Nurses and doctors from Katutura Intermediate Hospital in Windhoek and Oshakati State Hospital in Owamboland in the north of Namibia told The Namibian and IJ Hub the same story of chronic backlogs that are compromising patient care.

The shortages at Katutura and Oshakati — Namibia’s premier facilities, with between 750 and 850 beds each — suggest a system-wide problem in the public health sector.

The executive director of Namibia’s health ministry, Ben Nangombe, confirmed shortages of drugs and clinical supplies and conceded that procurement processes “may not be as efficient as we would want them to be”.

Nangombe also acknowledged staff shortages, but insisted that government had promised to approve the creation of not less than 4,000 critical positions to address the problem.

“There are those who claim that this is a gimmick,” he added. “Nothing could be further from the truth.”

Among the issues highlighted by hospital staff interviewed by IJ Hub was a serious shortage of nurses at Katutura, leading to a heavy reliance on tertiary students doing internships.

They said stock-outs of vital drugs such as those used to treat high blood pressure and heart disease often force poor patients to resort to expensive private pharmacies.

A high blood-pressure patient, who spoke to The Namibian on condition of anonymity, complained in June that he had been visiting Katutura over a three-month period to collect his amlodipine prescription, but had been sent away each time because it was not available.

“I am not on medical aid because I am unemployed, so I can’t afford the medicine from private pharmacies,” the patient said.

He explained that at state hospitals, patients pay as little as N$10 (R10) for drugs that cost N$150 from private outlets.

Health Minister Kalumbi Shangula admitted in the national assembly in March 2019 that his ministry had a persistent struggle to procure medicines and other pharmaceutical products for institutions across the country.

“Of late, the procurement system has not been responsive enough to our needs, to the extent that there have been intermittent stock-outs. But what is pleasing is the fact that there are renewed efforts and commitment to address this matter,” he said.

Health executive director Nangombe also noted in August 2019 that some of the challenges included late orders from staff and delays in deliveries from suppliers. He did not mention any problems at the ministry level.

Akuta Munyika, the acting medical superintendent of another northern hospital, Onandjokwe, told The Namibian that for medicines that are not consistently on the shelves, the issue is not budget cuts, but supply chain problems and inconsistencies on the side of manufacturers.

However, budgetary issues are clearly a contributing factor.

These challenges exist despite the health ministry being the third-biggest recipient of the national budget behind education (N$13.7-billion), and finance ( N$10.8-billion) ministries, receiving close to N$6.9-billion during the 2019/20 financial year.

However, a large portion of the ministry’s budget — N$3.7-billion — is spent on salaries and other benefits.

Its 2019/20 budget, at N$6.9-billion is just 4.6% higher than the previous year.

Presenting the 2019/20 national budget, Finance Minister Calle Schlettwein said the increase was designed to support the procurement of pharmaceuticals, the recruitment of additional health personnel, combating disease outbreaks and maintaining health infrastructure.

Katutura Hospital

Hospital staff at Katutura told The Namibian on condition of anonymity that the facility is badly understaffed. They said this could largely be attributed to inadequate state funding for recruitment.

Nurses said they find it hard to cope with the huge influx of patients who have stab wounds and car accident victims, particularly on Fridays and at month-end. The hospital serves as a primary referral centre.

The nurse said they are forced to do increasing amounts of overtime and that the hospital depends heavily on unqualified student nurses from tertiary institutions such the University of Namibia and the International University of Management who are doing internships as a study requirement.

According to a person familiar with the matter, full-time nurses often exploit the students, with some being forced to work overtime at odd hours.

Drug shortages at Katutura are said to include nevirapine syrup for HIV-infected children, antibiotics vital for the treatment of infections, such as penicillin V potassium medication and Amoxycillin, and medication for hyperthyroidism.

Sources said nurses are giving HIV-positive children tablets instead of syrup, which should not be happening.

Essential materials in short supply include haemo-glucose test (HGT) strips for testing diabetes, urine dipsticks, Foley catheters for draining urine, cotton wool and dressing ointments such as Betadine and ichthammol.

A nurse at Katutura said the pregnancy test kits in use at the hospital are substandard and take too long to read.

Insiders said sometimes when crucial medications and materials run out, nurses use their own money to buy them.

They said the position was similar, or worse, at clinics and health centres in Windhoek.

The Namibian reported in 2018 that the clinics are in a desperate way, with nurses having to attend to up to 70 or 80 patients daily. Patients allegedly wait in long queues for up to four hours before seeing a nurse.

However, despite the growing demand for health services in Windhoek, especially in informal settlements, state clinics always close over weekends, shifting the burden on to hospitals.

Oshakati Hospital

At a media conference late last month, Oshakati’s medical superintendent, Dr Korbinian Amutenya, painted a bleak picture of conditions at the hospital. The conference was called to express the hospital’s gratitude for the donation of a fluoroscopy machine by the ministry and other medical equipment worth N$350,000 by FNB Namibia.

He said the institution has a capacity of 750 beds but treats close to a million patients a year.

The superintendent revealed that challenges include a static staff establishment and a lack of key specialists, among them a paediatrician, neonatologist, neurosurgeon, dietician, paediatric surgeon and anaesthetist.

He said demand for haemodialysis services for kidney disease patients far exceeds what is available as the hospital has five dialysis machines, but needs more than three times this number.

The hospital has more than 50 patients on permanent haemodialysis.

Amutenya said key equipment such as a fluoroscope had not been available since 2011. It is understood that since 2011 the hospital had outsourced fluoroscopy to private organisations Ongwediva Medipark and Oshakati X-ray and Imaging Services.

Fluoroscopy is used for radiological examinations and procedures, including barium x-rays, cardiac catheterisation, arthrography and the placement of intravenous catheters.

Oshakati also needed a mammogram, an MRI scanner and computed tomography (CT) scanner. These had broken down and remained unrepaired because the supplier had not been paid.

Patients who could not be treated at the hospital were often referred to expensive private institutions at a high cost to the government.

Amutenya told the minister that some of Oshakati Hospital’s shortcomings need to be addressed as soon as possible to reduce the referral of patients to Windhoek Central and Katutura.

However, the superintendent added that despite the challenges and difficult environment, his staff members are soldiering on.

In response to Amutenya’s speech, Shangula — who was in the audience — conceded that the lack of fluoroscopy equipment had caused delays in diagnosis and case management, as well as referrals to private institutions at a high cost.

However, he said the government is committed to providing quality healthcare to all Namibians.

A staff member told The Namibian that Oshakati Hospital has been without injectable antibiotic penicillin for three months.

“It’s sad to see things falling apart, starting with personnel. We don’t have adequate staff to render services properly,” the staff member said.

She complained of shortages of basic materials such as sterile gloves, needles, nip tubes, syringes, admission files and sick-leave forms.

“Patients are often sent away because there are no resources. To make matters worse, medications are finished and we have to tell patients to buy at private pharmacies, which is never easy,” she added.

Haufiku fallout

Shangula was appointed health minister in December 2018 after a falling out between the former minister, Bernard Haufiku, and President Hage Geingob. Haufiku had criticised the government, alleging that certain health facilities were being neglected.

In November 2018 the Namibian Sun reported that Geingob had hit back at Haufiku for “shaming” the government when he asked the private sector and individuals to bail out a financially starved eye clinic at Windhoek Central Hospital.

The clinic was closed because of a lack of government support.

The public health sector suffers from a shortage of intensive care unit beds. At the moment, there are only 18 ICU beds in more than 350 facilities countrywide.

Shangula said in parliament in June 2019 that the government had plans to procure 10 paediatric ICU beds for the Windhoek Central Hospital, but did not say how much this would cost. The plan has yet to see the light of day.

The government recently allocated N$210-million to the health ministry for the provision of additional medicines and clinical supplies as well as for the recruitment of health professionals.

Pressed on procurement failures in state hospitals, health ministry executive director Ben Nangombe argued that the ministry manages one of the largest budgets in the public service and a substantial procurement budget for pharmaceuticals and clinical supplies of N$700-million a year.

“We are currently implementing the second phase of a turnaround strategy to improve and streamline the operations of the Central Medical Stores,” Nangombe said.

It had also approved the buying of vaccines, antibiotics, contraceptives and anti-retroviral drugs through “pooled procurement mechanisms”, whose members included Unicef, the World Health Organisation and other United Nations’ agencies.

The ministry had already placed orders with Unicef covering Namibia’s needs for at least 12 months. The UN agency’s prices would save the government between N$60-million and N$110-million.

Treasury had also authorised the ministry to procure clinical supplies including gloves, needles, syringes and cotton buds, and bids had already been submitted and evaluated.

The Treasury exemptions would buy the Central Procurement Board time to finalise the flighting of long-term tenders of between one and three years for drugs and clinical materials.

On staff shortages, Nangombe argued that almost every health facility “from the smallest clinic to the national referral hospital” would feel the positive impact of the government’s move to create 4,000 health jobs.

However, the government would take the prudent step of staggering recruitment “so as not to place unsustainable pressure on the fiscus”.

He also conceded reports of overcrowding at Katatura State Hospital, saying these were “of great concern to us”.

In response, the government had thrown open the Katatura Health Centre as a 24-hour operation and hired additional doctors, nurses and pharmacists.

On the equipment front, Nangombe said an “ultra-modern” x-ray machine had been commissioned at the Walvis Bay State Hospital, while anaesthetic machines had recently been handed over at facilities countrywide.

Reacting to the alleged exploitation of student nurses, he said Namibia is “a country of the rule of law” and that the Health Professions Council would crack down on abuses. DM