Government’s Programme of Action to 2018 includes its intention to extend the rollout of HIV therapy by up to 50 percent, to expand health facilities and to improve service-delivery yet further. Finance Minister Martin Dlamini said in his 2014/15 Budget Speech that despite the budget allocation to the Ministry of Health having doubled since 2007/08, even more resources are demanded by the challenges that persist.
Minister Dlamini listed these challenges as including a high rate of HIV, a high incidence of TB, a low life-expectancy and inadequate health facilities and personnel. He pointed out that the most recent health statistics show only 1 619 hospital and health-centre beds in the country, and that 85 percent of the population lives within a radius of eight km from a healthcare facility. With this sector continuing to be a government priority, Minister Dlamini said, the figures demonstrate that a lot more needs to be done to ensure that all Swazis - and most especially the labour force - are healthy. He disclosed that the Ministry of Health had developed a strategic plan to guide efforts aimed at the elimination of the challenges that face the nation, and detailed the actions that would be prioritised during 2014/15:
- To prolong the life of people living with HIV, the CD4 Count threshold for commencing treatment will be increased from 350 to 500. The drugs budget was increased to over E300-million to provide for this and other essential medicines.
- Complete the construction of a hospital for TB patients, buy equipment and construct institutional housing for TB healthcare providers. E28-million was provided for this purpose and the initiative is expected to improve the TB treatment success-rate from 73 percent in early 2014 to 85 percent by end-2014/15 financial year.
- Bring to operation the outpatient facility of Lubombo Regional Hospital: E25-million was provided for this endeavour.
- Construct a Filter Clinic in Mbabane to reduce congestion in Mbabane Government Hospital: E30-million was allocated towards both building the clinic and carrying out rehabilitation work at Mbabane Government Hospital. The overall objective is to reduce the number of referrals to South Africa.
- Enhance support to hospitals that receive subvention, in particular Raleigh Fitkin Memorial and Good Shepherd, primarily to ensure that they are able to retain healthcare personnel: E217-million was jointly allocated to the two hospitals mentioned for 2014/15.
- Ensure efficient implementation of the HIV/AIDS Project funded by the World Bank and European Union and which entails the construction and rehabilitation of all maternity and neonatal units in hospitals, health centres and training centres, as well as the strengthening of health systems and capacity building. In 2014/15 the project will, in addition, provide transport services to expecting women who live far from health centres, to enable them to deliver in a safe and secure environment. E5-million was provided in 2014/15 as counterpart funding to this project.
- Bring to operation the Renal and ICU Unit at the Mbabane Clinic. Government allocated E30-million towards this project for 2014/15.
The Plan to 2019
Making concrete its aspirations as enshrined in the Programme of Action to 2018, 10 April 2014 saw government through the National Emergency Response Council on HIV and AIDS (NERCHA) unveil a multi-sector, evidence-informed HIV/AIDS plan for the next five years. Called the Extended National Strategic Framework (eNSF) on HIV and AIDS, the initiative was officially launched by Prime Minister Sibusiso Dlamini during an occasion attended by Swazi Cabinet Ministers and NGOs alongside representatives of the UN Resident Coordinator and Swaziland’s international partners in the war against HIV/AIDS and TB. The PM’s keynote address covered the history of Swaziland’s battle with the pandemic, the current state of affairs and what the eNSF aims to achieve.
He said that even though government has in the 28 years since Swaziland saw its first case of HIV rolled out antiretroviral treatment to more than 100 000 people and taken on the responsibility of purchasing antiretroviral medication, reduced the transmission of HIV from mother to child to a tiny proportion of the figure ten years ago and reversed the HIV Prevalence Rate’s upward trend in the 15 - 24 age group, a massive and continuing challenge remains. Apart from 20 percent of the population living with HIV and potentially facing a lifelong dependence on medication and monitoring, PM Dlamini said, the incidence of new infections is too high and demands a new approach to achieving the resounding results that can only come from preventing infection in the first place. Quoting His Majesty King Mswati III who in his Speech from the Throne two months earlier had challenged the nation and those working in the HIV/AIDS arena to work hard towards creating an AIDS-free generation, the PM said that such is government’s goal as it launches the next stage in Swaziland’s national strategy to 2019.
The eNSF begins by taking stock of the shortcomings that currently stand in the way of achieving an AIDS-free generation: these include low and inconsistent condom use, gender-based violence, multiple concurrent sexual partners and a low level of male circumcision. The strategy’s target is a reduction of 50 percent in the rate of new infections among adults and the elimination of new infections among children. Deaths among those with HIV and the adverse socioeconomic impacts on the particularly vulnerable groups are to be reduced. The eNSF also aims to see improved efficiency and effectiveness, where needed, in national response planning, coordination and service delivery. Earlier HIV testing and counselling, higher intensity of social-/behavioural-change interventions and provision of additional condom-access sites are called for, alongside the further promotion of voluntary medical male circumcision and the prioritisation of the test-and-treat option for HIV-positive mothers, HIV-positive children under 14 years, people with TB/HIV co-infection and those with HIV/AIDS and hepatitis.
Prime Minister Dlamini concluded his keynote address by reiterating the country’s indebtedness to the United Nations and the United States government through the Global Fund and the President’s Emergency Plan for AIDS Relief, respectively. He pointed out that the Global Fund had recently committed a further US$ 80-million to Swaziland’s fight against HIV/AIDS, TB and malaria, and called on all concerned in the battle to work together to meet the requirements of the funding and ensure that the resources are spent to maximum effectiveness.
Speaking on behalf of the UN Resident Coordinator, Israel Dessalegne, World Health Organization (WHO) In-country Representative, Dr Owen Kaluwa, noted that NERCHA, when drawing-up the eNSF, took into consideration the flat-lining of resources. He commended NERCHA for managing to prioritise and find ways by which the national response could be effectively and efficiently managed, and said he was pleased to recognise that the government of Swaziland had already taken strides to increase its own domestic funding as part of the African Union roadmap as agreed to by member states.
This, said the Coordinator, will become critical as the world moves into the post-2015 Millennium Development Goals agenda and countries will be called upon to take ownership of their HIV response. With Swaziland now facing the task of making the eNSF operational and achieving its targets, Dessalegne said that as the country moved in the same spirit in which the document was developed - through broad stakeholder consultations - it was his hope that its implementation would see everyone continue working together. He concluded his address by saying that the UN was proud to be a partner in ensuring that collective support will see Swaziland achieve its eNSF targets.
Coordinator of the President’s Emergency Plan for AIDS Relief (PEPFAR), Lucille Bonaventure, speaking on behalf of the US Ambassador to Swaziland, Makila James, noted that as HIV-related challenges had evolved over the years, so should the response. She said that real success in combating HIV required evidence-based multi-interventions that were mutually reinforcing, multi-sector and which addressed behavioural, social and cultural norms that drove the epidemic and disproportionately impacted on young women and girls. The latter’s identification in the eNSF as the population group most at risk of new infections was encouraging, Bonaventure said, and as part of the response there was a need to address gender-based-violence (GBV) which was known as a clear link to the incidence and spread of HIV, adding that ending GBV was a major priority for the US government.
She described PEPFAR as the largest effort by any nation ever to combat a single disease, and said that the US government is proud of what it has been able to accomplish in partnership with the government of Swaziland. The Coordinator emphasised PEPFAR’s commitment to supporting the priorities as defined in the eNSF towards the common goal of an AIDS-free generation, saying that the kingdom’s new plan is also the PEPFAR plan, and will be a critical document to guide PEPFAR, other stakeholders and the government of Swaziland in assuring appropriate implementation of an optimal combination of HIV/AIDS prevention, care and treatment interventions. According to Bonaventure, when considering that 42 percent of pregnant Swazi women are HIV-positive, and that most are acquiring the disease while in their early 20s, it was clear that all stakeholders need to acquire a better understanding of the epidemic and use what they know to inform and guide strategies and priorities.
Ten weeks after the eNSF launch, PEPFAR announced a revamp of its HIV-prevention approach to accommodate priority groups that include female sex workers. Locally, this was conveyed at NERCHA headquarters by the overseer of PEPFAR Swaziland Prevention Programmes, Wendy Benzerga, who said that the alterations followed an instruction from the Office of the US Global AIDS Coordinator. While the former prevention approach operated from a ‘one size fits all’ perspective, she explained that there is now a focus on reaching priority groups outlined in the eNSF, such as female sex workers, adolescent boys and young men. PEPFAR’s new requirements were said to respond to epidemiology, demographics and context, resulting in a more strategic, targeted approach with correspondingly-tailored prevention packages.
The Swaziland HIV Incidence Measuring Survey reportedly provided some of this contextual information and epidemiological data: it revealed that the rate at which infection is spreading is highest among females aged 18-19 and 20-24 (3.84 and 4.17 percent, respectively). According to PEPFAR’s Benzerga, the tailored approach aligns with core eNSF programmes that will strive to achieve a reduction in incidence and which are included in PEPFAR’s stipulated ‘minimum package’ that priority populations will receive. She listed its components as:
- Targeted risk-assessment
- Education and counselling
- Condom promotion and skills training
- Informative sessions on HIV Testing and Counselling (HTC), with referral to HTC services
- Creating demand for relevant clinical services such as Voluntary Medical Male Circumcision
- Activities that serve to combat gender-based violence
THE WAR ON TB
Late June 2014 saw the kingdom’s National TB Programme Manager, Themba Dlamini, unveil a five-year plan to substantially reduce the prevalence of TB by 2019. Specifically, the objectives are to:
- Reduce the number of new TB cases by 25 percent
- Detect and enrol 40 000 TB cases cumulatively on treatment
- Achieve and maintain at least 85 percent treatment success rate among all detected TB cases
- Halve the mortality rate among TB and HIV co-infected patients from its current 10 percent
- Reduce MDR-TB prevalence among new TB cases from 7.7 to five percent
- Strengthen national TB-response management capacity to effectively coordinate and evaluate TB prevention, treatment and care interventions
Representing the Minister of Heath at the announcement was Director of Health, Dr Vusi Magagula, who elaborated on the efforts and commitment to fight TB in Swaziland. He began his address with a reminder that government had declared TB a National Emergency on 24 March 2011: he then described the current status of TB in the country as dire and continuing to be a major public health problem. Director Magagula listed the highlights of government’s response to the epidemic as:
- Implementation of the Directly Observed Treatment Short Course
- Decentralisation of TB services
- Integration of TB and HIV services to provide citizens with ‘One-Stop’ care
He went on to say that the Ministry had put in place the strategies necessary to diagnose, monitor and treat all TB patients in the country and to provide them with treatment, free of charge. Dr Magagula said that the Ministry deemed it important to decentralise TB healthcare facilities to ensure that services are available to all, and that a need was identified to launch a robust response to the epidemic through capacity building among healthcare workers, to decentralise TB services yet further and to integrate TB and HIV services fully. He pointed out that decentralisation cannot be expertly implemented without the proper training of healthcare workers to manage patients throughout their treatment process until they are cured.
Second-quarter 2014 saw Prime Minister Dlamini officially convey government’s gratitude to Medecins Sans Frontieres (MSF/Doctors Without Borders) for its dedication to the Swazi nation’s wellbeing. Speaking at an event held to analyse the successful outcomes of MSF’s five-year project to increase access to decentralised HIV/TB treatment and care in the Shiselweni region, the PM said that MSF had first arrived in Swaziland just when the country was at the peak of the HIV/TB response and needed innovative strategies plus additional resources to turn around the dual pandemic. He said as a country with a high HIV- and TB-prevalence, and with a large proportion of the HIV infected and affected people living in the rural areas, it was reassuring to see MSF making community mobilisation one of its strategies.
Dlamini said it was important to recognise that success in reversing the pandemic could only be achieved when each and every individual in both rural and urban communities made prevention and treatment their responsibility. He said that the programme of encouraging communities to take full ownership of the HIV and TB response has helped to decrease stigma and increase acceptance of the HIV-positive population. The PM pointed out that decentralising ART and TB services to reach the remote areas of the Shiselweni region had fitted well with government’s strategy of bringing services closer to the people in rural areas and improving service quality. He noted that this broadened access has been directly linked to a steady improvement in treatment effectiveness over the five-year period: five years on, Dlamini revealed, all 22 local clinics in the Shiselweni region now offer integrated care and treatment to more than 17 000 HIV-positive patients and have already treated more than 10 500 TB patients.
Swaziland’s Minister of Health, Sibongile Ndlela-Simelane, announced in early July 2014 the development of a programme that will handle issues relating to cervical cancer under the Sexual Reproductive Health Unit (SRHU) and will lead to doctors and nurses being available throughout the country’s remote areas. Cervical cancer is the most prevalent reproductive cancer among Swazi women, the leading cause of cancer-related hospital admissions and, accordingly, the highest cause of morbidity and mortality related to cancers in women in the country. Because the primary underlying cause of cervical cancer is infection with the commonly found and sexually transmitted Human Papilloma Virus (HPV), the association of HPV with HIV has seen the age of onset of cervical cancer fall dramatically and the progression to advanced disease accelerate similarly.
Cervical cancer has a readily detectable and treatable precursor condition: in Swaziland the first screen-and-treat services began in 2010 at three hospitals - Mbabane government, Hlathikhulu government and Raleigh Fitkin Memorial (RFM) – where the services continue to be provided. In addition to the treatment of pre-cancer lesions through cryotherapy that is available at the three institutions, RFM offers the Loop Electrosurgical Excision Procedure (LEEP). According to the SRHU, Swaziland has adequate screening services as the ‘Pap Smear’ is available in all hospitals, health centres and public health units, while visual inspections using acetic acid can be performed in 23 facilities countrywide. The Ministry of Health, with support from the WHO, has reportedly embarked on developing a HPV Plan which thus far has led to the production of a feasibility report.
Health Minister Ndlela-Simelane noted that screening rates in the target population remain low and that much education is needed, on two counts: to see more women going for tests early and regularly and thereby reverse the current scenario wherein most cervical cancer cases are detected late, and to minimise the number of women who have screens but subsequently fail to follow up because they have to travel long distances to reach the next level of care. She said it was against this background that the Ministry, with support from its partners, is expanding service provision both geographically and services-wise. The latter will include availing LEEP countrywide and cryotherapy in all hospitals, health centres, public health units and high-volume clinics, towards achieving universal coverage of screen-and-treat. In November the Ministry received supporting equipment worth E500 000 from Sweden’s International Development Cooperation Agency via the United Nations Population Fund.
On the eve of Africa Vaccination Week 2014 (22–27 April), Swaziland’s Minister of Health announced the availability at all clinics nationwide of a new vaccine to immunise babies against pneumonia and meningitis. Pneumococcal Conjugate Vaccine (PCV 13) is intended for administering to infants at six, 10 and 14 weeks of age: the Minister noted that pneumonia is among the leading causes of childhood deaths in the country and mostly affected those below the age of two years. She declared that the extent of the burden of pneumonia in Swaziland necessitated the introduction of PCV 13 into the national immunisation schedule and that it will contribute significantly towards the kingdom’s striving to achieve Millennium Development Goal Number Four, as well as Swaziland’s post-2015 goals such as Vision 2022.
Ndlela-Simelane described the advent of PCV 13 as the dawning of new era, for if the country’s children are protected against vaccine-preventable diseases, then it has a future and the nation will achieve its aim of attaining First World status within the next seven years. She said that no economic and social development can take place in a country where immunisation lags behind, as immunisation enables every child to reach their full physical and intellectual potential. Referring to certain religious beliefs that forbid immunisation, the Minister declared that the presence of even one unvaccinated child in a community poses a serious public health threat to the entire community, and she was therefore appealing to all Swazis to work together to get every child vaccinated. The WHO donated four
refrigerators and specialised transportation containers to ensure the ongoing safety and effectiveness of the vaccines.
Yet another target was set during this review period - to eliminate malaria by 2015 and attain certification thereof by 2018. The Health Minister said when making the announcement that the heightened initiative followed Swaziland being one of the eight SADC countries identified for malaria-elimination. She described the latter status as a call to action which required all stakeholders not to be complacent, but to step up their efforts in responding to the disease. The Minister said that current achievements had shown it was possible to turn the tide, and she called for continued vigilance with regard to interventions against malaria.
The National Malaria Control Programme disclosed that 488 cases of the disease were reported during 2013/14 and that 99 percent of the investigated cases were found to be imported from Mozambique. Health Promotion Coordinator, Teclar Maphosa, said that the infected patients came from areas such as Nhambane, Tete and Sofalia. She reminded the public that Swaziland has bilateral anti-malaria programmes with both Mozambique and South Africa, advised citizens to take anti-malaria prophylaxis when travelling to high-risk areas and stressed the importance of checking for symptoms in order to receive early treatment.
The WHO used the occasion to call upon stakeholders ranging from local government to the agricultural and environmental-protection sectors to join in Swaziland’s final big push to eliminate malaria. In-country Representative, Dr Owen Kaluwa, said that the health sector alone could not prevent the proliferation of vectors (disease-transmitting insects) and the needless suffering and deaths that result, but if acting in concert with other authorities the kingdom could witness the end of vector-borne diseases such as malaria.
He pointed out that malaria is the most deadly vector-borne disease globally and claims an estimated 627 000 lives every year, most of which are of African children under the age of five. Dr Kaluwa noted that even though malaria continued to be a major problem in a number of countries, intensified malaria prevention and control measures in Swaziland have dramatically reduced the malaria burden. In addition to reiterating the prophylactic measures highlighted by other speakers, he called upon all people residing in malaria-risk areas in the Lubombo region to support government’s programme by giving spray-teams ready access to their homes.