SECTION III: General Information about the Country Setting
18.1 HIV/AIDS
Disease burden: Globally, Namibia is ranked among the top 5 most AIDS-affected countries. HIV/AIDS is the most important public health problem in Namibia, ranking as the first cause of deaths and hospitalisations[1]. The year 2000[2] Sentinel Sero Survey (SSS), carried out at urban and rural sites in Namibia’s 13 regions, found that the HIV prevalence rate among pregnant women varied from 7% to 33%, with a weighted national prevalence[3] of 22.3%. This is an increase of 3% since the 1998 (SSS [4]). At the end of 2001, UNAIDS[5] estimated 230 000 adults and children to be living with HIV/AIDS. The greatest burden of the epidemic falls on women, who become infected at a younger age and account for 56% of all reported new HIV infections. Increased adult mortality has caused a dramatic rise in the number of orphans. Currently estimated at 82,000, it is predicted that Namibia will have 118,000 orphans by 2006. Please see chart overleaf.
Trends[6]: For the age groups 15-19, and 20-24, HIV prevalence has remained at the same level since 1998. However it is still increasing in all other age groups. Geographically, where it has been possible to compare longitudinal data, the SSS 2000 results indicate a trend of increasing prevalence in every region but two. The four sites with the highest prevalence were all in urban locations registering between 28 to 33% positivity. HIV prevalence is also high in rural sites close to major movement corridors. These sites are also all in the seven most populous regions of the country with over 66.7% of the population. Statistical modelling using the national HIV prevalence figure of 22.3% suggests that Namibia is in the second phase (HIV prevalence rises sharply) of the HIV epidemic. The model estimates that the national prevalence rate will level off at 24% by the year 2005.[7] (Please see annexure L for figure 3 Age specific HIV prevalence in pregnant women Namibia 2000 and figure 5 HIV Prevalence trends in pregnant women age 15 – 24 Namibia 1994 – 2000)
18.2 Tuberculosis
Disease burden[8]: Ten percent of all deaths in Namibia are due to TB, making it the second cause of reported deaths after HIV/AIDS and the fourth cause of morbidity. TB was the second most frequent cause of hospitalisation and a significant cause of outpatient department attendance in Namibia[9] between 1996 and 2000. Between 1991 and 2000, the rate of notification has risen from 430/100 000 to 619/100 000 in the year 2000. This escalation is attributed to the link between HIV and TB. The 1998 HIV SSS included measuring co-infection amongst TB patients and found a co-infection rate of 45%. Multi-drug resistance is also increasing. This places an additional strain on Namibia’s pharmaceutical budget and causes an increase in the average length of stay in hospitals.
Trends: The age group 15-45 years remained the most heavily affected for new pulmonary smear positive cases amongst both males and females during the past five years; this is consistent with the most affected HIV/AIDS age group.[10] Overall, the proportion of in-patients diagnosed with TB rose from 10% to 27% between 1995 and 1999, while the number of deaths increased by 64% over the same period[11]. Seven percent of in-patients aged 13 and over, and 3% of those under 13 have tuberculosis. Regional differences in incidence during the year 2000 ranged from 260/100,000 to 1,675/100,000 in Kunene and Erongo region respectively[12]; five regions[13] account for 50% of the overall burden of TB in Namibia[14], placing a heavy load on health facilities in these regions. In cases registered during 1995-2000, the increase was higher for females in the 14-24 year age group, whereas in males the increase was higher in the 25-44 and older age group[15]. In all age groups, except among children, the numbers of detected TB cases in males prevail over females[16]. Given that the steady escalation in the incidence and prevalence of TB is attributed to the HIV/TB link (45%[17] co-infection), statistical modelling predicts a similar rapid increase in HIV/TB co-infection before it levels off in 2005[18]. Increasing resistance to existing TB drugs is likely to play a contributory role.
18.3 Malaria
Disease burden: Malaria is endemic in the northern regions of Namibia, with an average incidence of 240,000 cases for the whole country, in the year 2000. Some 1,090,000 people live in malarious areas. Malaria is the first cause[19] of outpatient consultations and hospital admissions in Namibia. It is the leading cause of illness and death amongst Namibia’s under-five year olds, and the third important cause of death among adults. The mortality rate increased from 30/100,000 in 1998 to 45/100,000 in 2000 respectively.
Trends: Seasonal[20] climatic conditions generate high transmission risk, mainly between January and May in the north-eastern and north-western regions of the country. In these regions, malaria is an important cause of death. The effects of HIV/AIDS co-infection are believed to play an important role in this regard, particularly related to maternal deaths. Malaria also has a disproportionate effect on Namibia’s poorest rural households, particularly in the disadvantaged regions in the North. The increasing poverty levels brought about in these areas by the HIV/AIDS epidemic, and concomitant food insecurity, increase the potential for a rapid increase in malaria incidence.
19 Current economic and poverty situation
· With a total population of 1,8 million, Namibia’s GDP per capita was USD 1,173 in 2000[21]. This hides a significant disparity in income distribution, which is better represented in Namibia’s Gini co-efficient of 0.70 in 2000[22]. Half of Namibia’s population survives on approximately 10% of the average income, while the ratio of per capita income between the top 5% and the bottom 50% is approximately 50:1[23]. These differences are aggravated by a high national unemployment level of 35% (1998). In the age groups 15-19, and 20-24, the unemployment rate was 62% and 55% respectively[24]. In 2000, Namibia’s HDI was 0.770 increasing from 0.683 in 1999[25]. Namibia’s National Human Poverty Index score was 24.7 in 2000 [26]. The northern regions generally score considerably lower than the southern.
· HIV/AIDS, and HIV/TB co-infection (45% in Namibia) are not only health problems, but also socio-economic development problems. Poverty is both a cause and effect of HIV/AIDS, and of HIV/TB co-infection. Those most capable of increasing Namibia’s GDP, (i.e. those in the most productive and active age groups), are either those most affected by unemployment, or most affected by HIV/AIDS, or both. HIV/AIDS (and by implication, HIV/TB co-infection) affects Namibia’s economic growth, and increases poverty levels in several ways:
(a) Decrease in GDP: According to the IMF, as quoted in NDPII, 2.5% of GDP per capita will be lost per annum by 2010 if the HIV prevalence is not reduced.
(b) Declining health implies not only reduced productivity, but also increased care expenditure. The Namibian Government (GRN) currently allocates between 10%-12%[27] of the national budget to the health sector. This is not sufficient to make an impact on the burden of disease attributed to HIV/AIDS, TB and Malaria. The National Planning Commission estimates that the indirect and direct cost of medical care of HIV/AIDS to the Namibian economy will amount to N$8 billion by 2010, equivalent to 20% of the national GDP, or 6 times the expenditure on health in the public sector.
(c) Rising mortality: The ILO projects that Namibia is expected to lose a quarter to a third (35.1%) of its workforce by 2020. Apart from the premature loss of well-trained and experienced employees, many return to homes in the communal areas to die, adding to poverty levels in already vulnerable regions.
(d) Increase in vulnerable children: Orphans are projected to increase by 2006[28]. More than 50% of these AIDS orphans are living in the northern regions. These are the same regions, which already show both low development and high poverty indices[29].
Existing and anticipated poverty levels have implications for all 3 diseases, which are complexly and systemically related to poverty. Some of these links[30] are:
· Poverty is associated with food insecurity. Parents of about 30% of all children are unable to provide nutritious food of adequate quality and quantity and with the required frequency[31]. Recent trends also indicate rising food inflation – the food basket has been particularly influenced by the rising price of maize and grain products[32].
· In traditional rural areas, there is a reduction in labour availability, as illness, death, attendance at funerals, and time spent in care of the sick diverts labour. This labour diversion is directly linked to food security, as acreages of staple crops planted decrease, and less attention is given to crops at crucial times.
· The extended family absorbs orphaned children at this stage of the epidemic. However as numbers increase, so households are pushed further into poverty. Government orphan assistance to families caring for orphans does exist through family grants and options to waive school fees, but there is limited knowledge of this assistance and major obstacles exist in the communication and implementation of assistance programmes.
20. Current political commitment in responding to the diseases (indicators of political commitment include the existence of inter-sectoral committees, recent public pronouncements, appropriate legislations, etc.;
20.1 Existence of inter-sectoral committees
· In 1999, the Government of Namibia instituted an Expanded National Response strategy through the newly established National AIDS Coordination Program (NACOP), which stipulated a multi-sectoral coordinating mechanism. Specifically, the 1999 National Strategic Plan on HIV/AIDS (Medium Term Plan II) established two inter-sectoral committees at central level to deal with the epidemic. These are the National Aids Committee comprising Cabinet members and the National Multi-Sectoral Aids Co-ordination Committee (NAMACOC). NAMACOC comprises representation from 12 Government Ministries, the UN Theme Group, NGOs, Parastatals and the Private Sector. Since 1999, 80% of the sectors have established HIV/AIDS focal points and developed plans of action.
· All 13 administrative regions have a Regional AIDS Co-ordinating Committee (RACOC) chaired by the Regional Governor. (Please see organisational chart at Annexure A). The expanded response was also institutionalised in HIV/AIDS-related national policy documents. In 1999 the government also included TB in the Multi-sectoral National Response to HIV/AIDS.
· In each region, there are Constituency and Regional Development Councils (RDC), chaired by the Regional Councillors and Regional Governor respectively. The composition of both the RDCs and the CDCs is multi-sectoral. Duplication between these two regional structures (i.e. the RACOC and RDC structures) is avoided in that the chairperson of each is the Regional Governor.
20.2 Recent political pronouncements
· The President of Namibia continues his decade-long support in the fight against HIV/AIDS. Describing it in a recent address as a ‘war to be won’, he continued: “HIV/AIDS infections and deaths have risen to an alarming proportion in recent years. Thus it can no longer be considered as a health issue alone but a general development issue … We should therefore all rise to the occasion to halt the further acceleration of this pandemic … not only … by intensifying our educational campaigns, but also by changing our attitudes as individuals and communities towards the disease and those infected with it … we should stop sexual behaviours that put us at risk of infection like promiscuity, alcohol and drug abuse, and adopt a more supportive attitude to those living with the disease…it is also important that employers and insurance companies become part of this supportive system.” As a practical measure, he proposed[33] that doctors trained through public funds be contracted for long-term service in government hospitals because the “…issue of quality health care to our people is of paramount importance given the high prevalence of the HIV/AIDS pandemic which is killing thousands of our people who are in their productive age.”
· The President of Namibia took part in the African Heads of State Summit leading to the Abuja Declaration of April 2001.
· All 13 governors attended the XIII International AIDS Conference in Durban, in July 2000. A multi-sectoral group led by one of the regional governors attended the ADF 2000 in Addis Ababa and adopted the Africa consensus and plan of action: Leadership to overcome HIV/AIDS. The report on this forum was presented and discussed in the Namibian Parliament.
· More recently, the Minister of Health led the Namibian delegation to UNGASS in June 2001. Namibia has officially requested to be a part of the International Partnership against AIDS in Africa (IPAA), and plans to launch the IPAA in 2002. MoHSS Deputy Minister attended ICASA (2001) and the IPAA stakeholders meeting.
· In February 2001, the UN Secretary General's Special Envoy on HIV/AIDS in Africa, Mr. Stephen Lewis, visited Namibia on invitation of the government and had extensive meetings with the President, Ministers from key sectors, senior government officials and members of the regional authorities.
· In the same year, government supported the establishment of an organization for People Living with HIV/AIDS, called Lironga Eparu.
· The National Development Plan II (NDP2), which guides resource allocation for the period 2003-2007, has set as priorities for the nation, the prevention and control of HIV/AIDS, and disparity reduction in Namibia’s human development[34]. Also within this context, all sectors e.g. ministries of defence, education, foreign affairs, and information and broadcasting, are allocating funds to initiate HIV/AIDS activities.
· As part of the resource mobilisation efforts supporting the AIDS medium term plan and NDP2, a “Menu of Partnership Options” was compiled early in 2002 and launched at international (African Economic Summit in Durban, South Africa) and national for a by the Minister for Health. The menu enhances the partnership by private sector organizations in the fight against HIV/AIDS.
· The Government of Namibia is party to the Amsterdam Declaration to Stop TB (2000), and Namibia is a member of the Southern African TB Control Initiative (SATCI). The programme has recently undergone an extensive review and a strategic plan has been drafted earlier during 2002 with assistance from WHO and relevant targets have been included in NDP2.
· In 2000 the President of Namibia participated in and signed the Abuja Declaration on the Roll Back Malaria initiative. Subsequent to this, government has draft its RBM Strategy. Targets related to RBM are also included in NDP2.