Catherine Sasman
5 December 2008
interview
UNICEF's new country representative, Ian Mcleod, came to Namibia about six months ago after seven years in South Asia, and a stint in Africa's Mozambique, South Africa, as well as Rwanda and Somalia. And the development issues around the globe remain the same, more or less.
If you have to compare the situation in the countries you've worked at, how does the situation of women and children compare to that?
There are a lot of similarities, and a lot of differences. One similarity is the gender-based discrimination and violence against women and children.
A lot of the indicators here, particularly around maternal mortality, are quite similar.
But the real big difference is the coverage of services that relates to women's mortality rates or women's access to neo-natal services.
Over 80 percent of women here have access to skilled birth attendants. Some of the countries I have worked in have 20 to 40 percent coverage, and yet in those countries mortality as a result of childbirth is quite high.
So, there is some sort of contradiction in that. Here, you have got services, and some services are pretty good.
But the quality of the services could be considered as a contributing factor.
We are not really sure of the reasons for that. Next year, we will have discussions with the Ministry of Health [and Social Services] and the World Health Organisation to really focus the next couple of years on understanding why women are dying during childbirth.
The indicators point to a number of things. One is around the quality of service, and some of it has to do with the system in relation to the service.
For example, by law nurses are not allowed to actively remove the placenta - which is called the third stage of active life. And yet, this can cause hemorrhaging; it can be a cause of why women get sick and die.
I have not talked to nurses in that situation, but it must be extraordinarily frustrating for them.
We do know that there is an average of 15 percent of women who have problems during labour and are in need to have access to emergency services. There are a limited number of comprehensive emergency obstetric medical facilities in the country.
This is an issue Government recognises, and that there is a need for a road map, a strategic plan. It knows it needs to get better in at least the basic emergency obstetric care available.
We need to do more by doing detailed maternal audits to understand what the impact of HIV is on maternal deaths. Is it only women with compromised health as a result of HIV? Is it because of discrimination within the health facility? Is it because women are left alone in rooms to give birth, despite having been assigned to trained health caregivers?
Underpinning all is clearly the high number of young girls giving birth, and for a lot of these girls it is probably not their first child. Many have two children before the ages of 18 or 19, while their own health and nutritional situation is compromised.
There seems to be a whole lot of factors that we really do not know enough of.
This issue should be on the front pages of newspapers everyday because it is a bit of a scandal to have such a large number of women dying of childbirth when there are such great health facilities.
What we would like to be doing also is to engage a number of activists within the country. Part of the discussion is to involve the First Lady, women ministers and other senior women to get a real movement around this for change.
Do you have any idea to what extent women make use of traditional birth attendants?
There are two or three forms: there is the real traditional healers that women still go to while going to other health facilities; there are traditional birth attendants; and then there are those with some type of formal medical training.
There needs to be a task shifting, like in the removal of a placenta, where nurses should be able to step in, or even trained traditional attendants who have gone through a certain certification process.
Ideally, within the next five to ten years we would like to see 100 percent of the births take place in health facilities, and so on. But it is not going to happen tomorrow. So, it might be necessary to task shift down to make sure there are health workers that can take care of things too.
Also, consideration should be given of how the latest technology can be used to help, and how the private sector can get involved. I have seen this in India where there is a health system that is down to community and household level. But then again, it also has a great IT infrastructure.
What about the situation for children?
A positive indicator here is the enrollment of learners at primary levels. Namibia has more than 90 percent enrollment at that level. There are, however, challenges around the quality of education. This country has one of the worst education outcomes in this part of the region.
Again, we need to understand more about that. It may not have anything to do with the curriculum, but with the need to change teachers' attitudes. It may be more about a participatory method of learning, and making schools more child-friendly.
Schools are not just child-friendly by having physical environments that look nice, but children should, for example, not feel discriminated against because they don't have a school uniform or food.
But things are moving, like in the health sector. I think the ETSIP programme looks very good and there are a lot of dedicated people that are in place.
What worries me is the HIV/AIDS prevalence. It appears that the prevalence rate among younger men and women is less. But what is more important than prevalence is incidence. What we need to understand is, where were the last 1 000 infections in the country geographically, economically.
Young people still are not able to translate knowledge into skills and behaviour. It is the same elsewhere in the world, but elsewhere in the world you don't have a fifth of the population that is HIV positive.
This means that people have not necessarily internalised the risks involved. People think there are ARVs but ARVs are not fun. They are toxic and do nasty things to your body.
The issue of multiple and concurrent partners needs to be discussed, which is what is different in this part of the continent from north, west and east Africa, where young people have one partner in quick succession of the next when their viral loads are at its highest.
I am very worried by what is happening. We are now working on a new prevention strategy where we look at these issues.
It still continues to worry me that there is relatively good knowledge around HIV/AIDS but there is a lot of unsafe behaviour among young people. And this is the future of the country!
Even if it plateaus off and ARVs are rolled out, universal access to health facilities are available, the costs for the government are enormous.
Having said that, why is Namibia shy in telling its successes? It has the highest rate of anti-retroviral coverage of any developing country in the world; it has the highest coverage of prevention of mother to child transmission. And yet, when you go to global conferences and big meetings, everybody looks at Botswana and South Africa. We have not been telling our story.
Part of the commitment that we have made to Government is to help Namibia tell its success stories.
The current UNICEF country programme - 2006 to 2010 - is in its midterm. What are the strategic objectives of your institution?
We have just gone through a mid-term review process with Government to look at new and emerging issues.
When the country programme was developed, it was in 2004/05. It was a different country then to what it is now. We didn't have this demographic household survey information; we didn't know that children's mortality rates had gone up; we didn't know that some of the worst sanitation coverage of any country in this part of the world is found here; we didn't know infant and child mortality has gone up a little bit; we did not have the recent development plan; we didn't have a national plan of action on orphans and vulnerable children; and we didn't have huge amounts of money through the Global Fund and Pepfar in the country.
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