Namibia has been hailed for the tangible results it has achieved in the health sector since independence. And, although there has been much improvement, many more challenges remain such as the high HIV/AIDS prevalence rate, as well as the high number tuberculosis (TB) cases, despite a significant decrease over the years. The World Health Organisation (WHO) office in Namibia has contributed significantly to some of the achievements in the health sector, particularly in providing technical support and capacity building. New Era journalist, Alvine Kapitako, recently spoke to the former WHO country representative, Dr Magda Robalo, who served in Namibia for six years before taking up a new challenge in Ghana. In this wide ranging interview, Robalo spoke highly of the achievements in the health sector. Six years may appear a long time, but it is too short a period to transform the entire health sector of a nation, Robalo told New Era. Below is the interview in abridged form.
NE: If you were to single out one or two prominent achievements during your tenure in Namibia what would that be?
MR: I would have to say that I cannot talk about my achievements. First of all, WHO does not have programmes in Namibia. We support government programmes. Secondly, I work with a team, the WHO team and whatever we do is in collaboration with the WHO team, but most importantly, whatever we do is done in close collaboration with the partners that also support the Ministry of Health and Social Services, so I will be more comfortable in talking about our achievements – the achievements of the government, the partners and WHO. Besides HIV, TB and malaria, I can mention the successful partnership that we have been able to build, nurture and reap benefits from. We have been able to support Namibia with partnership building, advocacy, negotiations, dialogue, as well as coordination with bilateral and multilateral partners. By that I mean UN agencies, the US government, the Global Fund, German cooperation so that consistently throughout these years we have been able to offer both technical and financial support to the ministry of health. The power of smart partnerships is for me the most critical achievement that we collectively achieved in Namibia and I’m proud to have been at the centre of that process.
NE: Overall, what kind of legacy are you leaving behind?
MR: I think we are leaving behind strong policies, strong guidelines based on science that have been tested and that have the potential to take Namibia from where it is to better health. We are leaving behind strong partnerships that need to continue so that they can work for the benefit of the health sector. We are leaving behind financial resources coming from donors, sometimes through us and sometimes directly to the ministry, which will go a long way in improving health outcomes in this country. I think we are also leaving behind a very acute awareness by the political leadership of the importance of health in this country. I came and I found a political establishment very much concerned about health and we have continuously strengthened that commitment, that awareness to an extent that it has not reduced, but increased over the past six years and that is important, because without political commitment and support you cannot achieve much. So, I believe these are some of the components of my legacy in Namibia.
NE: In your view what are some of the problems facing Namibia in terms of health provison?
MR: The fact that Namibia is now in an era where things are improving, there is still a very high burden of communicable diseases, HIV/AIDS even though it has been going down its still very high. TB has also been going down, but it is still very high, malaria has gone to an extent that we are now talking about eliminating malaria, but we still need to work hard to get there. Maternal and child health is a big challenge, we need to continue working hard to bring the numbers down. At the same time, we have high levels of malnutrition and an increase in hypertension (high blood pressure), diabetes or what we call non-communicable diseases. Cancer is also one of them. We have a very high consumption of alcohol, we need to fight smoking and we have a very high rate of mortality due to road traffic accidents and so the package of health problems is such that we need to redouble our efforts, we need to prioritise, we need to find where best to invest, because we can’t do everything. These are some of the problems that Namibia will be struggling with for the next five, ten or fifteen years to come or more.
NE: The Minister of Health and Social Services, Dr Richard Kamwi, recently said that you came to Namibia at a time when HIV and AIDS, malaria and TB were at a peak and were claiming lives. What was your contribution to the fight against these three diseases and how do you feel to have been part of that challenge?
MR: I feel privileged, happy and at the same time humbled to have been part of dealing with the challenge and experiencing the change. Humbled because I’m just one player, the real people making a difference are the frontline health workers looking after patients on a daily basis, sometimes forty, fifty patients every day. But, when I came I knew this is a high burden HIV/AIDS country. TB is also high, but then I looked carefully and found that maternal mortality was also high and I said to myself, ‘ok we need to continue fighting HIV/AIDS, TB and malaria, but we also need to pay attention to maternal and child health and nutrition.’ We worked hard, putting policies in place, putting guidelines in place, helping to train people, helping to immunise children. We worked with the former prime minister (Nahas Angula) so that the alliance for improved nutrition was established. We created awareness and we continued to advocate for critical priorities to be given the attention they deserve and I think we are now seeing the fruits and the results of that. We looked for partners to give more money to the ministry and we successfully discussed and negotiated with the EU for them to invest in maternal and child health; the Global Fund continued investing even when there were times, when that funding to Namibia was in doubt. We spend some difficult times negotiating back and forth that was one of the moments also when I look back and I say, ‘ok we have been able to steer and help the government with the negotiations to such an extent that the funding was not cut and Namibia continues to benefit from Global Fund resources to implement its programmes.
NE: Maternal and infant mortality are a problem in Namibia. Every now and then we read and hear in the news media of women who die while giving birth, babies who die and mostly because of negligence on the part of the health personnel. What are your views on this and do you think Namibia will reach a point when these will no longer be a problem and how should we go about it?
MR: The death of any human being is a sad event. And when it happens due to preventable causes it is even more unfortunate. But, what I want to say also is that most women deliver safely and they have their babies. Fortunately, it’s not the majority of Namibian women who die while giving birth or their child dies after birth or just before birth. Fortunately, the vast majority of Namibian women give birth, remain alive and they give birth to very healthy babies. We have had unfortunate incidents of maternal and child mortality that were reported in the media. I am not in a position to say whether or not it was due to negligence, because for you to make a judgement you need much more than just media reports. You need thorough investigations so that you can attribute responsibility here and there. But we have helped the ministry establish what we call a maternal death audit review. Every time a mother dies while giving birth there is a thorough review of why it happened and what could have been done to prevent that from happening. The maternal death audit review committee is not meant to be a court of justice, but is meant to make us learn from our mistakes and then prevent things from happening next time. The reports that we have received from the health information system are telling us that maternal mortality is going down, but it’s too early for us to celebrate success. We need to wait for the results of the DHS (Demographic and Health Survey) that should be published this year and then we will know whether or not our efforts of the past five years have had an impact or not. I cannot say this will no longer be a problem, even though it is possible, there are countries in the world where no woman dies per year while giving birth, it is possible but I think we are still a long way from that. We just need to believe that we can make it, continue to work hard and put in place the policies and the resources that are needed. If everyone takes their responsibility seriously, we shall be able to see a Namibia where no woman dies while giving birth. It is indeed possible.
NE: What have you learnt from Namibia that the rest of the world can learn from, especially in the developing countries in terms of health services delivery?
DMR: I will single out political commitment, if only many other African countries could commit resources to the health sector the way Namibia does we would go a long way in improving the health of Africans in the 21st century. The political commitment of Namibia towards health is to be applauded, it it is bold and it is I would say, resilient. Year after year, you see the budget being allocated to the health sector and that is very significant. If you ask me ‘is it enough? I would say it is not enough’ we need more money. But there will never be enough money for all the things that we need to do, but the commitment counts. Namibia has not reached the 15 percent Abuja target of allocating financial resources to health, but it has been around 10 percent, 11 percent, 12 percent. Many African countries are at 3 percent, 5 percent, they are not there. So that’s one important thing and that is political commitment. It’s not just talk, the leadership walks the talk and other developing countries can learn lessons from Namibia in terms of that. Everything usually falls in place when there is political commitment.
WHO’s main focus has been on building capacity and you have been a great technical advisor to the Ministry of Health and Social Services. What has been your contribution through your work as Country Representative in elevating the status of the Namibia health sector?
MR: My role as the head of the WHO office was basically to provide strategic and policy advice to the Ministry of Health and Social Services, as well technical support in any area of health that you can imagine. It could be from things that people don’t hear about much like occupational health; it could be issues related to how do you make sure that when vessels move from one port to another any hazardous substance that may be there is safely transported. People don’t hear about that, but we worked with the ministry on those things. How do we look for potential transmission and outbreaks of diseases when people enter the borders of Namibia, while respecting their rights? We work on blood safety, making sure that the standards are kept and every year Namibia is able to provide safe blood to its citizens. As much as we work at a high level for strategic and policy advice, we also work in the field. If there are outbreaks I think you have seen me criss-crossing this country whenever there is a concern here and there, we are also there to find out what is happening and how it started; what are the measures to take; what can be done now and how do we make sure we deal with this disease decisively? Working with the ministry has taken me to Angola, Zimbabwe to discuss cross-border issues. So our work is quite diverse, we influence what the ministry does or does not do in many different ways. Always with the interest of getting the citizens of this country in a better status of health.
NE: And to what extent do you think the country’s health status has been elevated from what it was at independence and when you assumed duty here?
DMR: We should applaud the government of Namibia for embracing the primary health care strategy since independence and according every citizen the right to access health services. We know that Namibia is one of the most unequal societies in the world, where the gap between those who have and those who do not have is quite wide. But, the government has made it a point to ensure that no Namibian citizen is denied access to health services, because they are not able to pay for the services and that’s a bold decision that has been taken. Since independence, the expansion of the health infrastructure has been amazing, clinics, hospitals, outreach services have been expanded to every corner of Namibia. One of the challenges is that the country is huge and vast with a very small population scattered around the country. It is difficult and it is impossible to put a health infrastructure everywhere where people live, it is just not possible. It is not cost effective, it is not realistic to think that government can do it. But as much as possible services have been established. Where there is no physical infrastructure, there are outreach services, the health workers go and meet the communities to provide immunisation, to provide antenatal care and other services, so there has been a massive improvement since independence. If you look at the last six years, I cannot give you exact figures, but I have been at several inaugurations of health posts, health clinics and health infrastructure that the government has built to improve access to quality services. WHO has also been part of discussions on how to establish a system for health financing and health insurance so that we can have a safety net for preventing people from becoming poor, because they have to spend a lot of money on healthcare. But, we recognise that much more needs to be done and I want to emphasise this – we have come a long way, but much more needs to be done before we can say Namibia has reached a level where there is universal coverage and everyone who needs health services has access to it in a timely, affordable manner and in a way that his or her rights are respected and his or her health is promoted.
NE: When you came to Namibia what was the one thing that you wanted to achieve at the end of your service? And six years later have you achieved it?
DMR: I want to say that I did not have any pre-established agenda when I came to Namibia. I came with an open mind and I said I will find out from the people who are working there, from the government, from the partners, from the team, review the literature and then see where it is that WHO can make a difference with the resources we have at our disposal. So, that led me to identify maternal and child health and nutrition as an area where this office could put a focus on. HIV/AIDS was a major problem and so was TB and malaria, but we had quite a significant number of partners funding those – PEPFAR, the US government and the Global Fund. That did not mean that I was not concerned with HIV/AIDS or I was not supporting efforts to combat HIV/AIDS, TB and malaria. We said we will work on that, but we will make sure that we bring maternal and child health and nutrition up higher on the agenda so that we also tackle this problem, because while we were successfully preventing people from dying of HIV/AIDS they were dying during pregnancy. And I’m glad that as I’m leaving, maternal and child health is very high on the health agenda of Namibia.
NE: What does it feel to eventually be leaving Namibia?
DMR: As they normally say it’s never easy to say goodbye, so I have been privileged and I have been blessed during the past six years in Namibia, because I have enjoyed maximum support from the government, from the partners and from my team, including my colleagues in the UN system in Namibia so that I could do my work in a way that I hope it has been satisfactory to the government. So, I’m leaving with a sense of having tried my best to contribute something to improve the health of Namibians. I’m leaving with a sense of pride for having been associated with people who really care for the health of the citizens of this country. I’m leaving with a nostalgic feeling, because I have established relationships with many people across this country both at the ministry of health and other government ministries, civil society, even people at the grassroots, people working in the private sector.
NE: And do you think Namibia, and its health sector in particular will miss you?
DMR: That’s a question I cannot answer (laughs). I think we will need to ask people and find out whether they are fond of taking leave of me, but I can assure everyone that I have tried my best and I hope some of the seeds we have planted will make a difference in people’s lives