Maternal Health in Namibia: African Public Health Leadership and Systems Innovation Initiative

When maternal mortality almost doubled in fourteen years, health leaders in Namibia decided to make maternal health a priority – and set up a pilot in Khomas region – Kerry Cullinan reports

A sleek new minibus pulls up outside Okuryangava Clinic in Katutura, and the driver jumps out and asks the sister in charge where the patients are who need transport to the hospital.

A week prior to this, patients referred to the hospital would have to wait for hours for an ambulance that often didn’t arrive at all as it was attending to other cases.

But a little research found that few patients needed emergency treatment, so getting an ambulance for them was a waste of scarce resources. Instead, the Namibian Ministry of Health and Social Services has made a minibus available in Windhoek to transport clinic patients to the city’s two hospitals.

This is one of the immediate improvement initiatives introduced by a multi-stakeholder team set up to address maternal health in Khomas, the region that includes the country’s capital, Windhoek.

The Maternal Health Initiative is an offshoot of the African Public Health Leadership and Systems Innovation Initiative, which has brought health system leaders together over the past year in an effort to improve the Namibia’s health services.

The project is funded by the Bill & Melinda Gates Foundation and aims to develop a model for improving public health leadership and system performance that can be replicated in other similar settings.

The project is underpinned by three principles: local leadership development, social innovation and improved system performance.

The initiative applies a business-consulting approach called the “Innovation Lab”.  Through the Innovation Lab, multi-stakeholder teams are guided through an intensive leadership development and problem-based learning experience. The aim is to tackle a complex social and system problem through a multi-stakeholder and innovation response.

When deciding on a priority health problem to tackle as a pilot, it wasn’t hard for Namibian health leaders to choose maternal health.1 Between 2000 and 2006, maternal mortality jumped to 449 deaths per 100,000 births, an increase of 178 deaths.

“Maternal health captured the interest of Cabinet because of its poor performance in the light of the country’s commitment to the Millennium Development Goals, one of which is to cut maternal mortality by 75% by 2015,” says Len le Roux, who heads Synergos Namibia, one of the organisations facilitating the leadership initiative.

“We decided to pilot an intervention to improve maternal health at an operational level, by bringing together all players – the nurses, the doctors, the pharmacists – to clarify problems and what we could be doing to address these,” says Deputy Permanent Health Secretary Dr Norbert Forster.

The Maternal Health Initiative team settled on Khomas region as it has a relatively large population yet the lowest rate of women seeking medical attention in their first trimester of pregnancy – less than 7% – and outcomes that are similar to other regions. Yet the earlier pregnant women seek help, the easier it is to identify and manage high-risk pregnancies and complications.

The 20 participants in the team are from a range of backgrounds: nurses, doctors, private healthcare, NGOs and nurse training institutions. They are developing an integrated response to improving maternal health outcomes by addressing areas including frontline skills and capabilities, operations and community mobilisation.

The team’s work on frontline skills and capabilities seeks to improve the quality of care given by health workers by addressing their skills, mindsets and behaviours.

A 2005 survey of midwives revealed some severe skills gaps. Only about a third could properly monitor women in labour, while a mere 12% could correctly recognise all the signs and complications of post-partum haemorrhage, and less than 20% could manage this properly.

Nurses also complain that nothing had been done to upgrade their skills since they had graduated, many 20 years ago.

Faced with these findings, the team moved quickly to understand the driving factors and how to address them.  They consulted with a diverse set of stakeholders critical to maternal health, and found there was a disconnect between the theory-based training nurses received and the realities they faced in practical application.

Yet the team also found that potential solutions already existed within Namibia: the nursing council was eager to reintroduce in-service training; the private healthcare company Medi-Clinic was willing to share its skills upgrading training approach; and a professor from University of Cape Town offered a perinatal education programme for midwives that he and his team had developed.

Letha Taukuheke, a lecturer for midwifery at the University of Namibia, says, “I realised that pointing at others will not change anything. I need to look at myself and how I conduct training. By taking this onboard and applying it in my own area of responsibility, I can now see how I can become part of the solution.”

As Judith Flick from the Presencing Institute, one of the co-facilitators of the initiatiave explains, “The leverage point did not seem to lie in the introduction of new and foreign concepts, but with better and more diverse connections between the stakeholders within the system.”

On operations, the team is looking at the supply side of maternal health, with the aim of improving the performance of the local primary health centres so that antenatal care can happen at this level instead of at hospitals. They are looking at improving operating performance across key facilities, such as logistics, planning and coordination, and enhancing patient experience, including reducing waiting times.

After conducting detailed research, the team found that more than 80% of patient transport to either Windhoek Central or Katatura Hospitals was not for emergencies. This proved to be a significant drain on already scarce ambulance capacity and was easily rectified by implementing a dedicated patient transport minibus. Sister Barbara Harakuta, a nurse based at Okuryangava Clinic, is also part of the operations team.

“The minibus is a relief for us. Transport is a big problem for our patients. On average, there are only three ambulances operating in the Khomas region, which also covers some rural areas. There are no doctors here, and we can’t prescribe a lot of the medicines so the patients have to go to the hospital to see the doctors,” says Harakuta.

Harakuta’s clinic is crammed with patients, shuffling along on benches as the queue snakes towards the consulting rooms. Up to 300 patients a day pass through the clinic, which last saw a doctor two and a half years ago.

The operations team’s next target is antenatal clinic waiting times, which range from five to seven hours in Khomas. Ronald Whelan from McKinsey & Company, a management consultancy providing analytical and research support to the Initiative, says, “While primary healthcare facilities are obviously stretched, there is still a lot of latent capacity that can be unlocked in the system,” particularly in the afternoons.

Thokozile Lewanika, also a McKinsey & Company consultant, is assisting the team’s work on community mobilisation, which is looking at patient demand. Its main aims are to raise community awareness about the need for early maternal care and to improve local access to care.

“Our main concern was the low uptake of antenatal care among women in their first trimester of pregnancy. About 60% of maternal deaths in Namibia are due to infectious diseases like HIV/AIDS and malaria, which could be picked up and effectively managed if detected early in the pregnancy,” says Lewanika.

“Two big things drive late accessing of care. The first is lack of knowledge. You will find that a woman might be having her fifth child, but she still doesn’t understand the antenatal tests that are done to check for problems,” she says.

“The second is limited access. The majority of women say the taxi fare to the hospital is a barrier. The return fee is about N$15 on average, which is a lot when you have to choose between a meal and the fare.”

Other barriers mentioned by pregnant women are the negative attitudes of health workers, especially towards teen mothers. Some women also fear HIV and think that the HIV test is compulsory.

“Our primary message is that pregnant women must access antenatal care earlier. To do this, we have started a weekly interactive radio show where we will have a medical panel and people can call in,” says Lewanika.

The first show was aired in mid-August on RuKavango Radio, which has a large listenership. Further shows are planned for Oshiwambo, OtjiHerero and Damara/Nama radio.

“Radio will reach a wide audience but miss the one-on-one approach. So we are developing ANC foot soldiers. Volunteers from four NGOs that are part of the team are being trained to spread the message of the importance of early care at community gatherings and door to door campaigns,” she adds.

In addition, to make access easier for women living in Katutura, the family planning clinic being run by the Namibian Planned Parenthood Association (NAPPA) is going to introduce antenatal follow-up care. Some of public health clinics are considering providing ANC services as well.

“This will decongest the two hospitals, where all the antenatal care visits and births currently take place,”

Under the motto “fail early to learn fast,” the Maternal Health Initiative is now testing new approaches to develop them into successful ones that can be expanded to other regions. It is hoped that these experiments will make a significant contribution to a larger shift in the health system and its patients.

Contact

Len LeRoux
Director, Partnerships, Southern Africa
The Synergos Institute
152 Robert Mugabe Avenue
Windhoek
Namibia
Tel: +264 61 386950
Fax: +264 61 221492
lleroux@synergos.org