Voices Inspiring Change: the pioneer Josephine Angula

Namibia

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Voices Inspiring Change, an initiative of the African Collaborative for Health Financing Solutions (ACS) project, amplifies the voices, needs and perspectives of diverse and underrepresented members of society in sub-Saharan Africa through contextualized storytelling. It aims to fill a persistent gap by engaging and highlighting voices outside the typical stakeholder groups like policy makers, donors, partners, and technical advisers. It seeks to amplify the stories and knowledge of the full range of stakeholders who have a stake in how the universal health coverage (UHC) agenda is shaped and carried forward in their
country.

Voices Inspiring Change calls attention to the responsibility of decision-makers to listen to and include critical voices in policy discussions that support their country’s movement towards UHC. Policies are more equitable, responsive, and effective when they are inclusive of the voices they are intended to benefit.

Josephine Angula is short, with short hair, a crisp nurse uniform, and a round, friendly face, with freckles on her nose. She meets us in the lobby of Betesda Medical Centre, shakes hands firmly, and ushers us through the clinic, which, at 8:30 a.m., is already humming with patients.

Josephine is the owner and head nurse at Betesda Medical Centre. A trailblazer, her clinic was the first private medical center to be owned and run by a black nurse in Namibia.

“Unfortunately, I was the first one,” she says with a wry smile.

Josephine trained at Oshakati State Hospital in the north, received a Bachelor’s degree in nursing, helped to open a nursing division of the University of Namibia’s Onandjokwe campus, and worked in Windhoek at the private MediClinic, before getting the idea of starting her own private practice.

“I never knew that a nurse could operate on a private basis. I thought only doctors could operate as private medical practitioners. While I was at MediClinic, I came into contact with the Association of Private Nurses. I approached them and asked them to describe the type of degree I would need, and I started to think about the lack of health services among my community here in Katutura.”

I never knew that a nurse could operate as private medical practitioners."
-Josephine Angula

Katutura, where Betesda Medical Centre is located, is a township in northwest Windhoek. During the apartheid era, black Namibians were forcibly relocated to the area, which resulted in years of opposition. In fact, the name Katutura means “the place where people do not want to live” in Herero.[1]

Today, Katutura is home to around 60 percent of the population of Windhoek[2] and though it is vibrant and bustling, with street sellers, banks, churches, football pitches, and shopping centers, it remains one of the poorest neighborhoods in the city.

The majority of private health facilities in Namibia are located in urban areas, and financed through medical aid funds (i.e., private insurance), which cover a very limited portion of the population. The vast majority of Namibians—more than 80 percent—rely on the public health system, or pay out of pocket for services at private clinics.

When Josephine opened her clinic in 2002, there was only one consultation room and two staff. Things have changed dramatically: there are now 25 staff, including one full-time doctor and four registered nurses, and they are open seven days a week. The facility includes multiple consultation rooms, an emergency room, in-patient facilities, and X-ray and dental capabilities. They see approximately 60-80 patients a day, many of whom are on new low-cost medical aid plans, which medical aid funds have introduced in an attempt to increase market share.

In addition to the wide array of services Josephine’s clinic provides, she also recognizes the value of forming partnerships to ensure services are widely accessible in her community. Through local partnerships, she has performed voluntary medical male circumcision as part of HIV prevention and also administered pre-exposure prophylaxis, a medicine taken daily by individuals at risk of HIV,[3] to key populations.

Photo credit: Josephine Angula
"It’s not easy for the people to pay for their medical services, no matter whether they have medical aid or not. There is a deep need to research and analyze the economic status of Namibian citizens to understand the range they can afford."
-Josephine Angula

Josephine has a wide window into the health challenges her community faces. Chief among her concerns is the financial hardship patients face when trying to access healthcare services—even those who have medical aid, which approximately 98 percent of her patients do.

“It’s not easy for the people to pay for their medical services, no matter whether they have medical aid or not,” says Josephine. “There is a deep need to research and analyze the economic status of Namibian citizens to understand the range they can afford. The system does not benefit poor people.”

One consequence of unaffordability is that many of her patients receive health care in both sectors. She worries about continuity and quality of care in health facilities; the focus on curative care; and demotivated health workers: “The health team members, particularly the nurses at facilities, are so demoralized, they are so frustrated,” she says.

"I have learned that some illnesses, some challenges, are outside my ability to solve- they require bigger changes in the system. But still I stand firm."
Josephine Angula

She also bemoans the dearth of mental health services: “We don’t have the knowledge or skills to handle these cases. And at the state hospitals, there is no first step, there is only the curative step: the psychiatric hospital. We have to come up with a health system that incorporates mental health, and the first step is primary health care.”

Only 11 percent of total government health expenditure is spent on provision of primary health services. Seventy-one percent is spent on secondary and tertiary care. [4]

“Primary healthcare is the first step when it comes to services. Currently, a lot of money is pumped into healthcare, but it doesn’t solve the problems of the people. It’s much better to promote and prevent.”

As policymakers and technical experts in Windhoek create strategies to improve the quality of health services and pave the way for universal health coverage, she hopes that healthcare professionals will be instrumental in those conversations: “I feel that we who are interacting with the patients should be included in conversations about health system reform and universal health coverage. People who are with patients at the bedside need to be included in defining the problems and potential solutions.”

As our interview draws to a close, Josephine gives us a tour of the facility, and introduces us to her team. After 35 years of nursing, she remains optimistic. “I think the time is right to make changes.”

She’s also determined to do more. “I still suffer from sleepless nights,” she says. “My big dream is to open a free-standing health facility here in Katutura for the middle group of patients- something between the private and public facilities. I have experienced the financial hardship of the people —I want to be able to render quality care for the people without it costing what it currently does in private hospitals.”

In the meantime, Josephine continues to serve her patients each day—helping them to tackle their socio-economic problems when she can, and working outside the clinic to fight for a better health system.

hospital beds inside a hospital
Photo credit: Katherine Matus
"I feel that we who are interacting with the patients should be included in conversations about health system reform and universal health coverage. People who are with patients at the bedside need to be included in defining the problems and potential solutions."
Josephine Angula

“The nursing profession has made me strong. When I first established the clinic, I thought I was going to solve all the health problems of my patients. I have learned that some illnesses, some challenges, are outside my ability to solve—they require bigger changes in the system. But still I stand firm.”

 

This story was written by Lindsay Morgan based on an interview conducted by Lindsay Morgan; Iyaloo Ngodji (Synergos), and Katherine Matus (R4D).