WHO Director-General addresses Namibia's Parliament

Dr Margaret Chan
Director-General of the World Health Organization

Namibia's place in global health development: doing things the right way
Address to Parliament
Windhoek, Namibia

24 April 2012

Excellencies, Members of Parliament, ladies and gentlemen,

I am honoured, for many reasons, to address this country’s Parliament.

Namibia is a young country moving, in smart ways, in the right direction, especially with evidence-based strategies for improving health. You have accomplished a great deal already, especially in the past decade, and you aspire, in well-articulated, long-term plans, to do a great deal more.

You have the focus right. Poverty and poor health go hand-in-hand. They are the iron fist that puts the brakes on development.

The world learned something profoundly important last year as it watched the Arab Spring unfold and witnessed social protests all around the world. When deep social inequalities are ignored by government policies, public resentment festers and then explodes in protests that can threaten a nation’s political stability and security.

Protests against inequalities, in income levels, in opportunities, in access to services, can topple governments.

Namibia’s ambitions are clearly stated. That is: to develop an industrialized economy, to give citizens, all citizens, a quality of life that matches that seen in the world’s best-governed places.

Central to that ambition is a deep sense of political duty to realize the aspirations of your citizens, and a deep commitment to the principles of fairness and social justice.

As stated in Namibia’s third National Development Plan, “The state actors in both political and administrative positions are directed to ensure the effective delivery of public services to our citizens and realize ‘value for money’ in public expenditures.”

You have plans to stimulate economic growth, but you also have plans to ensure that the benefits of this growth are fairly and evenly distributed.

This is enlightened policy. This sets Namibia apart. You are going against the grain, avoiding some tempting mistakes made by many very rich and very poor countries alike. That is: to put absolute faith in economic growth as the be-all, end-all, cure-for all.

Market forces create wealth and generate benefits, but they have no rules that guarantee the fair distribution of these benefits. All too often, efforts to promote economic growth create big benefits for the privileged few but bypass masses of the poor.

Market forces, acting alone, will never solve social problems. Only enlightened whole-of-government policies that make equity an explicit objective can reduce social injustice.

Decades of experience tell us that this world will not become a fair place all by itself. Health systems will not automatically gravitate towards greater equity or naturally evolve towards universal coverage.

Economic decisions within a country will not automatically protect the poor or promote their health. Globalization will not self-regulate in ways that ensure fair distribution of benefits.

International trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines. All of these outcomes require deliberate policy decisions.

A recent Organization for Economic Cooperation and Development, or OECD, report underscores the importance of making equity an explicit policy objective. As documented in the report, income inequality in wealthy nations has reached the worst levels seen in nearly 25 years.

That report further concluded that societies with the least inequality had the best health outcomes, regardless of the levels of spending on health. In other words, money alone does not buy better health. Good policies that promote equity have a better chance.

As I said, Namibia is moving in the right direction, in smart ways, with impressive results, and impressive speed.

You are making good use of government regulatory powers to rein in health care costs and ensure that patients receive safe and effective medicines at the most affordable prices.

To get that promised “value for money”, the country operates a centralized procurement system for medicines and medical supplies. Care in the private sector has been regulated since 1994 by the Hospital and Health Facilities Act.

Your national drug policy, which concentrates on a limited number of essential medicines, provides comprehensive guidelines and regulations for the public but also for the private pharmaceutical sectors. These provisions are perfectly in line with WHO recommendations on national drug policies.

Experts on my staff inform me that this country maintains reasonable vital statistics on births and causes of death, but is not always able to reliably investigate all causes of death. Most important, however, is this country’s potential to have one of the best systems of vital statistics in sub-Saharan Africa.

Ladies and gentlemen,

Last month, Namibia celebrated 22 years of independence. In commemorating that event, President Pohamba reported on a number of government-supported development initiatives, like the provision of housing and farmland, and safe drinking water, rural electrification, and the expansion of health and education facilities.

Such initiatives put the country on the right track to reduce poverty. Above all, they promise to improve health outcomes by tackling the many root causes of illness that flourish alongside poverty.

As someone who has worked in public health for more than 35 years, I have deep admiration for the achievements and the long-range ambitions of this country’s leaders, its Minister of Health and Social Services, and the authors of Vision 2030.

This is a transformational vision. It aims to transform the economy, transform opportunities for employment, transform systems for health and education, and build the requisite capacities and infrastructures for sustaining progress. In doing so, it promises to transform the quality of life for all citizens.

As noted in the latest National Development Plan, experience all over the world has shown that a more equal distribution of income contributes to more rapid, stable, and sustained economic growth.

I could not agree more.

My staff who have read this very detailed vision inform me that it is exceptional in many ways. It is long-range and far-sighted, not a quick-fix for someone’s single term of office. A country like Namibia that inherits massive structural weaknesses has no place for quick fixes.

It is people-centred. The public was widely consulted as the vision took shape. This was the question: what can political leaders do to help this country’s citizens realize their aspirations for a better life, for themselves and above all for their children?

This is a pro-poor vision. It is deeply distressed by social inequalities and deeply committed to reducing them through wise investments. It fully appreciates the role of good health as an engine of economic development.

It is ambitious. It aims at nothing less than reversing the colonial legacy of income inequality and poverty. As so clearly stated, Namibia wants to become “the leading public provider of quality health and social welfare services in Africa.”

Above all, the vision is convincingly frank and honest. The picture it paints of this country’s current and future challenges is by no means a rosy one.

As Peter Katjavivi, former Director-General of the National Planning Commission and now the Chief Whip of the National Assembly, said in a recent media interview, “We should not hide the facts. At the end of the day, the facts will speak louder than the words.”

It takes great self-confidence to be frank and honest about setbacks and failures, structural weaknesses, huge obstacles, and missed targets. This is commendable. Political self-confidence, when supported by the people, breeds courage, and that translates into high ambitions and bold actions.

You are working against some world-class odds. Much conspires against success. Namibia has been handed a heavy historical legacy.

At independence, this country had two economic systems, two health systems, and two educational systems, one for the rich and privileged and one for the poor and powerless. The majority of the population was excluded from the productive economy.

Namibia has one of the highest levels of income disparity in the world. Namibia is ranked as a middle-income country, yet nearly a third of the population survives on incomes that fall below the international poverty line. Most eek out a living from a very small area of arable land.

Prevalence rates of HIV/AIDS are among the highest in the world, fuelling a related tuberculosis epidemic. It is no surprise that Namibia also has one of the highest rates of tuberculosis in the world.

In 2010, more than 11,000 TB cases were newly notified. Of these, well over half were co-infected with HIV. The country is further burdened by a high prevalence of drug-resistant strains of TB.

Diagnostic facilities for patients with multidrug-resistant TB are inadequate. One central laboratory does culture and drug susceptibility testing for first-line drugs, but susceptibility testing for second-line drugs must be conducted in South Africa.

Factors of geography and climate conspire against you. Namibia is one of the driest countries in Africa. A chronic food shortage forces a heavy dependence on imported foods, including staples. This food deficit is aggravated by frequent droughts and floods, and expressed as high rates of chronic malnutrition.

Most exports are in the form of commodities, which are exposed to large and unpredictable fluctuations in prices.

Namibia is the second most sparsely populated country in the world, and this makes the delivery of health services extremely costly.

Like many other African countries, health care in Namibia is crippled by a very low density of doctors and other health care staff. This critical shortage is further strained by the demands of chronic care for large numbers of people with HIV/AIDS or needing directly-observed treatment for TB.

In some rural areas, staff are so overworked that they cannot attend training sessions to improve their skills.

Most donor support is for infectious diseases, leaving other priority problems underfunded. Let me issue a stern warning on this issue. Monitoring shows that conditions like hypertension, diabetes, and cancers are on the rise.

Get on top of these chronic noncommunicable diseases as quickly as you can, especially through approaches that stress population-wide prevention. I know this is already high on your agenda. WHO staff, in the country, regional, and head offices, stand ready to support you.

You import most of your food. Watch out for processed foods that are loaded with fats, sugar, and salt, but low in essential nutrients. These cheap and convenient foods will aggravate childhood undernutrition and quickly bring you an epidemic of obesity in older children and adults.

Increasing rates of obesity and overweight are the warning signal that bad trouble is on the way. It arrives as a devastating wave of heart disease, hypertension, stroke, several diet-related cancers, and most especially diabetes.

As many countries in Asia have learned, the costs of caring for a disease like diabetes can easily devour the benefits of modernization and economic growth. These are the diseases that break the bank. For example, care for chronic diseases eats up a full 75% of the $2.6 trillion that the US currently spends on health care each year.

We must never forget: these diseases, especially diabetes and stroke, account for half of all global disability, adding considerably to their social and economic costs.

Ladies and gentlemen,

Against this background of heavy challenges and constraints, of historical problems and injustices, your achievements are all the more impressive.

Namibia has received international recognition for its success in rolling out antiretroviral therapy for HIV/AIDS. Within a year, the country more than doubled its target set for coverage, which is now among the highest in Africa. Thanks to good preventive measures, more and more babies are being born HIV-free.

The government provides 50% of the financial resources for the HIV/AIDS response. Such a high level of government commitment is rarely seen elsewhere in Africa, and is a major factor behind this success.

Attendance at antenatal clinics is high, as is delivery in health facilities. Nonetheless, maternal mortality remains unacceptably high. I know that prompt access to emergency obstetric care is a problem, as is this country’s shortage of skilled birth attendants.

Rates of neonatal and childhood deaths also need to decrease faster to meet the Millennium Development Goal.

The management of TB has improved in significant and commendable ways, reducing the country’s estimated TB burden substantially within a decade. People co-infected with TB and HIV are being managed much more effectively. Increased coverage with antiretroviral therapy has unquestionably had a positive impact on the country’s TB epidemic.

Again, within just a decade, deaths attributed to malaria have been cut by well over 80% and the malaria map has shrunk dramatically, with transmission now largely confined to the northern part of the country.

The Ministry of Health and Social Services has recently articulated careful plans to make Namibia malaria-free in the near future. These are realistic plans, fully aware of the added demands of an elimination goal, and they are good plans with a good chance of success. These are whole-of-government plans that engage ministries responsible for home affairs, immigration, finance, and customs.

This country, long a vocal advocate for regional integration, knows very well that Namibia can never become and remain malaria-free until action is taken beyond its borders. Namibia is now leading the so-called elimination 8, or E-8, initiative. This is a group of eight countries in southern Africa that are pulling together to eliminate malaria.

Namibia is one of four countries, joined by Botswana, South Africa, and Swaziland, that have already achieved low levels of malaria transmission. They will be pulling with them an additional four neighbours with a more difficult malaria problem, namely Angola, Mozambique, Zambia, and Zimbabwe.

Public health is trained in compassion and driven by passion. This country’s health policies show an abundance of both.

For passion, you need look no further than the words and deeds of Minister Kamwi. In an op-ed published in the Wall Street Journal, he wrote passionately about malaria, the lives it claims and the development it stunts in Africa.

He argued, heatedly, for freedom to fight malaria the right way.

Doing so means a multi-pronged attack, using not only bednets and medicines, but also the judicious spraying of insecticides to keep mosquitoes out of buildings and people’s homes.

Ladies and gentlemen,

I have a final comment.

Various studies from international bodies rank Namibia as a middle-income nation with bright economic prospects. OECD has praised this country for its prudent macroeconomic policies and favourable growth momentum.

Some observers have asked: Why should a country like Namibia that is basically on its way up undertake such a massive government-sponsored development effort?

The task is hard, but the answer is easy.

Because it is the right, enlightened, and far-sighted thing to do. Because it is an act of good, compassionate, and passionate government.

Last week, Time magazine ran a cover story about the remarkable comeback of Colombia, once known for drugs, guns, gangs, thugs, and murders, as a regional power in the Americas.

In an interview, Juan Manuel Santos, the country’s president, attributed this economic and political rebirth to policies that distributed resources, especially mining and oil revenues, with greater fairness in what he described as “a sort of affirmative action for the poorest regions.”

As he advised, “Use the markets as much as possible and the state as much as necessary.”

In a sign of the times, he concluded with the following observation:

“When you ask people in the US, Europe, and Japan today if their children will have a better future, they say no. In Colombia, they are saying yes.”

On Namibia’s Independence Day last month, one media outlet sent reporters out on the streets to get personal views of what independence means for the country, its people, and their shared future together. “Liberty is a treasure,” said one. “Things have changed,” said another. “Today, we have development, opportunities, and a future in absolute freedom.”

In more concrete terms, people cited visible signs of development and improved infrastructure, flourishing trade, and the growth of tourism.

As one academic observed, “Development is taking place because of our own initiatives. We fought hard for our freedom, and this means a right to manage oneself, and do it the right way.”

As part of the ceremony, 22 white doves were released to fly in the sky, in absolute freedom, to commemorate the country’s peace, tranquillity, and harmony.

I think we can all conclude: The people of Namibia are saying yes. The future looks bright for them and their children.

This is a country that has taken charge of its destiny.

I wish you, and the health of your citizens, all the best.

Thank you.