1. At independence, in 1990, the Namibian Ministry of Health and Social Services (MoHSS) inherited a health system from the colonial era that was fragmented along ethnic lines, inequitable in terms of accessibility, and extremely skewed towards curative services. This paper describes the main reform initiatives that have taken place since independence.

2. The Republic of Namibia is situated in Southern Africa. The country’s western boundary is formed by the Atlantic Ocean, while it borders on Angola, Zambia and Zimbabwe to the North, Botswana to the East and South Africa to the South. Large parts of the South and West are desert, giving way to a semi-arid environment centrally and a sub-tropical to tropical environment in the northern areas.

 

The Population

3. In 1999, the total population is estimated at around 1.75 million. The majority of the population is under 16 years. More than 50 per cent live in the North of the country, mostly on communal land. Other densely populated areas include the capital, Windhoek, and the cost around the main port of Walvis Bay and the resort town, Swakopmund.

 

The Political System

4. After a protracted liberation war against the illegal occupation by apartheid South Africa, Namibia gained its independence in 1990. The country has a parliamentary democracy. The governing party, the South West African People’s Organisation (SWAPO), holds a two-thirds majority in parliament. The country is divided into 13 administrative regions, which are each governed by an elected regional governor.

 

The Economy

5. Namibia has a mixed economy. Main economic areas include agriculture, fisheries, mining and a small but growing sector of secondary industries. Growth of GDP since independence has averaged at around 2.5 per cent. The total GDP in 1996 was NA$14 billion (US$3.5 billion). This translates into a GDP per capita of around US$2,000. This figure conceals the extreme disparity in the distribution of wealth within the population.

Health

6. The health profile of the population reflects the skewed wealth distribution as well as the classic disease problems of a developing economy. Main causes of death during 1997 were: malaria, AIDS, tuberculosis, gastro-enteritis, respiratory infections, injuries, cardiovascular diseases and cancer.

 

The Health Sector

7. The health sector is pluralist. There is a well-established private for profit health sector with general and specialist medical and allied health practitioners. Private hospitals provide services in most of the main centers. There are a number of mission health services, mostly in the communal areas in the North. The traditional sub-sector, represented by traditional healers, birth attendants and other practitioners is fairly prominent in rural areas.

 

8. The public health sector consists of a small military medical service and the MoHSS. The Ministry has 34 health districts and 13 regions as well as 5 directorates in its head office in Windhoek. Prominent public health programmes include the malaria, AIDS, and TB control programmes; the reproductive health programme; the nutrition programme and the Information, Education and Communication (IEC) programme. The Ministry operates 230 clinics, 35 health centers (average 10 beds each), 31 district hospitals (average 120 beds each), 3 regional referral hospitals (average 500 beds each) and one national hospital with 450 beds. The bed per population ratio is 3:1,0000.

 

9. The 1998/99 MoHSS budget of NA$950 million (US$150 million) translates into a per capita expenditure of US$85. Currently, around 65 per cent of operational expenditure is related to salary costs and 60 per cent of the budget goes to community health services, which includes all district and national public health programmes.

 

Health Sector Reform in Namibia

10. Developments in the Namibian health sector over the last 5 to 8 years have strongly been affected by reform. The following is a catalogue of initiatives that have been completed or are ongoing.

 

Performance Improvement of the Civil Service

11. During 1994 the Office of the Prime Minister established a Wages and Salaries Commission (WASCOM), which investigated all aspects of public service performance. Policies flowing from the initiative include the reduction of the civil service salary bill by 2 per cent annually over 5 years; revision of salary levels; development of a new grading system; introduction of an improved appraisal system and application of performance-related pay; as well as the introduction of a Public Service Charter.
12. In 1994 the Ministry of Finance introduced a new computerized and network-linked funds control system (FCS). The system is currently being refined and plans exist to expand the network to the regional offices of all sector ministries. The system has improved budgeting and accounting procedures considerably. In order to enhance the equitable allocation of resources to regions and districts, the Ministry is currently also in the process of developing a resource allocation formula.

 

Decentralisation

13. In 1992 Regional Councils were established in Namibia. They have so far executed a relatively narrow local government function. Line-ministries are currently in the process of assessing functions that could be delegated to the Councils.

 

14. Within the MoHSS decentralisation by way of deconcentration of management from the centre to the health regions and districts is ongoing. For this purpose regional management teams have to be established in all 13 administrative regions.

 

15. MoHSS district management team members participate in constituency development committees, while the Regional Medical Officer and his/her representatives are members of the Regional Development Committees. The latter are chaired by the Regional Executive Officer and accountable to the respective Regional Governors.

 

16. Regarding the hospital sub-sector, the Ministry is investigating options to enhance the management of referral hospitals. In a parallel initiative an independent medical laboratory service is currently being established. It will be known as the Namibia Institute of Pathology (NIP) and will be governed by a Board to be appointed by the Minister shortly.

 

Improving the Functioning of the Ministry of Health and Social Services

17. Internal restructuring is currently ongoing. The aim is to develop a more rational system that will ensure improved efficiency, cost-effectiveness and quality of services. At national level the exercise aims at enhancing the main functions of policy development, strategic planning, co-ordination, technical backstopping, capacity building and training, as well as monitoring and performance measurement. In line with this aim, the Ministry is reviewing all functions of directorates and divisions in the head-office.

 

18. As part of the aim to improve resource management at all levels, the new structure will also considerably strengthen programmes dealing with the management of finance, personnel, buildings, medical equipment and transport. In addition, programmes related to the quality of institutional care are being strengthened, while primary health care and public health services are being consolidated.
19. Part of the process of streamlining services includes the development of essential service packages for all levels, i.e. from communities up to the tertiary hospital. The finalisation of the essential service packages will serve as a guide for the determination and standardisation of essential resources and support. These include the development of training curricula, standards and norms for physical facilities and essential equipment lists.

 

20. The Ministry is currently also in the process of reviewing the area of development co-operation and is busy drafting a development co-operation policy. As part of the formulation of this policy, the Ministry is investigating the feasibility of the sector-wide approach in the Namibian context.

 

21. In order to add impetus to the reform process in the Ministry and in order to better organise the multitude of initiatives taking place, all levels and programmes are currently being encouraged to develop strategic development plans. Plans are to include relevant monitoring and evaluation tools, including essential indicators that will form the basis of the Ministry’s future management information system.

 

Broadening Health Financing Options

22. The main financing sources for the Ministry remain the state revenue fund and development aid. Donor contributions constitute around 30 per cent of total development expenditure and 6 per cent of total MoHSS expenditure (operational plus development). All donor funding has so far been in grant form.

 

23. The Ministry collects user-fees at all facilities. Fees were introduced before independence. In 1993 the Ministry increased fee levels and is currently busy with revision. Fees are charged for two patient categories: (a) private patients, i.e. all those who have private medical aid schemes (this includes the majority of private sector and government employees), and (b) state patients (the majority of the general population). An exemption mechanism for the poor is in place. The current fee revision focuses on fee increases for private patients with the aim of full cost recover. State patient fees will be kept at nominal levels and certain primary health care services will continue to be offered free of charge.

 

24. Fees collected are unfortunately not retained within the Ministry and accrue directly to the Treasury. The Ministry is in the process of exploring possibilities to negotiate with the Ministry of Finance for the retention of at least a certain proportion of the collected fees.

 

25. The Ministry is currently also evaluating alternative financing options, e.g. social insurance, which may have to be introduced in future in order to complement decreasing state revenue fund allocations.

Introduction of Managed Competition

26. The Ministry applies the principle of managed competition in the area of buying-in support services, such as catering and security services and maintenance and repair of equipment. These services are procured by competitive tendering through the national Tender Board. In order to enhance competition, the Ministry ensures that tenders are designed for smaller service and/or supply volumes by dividing tenders into lots that cover selected districts and/or regions rather than the whole country. Local suppliers are thus encouraged to enter bids and competition is increased.

 

27. The Ministry has been buying-in clinical services from private medical practitioners for a number of years. This is pertinent to some smaller district hospitals where originally local private medical practitioners were used exclusively to provide services on a session basis. The Ministry is however also employing state medical officers at all district hospitals in order to enhance the public/private mix in service provision.

 

Working with the Private Sector

28. Besides direct contractual collaboration as described above, the Ministry’s hospitals are open to private medical practitioners, who admit their patients for any of the services offered, e.g. diagnosis, treatment, operations etc. This practice is encouraged by the medical aid scheme for government employees which separately pays the practitioners and the hospital for the respective services rendered.
29. The Ministry also contracts-in consultant services of private specialists. For example, in the absence of its own CT scanner in the national hospital, the Ministry has, for a number of years, been purchasing this service from a private radiologist.
30. Regarding the not-for-profit private sector, the Ministry has recently updated and formalised its agreement with all church health services. The terms of the co-operation have been considerably clarified and stipulate, amongst others, that the Ministry fully subsidises operational costs and up to 50 per cent of capital costs; the missions comply, as far as possible, with MoHSS policy related to service provision; and salaries and personnel benefits remain at comparable levels.

 

Conclusion

31. A considerable number of reform initiatives are currently ongoing in the Namibia health sector. The Ministry of Health and Social Services is thereby putting in place systems and mechanisms that will provide the necessary tools to manage the challenges expected to arise beyond the year 2000.