Namibia: State of the Nation's Health

Namibia: State of the Nation’s Health Findings from the Global Burden of Disease

Namibia: State of the Nation’s Health explores the progress Namibia has experienced over the last two decades and the new challenges it faces as its population grows and ages. This report provides information about the diseases and injuries that prevent Namibians from living long and healthy lives. It also sheds light on risk factors that cause poor health, ranging from poor diets to alcohol and drug use. Finally, the report compares Namibia’s health performance to that of peer countries.

Namibia: State of the Nation’s Health Findings from the Global Burden of Disease

Namibia: State of the Nation’s Health

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This report was prepared by the Institute for Health Metrics and Evaluation (IHME) through funding from the WHO Namibia Country Office.

The contents of this publication may be reproduced and redistributed in whole or in part, provided the intended use is for noncommercial purposes, the contents are not altered, and full acknowledgment is given to IHME . This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International Public License. To view a copy of this license, please visit http://creativecommons. org/licenses/by-nc-nd/4.0/.

For any usage that falls outside of these license restrictions or for general questions about this document, please contact the IHME Global Engagement Team at engage@healthdata.org.

Citation: Institute for Health Metrics and Evaluation (IHME). Namibia: State of the Nation’s Health: Findings from the Global Burden of Disease.

Seattle, WA : IHME , 2016.

Institute for Health Metrics and Evaluation 2301 Fifth Avenue, Suite 600 Seattle, WA 98121 USA

www.healthdata.org To express interest in collaborating or request further information, please contact IHME: Telephone: 1-206-897-2800 Fax: +1-206-897-2899 Email: engage@healthdata.org

Cover photo: Eric Bauer flickr photostream, Sesriem, Hardap, Namibia, October 2014 Copyright Š 2016 Institute for Health Metrics and Evaluation ISBN 978-0-9910735-6-6

Contents 5

Acronyms

5

Terms and definitions

6

Foreword

7

Preface

9

The Global Burden of Disease at a glance

11

Report highlights

13

Findings

31

Preventing health loss: risk factors for ill-health

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Comparing Namibia to its peers

39

Conclusion

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Annexes

About IHME At the Institute for Health Metrics and Evaluation (IHME), we are diagnosing health problems and identifying the world’s solutions to address them. IHME was launched at the University of Washington in 2007 with funding from the Bill & Melinda Gates Foundation and the state of Washington. Under the leadership of Christopher J.L. Murray, MD, DPhil , researchers began gathering rigorous, scientific evidence on health to launch a new era of independent, objective assessments. Today, IHME is recognized as one of the leading health metrics organizations in the world, and its research is having an impact on health policy globally. IHME makes its findings available so that policymakers have the evidence they need to make informed decisions about how to allocate resources to best improve population health.

About WHO The World Health Organization (WHO) is building a better future for people everywhere. Health lays the foundation for vibrant and productive communities, stronger economies, safer nations, and a better world. Our work touches lives around the world every day – often in invisible ways. As the lead health authority within the United Nations (UN) system, we help ensure the safety of the air we breathe, the food we eat, the water we drink, and the medicines and vaccines that treat and protect us. The Organization aims to provide every child, woman, and man with the best chance to lead a healthier, longer life. WHO has been at the center of or behind dramatic improvements in public health since it was established in 1948, gathering the world’s top health experts, defining solutions, delivering guidelines, and mobilizing governments, health workers, and partners to positively impact people’s health. The Organization works in close collaboration with other UN agencies, donors, non-governmental organizations (NGO s), WHO collaborating centres, and the private sector. It contributes to promoting the general health of people across the world. Over 7,000 public health experts from all over the globe work for WHO, in most countries worldwide.

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Namibia: State of the Nation’s Health

Acronyms COPD

Chronic obstructive pulmonary disease

DALYs

Disability-adjusted life years

GBD

Global Burden of Disease

IHD

Ischemic heart disease

IHME

Institute for Health Metrics and Evaluation

LRI

Lower respiratory infections

YLDs

Years lived with disability

YLLs

Years of life lost

Terms and definitions Years of life lost (YLLs) The number of years of life lost due to premature death. It is calculated by multiplying the number of deaths at each age by a standard life expectancy at that age.

Years lived with disability (YLDs) The number of years of life lived with short-term or long-term health loss weighted by the severity of the disabling sequelae of diseases and injuries.

Disability-adjusted life years (DALYs) The main summary measure of population health used in GBD to quantify health loss. DALYs provide a metric that allows comparison of health loss across different diseases and injuries. They are calculated as the sum of YLLs and YLDs; thus, they are a measure of the number of years of healthy life that are lost due to death and nonfatal illness or impairment.

Risk factors Potentially modifiable causes of disease and injury.

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Foreword A consistent and comparative description of the burden of diseases and injuries, and the risk factors that cause them, is an important input to health decision-making and planning processes. In other words, to align health systems with the populations they serve, policymakers first need to understand the true nature of their country’s health challenges – and how those challenges are shifting over time. When deciding how to set countries’ health agendas, along with information about policies and their costs, evidence on diseases burden can be most useful.

A framework for integrating, validating, analyzing, and disseminating such information is needed to assess the comparative importance of diseases, injuries, and risk factors in causing premature death, loss of health, and disability in different populations. The Global Burden of Disease (GBD) exercise provides such a tool to quantify health loss from hundreds of diseases, injuries, and risk factors, so that health systems can be improved and disparities can be eliminated. GBD research incorporates both the prevalence of a given disease or risk factor and the relative harm it causes. GBD creates a unique platform to compare the magnitude of diseases, injuries, and risk factors across age groups, sexes, countries, regions, and time.

For decision-makers, health sector leaders, researchers, and informed citizens, the GBD approach provides an opportunity to compare their countries’ health progress to that of other countries, and to understand the leading causes of health loss that could potentially be avoided, like high blood pressure, smoking, and household air pollution. GBD tools allow decision-makers to compare the effects of different diseases, such as malaria versus cancer, and then use that information at home.

Led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is the single largest and most detailed scientific effort ever conducted to quantify levels and trends in health. It is truly a global effort, with over 1,000 researchers from almost 100 countries, including 26 low- and middle-income countries, participating in GBD 2013. To make these results more accessible and useful, IHME has distilled large amounts of complicated information into a suite of interactive data visualizations that allow people to make sense of the over 1 billion data points generated.

Disease burden information specific to Namibia will provide important information during the country’s process of making policy decisions related to universal health coverage. WHO, Namibia is very proud to work with IHME and the Ministry of Health and Social Services to examine the burden of disease in Namibia.

Dr. Monir Islam WHO Country Representative to Namibia

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Namibia: State of the Nation’s Health

Preface The Global Burden of Disease (GBD) study provides policymakers with key insights to reduce premature death and disability by generating annual updates about the health challenges that countries face. Just as economic data help Namibia’s Ministry of Finance assess the state of the economy and make adjustments to promote growth, GBD provides a road map to help policymakers align their health systems with patterns of disease burden in the country. It also helps them identify priority areas for intervention, such as tobacco smoking, poor diets, and drug and alcohol use.

We are very pleased with the strong collaboration between IHME and WHO in different areas aimed at improving population health across countries. This report, which focuses on the burden of disease in Namibia, is one of the products of this collaboration which will be useful to guide the country’s efforts toward universal health care coverage.

The engagement with WHO Namibia represents an exciting advancement and extension of the collaboration that began with WHO in the 1990s and was solidified in 2015 with the signing of a memorandum of understanding (MOU) between IHME and WHO Headquarters. This MOU lays the foundation for a mutually beneficial collaboration, with both organizations working together to build country capacity and uptake of global health estimates for decision-making, to share data, including helping to facilitate access to additional data to improve global health estimates, and to share knowledge on methodological advancements.

More than 1,000 collaborators in 93 countries contributed to the Global Burden of Disease 2013 study. These collaborators have enriched GBD research by vetting the methodology and results and identifying important datasets to fill gaps. GBD collaborators have also boosted GBD’s status as a global public good, raising awareness of the study’s findings in their home countries and making it an even better tool for local health policymaking.

In addition to its collaborations with WHO, IHME is also working with researchers in China, Australia, India, Indonesia, Mexico, Saudi Arabia, and the United Kingdom to produce local-level disease burden estimates to inform local health planning decisions.

It is my sincere hope that the findings presented in this report can be used to improve Namibians’ quality of life, leading to longer and healthier lives for all.

Dr. Christopher J.L. Murray Institute Director and co-founder of the Global Burden of Disease

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Acknowledgments Namibia: The State of the Nation’s Health is the result of collaboration between the WHO Namibia Country Office and IHME .

In particular, we thank Prof. Monir Islam and Dr. Tomas Zapata from WHO Namibia for providing critical input and support.

Findings in this report came from the Global Burden of Disease study coordinated by IHME , a multipartner research enterprise from which comprehensive and comparable annual estimates of disease burden by country, age, and sex are produced for more than 300 causes of disease and injury and 79 risk factors. IHME is the coordinating center for more than 1,700 GBD experts from more than 124 countries. Data are from papers published in The Lancet that are part of the 2013 GBD update.

The research presented in this report is based on the following studies published in The Lancet: • Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. 2015 Jan; 385(9963):117–171.

• Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Published online June 8, 2015. http://dx.doi. org/10.1016/S0140- 6736(15)60692-4.

• Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Published online August 26, 2015. http://dx.doi.org/10.1016/S0140- 6736(15)61340-X. • Global, regional, and national comparative risk assessment of 79 behavioral, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Published online September 11, 2015. http://dx.doi.org/10.1016/S0140-6736(15)00128-2 At IHME , Christopher Murray, William Heisel, Tom Achoki, and Katherine Leach-Kemon provided leadership in overseeing the creation of this report.

Michael MacIntyre, Kelsey Bannon, and Jamie Schoenborn provided strategic guidance and operational support for launching the project. Analyses were conducted by Michelle Subart. Kevin O’Rourke provided overarching production support and content review. Adrienne Chew edited the report, and Michelle Subart fact-checked it. Dawn Shepard served as the report’s graphic designer. This report was written by Jed Blore.

Funding for this report came from WHO Namibia Country Office.

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Namibia: State of the Nation’s Health

The Global Burden of Disease at a glance About the Global Burden of Disease The Global Burden of Disease (GBD) study is a powerful platform for understanding the main drivers of poor health at international, national, and local levels. Coordinated by the Institute for Health Metrics and Evaluation (IHME), GBD measures all of the years lost when people die prematurely or suffer from disability. It estimates healthy years lost from over 300 diseases, injuries, and risk factors from 1990 to 2013. The GBD findings are available for 188 countries. This project will allow decision-makers to rank health problems, understand how health trends have changed over time, and compare health outcomes across communities. This study provides the most comprehensive picture of health loss across countries to date. GBD results can also be viewed through publicly accessible visualization tools on IHME ’s website at http://www.healthdata. org/results/data-visualizations.

Global Burden of Disease methods GBD uses more than 50,000 data sources from

around the world to estimate disease burden.

As a first step, GBD researchers estimate child and adult mortality using data sources such as vital and sample registration systems, censuses, and household surveys. Years lost due to premature death from different causes are calculated using data from vital registration with medical certification of causes of death when available, and sources such as verbal autopsies in countries where medical certification of causes of death is lacking. Years lived with disability are estimated using sources such as cancer registries, data from outpatient and inpatient facilities, and direct measurements of hearing, vision, and lung function.

Once they have estimated years lost due to premature death and years lived with disability, GBD researchers sum the two estimates to obtain disability-adjusted life years. Finally, researchers quantify the amount of premature death and disability attributable to different risk factors using data on exposure to and effects of the different risk factors. GBD researchers use advanced statistical modeling to estimate disease burden. As with any modeled estimates, such as

weather forecasts and gross domestic product data, the findings in this report have limitations, such as those stemming from poor-quality and/or missing data.

In Namibia, for example, data on the leading causes of death, and particularly cardiovascular diseases, injuries, drug and alcohol use disorders, and risk factor exposures are lacking. Efforts to improve data availability and quality in Namibia will boost the accuracy of GBD findings.

For more information about GBD methods, see the papers referenced in the acknowledgments section of this report.

Utility of the Global Burden of Disease for policymaking GBD results allow decision-makers to compare healthy

years lost from fatal conditions, such as cancer, to those lost from nonfatal conditions, such as low back and neck pain. The study provides more policyrelevant information than cause of death data by shedding light on conditions that cut lives short, not just those that kill people primarily in old age. The GBD study also provides insight on potentially preventable causes of disease and injuries, known as risk factors.

GBD tracks 79 risk factors, which range from poor diets and high blood sugar to unsafe water and micronutrient deficiencies. Examining the ranking of diseases, injuries, and risk factors in a country, province, or county can help policymakers decide where to invest scarce resources to maximize health gains.

The GBD approach is being applied at the local level, as seen in recent publications examining disease burden across China and the United Kingdom.

Learn more To learn more about participating in GBD research, contact the GBD Secretariat at gbdsec@uw.edu.

GBD Technical Training Workshops provide in-depth training in GBD methods, results, and data visualizations. For more information, visit http://www.healthdata.org/gbd/training.

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Namibia: State of the Nation’s Health

Report highlights Life expectancy rebounding from dramatic declines in the 1990s and 2000s • Between 1990 and 2004 life expectancy for males and females decreased by nine and 12 years, respectively, mainly due to the HIV/AIDS epidemic.

• Between 2004 and 2013 life expectancy rebounded and rose by 11 years for females but only by six years for males.

• Life expectancy for males in 2013 was still below 1990 levels.

Progress and challenges • The peak of the HIV/AIDS epidemic occurred in 1998, which was followed by a dramatic decline in the number of new cases for both males and females. Rates of death from HIV/AIDS peaked in 2005. By 2013, death rates had more than halved for females, and almost halved for males.

• Despite Namibia’s progress in the fight against HIV/AIDS , it remains the leading cause of death and premature mortality for all ages, killing up to half of all males and females aged 40-44 years in 2013. Tuberculosis and lower respiratory infections were the next leading causes of death and premature mortality in 2013, behind HIV/AIDS .

• Non-communicable diseases (NCDs) as causes of premature mortality, disability, and total health loss (DALYs) rose in importance over the period 2000 to 2013. Significant rises were observed for stroke, low back and neck pain, ischemic heart disease, depressive disorders, COPD, and diabetes. In contrast, significant decreases were observed for some communicable conditions, including diarrheal diseases, neonatal conditions, and malaria.

Preventing death • Risk factors are key drivers of the diseases and injuries that kill people prematurely. Unsafe sex was the leading risk factor for death for both males and females. Alcohol and drug use was the second-leading risk for males, rising from eighth in 2000.

• Risk factors for non-communicable diseases, particularly cardiovascular disease (high blood pressure, poor diet, obesity/overweight) remained among the leading risks of death for both males (third, fourth, and ninth in 2013, respectively) and females (second, third, and fourth in 2013, respectively).

• Despite increased global awareness of health risks of tobacco smoke, it remains a leading risk for males (fifth) and females (ninth).

Comparing Namibia to its peers • Compared to other countries in sub-Saharan Africa, only Botswana had a higher life expectancy for both sexes combined in 2013 (66 years versus 61 years for Namibia) • In 2013, Namibia had the lowest rate of new cases of HIV/AIDS , and the lowest mortality rate from HIV/AIDS among countries comprising southern sub-Saharan Africa (Botswana, Lesotho, Swaziland, South Africa, and Zimbabwe).

• Of the six countries in the southern sub-Saharan African region, Namibia had the third-highest rates of injury deaths among males.

• Injuries, including suicide (self-harm), road injury, and homicide (interpersonal violence), disproportionately killed young males in 2013. Almost half of all deaths in males 20-24 years old are from injuries, compared to just 15% for females. Among the injury categories for males 20-24 years old, self-harm was the leading cause of death, followed by interpersonal violence.

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Namibia: State of the Nation’s Health

Findings In Namibia, life expectancy for males and females can be separated into two distinct phases: a phase of decline (phase 1, from 1990 to 2004), and a phase of increase (phase 2, from 2004 to 2013; see Figure 1a). In phase 1, as the HIV epidemic began to take hold, life expectancy for males and females dramatically declined. For females, life expectancy decreased by 12 years (66 years in 1990 to 54 years in 2004). For males, life expectancy decreased by nine years (59 years in 1990 to 50 years in 2004). In phase 2, as the incidence of HIV declined, life expectancy increased for both males and females. For males, life expectancy increased by six years (from 50 years in 2004 to 56 years in 2013). For females, life expectancy increased by 11 years (from 54 years in 1990 to 65 years in 2013). However, life expectancy for males and females is still not at the level it was in 1990.

In addition, the gap in life expectancy between males and females has grown as improvements in male life expectancy have plateaued since 2011 (in 2013, the gap between life expectancy for males and females was nine years; in 1990 this gap was seven years).

HIV/AIDS and TB contributed a decrease of 3.6 years of life expectancy from 1990 to 2013 for both sexes combined (see Annex Figure 1).

However, this decrease was slightly offset by reductions in mortality from diarrheal diseases, lower respiratory conditions, and other infectious diseases, which together contributed to an increase of 1.6 years in life expectancy (see Annex Figure 4).

Figure 1a Life expectancy for males and females, Namibia, 1990–2013 males

females

global

80

Life expectancy at birth

75 70

1990 65.7 years

65

2013 65.4 years

60 55

1990 59.0 years

2013 56.2 years

50 45 1990

2000

Global

1990

males

63.0

68.8

females

67.7

74.3

2010

2013

2013

13

Figure 1b Life expectancy for males and females combined, sub-Saharan Africa, 2013

Namibia Life expectancy 61 Years

Age 48

50

55

Namibia has the second–highest life expectancy in southern subSaharan Africa Life expectancy for males and females declined dramatically from 1990 to 2004, then rebounded from 2004 to 2013, to be second highest in southern sub-Saharan Africa behind Botswana.

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60

65

70

75

80

84

Figure 1b compares life expectancy in Namibia to other countries in southern sub-Saharan Africa: Lesotho, Swaziland, Zimbabwe, South Africa, and Botswana. Of these countries, in 2013 only Botswana had higher life expectancy for both sexes combined (66 years). Lesotho had the lowest life expectancy (48 years). The sub-Saharan Africa region, comprising Botswana, South Africa, Swaziland, Zimbabwe, and Lesotho, had an overall life expectancy of 60 years in 2013 for both sexes combined.

It is clear that the HIV epidemic had a substantial impact on health in Namibia. Figure 2 shows the dramatic rise in rates of new cases (incidence rates) of HIV from 1990 to 1998 for males and females. Over this period, rates of new cases of HIV for females increased almost 10-fold, from 160 per 100,000 in 1990 to over 1,000 per 100,000 in 1998. Similarly for males, rates of new cases increased from 240 per 100,000 in 1990 to 1,000 per 100,000 in 1998. From 1998 to 2013, rates of new cases of HIV declined almost as dramatically as they had increased. For males, rates of new cases declined to 290 per 100,000 in 2013. For females, incident cases declined to 320 per 100,000 in 2013. Though these rates are still higher than in 1990, they are far below numbers at the peak of the epidemic, and the trend suggests further declines post-2013.

It is also useful for health resource planning to consider the total number of new cases. In 2013, there were approximately 3,900 new cases of infections for females, and 3,100 for males (see Figure 3), falling from the peak in 1998 of 9,400 new cases in females and 8,200 new cases in males.

Figure 4 compares rates of new cases of HIV in Namibia to the countries in southern sub-Saharan Africa. Of note, in 2013 Namibia had the lowest rate of new cases (300 per 100,000, both sexes combined) in the region. Swaziland had the highest rate (810 per 100,000). The peak of the epidemic occurred earlier in all other countries except South Africa, which also peaked in the same year as Namibia (1998). In 1998,

Namibia: State of the Nation’s Health

Figure 2 New cases of HIV/AIDS per 100,000 people for males and females, Namibia, 1990–2013. Shaded areas indicate the uncertainty interval around each estimate.

Male

Female

1,200

New cases per 100,000

1,000

800

600

400

200 1990

1995

2000

2005

2010

Figure 3 Numbers of new cases of HIV/AIDS for males and females, Namibia, 1990–2013. Shaded areas indicate the uncertainty interval around each estimate.

Male

Female

10,000

Number of new cases

8,000

6,000

4,000

2,000

1990

1995

2000

2005

2010

Findings

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Figure 4 New cases of HIV per 100,000 people for both sexes combined, Namibia and countries in Southern sub-Saharan Africa, 1990–2013 2,500

Botswana South Africa Zimbabwe

New cases per 100,000

2,000

Swaziland Lesotho Namibia

1,500

1,000

500

1990

1995

HIV/AIDS New cases of HIV/AIDS grew rapidly from 1990, peaking in 1998 and then declining almost as rapidly from 1998 to 2013.

2000

2005

2010

rates of new cases in South Africa were 50% higher (1,500 per 100,000) than in Namibia. Also, South Africa’s rate of new cases has not declined as rapidly as Namibia’s rate, and in 2013 South Africa had a new case rate of 710 per 100,000 compared to Namibia’s rate of 300 per 100,000.

In Namibia, death rates from HIV peaked in 2005 (see Figure 5) for males (510 deaths per 100,000 people) and females (460 deaths per 100,000 people). In 2013, the death rate for females more than halved from the peak in 2005 (170 per 100,000 in 2013). The death rate for males also halved from the peak in 2005 (240 per 100,000 in 2011) before increasing again from 2011 to 2013, to 280 per 100,000.

Comparing Namibia to other countries in southern sub-Saharan Africa (Lesotho, Swaziland, Zimbabwe, South Africa, Botswana), Namibia had the lowest mortality rate from HIV/AIDS in 2013 (220 per 100,000 both sexes combined), followed by Botswana (350 per 100,000; see Figure 6). Lesotho had the highest HIV/AIDS mortality rate, at 620 per 100,000 in 2013. For all countries in southern sub-Saharan Africa, HIV/AIDS mortality rates are lower in females compared to males.

Progress and challenges Understanding the health progress the country has made in HIV/AIDS and in other areas, as well as the problems it faces, is essential for health planning and policymaking. While mortality from HIV/AIDS has improved and new cases have decreased, an examination of the leading causes of

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Namibia: State of the Nation’s Health

Figure 5 Deaths from HIV/AIDS per 100,000 people for males and females, Namibia, 1990–2013. Shaded areas indicate the uncertainty interval around each estimate.

Male

Female

Deaths per 100,000

600

510 460 400

200

1990

1995

2000

2005

2010

Figure 6 Deaths from HIV/AIDS per 100,000 people, both sexes combined. Namibia and countries in southern sub-Saharan Africa, 1990–2013

1,000

Botswana South Africa Zimbabwe Lesotho Namibia

Deaths per 100,000

Swaziland

500

1990

1995

2000

2005

2010

Findings

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death in Namibia indicates that it remains the number-one cause for both males and females since the year 2000 (see Figures 7a and 7b).

Figures 7a and 7b show how the other leading causes of death for males and females changed between 2000 and 2013. For example, tuberculosis remained the second-leading cause of death for both males and females, and lower respiratory infections remained the third-leading cause for males and the fourth-leading cause for females over the same period. Cardiovascular diseases have increased in rank for both males and females, with ischemic heart disease rising from fifth to fourth for males and sixth to fifth for females. Stroke (cerebrovascular disease) has increased from sixth to fifth for males, and from fifth to third for females. This highlights the importance of focusing attention on NCDs, especially cardiovascular diseases, and their associated risk factors, to tackle the rising importance of these leading causes of death in Namibia.

HIV/AIDS In 2013, Namibia had the lowest rate of new HIV/ AIDS cases and the lowest death rate from HIV/AIDS in the southern sub-Saharan African region.

Figure 7a Leading causes of death for females, Namibia, 2000–2013 Communicable, maternal, newborn, and nutritional disorders

Non-communicable diseases

Injuries

decrease

Females 2000 Ranking

2013 Ranking

HIV/AIDS

1

1

HIV/AIDS

Tuberculosis

2

2

Tuberculosis

Diarrheal diseases

3

3

Cerebrovascular disease

Lower respiratory infections

4

4

Lower respiratory infections

Cerebrovascular disease

5

5

Ischemic heart disease

Ischemic heart disease

6

6

Diarrheal diseases

Diabetes

7

7

Diabetes

Hypertensive heart disease

8

8

Hypertensive heart disease

COPD

9

9

COPD

Other neonatal 10 Preterm birth complications 11 Asthma 12 Road injuries 13 Malaria 14 Neonatal encephalopathy 15 Other cardiovascular 16 Endo/metab/blood/immune 17 Cardiomyopathy 18 Meningitis 19 Self–harm 20 Interpersonal violence 21 Chronic kidney disease 23

10 Endo/metab/blood/immune 11 Asthma 12 Other cardiovascular 13 Other neonatal 14 Cardiomyopathy 15 Road injuries 16 Preterm birth complications 17 Neonatal encephalopathy 18 Interpersonal violence 19 Chronic kidney disease 20 Self–harm 21 Malaria 23 Meningitis

Note: COPD = chronic obstructive pulmonary disease Endo/metab/blood/immune = Endocrine, metabolic, blood, and immune disorders Note:

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same or increase

COPD = chronic obstructive pulmonary disease

Namibia: State of the Nation’s Health

Figure 7b Leading causes of death for males, Namibia, 2000–2013 Communicable, maternal, newborn, and nutritional disorders

Non-communicable diseases

same or increase decrease

Males

2000 Ranking

2013 Ranking

HIV/AIDS

1

1

HIV/AIDS

Tuberculosis

2

2

Tuberculosis

Lower respiratory infection s3

3

Lower respiratory infections

Diarrheal diseases

4

4

Ischemic heart disease

Ischemic heart disease

5

5

Cerebrovascular disease

Cerebrovascular disease

6

6

Diarrheal diseases

COPD

7

7

Self–harm

Self–harm

8

8

COPD

Road injuries

9

9

Road injuries

Malaria 10 Preterm birth complications 11 Other neonatal 12 Interpersonal violence 13

10 Interpersonal violence 11 Diabetes 12 Asthma 13 Other neonatal

Diabetes 14

14 Preterm birth complications

Neonatal encephalopathy 15

15 Hypertensive heart disease

Asthma 16 Hypertensive heart disease 17 Mechanical forces 18 Meningitis 19 Chronic kidney disease 20 Endo/metab/blood/immune 21 Drug use disorders 26 Note:

Injuries

16 Malaria 17 Endo/metab/blood/immune 18 Chronic kidney disease 19 Drug use disorders 20 Neonatal encephalopathy 22 Mechanical forces 25 Meningitis

COPD = chronic obstructive pulmonary disease

Note: COPD = chronic obstructive pulmonary disease Endo/metab/blood/immune = Endocrine, metabolic, blood, and immune disorders

Namibia has made significant progress in reducing deaths from diarrheal diseases. For males and females, diarrheal diseases fell in rank, from fourth for males and third for females in 2000, to sixth in 2013.

There are important differences in the leading causes of death for males and females. For males, injuries feature prominently in the top 10, with suicide (self-harm) and interpersonal violence both rising in importance from 2000 to 2013 (self-harm increased from eighth to seventh; interpersonal violence increased from 13th to 10th; road injuries remained ninth). These same causes do not feature in the top 10 causes of death for females (self-harm remained 20th, road injuries were 15th, and interpersonal violence was 18th).

Causes connected by a dashed line indicate a decrease in ranking from 2000 to 2013 while causes connected by a solid line indicate an increase or no change in ranking from 2000 to 2013. Communicable,

HIV/AIDS remained the leading cause of death in 2013 despite Namibia’s tremendous progress in tackling HIV/AIDS.

Findings

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Males die from injuries at much higher rates than females, particularly from: • self-harm • road injuries • interpersonal violence

neonatal, maternal, and nutritional conditions are indicated by red boxes, non-communicable conditions are indicated by blue boxes, and injuries are indicated by green boxes.

Figure 8 shows how the causes of death differ across age groups in Namibia for males (top) and females (bottom). As in Figures 7a and 7b previously, the disparity of injury deaths in males versus females can be seen clearly in the age patterns from ages 10-35. The reasons for this disparity are to be found in an examination of risks. That is, males engage in behavior that increases the risk for injuries at a higher rate than females (alcohol and drug use). A further examination of risks for health loss is presented later in this report. Figure 8 indicates that the peak in injury deaths occurs for males between the ages of 20 and 24 years. Self-harm and interpersonal violence contribute to almost a third of all deaths in this age group (29%), with unintentional injuries and transport injuries contributing a further 10% each (total 49%). Thus, almost half of all deaths are attributed to these injury categories. For females, in contrast, self-harm and interpersonal violence contribute only 8% of deaths, and unintentional and transport injuries contribute a further 4% each (total, 16%).

Given the importance of self-harm and interpersonal violence as causes of young male deaths, Figure 9 provides more detailed information. This figure reveals that self-harm is responsible for the largest proportion of male deaths, peaking at 18% in ages 20-24. Interpersonal violence contributes a further 11% of deaths (total 29%). At age 40, these two causes contribute to 6% of deaths.

A comparison of self-harm, interpersonal violence, and road injuries in Namibia and other countries in southern sub-Saharan Africa is given for males and females in Figure 10, which indicates that males are injured at far greater rates than females. Only Lesotho and Swaziland have higher rates of injury-related deaths in males.

Distinct patterns of death across the lifespan

Males aged 20-24 Deaths from self-harm, road injuries, and interpersonal violence peak in males aged 20-24. Together, these causes account for almost 50% of all deaths in this age group.

20

The percent of deaths due to different causes by age, given in Figure 8, indicates three additional patterns of death across the lifespan that correspond to three periods of life: early childhood, young adolescence to mid-adulthood, and late adulthood.

First, in children under 5, deaths are overwhelmingly caused by neonatal disorders and diarrhea, lower respiratory conditions, and other infectious causes (see also Annex Figure 1). Second, as early as 10-14 years of age, HIV/AIDS and TB are leading causes of death, accounting for over a quarter of deaths in children in this age group (39%). The age breakdown for HIV/AIDS is given in Figure 11.

Figure 11 shows a peak in HIV/AIDS deaths in 40-44 year olds, which contributes to almost half of all deaths in males and females in this age group (48%). TB contributes a further 13%.

The third distinct pattern visible in Figure 9 corresponds to mid-tolate adulthood, beginning at age 55. For both males and females, cardiovascular diseases account for almost a quarter of all deaths in this age group (24%, 55-59 years of age). The age pattern and breakdown of the cardiovascular diseases category into their various causes indicates that the peak for cardiovascular deaths comes in the 80+ age group (see Annex Figure 6). Deaths are slightly higher from stroke (cerebrovascular disease; 16% in 80+ age group; see Annex Figure 6) than ischemic heart disease (14% in 80+ age group; see Annex Figure 6). Cancers

Namibia: State of the Nation’s Health

Figure 8 Percentage breakdown of total deaths by age group, for males and females, Namibia, 2013 Males 100%

Percent of total deaths

80%

60%

40%

20%

28

4

1–

–3

64

da

ys ye ar s 5– 9 ye ar 10 s –1 4 ye ar 15 s –1 9 ye ar 20 s –2 4 ye ar 25 s –2 9 ye ar 30 s –3 4 ye ar 35 s –3 9 ye ar 40 s –4 4 ye ar 45 s –4 9 ye ar 50 s –5 4 ye ar 55 s –5 9 ye ar 60 s –6 4 ye ar 65 s –6 9 ye ar 70 s –7 4 ye ar 75 s –7 9 ye 80 ars + ye ar s

ys da

27 7–

0–

6

da

ys

0%

Females

Percent of total deaths

100%

80%

60%

40%

20%

da 28 ys –3 64 d 1– ays 4 ye ar s 5– 9 ye ar 10 s –1 4 ye ar 15 s –1 9 ye ar 20 s –2 4 ye ar 25 s –2 9 ye ar 30 s –3 4 ye ar 35 s –3 9 ye ar 40 s –4 4 ye ar 45 s –4 9 ye ar 50 s –5 4 ye ar 55 s –5 9 ye ar 60 s –6 4 ye ar 65 s –6 9 ye ar 70 s –7 4 ye ar 75 s –7 9 ye 80 ars + ye ar s

27 7–

0– 6

da ys

0%

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deficiencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

Note: LRI: lower respiratory infections Diabetes/urog/blood/endo: Diabetes and urogenital, blood, and endocrine disorders

Findings

21

Figure 9 Percent of total deaths from self-harm and interpersonal violence by age group, males, Namibia, 2013 Self-harm

Interpersonal violence

30

Percent of total deaths

25

20

15

10

5

s ye ar s +

80

s

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–7 75

s 70

–7

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ye ar

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–6 65

s 60

–6

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ye ar

s

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55

–5

s 50

–5

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–4

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–3 35

45

s

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9

ye ar

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s 25

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5–

ys

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28

–3

27 7–

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ys

0

Figure 10 Age-standardized injury deaths per 100,000 for males and females, Namibia and countries in southern sub-Saharan Africa, 2013 Transport injuries

Self-harm

Interpersonal violence

Males

Females Botswana

S. Africa

Zimbabwe

Namibia

Swaziland

Lesotho 150

100

50

0

Deaths per 100,000

22

Namibia: State of the Nation’s Health

0

50

Deaths per 100,000

100

150

Figure 11 Percent of total deaths from HIV/AIDS and TB by age group, both sexes, Namibia, 2013 Tuberculosis

HIV/AIDS

60

Percent of total deaths

50

40

30

20

10

While deaths are a commonly used metric for population health, a focus solely on deaths gives equal weight to causes of death regardless of age. For example, a death at age 90 is given the same weight as a death at age 10. Decision-makers want to know which causes, injuries, and risks lead to premature mortality. The GBD study uses a metric to count the premature aspect of death, called Years of Life Lost (YLL s) that quantifies the number of years a person loses at the age of their death. For every death from a particular cause, the number of years lost is estimated based on the highest life expectancy in the deceased’s age group. This metric gives greater weight to causes of deaths occurring at younger ages. Figure 12 provides a ranking of the YLL s by sex in Namibia from 2000 to 2013.

Figure 12 shows that the leading causes of premature mortality in Namibia in 2013 for males and females, and trends over time, are very

rs

rs

yea

80+

yea

rs

79

yea

75–

yea

rs

74 70–

yea

rs

69 65–

yea

rs

64 60–

yea

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59 55–

rs

Preventing premature mortality

54

yea

cause fewer deaths in this phase of life than chronic respiratory diseases (peak cancer deaths occur in ages 60-64, 6%, compared with 12% for chronic respiratory diseases in ages 70-74). COPD is the largest cause of death of the chronic respiratory diseases (8% in ages 70-74; see the Annex), followed by asthma (3%).

To gain a clearer picture of Namibia’s most important health problems, it is essential to compare the impact of different diseases and injuries by taking into account not just causes of death, but also causes of early death (premature mortality) and disability.

50–

yea

rs

49 45–

yea

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s

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ays

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s

0

Premature mortality Premature mortality, in comparison to deaths, takes into account the years of life lost in comparision to a reference life expectancy.

Conditions that typically cause deaths in younger ages increase in relative importance, while conditions that typically cause deaths in older ages decrease in relative importance, compared to simple rankings of causes of death.

Findings

23

Figure 12 Leading causes of premature mortality (YLLs) for females and males, all ages, Namibia, 2000–2013 Communicable, maternal, newborn, and nutritional disorders

Non-communicable diseases

Injuries

same or increase decrease

Females 2000 Ranking HIV/AIDS Tuberculosis Diarrheal diseases Lower respiratory infections Other neonatal Cerebrovascular disease Preterm birth complications Neonatal encephalopathy Malaria

2013 Ranking

1

1

3

3

2

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4

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5

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Road injuries 10

10

Diabetes 12 Meningitis 13

12

Ischemic heart disease 11

11

13

Endo/metab/blood/immune 14 Protein-energy malnutrition 15

14 15

Interpersonal violence 16 Asthma 17

16 17

Congenital anomalies 18 Self-harm 19

18 19

HIV/AIDS Tuberculosis Lower respiratory infections Diarrheal diseases Cerebrovascular disease Other neonatal Preterm birth complications Neonatal encephalopathy Diabetes Ischemic heart disease Road injuries Endo/metab/blood/immune Interpersonal violence Congenital anomalies Malaria Hypertensive heart disease Self-harm COPD Cardiomyopathy

Hypertensive heart disease 20

20

Asthma

COPD 21 Cardiomyopathy 22

21

Meningitis

24

Protein-energy malnutrition

Males 2000 Ranking HIV/AIDS Tuberculosis Diarrheal diseases Lower respiratory infections Preterm birth complications Other neonatal Self-harm Road injuries Malaria

2013 Ranking

1

1

3

3

2 4 5 6 7 8 9

2 4 5 6 7 8 9

Neonatal encephalopathy 10

10

Cerebrovascular disease 12

12

Interpersonal violence 11

Ischemic heart disease 13

COPD 14 Protein-energy malnutrition 15 Congenital anomalies 16 Mechanical forces 17

Meningitis 18 Diabetes 19

Asthma 20

11

13

14 15 16 17

18 19

HIV/AIDS Tuberculosis Lower respiratory infections Diarrheal diseases Self-harm Road injuries Interpersonal violence Ischemic heart disease Other neonatal Preterm birth complications Cerebrovascular disease Neonatal encephalopathy COPD Malaria Diabetes Congenital anomalies Drug use disorders Endo/metab/blood/immune Mechanical forces

20

Asthma

21

21 Meningitis

23

23 Protein-energy malnutrition

Note: COPD = chronic obstructive pulmonary disease Endo/metab/blood/immune = Endocrine, metabolic, blood, and immune disorders

24

Namibia: State of the Nation’s Health

similar to the leading causes of deaths. However, as YLL s place more weight on the causes of death that occur in younger age groups, the rankings for causes of death that kill children and young adults (neonatal conditions, diarrheal diseases, self-harm, road injuries, and interpersonal violence) are slightly higher. Similarly, the rankings for causes of death that kill older adults (like ischemic heart disease and stroke), are slightly lower when considering YLLs.

Low back and neck pain, and depressive disorders

Non-fatal health outcomes

were the leading causes of disability among Namibians in 2013.

As life expectancy for Namibians improves, they are likely to increasingly suffer from disabling conditions. This trend has important implications for the health system which must care for the growing number of patients. For example, low back and neck pain was the leading cause of disability in 2000 and in 2013 (see Figure 13). In the Global Burden of Disease (GBD) study, disability includes any short- or long-term suffering and takes into account the severity of a given disease or injury. Disability from other causes remained stable, with the notable exception of diabetes, which rose from 25th in 2000 to 15th in 2013.

Declines in disability from 2000 to 2013 were recorded for diarrheal diseases (from 17th in 2000 to 22nd in 2013), falls (14th in 2000 to 26th in 2013) and malaria (from 16th in 2000 to 29th in 2013). Of the top 20 causes of disability in 2013, 17 were NCDs, and only three were communicable and nutritional diseases (iron-deficiency anemia, third, HIV/ AIDS , fourth, and TB , ninth).

Figure 13 Leading causes of disability (YLDs), both sexes, Namibia, 2000–2013 Communicable, maternal, newborn, and nutritional disorders

Non-communicable diseases

Injuries

same or increase decrease

2000 Ranking

2013 Ranking

Low back & neck pain

1

1

Low back & neck pain

Depressive disorders

2

2

Depressive disorders

Iron-deficiency anemia

3

3

Iron-deficiency anemia

HIV/AIDS

4

4

HIV/AIDS

Skin diseases

5

5

Skin diseases

Sense organ diseases

6

6

Sense organ diseases

Anxiety disorders

7

7

Anxiety disorders

COPD

8

8

COPD

Tuberculosis

9

9

Tuberculosis

Intellectual disability 10 Migraine 11 Alcohol use disorders 12 Chronic kidney disease 13 Falls 14 Oral disorders 15 Diabetes 25

10 Migraine 11 Intellectual disability 12 Alcohol use disorders 13 Chronic kidney disease 14 Oral disorders 15 Diabetes 26 Falls

Note: COPD = chronic obstructive pulmonary disease Note:

COPD = chronic obstructive pulmonary disease

Findings

25

While disability is most common in older people, it can affect a person of any age and can interfere with children’s education and adults’ ability to work. Figure 14 shows how the causes of disability vary across the lifespan. Disability from nutritional deficiencies (particularly iron-deficiency anemia, with a smaller contribution from proteinenergy malnutrition, see Annex Figure 7) is a major problem for children up to age 10, contributing over 50% of disability in the youngest age groups. From age 10 to 50, disability from mental illness and substance use disorders becomes increasingly pronounced. In Namibians aged 20 to 24, mental illness and substance use disorders contribute to over 40% of all disability. Within this category, depressive disorders are the largest contributor of disability (14%), followed by anxiety disorders (6%) and alcohol use disorders (5.5%; see Figure 15). The leading cause of disability overall, low back and neck pain, tends to affect older adults, peaking in the 55-59 year age group (16%; see Annex Figure 8).

Figure 14 Percentage breakdown of total disability (YLDs) by age group, both sexes, Namibia, 2013 100%

Percent of total YLDs

80%

60%

40%

20%

da ys ye ar s 5– 9 ye ar 10 s –1 4 ye 15 ar s –1 9 ye 20 ar s –2 4 ye 25 ar s –2 9 ye 30 ar s –3 4 ye 35 ar s –3 9 ye 40 ar s –4 4 ye 45 ar s –4 9 ye 50 ar s –5 4 ye 55 ar s –5 9 ye 60 ar s –6 4 ye 65 ar s –6 9 ye 70 ar s –7 4 ye 75 ar s –7 9 ye 80 ars + ye ar s 4

1–

ys

64

da –3 28

27 7–

0–

6

da

ys

0%

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deficiencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

Note: LRI: lower respiratory infections Diabetes/urog/blood/endo: Diabetes and urogenital, blood, and endocrine disorders

26

Namibia: State of the Nation’s Health

Figure 15 Percent of total disability (YLDs) by age group for mental and substance use disorders, both sexes, 2013, Namibia

Percent of total YLDs

40%

30%

20%

10%

4

1–

64

da

ys ye ar s 5– 9 ye ar 10 s –1 4 ye ar 15 s –1 9 ye ar 20 s –2 4 ye ar 25 s –2 9 ye ar 30 s –3 4 ye ar 35 s –3 9 ye ar 40 s –4 4 ye ar 45 s –4 9 ye ar 50 s –5 4 ye ar 55 s –5 9 ye ar 60 s –6 4 ye ar 65 s –6 9 ye ar 70 s –7 4 ye ar 75 s –7 9 ye 80 ars + ye ar s

ys da 28

–3

27 7–

0–

6

da

ys

0%

Schizophrenia

Eating disorders

Alcohol use disorders

Autistic spectrum disorders

Drug use disorders

ADHD

Depressive disorders

Conduct disorder

Bipolar disorder

Intellectual disability

Anxiety disorders

Other mental & substance use disorders

A fuller understanding of Namibia’s health problems To gain the clearest picture of Namibia’s most important health problems, it is essential to compare the impact of different diseases and injuries by taking into account not just early death, but also disability.

The metric that allows us to compare years lost from early death and disability combined is known as “disease burden,” or disability-adjusted life years (DALYs). Figure 16 provides this comparison of disease burden from different causes, revealing that HIV/AIDS remains the single most important health problem in the country in 2013. Reflected in Figure 16 is progress in tackling diarrheal diseases (declining in rank from third in 2000 to fourth in 2013) and malaria (declining in rank from seventh in 2000 to 18th in 2013), while burden of disease from NCDs such as stroke has risen in importance. Injuries that disproportionately affect young males increased in importance from 2000 to 2013. This includes self-harm, which rose from 11th in 2000 to seventh in 2013, and interpersonal violence, which rose from 13th to 12th in 2013. Road injuries remained the eighth-leading cause of disease burden. Figure 16 also highlights the importance of going beyond death statistics to understand

Findings

27

Figure 16 Leading causes of disease burden (DALYs), both sexes, Namibia, 2000–2013 Communicable, maternal, newborn, and nutritional disorders

Non-communicable diseases

Injuries

same or increase decrease

2000 Ranking

2013 Ranking

HIV/AIDS

1

1

HIV/AIDS

Tuberculosis

2

2

Tuberculosis

Diarrheal diseases

3

3

Lower respiratory infections

Lower respiratory infections

4

4

Diarrheal diseases

Other neonatal

5

5

Cerebrovascular disease

Preterm birth complications

6

6

Other neonatal

Malaria

7

7

Self-harm

Road injuries

8

8

Road injuries

Cerebrovascular disease

9

9

Preterm birth complications

Neonatal encephalopathy 10

10 Low back & neck pain

Self-harm 11

11 Ischemic heart disease

Ischemic heart disease 12

12 Interpersonal violence

Interpersonal violence 13

13 Depressive disorders

Iron-deficiency anemia 14

14 COPD

COPD 15

15 Neonatal encephalopathy

Low back & neck pain 16

17 Iron-deficiency anemia

Depressive disorders 17

18 Malaria

COPD = obstructive pulmonary diseasedisease Note: COPD Note: = chronic chronic obstructive pulmonary

The leading causes of disease burden (disability and premature mortality) in Namibia in 2013 were:

1. HIV/AIDS 2. tuberculosis 3. lower respiratory infections

28

a country’s health problems. In addition to low back and neck pain, depressive disorders, which tend to cause disability rather than death, were among the top 15 causes of disease burden (13th).

When analyzing the leading causes of disease burden by sex, some important differences emerge (see Figure 17). Self-harm (fifth), road injuries (sixth), and interpersonal violence (seventh) were all among the top 10 causes of burden for males, but not for females. In contrast, depressive disorders (fifth), cerebrovascular disease (sixth), and low back and neck pain (seventh) were among the top 10 causes of burden for females, but not for males.

Information on the patterns of disease burden from different causes across age groups can be useful for tailoring health services and interventions to specific age groups. This information is given for disease burden in Annex Figure 9.

Namibia: State of the Nation’s Health

Figure 17 Leading causes of disease burden (DALYs), males (top) and females (bottom), Namibia, 2000–2013 Communicable, maternal, newborn, and nutritional disorders

Non-communicable diseases

Injuries

same or increase decrease

Males 2000 Ranking

2013 Ranking

HIV/AIDS

1

1

HIV/AIDS

Tuberculosis

2

2

Tuberculosis

Diarrheal diseases

3

3

Lower respiratory infections

Lower respiratory infections

4

4

Diarrheal diseases

Preterm birth complications

5

5

Self-harm

Other neonatal

6

6

Road injuries

Self-harm

7

7

Interpersonal violence

Road injuries

8

8

Other neonatal

Malaria

9

9

Preterm birth complications

Neonatal encephalopathy 10

10 Ischemic heart disease

Interpersonal violence 11

14 Neonatal encephalopathy

Ischemic heart disease 13

15 Malaria

Females 2000 Ranking

2013 Ranking

HIV/AIDS

1

1

HIV/AIDS

Tuberculosis

2

2

Tuberculosis

Diarrheal diseases

3

3

Lower respiratory infections

Lower respiratory infections

4

4

Diarrheal diseases

Other neonatal

5

5

Depressive disorders

Preterm birth complications

6

6

Cerebrovascular disease

Cerebrovascular disease

7

7

Low back & neck pain

Depressive disorders

8

8

Other neonatal

Neonatal encephalopathy

9

9

Preterm birth complications

Malaria 10 Low back & neck pain 13 Diabetes 14

10 Diabetes 13 Neonatal encephalopathy 18 Malaria

Findings

29

30

Namibia: State of the Nation’s Health

Preventing health loss: risks factors for ill-health Risk factors are key drivers of the diseases and injuries that cause burden. By addressing these risk factors, much of Namibia’s disease burden could be reduced. Risk factors fall into three different categories: behavioral, metabolic, and environmental/occupational. Given that HIV is the leading cause of deaths and premature mortality in Namibia, it is not surprising that unsafe sex is the leading risk factor for both males and females, and has remained the leading risk from the year 2000 to 2013 (see Figure 18). Almost 19% of deaths are attributable to unsafe sex (see Figure 18).

Figure 18 Leading risk factors attributable to deaths in Namibia, 2000–2013 Metabolic risks

Environmental/occupational risks

Behavioral risks

same or increase decrease

Males 2000 Ranking

2013 Ranking

Unsafe sex 1

1 Unsafe sex

High systolic blood pressure 2

2 Alcohol and drug use

Dietary risks 3

3 High systolic blood pressure

Tobacco smoke 4

4 Dietary risks

Unsafe water, sanitation, and handwashing 5

5 Tobacco smoke

High fasting plasma glucose 6

6 High fasting plasma glucose

Air pollution 7

7 Air pollution

Alcohol and drug use 8

8 Unsafe water, sanitation, and handwashing

Child and maternal malnutrition 9

9 High body mass index

High body mass index 10

2000 Ranking

Unsafe sex 1 High systolic blood pressure 2 Unsafe water, sanitation, and handwashing 3 Dietary risks 4 High body mass index 5 High fasting plasma glucose 6 Air pollution 7 Child and maternal malnutrition 8 Tobacco smoke 9 Sexual abuse and violence 10 Alcohol and drug use 12

10 Child and maternal malnutrition

Females

2013 Ranking

1 Unsafe sex 2 High systolic blood pressure 3 Dietary risks 4 High body mass index 5 High fasting plasma glucose 6 Alcohol and drug use 7 Air pollution 8 Unsafe water, sanitation, and handwashing 9 Tobacco smoke 10 Sexual abuse and violence 12 Child and maternal malnutrition

31

Some of the leading causes of disease burden for females do not feature among the top 10 causes of disease burden in males, and vice versa. These include: Females

5. depressive disorders Males

5. self-harm

In addition, given the large burden of injuries among young males, it is also unsurprising that alcohol and drug use is the second-leading risk of death for males (rising from eighth in 2000), and only sixth for females (though this is higher than in the year 2000, when it was the 12th leading risk for death). Ten percent of deaths are attributable to alcohol and drug use (see Figure 19).

High systolic blood pressure is an important risk for both males (third) and females (second). High blood pressure causes ischemic heart disease and stroke, which, as indicated in Figures 7a and 7b earlier in this report, are in the top five leading causes of death for males and females, and increased in importance from 2000 to 2013. Twelve percent of all deaths are attributed to high blood pressure.

Having a poor diet is the third and fourth leading risk for females and males, respectively; 10% of deaths are attributable to this risk (see Figure 19). Dietary risks include eating too little fruit, vegetables, whole grains, and nuts and seeds, and eating too much salt, red meat, and processed meat, as well as consuming trans fats. The main diseases associated with poor diets are ischemic heart disease and stroke.

Despite the increased awareness of the health risks of tobacco globally, it remains a leading risk of death for males (fifth) and females

Figure 19 Top risk factors for deaths, all ages, both sexes, Namibia, 2013 Unsafe sex High blood pressure Dietary risks Alcohol & drug use High fasting plasma glucose High body mass index Tobacco Air pollution WaSH Low glomerular ďŹ ltration Malnutrition Low physical activity Sexual abuse & violence High total cholesterol Occupational risks Other environmental Low bone mineral density 0%

5%

10%

15%

Note: WaSH = Water, sanitation, and handwashing LRI = lower respiratory infections NTDs = neglected tropical diseases urog = urogenital diseases endo = endocrinological disorders

32

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deďŹ ciencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

Namibia: State of the Nation’s Health

(ninth); 6% of all deaths are attributable to this risk (see Figures 19 and 20). Tobacco smoke is a major contributor to lung cancer and COPD. Tobacco smoke also contributes to other diseases such as ischemic heart disease, stroke, and colorectal cancers. The number of smokers is increasing in Namibia, which is largely due to population growth (see Annex Figures 10 and 11).

The metabolic risks of high body mass index and high fasting plasma glucose are leading risks of death for females (fourth and fifth respectively) and males (ninth and sixth respectively), and have either remained the same since 2000 (high fasting plasma glucose for males), or increased in rank (high body mass index for males and females, high fasting plasma glucose for females). High body mass index is a measure of obesity and overweight, and is a major cause of diabetes as well as being associated with ischemic heart disease. High fasting plasma glucose (high blood sugar) is a major cause of diabetes but is also linked to deaths from cardiovascular diseases and HIV/AIDS and tuberculosis.

As Namibian males die from injury deaths at much higher rates than females, it is important to look at the leading risk factor related to injuries (alcohol and drug use) for males separately. Both the rate (Figure 20) and number (Figure 21) of injury deaths attributable to alcohol and drug use rose dramatically from 1990 to 2010. However, the large uncertainty intervals from 2005 to 2013 indicate the need for additional information for this risk factor.

To identify areas where the biggest health improvements can be made in every age group, it is necessary to understand the risk factors that are the most problematic in different age groups. In ages 0 to 5, malnutrition and water and sanitation were the leading risks, contributing to 21% and 14%, respectively, of deaths due to diarrheal diseases,

1. Unsafe sex was the leading risk of death for both males and females in 2013, followed by: Males

2. alcohol and drug use Females

2. high blood pressure

Figure 20 Injury deaths per 100,000 attributable to alcohol and drug use, males, Namibia, 1990–2013. Lines indicate uncertainty interval.

50

Deaths per 100,000

40

30

20

10

0 1990

1995

2000

2005

2010

Preventing helath loss: risk factors for ill-health

2013

33

Figure 21 Numbers of injury deaths attributable to alcohol and drug use, males, Namibia, 1990–2013. Lines indicate uncertainty interval.

600

Deaths per 100,000

500

400

300

200

100

0 1990

1995

2000

2005

2010

2013

LRI , and other common infectious diseases (see Annex Figure 12). In

Metabolic risks are among the top 10 risks of death for males and females. These risks are associated with diabetes and cardiovascular disease.

34

ages 15-49, unsafe sex was the leading risk of death, contributing to 35% of deaths (see Annex Figure 13). The second-leading risk in this age group was alcohol and drug use, associated with almost 15% of total deaths (see Annex Figure 13). In ages 50-69, high blood pressure was the leading risk, contributing to over 20% of deaths, followed by poor diet, contributing to almost 20% of deaths. This was mainly due to effects on cardiovascular disease, with a smaller effect due to diabetes, urogenital, blood, and endocrine diseases.

Even though people are dying from poor diets, tobacco smoke, and obesity/overweight later in life, it is their aggregate exposure to these risks over the course of a lifetime that causes these deaths.

Namibia: State of the Nation’s Health

Comparing Namibia to its peers Comparing a country’s health system performance to a set of relevant countries can help to identify diseases, injuries, or risk factors where outcomes are worse or better than countries in similar circumstances.

The leading causes of death for Namibia are compared to other countries in southern sub-Saharan Africa in Figure 22. The top nine causes of death in these comparison countries (Botswana, Lesotho, South Africa, Swaziland, and Zimbabwe) are very similar, with the exception of Zimbabwe (which has a lower burden of COPD, see Figure 22). South Africa and Zimbabwe also have notably higher death rates from chronic kidney disease.

Namibian children had

the second lowest probability of dying before their fifth birthday among countries in southern sub-Saharan Africa in 2013.

Figure 22 Heat map of death rates for leading causes of deaths, per 100,000, age-standardized, for southern sub-Saharan African countries, 2013. Cells are color-coded according to rank. Causes are ordered according to their rank for Namibia.

Namibia

Botwana

Lesotho

S Africa

Swaziland

Zimbabwe

HIV/AIDS

1

1

1

1

1

1

Cerebrovascular disease

2

2

4

2

2

3

Tuberculosis

3

3

2

7

5

4

Ischemic heart disease

4

4

5

3

4

6

Lower respiratory infections

5

5

3

4

3

2

Diabetes

6

8

7

5

6

7

COPD

7

6

8

6

7

13

Diarrheal diseases

8

7

6

9

8

5

Hypertensive heart disease

9

9

9

8

9

12

Self–harm

10

10

11

19

10

15

Asthma

11

17

12

12

12

18

Road injuries

12

11

13

13

11

10

Cardiomyopathy

13

15

18

15

16

24

Chronic kidney disease

14

16

14

10

14

8

Other cardiovascular

15

26

16

17

17

16

Endo/metab/blood/immune

16

13

17

22

15

48

Alzheimer’ disease

17

12

22

14

20

14

Interpersonal violence

18

18

10

11

13

27

Malaria

19

25

93

27

19

Adverse medical treatment

20

14

28

29

25

49

Epilepsy

21

32

25

28

24

40

Falls

22

28

34

39

33

17

Other neonatal

23

22

19

24

28

67

Preterm birth complications

24

23

15

27

22

21

Cirrhosis due to alcohol

25

35

37

33

19

34

Note: COPD = chronic obstructive pulmonary disease Endo = endocrine Urog = urogenital

35

Figure 23 Probability of death in Namibia and comparison countries, males and females, 0-14 years, 2013 Males

Females Germany Italy France United Kingdom Canada United States Saudi Arabia Argentina Mexico Turkey Brazil Botswana Namibia South Africa India Zimbabwe Swaziland Lesotho

12%

10%

8%

6%

4%

2%

0%

0%

2%

Probability of death

4%

6%

8%

10%

12%

Probability of death

Note:

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

LRI = lower respiratory infections

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deďŹ ciencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

NTDs = neglected tropical diseases urog = urogenital diseases endo = endocrinological disorders

Another way to evaluate Namibia’s health progress is to compare the probability of death by broad age groups to countries around the world.

Figure 23 provides the risk of dying for males and females aged 0 to 14 years. Namibian children have the second-lowest probability of dying in the region (4% for females, 5% for males), behind Botswana.

For Namibians aged 15-49, the probability of dying is the lowest in the region for females, and the third lowest for males (behind Botswana and South Africa; see Figure 24).

36

Namibia: State of the Nation’s Health

Figure 24 Probability of death in Namibia and comparison countries, males and females, 15-49 years, 2013 Males

Females Italy Germany United Kingdom Canada France Saudi Arabia United States Turkey Argentina Mexico Brazil India Namibia Botswana South Africa Zimbabwe Swaziland Lesotho

60%

50%

40%

30%

20%

10%

0%

0%

10%

Probability of death

20%

30%

40%

50%

60%

Probability of death

Note:

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

LRI = lower respiratory infections

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deďŹ ciencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

NTDs = neglected tropical diseases urog = urogenital diseases endo = endocrinological disorders

Comparing Namibia to its peers

37

38

Namibia: State of the Nation’s Health

Conclusion Namibia has gone through two distinct health-related phases. The first phase, from 1990 to 2004, was characterized by rising cases and deaths due to HIV/AIDS, which caused life expectancy to decrease dramatically from 1990 levels. However, in phase 2, from 2004 to 2013, new cases of HIV/AIDS had more than halved from the peak, as had deaths from HIV/ AIDS. Life expectancy rebounded, though in 2013 it remained below 1990 levels. Despite this, in 2013 HIV/AIDS was still the leading cause of death, and among ages 40-44 kills almost half of all males and females. Continued investment in the tremendous public health efforts on prevention and treatment that led to the decrease in HIV/AIDS in phase 2 is critical.

There has been significant progress in addressing other infectious diseases, such as diarrheal disease, lower respiratory infections, and malaria. However, Namibia faces many challenges, including the rising importance of non-communicable diseases and injuries. Cardiovascular diseases, such as ischemic heart disease and stroke, are increasingly contributing to health loss in the Namibian population, particularly among older adults. Injuries are a leading cause of death among adolescents and young adults, with males much more affected than females. This is partly due to the higher levels of risk behavior in males, particularly alcohol and drug use, that are linked to injuries.

Measures aimed at mitigating alcohol and drug use, as well as other risks, including unsafe sex, high blood sugar, and high body mass index, will play a key role in reducing deaths in Namibia. Considering the increasing significance of NCDs and injuries in Namibia, investment in preventative measures targeting the important modifiable risk factors presents an attractive investment case for decision-makers.

Despite the advanced statistical methods used in GBD, a lack of available data2 for Namibia tempers the conclusions that can be drawn. GBD 2013 includes an estimate of uncertainty for each result. Uncertainty stems from many factors, but one factor is the most important: the underlying data. If there are few data, the estimates are based on information from other countries in the region, as well as covariates. Reducing uncertainty is of great importance, as it allows greater confidence in results and gives policymakers and other health decision-makers greater confidence in allocating resources and making decisions. One way to easily reduce uncertainty is to strengthen the underlying data, utilize all available data, or collect more data. IHME is committed to collaborate with all health system stakeholders to provide timely and detailed information on burden of disease for decision-making. A collaboration between IHME and stakeholders in Namibia can help to ensure that future updates of the Global Burden of Disease reflect all available evidence, and new evidence as it becomes available.

Namibia has made significant progress tackling HIV/ AIDS and reducing deaths from communicable diseases like diarrhea and malaria. New challenges, like the rise of NCDs, and existing challenges, like the disproportionate burden of injuries among young men, remain.

A list of citations to data sources used for GBD 2013 Namibia is available at http://ghdx.healthdata.org/gbd-2013-data-citations?components=-1&locations=195&causes=294&risks=169&impairments=191 2

39

Annexes Annex Figure 1 Change in life expectancy for both sexes by broad cause group, southern sub-Saharan Africa, 1990 – 2013

Lesotho

Swaziland

Zimbabwe

South Africa

Namibia

Botswana

50

55

60

65

70

Years

1990

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

2013

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

LRI = lower respiratory infections

Neonatal disorders

Digestive diseases

Unintentional injuries

NTDs = neglected tropical diseases

Nutritional deďŹ ciencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

Note:

urog = urogenital diseases endo = endocrinological disorders

41

Annex Figure 2 Change in life expectancy at birth, both sexes, Namibia, 1990–2013

Namibia: New causes contributed to change in life expectancy Change in life expectancy

Decreased life expectancy causes

Years lost

Years gained

Increased life expectancy causes

1990

62 years

-3.6

HIV/AIDS & tuberculosis

+1.6

Diarrhea/LRI/other

2013

61 years

-0.3

Intentional injuries

+0.5

Neonatal disorders

-0.2

Diabetes/urog/blood/endo

+0.2

Nutritional deficiencies

-0.1

Transport injuries

+0.1

NTDs & malaria

-0.1

Mental & substance use disorders

+0.1

Other group I

+0.1

Maternal disorders

+0.1

Chronic respiratory

-1.7 change

Note: LRI = lower respiratory infections

4.4 total years lost

NTDs = neglected tropical diseases urog = urogenital diseases endo = endocrinological disorders

2.7 total years gained

Namibia 50

55

Years

60

65

70

Annex Figure 3 Percent of total deaths from diarrheal diseases, lower respiratory infections, and other infectious diseases broken down by component, by age group, Namibia, 2013

Diarrheal diseases

50%

Intestinal infectious diseases Lower respiratory infections 40%

Otitis media Meningitis Encephalitis Diphtheria Whooping cough Tetanus Measles Varicella

Percent of total deaths

Upper respiratory infections

30%

20%

10%

y –3 64 s 1– da 4 ys ye 5– ars 9 10 yea rs –1 4 15 ye –1 ars 9 20 ye –2 ars 4 25 ye –2 ars 9 30 ye –3 ars 4 35 ye –3 ars 9 40 ye –4 ars 4 45 ye –4 ars 9 50 ye –5 ars 4 55 ye –5 ars 9 60 ye –6 ars 4 65 ye –6 ars 9 70 ye –7 ars 4 75 ye –7 ars 9 80 yea + rs ye ar s

da

28

27

0–

42

7–

6

da

ys

0%

Namibia: State of the Nation’s Health

Annex Figure 4 Percent of total deaths from diarrheal diseases, lower respiratory infections, and other infectious diseases broken down by component, Namibia, 1990–2013 Diarrheal diseases

25%

Intestinal infectious diseases Lower respiratory infections Upper respiratory infections

20%

Percent of total deaths

Otitis media Meningitis Encephalitis Diphtheria Whooping cough Tetanus Measles Varicella

15%

10%

5%

0% 1990

1995

2000

2005

2010

2013

Annex Figure 5 Numbers of deaths from diarrheal diseases, lower respiratory infections, and other infectious diseases broken down by component, Namibia, 1990–2013 Diarrheal diseases Intestinal infectious diseases Lower respiratory infections

3

Otitis media Meningitis Encephalitis Diphtheria Whooping cough Tetanus Measles Varicella

Deaths in thousands

Upper respiratory infections

2

1

0 1990

1995

2000

2005

2010

2013

Annexes

43

Annex Figure 6 Percent of total deaths due to cardiovascular diseases by age group, both sexes and all ages, Namibia, 2013 Rheumatic heart disease

40%

Ischemic heart disease Hypertensive heart disease Cardiomyopathy Atrial fibrillation Aortic aneurysm Peripheral vascular disease Endocarditis Other cardiovascular

Percent of total deaths

Cerebrovascular disease 30%

20%

10%

y 64 s 1– da 4 ys ye 5– ars 9 10 yea rs –1 4 15 ye –1 ars 9 20 ye –2 ars 4 25 ye –2 ars 9 30 ye –3 ars 4 35 ye –3 ars 9 40 ye –4 ars 4 45 ye –4 ars 9 50 ye –5 ars 4 55 ye –5 ars 9 60 ye –6 ars 4 65 ye –6 ars 9 70 ye –7 ars 4 75 ye –7 ars 9 80 yea + rs ye ar s

da

28

–3

27

0–

7–

6

da

ys

0%

Annex Figure 7 Percent of total disability (YLDs) due to components of nutritional deficiencies by age group, both sexes, Namibia, 2013

Protein-energy malnutrition

50%

Iodine deficiency Vitamin A deficiency

Percent of total YLDs

40%

Iron-deficiency anemia Other nutritional

30%

20%

10%

44

ys ye ar s 5– 9 ye ar 10 s –1 4 ye ar 15 s –1 9 ye ar 20 s –2 4 ye ar 25 s –2 9 ye ar 30 s –3 4 ye ar 35 s –3 9 ye ar 40 s –4 4 ye ar 45 s –4 9 ye ar 50 s –5 4 ye ar 55 s –5 9 ye ar 60 s –6 4 ye ar 65 s –6 9 ye ar 70 s –7 4 ye ar 75 s –7 9 ye 80 ars + ye ar s

da

4

1–

da ys

27

36 4 28 –

7–

0–

6

da ys

0%

Namibia: State of the Nation’s Health

Annex Figure 8 Percent of total disability (YLDs) due to components of musculoskeletal disorders by age group, both sexes, Namibia, 2013

Rheumatoid arthritis

25%

Percent of total YLDs

Osteoarthritis Low back & neck pain Gout Other musculoskeletal

20% 15% 10% 5%

1– da 4 ys ye 5– ars 9 10 yea rs –1 4 15 ye –1 ars 9 20 ye –2 ars 4 25 ye –2 ars 9 30 ye –3 ars 4 35 ye –3 ars 9 40 ye –4 ars 4 45 ye –4 ars 9 50 ye –5 ars 4 55 ye –5 ars 9 60 ye –6 ars 4 65 ye –6 ars 9 70 ye –7 ars 4 75 ye –7 ars 9 80 yea + rs ye ar s

ys –3

64

da 28

6 0–

7–

27

da

ys

0%

Annex Figure 9 Percentage breakdown of total disease burden (DALYs) by age group, both sexes, Namibia, 2013 100%

Percent of total DALYs

80%

60%

40%

20%

da ys ye ar s 5– 9 ye ar 10 s –1 4 ye ar 15 s –1 9 ye ar 20 s –2 4 ye ar 25 s –2 9 ye ar 30 s –3 4 ye ar 35 s –3 9 ye ar 40 s –4 4 ye ar 45 s –4 9 ye ar 50 s –5 4 ye ar 55 s –5 9 ye ar 60 s –6 4 ye ar 65 s –6 9 ye ar 70 s –7 4 ye ar 75 s –7 9 ye 80 ars + ye ar s 4

1–

ys

64

da 28 –3

7– 27

0– 6

da

ys

0%

Note:

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

LRI = lower respiratory infections

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deficiencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

NTDs = neglected tropical diseases urog = urogenital diseases endo = endocrinological disorders

Annexes

45

Annex Figure 10 Number of smokers for males and females, all ages, Namibia, 1980–2013. Shaded areas indicate uncertainty.

Male

Female

Number of smokers in thousands

150

100

50

1980

1990

2000

2010

Annex Figure 11 Prevalence of smokers for males and females, all ages, Namibia, 1980–2013. Shaded areas indicate uncertainty.

Male

Female

Prevalence of smoking

30%

20%

10%

0% 1980

46

1990

Namibia: State of the Nation’s Health

2000

2010

Annex Figure 12 Percent of total deaths attributable to risk factors in children under 5, both sexes, Namibia, 2013

Malnutrition WaSH Air pollution Unsafe sex Alcohol & drug use Tobacco Low glomerular ďŹ ltration High fasting plasma glucose High blood pressure Sexual abuse & violence 0%

5%

10%

15%

20%

Percent of total deaths Note: WaSH = Water, sanitation, and handwashing LRI = lower respiratory infections NTDs = neglected tropical diseases urog = urogenital diseases endo = endocrinological disorders

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deďŹ ciencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, neonatal, and nutritional disorders

Mental & substance use disorders

War & disaster

Annexes

47

Annex Figure 13 Percent of total deaths attributable to risk factors in adolescents and adults, both sexes, ages 15 to 49 years, Namibia, 2013 Unsafe sex Alcohol & drug use High fasting plasma glucose Sexual abuse & violence High blood pressure WaSH Dietary risks Tobacco High body mass index Air pollution Low glomerular filtration High total cholesterol Occupational risks Low physical activity Malnutrition Other environmental Low bone mineral density 0%

10%

20%

30%

Percent of total deaths Note: WaSH = Water, sanitation, and handwashing LRI = lower respiratory infections NTDs = neglected tropical diseases urog = urogenital diseases endo = endocrinological disorders

48

HIV/AIDS & tuberculosis

Cancers

Diabetes/urog/blood/endo

Diarrhea/LRI/other

Cardiovascular diseases

Musculoskeletal disorders

NTDs & malaria

Chronic respiratory diseases

Other non-communicable

Maternal disorders

Cirrhosis

Transport injuries

Neonatal disorders

Digestive diseases

Unintentional injuries

Nutritional deficiencies

Neurological disorders

Self-harm & violence

Other communicable, maternal, newborn, and nutritional disorders

Mental & substance use disorders

War & disaster

Namibia: State of the Nation’s Health

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