"The States party to the present Covenant recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health."
-International Covenant on Economic, Social and Cultural Rights

The rights to life and health remain unfulfilled for many Namibians. Namibia’s progress toward the MDG to reduce child mortality is slow, and its situation with respect to the other MDGs for the improvement of health, in the areas of trying to reduce maternal mortality and the prevalence of AIDS, malaria and TB, is stagnant or worsening. Due principally to AIDS, between 1991 and 2001 life expectancy at birth declined precipitously from 63 years to 50 for females and from 59 to 48 for males.⁷⁹

Issues Identified
The key challenges to the fulfilment of rights to life and health in Namibia are: the high HIV prevalence, poor child health and the heavy burden of preventable diseases and high maternal mortality.

High HIV Prevalence
Statement of Rights Unfulfilled
The inability to deal effectively with AIDS is not only Namibia’s foremost challenge to fulfilling rights to life and health, it is a threat to the fulfilment of all human rights in the nation. The 2002 sero-sentinel survey found that 22% of pregnant women were HIV-positive. At 43%, the sero-prevalence was highest in Caprivi. The other most severely affected regions were Oshana (30%), Khomas (27%), Oshikoto (26%) and Omusati (25%). Infection rates continue to rise for all age groups except for 15 to 19 year olds, which fell to 11% from 12% in 2000. The 25 to 29 year age group, having an infection rate of 28%, was the worst affected.80 AIDS has been the leading cause of death since 1996. In 1999, AIDS was responsible for 26% of all reported deaths and 46% of deaths among 15 to 49 year olds. By the end of 2003 more than 136,000 HIV cases had been reported.81 Although the rate of new HIV infections may be slowing down, there are now more people falling ill, dying and leaving behind a rising number of Orphans and Vulnerable Children (OVC). Causality Analysis
The immediate causes of Namibia’s high HIV prevalence are high rates of unprotected sex with an infected person and mother-to-child transmission of HIV. Intravenous drug use is not a common problem, the blood supply for transfusions is effectively screened and safe injection practices are in place.

Unprotected Sex with an Infected Person
Namibians, on average, first have sex at age 18 for men and age 19 for women but a significant group of people, 6% of women and 12% of men, are having sex before turning 15. Almost all Namibians are sexually active before their 20th birthday.82 Teenage pregnancy has dropped to 18% in 2000 from 22% in 1992 among 15 to 19 year olds.83 Still, 39% of 19 year olds are either mothers or are pregnant. The use of condoms during all risky sexual interactions would have kept the HIV prevalence low. However, in 2000 only 43% of women and 67% of men reported using a condom during their last high-risk sexual encounter, and only 9% of women reported consistent condom use. The underlying causes of HIV transmission through unprotected sex are as follows:

• Many Namibians have multiple sexual partners. In 2000, 17% of unmarried men ages 15 to 59 years reported having sex with two or more partners annually. This rate rises to over 20% in the 20 to 24 year age group and to 25% among 25 to 29 year olds. Almost 20% of married Namibians reported having sex with someone other than their spouses, as did about 30% of married women between the ages of 15 and 20 years.85
• The high prevalence in Caprivi is attributable to its transit position bordering Zambia, Botswana and Zimbabwe that have high infection rates.86 But issues of stigma and fear are also much higher among Caprivians than among the rest of the country. Only 8% of Caprivi men and 22% of Caprivi women acknowledge knowing someone who has AIDS or died of AIDS compared to a national average of 53% of men. This is surprising given the fact that Caprivi has the highest and longestrunning HIV-infection rate.87
• The high prevalence of Sexually Transmitted Infections (STIs)88 also increases the risk of HIV transmission. In 2002, the HIV prevalence among STI patients was 39% for females and 38% for males.89
• Few Namibians know the HIV status for themselves or their partners. Less than 25% of Namibians in the sexually active age group reported having had an HIV test. In rural areas the proportion tested was only about 15%. In Caprivi, only 5% of women and 8% of men reported having had an HIV test.90
• Sexual exploitation of women is a common feature. "Sugar daddies" are a widespread phenomenon.91 Many girls first have sex with a significantly older (10 years or more) partner while most boys first have sex with someone the same age or younger,92 about one in six young women have had sex in exchange for money or material rewards93 and among 13 to 19 year old STI patients in 2002, the HIV prevalence was 23% for girls and 6% for boys, suggesting that teenage girls are having sex with older men.94 Moreover, about 70% of women in rural areas report that decisions about sex are made mostly by men, which limits the abilities of women to negotiate condom use.95
• If a wife refuses to have sex close to 20% of Namibian men agree that a husband has the right to yell at her or have sex with someone else, and close to 7% agree that he has the right to force her to have sex. In Kavango and Ohangwena, over one-quarter of men agree that raping a wife is justified if she refuses sex.96
• Many people lack accurate information about HIV/AIDS and do not have condoms when they need them.
• Alcohol, which is commonly abused in Namibia, decreases inhibitions and self-control and thus makes people prone to risky sexual behaviour and committing sexual abuse.

Mother-to-Child Transmission
MOHSS estimated in 2002 that every year 15,400 HIV-positive mothers give birth, leading to HIV infection of some 6,180 infants pre-partum, during labour or through breastfeeding.97 Underlying mother-to-child transmission are the mother’s ignorance of her HIV status associated with stigma and culture of shame and fear; the cost implications of breast milk substitutes and antiretroviral drugs; and, inadequate provision and uptake of Prevention of Mother-to-Child Transmission (PMTCT) prophylaxis such as nevirapine.

Root Causes
One of the root causes of Namibia’s high HIV prevalence is the low status of women. Negative cultural perceptions of the sexual rights of women are compounded by limited access of women to employment and resources resulting in high poverty and economic dependency levels of women. Women often do not have the chance to decide freely when, how and with whom to have sex. Sex in exchange for rewards and security is common across all ages. The stigma and discrimination restricting women to access preventive methods and treatment and the cultural norms that accept people having multiple sexual partners increase female vulnerability.

The ‘social forces’ of unemployment and connected high mobility - especially of males in search of employment - have contributed to the break-up of family structures and to the accelerated spread of HIV. Various studies have indicated that men feel unable to live up to societal expectations of the male taking care of himself and dependents. Ensuing loss of perspective fuel alcohol abuse, compensatory sexual relationships and violence. Ironically, it is often the wealthier men who have the means to engage in transgenerational, transactional or commercial sex, which are also fuelling the spread of HIV, especially among young girls.

Despite government efforts, the response to the pandemic has been delayed and is currently still suffering from a lack of leadership and commitment at all levels and amongst all stakeholders to make a reality the important programmatic interventions contained in MTPIII, which defines the roles of ministries, NGOs, the private sector and development partners in fighting HIV/AIDS.98 There is weak multi-sectoral coordination of HIV/AIDS prevention, care and support. This results in limited access to information while unemployment is taking away hope for the future and limiting options of healthy preoccupations.

Role Analysis
Sexual partners have the duty to know their HIV status, use condoms, be faithful to each other and respect each other’s rights. Everyone is responsible for abstaining from sex if they are not in healthy and committed relationships. Mothers have the duty to know their status and to get PMTCT treatment if they are infected and pregnant. Parents have specific responsibilities to provide their youth with a supportive environment with guidance and care. Parents, teachers and health workers are obliged to provide complete and accurate information about HIV prevention and AIDS to youth and their own peers. Family, community and national leaders are obliged to talk about HIV/AIDS, confront harmful cultural practices and beliefs, speak out against stigma and discrimination, encourage healthy relationships and discourage alcohol abuse. They also have the duty to promote proper condom use, HIV testing and treatment.

There is a greater need for involvement of people living with HIV/AIDS at all levels and for an environment to be created where they would be more open to declare their status. The government has the duty to fulfil MTPIII activities. With the growing numbers of development partners joining the fight against HIV/AIDS, coordination will become one of the key priorities for government to avoid duplication of efforts and loss of resources at the expense of beneficiaries. There needs to be greater coordination among stakeholders for adequate knowledge generation, collation, distribution and documentation, as well as anticipating and preparing for the shortage in skilled human resources. NGO’s, faith-based organisations and CBO’s are important providers of services that link youth, family and the wider community. They have a role to cater for programmes responding to specific needs of the community and to initiate social change by questioning the negative norms practiced while building the positive value base in the society. The private sector has a role to mobilize funds and to develop workplace HIV/AIDS programmes. The UN partners and the international community have a role to bring in the technical know-how, global perspective, new research and to play a more vigilant and vigorous role in coordinating their efforts for HIV/AIDS prevention and treatment. The government, civil society and the international community are obliged to provide the funds adequate for HIV prevention, testing and treatment and to support all duty-bearers in fulfilling their roles.

Capacity-gap Analysis
Significant proportions of Namibians, particularly rural women, do not have complete and accurate information about HIV/AIDS. In 2000, 8% of men and 4% of women did not know of AIDS or if it can be avoided; 65% of women and 49% of men did not know that abstaining from sex is a way to avoid HIV; 14% of women and 8% of men did not know that using condoms helps avoid HIV; 24% of women and 11% of men did not know to limit their number of sexual partners; 17% of women and 13% of men did not know that a healthy looking person can have HIV; and 14% of women and 16% of men did not know that HIV can be transmitted to children during pregnancy or delivery.99

Irrespective of risk some men believe that they do not have to use condoms and that they have a right to sex, particularly with their wives and in transactional relationships.100 Girls are conditioned to accept gifts in exchange for love and sex.101 Women lack the power and skills to negotiate condom use. Some people do not have condoms when they are in high-risk sexual situations. Some Namibians believe that having multiple sexual partners is culturally acceptable.102 Many Namibians are uncomfortable talking about sex, HIV/AIDS.103

Many Namibians do not want to get tested for HIV due to stigma and discrimination and the fact that AIDS treatment is still very limited. As of middle 2004/05 the seven state hospitals and five statesubsidised church hospitals providing ART had served about 3,000 patients. MOHSS aims to have 5,000 patients on ART by the end of 2004.104 Strong interventions must be implemented at all levels to counter the vicious cycle of stigma, discrimination, fear, lack of human rights of women and alcohol abuse.

Voluntary Counselling and Testing (VCT) services are still very limited. As of early 2004 there were six New Start VCT centres in areas of high HIV prevalence. Their monthly number of clients climbed from 200 in February 2003 to 1,000 in March 2004.¹⁰⁵

Many mothers do not have access to PMTCT treatment. As of early 2004 the 12 hospitals providing ART also provided nevirapine to approximately 1,500 clients, accounting for less than 10% of the annual births to HIV-positive mothers per year.¹⁰⁶

Children living with HIV/AIDS are treated in the same way as adults carrying the virus. Children have their needs, very different to those of adults and need special care.

The government, NGOs, the public sector and development partners are short of the skills and resources to fully implement MTPIII. Also, the question still remains whether HIV/AIDS really is a top priority in Namibian society that is often preoccupied with economic challenges such as unemployment. There needs to be more coordination and leadership to encourage healthy lifestyles, behaviours and practices and to translate policies and plans into full-scale action. There is also not enough coordination of information generation and research applicable to Namibia.

The capacity of the government in coordinating the efforts at the national level is far from adequate. The high turnover of staff, understaffing, results in the need for continuous capacity development training, the workload to manage multiple programmes in the face of increased numbers of deceased workers as an impact of HIV/AIDS is a major roadblock not only in achieving the goals on HIV/AIDS prevention, care and support but also to monitor and sustain the ongoing critical public health initiatives. Barriers still exist in improving and increasing opportunities through community programmes by NGO’s, faith-based organisations and civil society at large. The programmes are not occurring at a scale and the various efforts have not come together in a concerted way on HIV prevention or mobilizing people on rejecting harmful traditional practices. Funding through the private sector has still not gained momentum and the rigour in mobilising civil society for ‘societal change happen’ is still beyond reach.

The UN is still lacking in the level of scale of support and joint efforts in response and the donor community in advocating for funds mobilization. Despite a substantial financial commitment to AIDS by the government and its development partners, it is estimated that Namibia will remain US$25 million short of the money required to fight the epidemic every year over the next five years,¹⁰⁷ although his calculation does not include recent commitments made by the US and the Global Fund.

Poor Child Health and the Heavy Burden of Preventable Diseases
Statement of Rights Unfulfilled
Preventable diseases violate the rights to life and health of many Namibians. Beyond HIV/AIDS, malaria and TB are also preventable obstacles to health rights.

As estimated in 2001, for every 1,000 live births 52 children die before age one and 71 die before age five. These figures marked improvement on the 1991 mortality rates of 67 for infants and 87 for children under five.108 The rate of improvement, however, is too slow to meet the national targets set in NDPII. MOHSS projects that the impact of AIDS will further slow progress in reducing child mortality. In 2021 infant mortality is expected to be about 60% higher than it would have been without AIDS.109 The regional differences in child mortality are enormous. Under five mortality ranges from 51 in the central region of Khomas and Erongo to 113 in the northeastern region of Kavango. Rural children are more likely to die than their urban peers.¹¹⁰

Consistent with global evidence that an infant’s risk of death is 15 times greater in the first month of life,111 in 2000 the neonatal mortality rate was 22 per 1,000 live births, slightly higher than the postneonatal (one to 11 months) mortality rate of 17. Neonatal mortality was also greater than the death rate of children 12 to 59 months old (child mortality rate), which was 21 per 1,000 children reaching their first birthday. Neonatal mortality was highest in rural areas (28) and in the northern regions of Oshana, Oshikoto, Ohangwena and Omusati. (31).¹¹²

Malaria is the leading cause of illness and death among children younger than five years and the third leading cause among adults. It is the leading cause of health facility visits and consistently the top cause of hospital admissions of children under 13 years, accounting for 25, 28 and 36% in 1999, 2000 and 2001. An average of 400,000 outpatients, over 30,000 inpatients and 764 deaths are registered annually due to malaria. Between 1996 and 2003, the number of malaria cases averaged 238 per 1,000 Namibians and number of deaths averaged 49 per 100,000. Between 1996 and 2001 Kavango led the nation in malaria mortality, its rate averaging 120 per 100,000. The next worst affected regions-(in order) Oshana, Oshikoto, Caprivi, Omusati and Ohangwena-all had mean annual malaria mortality rates between 55 and 84 per 100,000.¹¹³

Namibia is the third worst TB-affected country in the world.114 TB is among the four top causes of hospital deaths. Pulmonary TB caused an annual average of 1,747 hospital deaths between 1999 and 2002 with a high of 107 deaths per 100,000 in 2001. Notification rates for all forms of TB rose from 652 per 100,000 in 2001 to 678 in 2002. Close to 9% of TB patients die before completing their treatment.¹¹⁵

About 30%-40% of people with HIV are also infected with TB. TB is the most common opportunistic infection and cause of death among people with HIV. Increased TB cases in HIV-infected people pose risks of TB transmission to the general population. Hence, prevention of HIV is crucial to control TB. TB and HIV impact on economic development and pose new challenges to health and social systems which increasingly have to address issues such as integrating HIV and TB services, facilitating access to drugs and treatment, and caring for infected people.

In 2002, regional variation in TB notification rates ranged from 306 per 100,000 in Kunene to 1,177 in Erongo. In descending order, Khomas, Erongo, Oshikoto, Ohangwena, Omusati and Kavango reported the highest number of TB cases, accounting for about 70% of the TB burden in the country. Adults aged 25 to 44 show the highest prevalence of TB, while females are more affected in the zero to 24 year age group and males have higher incidence from 25 years onwards.¹¹⁶

Causality Analysis
The immediate cause of Namibia’s poor child health and the heavy burden of preventable diseases is exposure to diseases.

Exposure to Diseases
HIV, poor nutrition and alcohol abuse are the primary underlying causes of exposure to diseases in Namibia. A related underlying cause is the likely decreasing efficacy of anti-malaria drugs, which MOHSS is currently addressing through treatment policy revision.

As HIV attacks the immune system, it contributes to the preventable disease burden by making HIVpositive people susceptible to infections and thus giving infections the opportunity to spread more widely. The resurgence of TB is a prime case in point. About 30%-40% of TB sufferers are HIVpositive. ¹¹⁷

Like HIV, malnutrition is both a preventable condition as well as a causal factor behind susceptibility to other preventable conditions and diseases. Data on adult malnutrition is not available, but judging by the proportion of households spending large shares of their income on food, the level of food insecurity and the high rates of child malnutrition, it is likely a serious problem. In 2000, 12% of babies were born underweight as a result of pre-partum maternal undernutrition and poor health. Chronic child malnutrition was widespread, as evidenced by the 24% of children under age five who had low height-for-age (stunting). At 9% nationwide, acute malnutrition (wasting) was less severe. Malnutrition was worst in Ohangwena, where 36% of children under age five were underweight, 28% were suffering from chronic malnutrition and 15% showed acute malnutrition. Khomas, Kavango, Omusati and Omaheke also had chronic malnutrition rates above the national average.

Alcohol abuse directly weakens immunity and health. It may cause congenital birth defects in children born to alcohol abusing parents. It contributes to maternal malnutrition and low birth weight in newborn children. At a social level it directly relates to unemployment, reduced household income, decreased cash and food availability, family violence, sexual crimes and abuse and increased risks of HIV exposure.

Lack of Access to Health Services
Health services have improved markedly since Independence but significant numbers are still not getting the care they need, in part because large proportions of the population can only be reached by mobile outreach services. From 1990 to 2002 measles immunisation of infants increased from 57% to 71%.118 Between 1992119 and 2000,120 infant DPT3 immunisation coverage rose from 70% to 79%, the percentage of one-year-olds fully vaccinated increased from 58% to 65%, the coverage of maternal tetanus toxoid immunisation improved from 61% to 85%, the proportion of women attending four or more antenatal care visits rose from 56% to 69% and the proportion of mothers receiving skilled attendance at birth increased from 68% to 76%. Between 1996 and 2000, 52% of new mothers did not receive any post-natal care. Emergency Obstetric Care (EmOC), the single most important service to reduce MMR has not been made fully available.

Despite an increase in the proportion of mothers who receive skilled midwifery support, 24% of deliveries still take place at home without professional care. In some regions the home delivery rate is as high as 40%. Integrated Management of Childhood Illnesses (IMCI), a noted approach to enhance the cost-efficiency of health services, was launched in 1990 and is operational in only 12 of the 34 health districts.¹²¹

Underlying the significant gaps that remain in access to healthcare is the inadequacy of government revenue to meet all of the nation’s needs immediately. Government’s financial commitment to health has been relatively high. However, it has declined steadily since 2000 with its current share of the total budget standing at 9.2% in 2004/05.122 This falls short of the 15% pledge made by heads of state during the Organization of African Unity’s Abuja Summit in 2000. Close to 75% of the public health sector’s expenditures are dedicated to payments to personnel.

Underlying exposure to preventable diseases are environmental and behavioural factors and the risks of childbirth.

Environmental factors exposing Namibians to preventable diseases include the climate, population density and access to safe water and sanitation:

• The northern regions of Namibia have the highest rates of malaria morbidity and mortality, due to high seasonal rainfall and an environmental feature of longstanding, stagnant water. The predominantly seasonal nature of malaria transmission in Namibia (January to June) confers little or no immunity against the disease. While pregnant mothers and young children are most at risk, all ages are affected. The heavy rains in 2001 led to the malaria incidence and death rates to shoot to 408 per 1,000 and 96 per 100,000 respectively.123
• Recurrent floods in Caprivi and droughts in parts of the country are major causes of food insecurity and malnutrition. The very high rates of TB morbidity and mortality in areas like Erongo are partly attributable to the cold and damp climate, which keeps people indoors without adequate ventilation.
• Where populations are dense the risks of contracting vector- and airborne diseases such as malaria, respiratory infections and TB are higher. The malarial northern regions are also Namibia’s most densely populated.124 High population densities in many rural areas and informal urban settlements also increase risks to waterborne illnesses where the water quality and sanitation are poor.
• Namibia’s high morbidity due to gastrointestinal disorders, notably including diarrhoea and high prevalence of and mortality due to malnutrition are caused in part by poor sanitation and water quality. In 2001, 87% of households had access to safe water and 44% used safe sanitation. While the use of safe sanitation was especially low in rural areas (20%), Namibia’s arid climate mitigates many of the negative effects of such poor sanitation. The regional variance of households having safe sanitation closely mirrors that of access to safe water.¹²⁵
• The negative correlation between the rates of access to safe water and the prevalence of diarrhoea in children younger than five years. The positive correlation between expanding access to safe water and improving health is also evident.

  Underlying exposure to preventable diseases are behavioural factors linked to a lack of knowledge of and access to treatment and preventative measures:

  • Only 28% of newborns are exclusively breastfed for the first six months of life.126
  • Only 43% of children younger than five years live in households that do not use salt iodized to at least 15 parts per million with usage lowest in Omaheke. Iodine deficiency can harm the cognitive abilities of children with lifelong consequence.¹²⁷
  • Health care was not sought for 47% children showing symptoms of acute respiratory infections, 64% of children with a fever and 49% of children with diarrhoea.¹²⁸
  • The use of bed nets is one of the most effective ways to prevent malaria transmission. Among children under five use of Insecticide-treated Nets (ITN), treated or not, remains low at 7%.129 The highest ITN use rates are in Kavango (19%) and Caprivi (34%).130 Though data on other age groups is lacking, it is likely to be similar.
  • About one in six TB patients stop treatment before being cured. The defaulter rate improved, however, from 20% in 1996 to about 14% in 2001. Ten regions show defaulter rates between 10% and 15%, while Khomas, Hardap and Otjozondjupa are above 20%, Ohangwena having the lowest at 5%.¹³¹

  Root Causes
  The root causes of Namibia’s poor child health and heavy burden of preventable diseases are a lack of education, affecting child care, poverty, distances to health facilities, environmental factors and the close connection with HIV/AIDS affecting levels of immunity.

  Role Analysis
  Families and communities have to ensure that mothers and children receive the necessary prevention and treatment for TB, Malaria and other preventable diseases. MOHSS is responsible for providing healthcare for all Namibians, as well necessary outreach and emergency services. MOHSS and MBESC, in tandem with communities, are responsible for improving health education.

  Capacity Gap Analysis
  No comprehensive assessment of the impact of AIDS on the health system is available, but it can be assumed its capacity is suffering from similar effects as the education sector, which has been assessed. The AIDS-related increase in morbidity and mortality also increases the burden of care on the health system. MAWRD is short of the resources, skills and staff to ensure food security for all Namibians.

  The gaps in combating preventable diseases are similar to those for fighting HIV/AIDS and improving general health conditions. Families and communities often lack the knowledge, money and transport to ensure proper healthcare. MOHSS lacks the resources to construct health facilities and EMUs close to all Namibians. MBESC’s current school curricula need to do more to cover preventable diseases in health education. MAWRD is short of the resources, skills and staff to ensure food security. Namibia’s Expanded Programme on Immunisation (EPI) is challenged with stagnant growth in coverage, sporadic implementation, measles outbreaks and the fear of wild polio virus spreading from northern neighbours. About half of the health districts have immunisation coverage levels of less than 70%.132 Finally, the government lacks the revenue and economic growth to alleviate poverty and fulfil the rights of all Namibians as fast as necessary.

  High Maternal Mortality
  Statement of Rights Unfulfilled
  The low general health conditions violate the rights to life and health of many Namibians. Along with HIV/AIDS, maternal and child health are particularly critical issues facing Namibia.

  Based upon women’s reports of deaths of their sisters related to pregnancy and delivery over the previous 10 years, in 2000 it was estimated that the maternal mortality ratio was 271 per 100,000 live births, an increase from 225 in 1992.133 This technique, known as the sisterhood method, cannot be used to compare current progress in maternal mortality rates. When using a model based on proxy indicators of maternal health to estimate maternal mortality the results show rates of 370 in 1990 and 300 in 2000—higher than the MOHSS estimates but indicative of improvement. Poor and historically disadvantaged regions, including Kavango, Ohangwena, parts of Omaheke, Kunene and Oshikoto, show the weakest proxy indicators of maternal health (total fertility rate and skilled attendance at birth).¹³⁴

  Causality Analysis
  The immediate causes of the high maternal mortality in Namibia are complications due to pregnancy and childbirth which are aggravated by exposure to diseases, malnutrition, weakened immunities, lack of appropriate care practices, and limited access to health services.

  • Only 51% of sexually active women were using any modern method of contraception in 2000.135
  • There is no reliable data on illegal abortions, but a hospital-based study on abortion found that about 17% of maternal deaths resulted from abortion-related complications.136
  • Comprehensive data on late-seeking and none-seeking of treatment is not available. In 2000, 14% of women reported that they needed family permission before getting treatment. ¹³⁷

  Childbirth is inherently risky. The major causes of maternal deaths in Namibia include ruptured uterus, haemorrhage, eclampsia and septicaemia.138 Teenage mothers are at increased risk of obstructed and prolonged labour, fistula and pre-eclamptic toxaemia, and are twice as likely to die from childbirth as women in their twenties. Fertility rates are useful indicators of the risk of childbirth complications. As shown in the accompanying figure, fertility rates have declined significantly, most likely as a result of improved contraception uptake and the waning of the post-Independence baby boom, which may also be due to the effects of HIV/AIDS. Even so, Namibia’s total fertility rate remains high. Teenage girls account for 9% of Namibia’s total fertility and women over 40 years of age contribute 11%.139 Underlying Namibia’s high fertility are the low uptake of contraception; cultural beliefs that women need to prove their fertility before marriage; the norm to have many babies due to low survival expectations, which is particularly strong among the poor and uneducated; and gender roles.

  Root Causes
  The root causes of high maternal mortality are the increasing HIV prevalence; food insecurity; the lack of education; poverty; unwanted pregnancies; the illegality of abortion; the distance to health facilities; the lack of strong community-based healthcare programmes; the slow growth of GDP and government revenue; negative cultural perceptions of gender roles; and the stigma, discrimination and fear associated with HIV/AIDS.

  Role Analysis
  Families and communities have the responsibility to ensure that mothers get proper healthcare. MOHSS is responsible for providing accessible healthcare for all Namibians and ambulance services. MOHSS, MBESC and community leaders are responsible for providing health and nutrition education. MAWRD is responsible for helping communities to be food secure. The Parliament has a duty to legislate to ensure women’s reproductive rights. Family, community and national leaders are obliged to speak out against negative gender stereotypes, harmful cultural practices and the stigma and discrimination associated with HIV/AIDS. The government, civil society and the international community have a duty to ensure that the relevant ministries are funded adequately and that all dutybearers have the capacity to fulfil their roles.

  Capacity Gap Analysis
  Families, communities and community leaders often lack the knowledge, money and transport to ensure that those in need receive proper healthcare. 45% of Namibians live further than one hour from a health facility.140 In 2000, 46% of women reported having difficulty getting transport to healthcare, 43% said that no health facility was nearby, 37% did not have enough money to pay for health services and 21% did not know where to go.141 EmOC is only available in district and regional hospitals, too far for many pregnant women to reach in time.

  Namibia’s limited antenatal and postnatal care have little impact in lowering maternal mortality and morbidity because, in many cases, the services are more for infants.

  MOHSS lacks the resources to construct health facilities and EMUs close to all Namibians, provide comprehensive health education for all Namibians and provide adequate ambulance services and community outreach. There is also a lack of a strong community-based health programme and the reproductive health policy does not comprehensively cover EmOC. Abortion is illegal except under limited circumstances, and support for legalised abortion remains weak.

  Conclusion
  Namibia’s foremost challenge to improve the wellbeing of the nation is to ensure that the vast majority lead long and healthy lives. With HIV/AIDS raging through the population many Namibians suffer from ailments that can be prevented and treated, improvements in the access, uptake and delivery of key health services are critical areas for heightened attention and support. Communitybased health programmes are key strategies to pursue because they can reach households and alleviate the increasing AIDS-related burden on the health system and cost-effectively improve public health.

  Ultimately, good health and the sustenance of life are in the hands of all government ministries and sectors, not just that of the MHSS. Just as the impact of HIV/AIDS is felt in the delivery of health services, it is affecting family and community capacities to care for their children, ensure food security, earn income and to be productive citizens. Hence, the centrality of the message that HIV/AIDS is not just a health problem, but a developmental issue needs to be heard and acted upon across the nation.