Namibia is recognized as one of the few African nations to reach continental health targets outlined in the Abuja Declaration, allocating at least 15% of its national budget to health.

Despite that progress, the country is struggling with its rollout of the human papillomavirus vaccine, which was set to begin in April.

Over the years, Namibia’s government has dedicated a sizeable portion of its budget to health and social services, with the proportion increasing over the years. This has not, however, always translated into improved health delivery, as seen in the delayed rollout of vaccinations for human papillomavirus, or HPV, which causes an estimated 90% of cervical cancers in women.

On Wednesday, Namibia’s minister of health and social services Kalumbi Shangula told VOA the country is on track with the mass immunization of adolescent girls and is simply figuring out the logistics. But he also highlighted Namibia’s upper-middle income classification by the World Economic Forum as a barrier to health funding in the country.

“We are convinced that the basis for ranking is not sound because you use the denominator as the population,” said Shangula. “You know the population in Namibia is small. The smaller the denominator, the higher the product, but we have many countries — maybe even those ones with 50 million who are in a similar situation like Namibia — but they are ranked as least developed countries.”

Last month, Namibia’s cabinet charged Peya Mushelenga, minister of international relations and cooperation, with lobbying other middle-income countries at forums such as the World Bank and United Nations “to put direct pressure on Bretton Woods Institutions to adopt the United Nations Development Program Multi-Dimensional Poverty Index as a more accurate determinant of a country’s development status.”

The government believes the lower ranking is a more accurate indication of the country’s development profile and will help it obtain loans and grants to aid its development programs.

“We have high unemployment rate, rapid urbanization and so forth,” Mushelenga said.

Some critics have refuted the idea of middle-income status as a barrier to delivering health care by pointing out how local middlemen known as “tenderpreneurs” have become instant millionaires through government procurement of essential health services and products, which does not translate to health care gains for the public.

Wade Henckert, a political scientist and lecturer at a local university, said Namibia’s upper-middle-income status has the advantage of giving Namibia access to international capital financial markets and potential foreign direct investment, which is good for development.

“The delay in rolling out the HPV vaccine in Namibia continues to highlight the challenges the country faces in procuring vaccines and also providing essential health care services,” said Henckert. “While a downgrade in ranking may potentially make Namibia eligible for grants from organizations like GAVI, it is essential to consider that the broader implications of such a decision could also deter investor confidence in the country.”

Henckert said tenderpreneurship, while widespread in Africa, is exploited to an unusual degree in Namibia because of loopholes in procurement that make it lucrative for opportunistic businesspeople to take advantage of Namibia’s health care procurement system.

Macroeconomic factors such as the reported slowdown in production by one of the leaders in HPV vaccine producers, Merck, could be a variable hurting Namibia’s rollout of HPV vaccines, although VOA could not independently verify this.