His Budget Speech continued with the affirmation that significant investment has been made by government and development partners in the health sector during the COVID-19 response. Major investments were said to include:
• Repurposing of the National TB Hospital in Manzini
• Construction of oxygen plants at the Luke Commission and Lubombo Hospital
• Installation of bulk oxygen tanks at the Luke Commission and Raleigh Fitkin Memorial Hospital
• The building of a ward for COVID-19 at Lubombo Referral Hospital
Construction of Lubombo Referral Hospital began during 2002/3, but the initiative was mothballed soon thereafter, until recommencing in 2011. The facility became operational in October 2014, before encountering a series of challenges that in 2019 led to a recommendation that it be closed. Early 2020 then witnessed resuscitation efforts along with an E57-million capital projects budget allocation, which proved fortuitous: less than a week after the Prime Minister led a delegation to assess the preparedness of the hospital – which duly received the green light – the country confirmed its first case of COVID-19.
The factors that make Lubombo Referral Hospital ideal were said to include:
• Located away from the hustle and bustle of Mbabane and Manzini, and isolated enough not to pose any threat of further contamination
• Accommodates up to 200 patients in the worst-case scenario
• Dedicated ambulance-parking: two such vehicles have been reserved for the COVID-19 crisis
• Incoming patients will use one exclusive entrance point to the main building
• All wards/rooms have red bin-liners for incinerator-destined waste
• The Intensive Care Unit (ICU) includes four rooms, each with a maximum of four beds, and is complemented by an operating theatre
• Once stabilised, post-ICU patients are moved to another department
• Each department has a dedicated team of doctors, supervisors and nurses, this to ensure containment of the virus
Returning to the 2022/23 Budget Speech, Finance Minister Rijkenberg continued:
• Regional hospitals have improved their capacity to manage severely ill patients. This capacity will assist the country to manage other critically ill patients even post-COVID-19. The country has developed a surveillance system for COVID-19 and other illnesses in order to monitor and respond quickly should another outbreak occur in the future.
• Government is in the process of decentralising the treatment of Non-Communicable Diseases (NCD) such as diabetes, and which have been spread out among 116 of 239 primary health facilities. In addition, the associated medicines have been declassified so that they can be accessible at clinic level.
• Phase 1 construction at Mbabane Government Hospital has been completed, and Phase 2 will begin this new financial year.
• The repurposed Manzini Hospital with a focus on treatment of NCDs is near completion. The oncology unit will move in immediately, allowing government to expand chemotherapy treatment to nearly four times that which could be offered at Mbabane Government Hospital.
• In an effort to improve access to health services, the construction of six new clinics is under way.
• Following the high burden of Human Papilloma Virus (HPV) infection and cervical cancer cases in the country, government has budgeted E20-million and plans to introduce the HPV vaccine for schoolgirls aged 9–14 years.
Remuneration
The Finance Minister conceded that a persistent challenge over the last few years has been adequate and timely payment for medicines. He said that government has prioritised this issue since 2019, and the stock and supply of medicines has been improving steadily ever since: in particular, the clearance of arrears in this area has had a significant positive impact on the supply and pricing of medicines. Rijkenberg gave an assurance that government will continue to prioritise this sector and ensure that orders and payments are made on time, this to avoid gaps in the medicine supply. He added that an electronic Logistics Management Information System is being rolled out to enhance the efficiency, transparency and accountability of medicines supply and delivery. Yet further, government is exploring other avenues to enhance efficiency, including outsourcing the procurement and dispensing of medicines to the private sector.
HIV/AIDS
Minister Rijkenberg informed Parliament and the nation that HIV-prevalence in the kingdom now stands at 27 percent, with estimated new infections for the year declining to 3 300: he described the achievement as attributable to the country’s HIV-response initiatives. Eswatini has surpassed the 95-95-95 HIV/AIDS milestone, he declared, even though COVID-19 has posed a risk to hard-won gains made in previous years. Rijkenberg emphasised that government, alongside and its partners, has remained vigilant to the devising of various strategies to both maintain the milestones reached and keep all Emaswati in good health. He said that government continues to appreciate the support of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Geneva-registered Global Fund.
Big Helping Hand
The latter recently bestowed on Eswatini a US$54-million grant allocation for its fight against malaria, TB and HIV during the period ending 2024, significantly more than the allocation that began in 2018 and ended in 2020 for malaria and 2021 for both TB and HIV. Government said that the kingdom was highly indebted to the Global Fund for continuing to support its endeavours to build resilient and sustainable systems for health: the allocations were initiated in 2003, and with the latest disbursement exceed in total the equivalent of over E4.2-billion.
Government also continued to encourage the principal recipients of the grant to intensify their collaborations with all implementing partners in order to fast-track projects and processes on the ground, and thereby realise tangible benefits for the health sector, ensuring that the Sustainable Development Goal of healthcare for all was attained. It emphasised how intervention programmes that have benefited from the Global Fund over the years have brought Eswatini close to the elimination of malaria, decreased the incidence of TB and seen a reduction in new HIV infections. The Administration attributed the improved grant to “the vision, leadership and commitment demonstrated by His Majesty King Mswati III” in the country’s response against HIV, TB and malaria, pointing out that the monarch had made a pledge of US$6-million to the Global Fund during the Replenishment Summit held in France. The kingdom was “already seeing the fruits of HM’s vision, foresight and commitment to the fight against the three dread diseases and for overall universal health”, an official statement observed.
Also congratulated for working closely with government to attract this level of funding from the Global Fund over the years were the Country Coordinating Mechanism, Ministry of Health, National Emergency Response Council on HIV and AIDS (NERCHA) and in-country partners such as PEPFAR, the United States government, the United Nations (UN) and the European Union (EU). The Kingdom of Eswatini formally expressed its appreciation of the role played by development partners in supporting the HIV and AIDS response, as the intervention went a long way towards achieving measurable results and impacted on joint-response to Eswatini’s development needs: the country had made great progress in the war against HIV. PEPFAR, as a key partner, had over the years invested heavily in the HIV response and thus made a telling contribution towards the vision of ending AIDS.
Government asserted that Eswatini had already saved over 15 000 lives, prevented millions of HIV infections, and was moving towards controlling the global HIV/AIDS epidemic by 2022. It acknowledged the role that the UN has played through the implementation of the United Nations Development Assistance Framework, which is a programme that commenced in 2016 with a financial envelope of US$80-million to support the fast-tracking of Eswatini’s development objectives in collaboration with development partners, and working to deliver a harmonised response to HIV and AIDS. The statement concluded by emphasising the importance of giving an assurance that this framework – which runs until 2025 – is nationally-owned and anchored on national development priorities, the 2030 Agenda and the principles of the UN Charter.
HIV/AIDS Situation Report
As articulated in a media release issued by the National HIV and AIDS Information and Training Centre, Eswatini has set a target of ending AIDS eight years earlier than the global timeframe, this as part of His Majesty King Mswati III’s vision of ‘A First World Eswatini by 2022’. Recent evidence indicates that the country is on the right trajectory to reach this target:
• Swaziland (sic) HIV Incidence Measurement Survey (SHIMS) 2 reported that the massive scale-up of prevention interventions, HIV testing and treatment had slashed the rate of new infections (HIV Incidence) by 44 percent
• 94 percent of HIV-positive mothers receive HIV treatment to prevent transmission of the virus to their children during pregnancy and childbirth
• The country had also reduced AIDS-related deaths by more than 50 percent, with 70 percent of those living with HIV receiving antiretroviral treatment (ART), and retention of people on treatment after one-year standing at 93 percent – one of the highest retention rates in the world
• HIV incidence among adults aged 15 years and older was 1.36 percent – 1.70 percent among females and 1.02 percent among males. Among adults 18-49 years, HIV incidence was almost halved, to 1.39 percent
• The percentage of all HIV-positive adults with viral load suppression (VLS), an indication that the infection is under control, was 73.1 percent, with 76.0 among females and 67.6 percent among males. The VLS was estimated using all people living with HIV as a denominator, regardless of knowing their HIV status or use of antiretroviral drugs. Among all HIV-positive adults aged 18-49 years, twice as many (71.3 percent) were virally suppressed in SHIMS 2 as compared to SHIMS 1 (34.8 percent)
These results indicated that Eswatini had made substantial progress towards achieving all three of the 90-90-90 global targets set by the Joint United Nations Programme on HIV/AIDS (UN-AIDS).
The country is however still faced with major challenges, none more concerning than the fact that – even with the HIV prevalence stabilised at 27 percent in people aged 15-49 years – HIV prevalence remains high. National survey data shows that adolescent girls and young women (AGYW) face significantly greater risk of HIV than their male peers, with young women aged 20-24 years being five times more likely to be infected than young men of the same age – 20.9 percent compared to 4.2 percent. One in every five young women 20-24 years is HIV-positive, increasing to one in every three for women 25-30 years.
HIV Response to intensify efforts to address key populations’ issues:
• HIV prevalence among adolescents and young people is an indicator of new infections acquired rather than a survival effect of the treatment programme. Evidence also shows that most HIV infections in Eswatini are transmitted heterosexually, although risk factors vary.
• In AGYW, sex workers, men who have sex with men (MSM), people who inject drugs, transgender people and prisoners are disproportionately affected by HIV.
• Key populations are particularly vulnerable to HIV infection due to their high-risk sexual behaviour and higher internal and external stigma and discrimination, which constitutes a major barrier to their service uptake. HIV prevalence among female sex workers (FSW) is estimated at 60.5 percent, while prevalence among MSM is 12.6 percent.
• On the other hand, prevalence of syphilis among MSM was 1.2 percent, and 6.6 percent among FSW. Gender inequalities, differential access to services, and sexual violence, increase women’s vulnerability to HIV, especially younger women who are biologically more susceptible.
In responding to issues of these key affected populations, the country is intensifying efforts to address human rights and gender-related barriers to service access, and to ensure appropriate focus on interventions that respond to them. The response has taken a more location- and population-specific prevention approach, and aims to provide tailored and differentiating services for key and vulnerable populations in underserved and/or high-burden regions and Tinkhundla. This talks to a significantly enhanced focus on HIV prevention, including linkages to Sexual Reproductive Health and Gender Based Violence services, among adolescents and young people, especially highly vulnerable adolescent girls and young women. The success of this paradigm shift will however rely on all involved playing their part, starting with ensuring that each Liswati (in targeted key populations or not) recognises his/her HIV risks and accesses appropriate services to minimise their vulnerabilities or even completely remove them.
ROAD USERS’ FRIEND
Sincephetelo Motor Vehicle Accidents Fund (SMVAF) is the instrument by which government compensates road-accident victims who have suffered bodily injuries or loss of support following the death of breadwinners. Its mission further includes collaborating with stakeholders in the prevention of road-traffic accidents through implementing global best practices. As part of the means to achieve its vision of becoming the most effective, self-sustaining road-accident fund regionally, SMVAF regularly collaborates with its neighbouring peers as well as law-enforcement entities from within and beyond Eswatini’s borders. Locally, SMVAF is renowned for its high-visibility presence at events that attract thousands of Emaswati and visitors from abroad: in addition to awareness-raising stalls, Fund personnel offer free breathalyser-tests and even ‘designated-driver’ services to ferry tourists back to their lodgings.
SMVAF recently sponsored a ‘summit’ on behalf of the Road Safety Council and aimed at addressing the challenge of devising effective interventions in the face of ever-increasing fatalities and injuries on the region’s roads. The think-tank attracted a significant number of stakeholders from within Eswatini and beyond its borders, and was officially opened by the Minister of Public Works and Transport, who began by pointing out that annually, 1.3-million people die worldwide as the result of road accidents, which are now the leading cause of death among children and young adults aged 5 – 29. As most vehicular crashes are avoidable, he opined, it was unacceptable that they should threaten any country’s future.
Shifting focus to Eswatini, the Minister said it was time that private vehicles also be regularly subjected to stringent checks and inspections, and that a determination should soon be made on what interval would be best for mandatory roadworthy tests. The kingdom was nonetheless moving on the right track, he observed, as the diverse range of entities scheduled to deliver presentations – the World Health Organization plus local and regional law-enforcement agencies, traffic departments, emergency services, NGOs, insurance companies and even breweries – was in line with the African Road Safety Charter. The latter was adopted by the African Union Commission Assembly in 2016 and seeks to establish a policy framework for road safety improvement in each country and Africa as a whole, and thereby drastically reduce the number traffic accidents.
MALARIA
Finance Minister Rijkenberg in his 2022/23 Budget Speech said that the Administration wished to express appreciation to His Majesty for continued support of the national programme towards a malaria-free Eswatini. The Eswatini Malaria Elimination Fund is rooted in a launch by the King with a capital funding of E5-million: a Board to manage the Fund was subsequently established, followed by the Eswatini Malaria Elimination Scorecard. The resulting setup enables healthcare authorities to identify malaria hotspots with accuracy, and target them for complete eradication.
His Majesty King Mswati III was at the time of the Fund’s birth the Chairperson of the African Leaders Malaria Alliance, and he sought to mobilise resources to eliminate the disease in Eswatini, Southern African Development Community countries, and Africa as a whole. The King and President Macky Sall of Senegal had in 2019 initiated a continent-wide campaign known as ‘Zero Malaria Starts With Me’: endorsed by African Heads of State and Government, this ‘war against malaria’ promoted strong national ownership of anti-malaria initiatives across all sectors and all levels of societies with its assertion that everyone has a role to play.
The campaign corresponded with Eswatini’s existing goal of eliminating malaria in the kingdom by 2022, and a renewed call went out to politicians, public servants, the private sector, youth, chiefs and other traditional leaders – many of whom were in attendance at the launch – to stand up and individually declare that zero malaria starts with them. His Majesty once again emphasised that together, citizens can make Eswatini the first country in Sub-Saharan Africa to eliminate malaria, and added that one important step towards ensuring that outcome would be to provide enough resources for a sustained campaign against malaria in the kingdom.
He pointed out that Eswatini faced a US$5.5-million (E80-million) budget gap to eliminate malaria, then urged everyone to protect those at risk and respond to each case in a timely manner: this included monitoring cases that cross the borders, a means to avoid risking the progress already made. Fast-forward to the launch of the first national end malaria fund, the King explained that it will exist to mobilise the necessary resources to close the funding gap and ensure that Eswatini eliminates malaria by 2022, then prevents the reintroduction of the disease thereafter. He furthermore described it as a public-private partnership comprising representatives of the public and private sectors, as well as those of communities.
Following significant achievements by the kingdom, the World Health Organization classified the country as ‘ready for malaria elimination’, and for the country to qualify for malaria elimination, robust systems have been put in place. These include:
• Free malaria treatment in all health facilities, including those run by the private sector
• All households in malaria-risk areas are sprayed annually with residual insecticides, and a spray-coverage area of up to 90 percent is consistently maintained
• Government distributes bed-nets to all populations living in malaria-prone areas, with a special focus on pregnant women and children younger than five years
• A surveillance system maps out all confirmed malaria cases and all interventions delivered in each household, thus helping to provide full understanding of the malaria situation
Eswatini has invested a significant amount of resources in the area of research to ensure that the strategic direction of the programme is always informed by scientific evidence: this includes ongoing appraisal of the efficacy of the drugs and insecticides being utilised. The kingdom has established and strengthened its collaboration with neighbouring South Africa and Mozambique through the Lubombo Spatial Development Initiative to address the issue of cross-border transmission. His Majesty described investment in cross-border collaboration as critical, since “mosquitoes and parasites do not respect borders or boundaries”.
Implementation of the abovementioned interventions would not have been possible had it not been for the commitment shown by government fronting up to 70 percent of resources for the implementation of malaria elimination interventions. The recent World Malaria Report was however an alarm bell, as it indicated that the progress made against malaria is stalling, and the resources available for malaria are at risk. The report was also a call to action, that progress needs to be accelerated, especially at national and regional levels.
The launch of the End Malaria Fund was therefore regarded as marking a significant milestone in the fight against malaria for Eswatini and the whole of Africa, progressing towards “eliminating malaria in this lifetime”. His Majesty King Mswati III pointed out that government had thus far spent substantial sums of money fighting malaria, and it was now “time for us to unite and declare zero tolerance in the war on malaria…we have to work together as African nations to eliminate this challenge which has deprived us of many of our beloved friends and relatives”.
The King concluded by disclosing that the Fund will be managed in perpetuity by a Board of Directors which “must effectively contribute to the implementation of priority national initiatives just like government, the private sector and other stakeholders have done. The primary focus and function of the Board will be overseeing the elimination of malaria in Eswatini…I urge its members to work with diligence”.
