will, among others, evaluate the achievements of the Ministry of Health and Social Services in terms of the country’s third National Development Plan (NDP3), the Millenium Development Goals and the Southern African Development Community (SADC) targets,� said Bertha Katjivena,
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the Director of Policy, Planning and Human Resource Development in the Ministry of Health and Social Services. Biomarkers that will be collected as part of the survey include the prevalence of anemia among women and men aged 15 to 64 and children under six years old; HIV infections among women and men aged 15 to 65, blood glucose and blood pressure levels among women aged 15 to 64 as well as height and weight measurements.
A team of more than 10,000 health workers and medical employees are at the forefront of providing healthcare services in Namibia.
Type of Practitioner/ Specialist
Total
Anaesthetist 27 Anatomical and Forensic Pathologist 2 Anatomical Pathologist 9 Cardiologist (Paediatric) 2 Cardiothoracic Surgeon 5 Chemical Pathologist 2 Clinical Pathologist 4 Dermatologist 5 Diagnostic Radiologist 25 Family Physician 9 Haematological Pathologist 2 Microbiological Pathologist 1 Neurologist 12 Obstretrician and Gynaecologist 21 Occupational Medicine 2 Ophthalmologist 12 Orthopaedic Surgeon 17 Otorhinolaryngologist 5 Paediatrician 15 Physician 16 Physician and Cardiologist 3 Plastic and Reconstructive Surgeon 11 Radiation Oncologist 2 Specialist in Emergency Medicine 1 Specialist in Nuclear Medicine 1 Surgeon 21 Urologist 9
Access to clean water and sanitation remains a major challenge.