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Comprehensive Analytical Profile: Swaziland

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This analytical profile provides a health situation analysis of the Swaziland and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to Country Context
2. Health Status and Trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context

The Kingdom of Swaziland is a mountainous landlocked country covering 17,364 square kilometres in the south-eastern corner of Africa. Three quarters of its area is bordered by South Africa and one quarter by Mozambique. According to the 2007 population census, the population of Swaziland is 1,018 449 inhabitants with about 78.9% residing in rural areas. 52% of the population is under the age of 20 years. The geographical population distribution between the four regions of the country is as shown in table 1 below.

In 2007 the total number of households was 212, 403 with an average household size 4.7 persons.

Health Status and Trends

Available information shows that previous gains on the health status are being eroded by the advent of the double burden of communicable and non-communicable diseases. Such has resulted in high mortality rates in the country. The average life expectancy at birth has decreased from 58.8 years in 1997, to 43 years in 2007.

The Human Development Index (HDI) declined 0.523 in 1995 to 0.494 in 2005 and increased 0.498 in 2010. Increasing trends have been observed in the country's Crude Death Rate (CDR), Infant Mortality Rate (IMR), Under-Five Mortality Rate (U5MR) and Maternal Mortality Rate (MMR). Crude death rate per 1 000 population increased from 26.2 in 2005 to 31 in 2007(Population Census 2007). Infant Mortality (IMR) per 1 000 live births stabilised from 87 per 1000 in 2000 to 85 in 2007 (MDG Report 2010). The under-five mortality also stabilised from 122 in 2000 to 120 in 2007.

The stabilization can be explained by the focus of Government interventions on orphans and vulnerable children due to surging numbers of child-headed households. According to Black et. al. , the five major causes of child mortality in Swaziland are AIDS, which accounts for 49 per cent; pneumonia, 12 per cent; preterm birth complications, 9 per cent; diarrhoea, 8 per cent; and other infections, 7 per cent. Underlying these direct causes are a variety of complex and interrelated factors that contribute to ill health and mortality, including poverty, vulnerability, lack of education, and poor health care services.

Progress
Progress on SDGs
The Health System
Health system outcomes

The advance of HIV/AIS pandemic and re-emergence of TB has not only overstretched the capacity of the established Primary Healthcare (PHC) structures and institutions making them susceptible in terms of ability to cope and produce positive results. This has also brought in the challenge of vertical programming of health services. A negative trend in PHC indicators has been observed in the country since the mid-90.

This trend is likely to continue until a negative trend is observed in terms of HIV/AIDS, TB and non-communicable diseases. HIV and TB have diverted both human and financial resources away from other PHC interventions which were adequately supported before.

Leadership and governance

The Minister of Health is the political head of the health sector responsible for policy issues. The chief administrator is the Principal Secretary who is responsible for policy implementation, monitoring and supervision.

The Director of Health Services is the technical head of the ministry in charge of health services. He is assisted by two deputy directors, one in charge of Health Services (Clinical) and the other of Public Health Services. Other key senior technical officers at the ministry headquarters include the Legal Advisor, Chief Nursing Officer, Senior Health Administrator, Principal Personnel Officer, Principal Planning Officer and Financial Controller.

The Ministry has reviewed the organizational structure in line with new and emerging challenges. This reform agenda has seen the establishment of new departments such as procurement and logistics management unit. At the regional level, each Regional Health Office is headed by a Regional Health Administrator and supported by a Regional Health Management Team (RHMT) whose mandate is to provide technical leadership in executing MOH policies.

Community ownership and participation

The National Health Policy 2007 calls for the involvement of beneficiaries in all healthcare services provided in the country. In this regard the Ministry have set up health committees which act as overseers of rural healthcare facilities in collaboration with facility based managers.

The main idea of involving the community is to ensure that community views in the delivery of healthcare services are taken into consideration. The country has a compliment of 4,000 rural health motivators, home based carers and community birth attendants. These are non-health professionals

The increase in patient load has necessitated the establishment of home based care to provide comprehensive health care package to people living with a chronic and or terminal illness. These services include nursing care; preventive; curative; palliative; rehabilitative; end of life care and referral services. Such services are provided collaboratively within health care facilities; through family members, RHM’s and community carers and counsellors.

Partnerships for health development

Public-Private Partnerships in the country are still at infancy stage. A number of partnerships are in areas of HIV/AIDS and TB. The main partnerships which have been in practice for a long time relates to sharing of medicines and medical supplies between States funded healthcare facilities and private healthcare providers.

In this partnership, the Government has been providing free, TB medicines, vaccines and Anti-Retroviral Drugs to private healthcare providers for free of charge. Other initiatives in healthcare infrastructure development has been slow and currently various projects are being explored to be implemented using this approach.

Other partnerships include the Ministry of Health and Non-governmental Organizations. This partnership is financed by solely by Government where contributions to their operational costs are made. It is estimated that approximately 25 per cent of the Ministry of Health budget is spent on Non-Governmental Organizations. There are approximately 20 Non-Governmental organizations who receive financing from Government.

Health information, research, evidence and knowledge

Evidence shows that access to the right information at the right time can often be the difference between life and death. UNICEF’s James Grant estimated that getting medical and health knowledge to those who need it and applying it, could have prevented 34 million deaths each year in the 1980s. This is because information is power.

With a vision to have a health information a system that will be comprehensive, efficient and effective in supporting the health sector and other relevant stakeholders in the delivery of health services by the year 2015, Swaziland has had a Health Information System (HIS) since 1978, and this HIS was initially based at the Central Statistical Office (CSO). From 1979 onwards, health information was collected, stored and analysed at the Ministry of Health (MOH).

Health financing system

The country spends approximately 3.8 per cent of GDP on health care (including private health expenditures). Approximately 65 per cent of healthcare funds come from Government, accounting for approximately 2 per cent of GDP, while additional funding comes from development partners, the private sector and individuals.

Some mission operated health facilities and NGOs receive a large portion of their resources from Government following the declining of the global donor base. Household expenditures as percentage of total private health expenditures were estimated to have increased from 34.9 per cent to 41.7 per cent between 1998 and 2002.

The share of Government expenditure on health has increased almost six fold in the past decade from 19 million USD$ in 1998 to 113 million USD in 2009. As a share of the total budget it translates to 7 per cent of the total Government budget in 1998 increasing to 9 per cent in 2009. Despite the significant increase in absolute figures the share of the budget allocated to health did not increase significantly as a percentage of the total budget.

Service delivery

The country is pursuing the goal of universal coverage in line with the primary healthcare principles. The formal health sector is based on the concepts of primary health care and decentralization. Its infrastructure is made up of 7 government hospitals, 2 mission hospitals and 1 industry supported hospital. There are also, 8 public health units, 12 health centres, 76 clinics and 187 outreach sites. In addition, there are 73 mission health facilities (health centres, clinics and outreach sites), 62 private clinics and 22 industry-supported health centres and clinics.

Based on the projected total population size for 2010 of about 1, 046,197 people in the four regions of the country, this translates into 25 facilities per 100 000 people overall.

A functional referral system for rationalization of service delivery at the various levels in line with the Essential Healthcare Package has been developed. Guidelines and implementation procedures will assist in reducing the congestion at the referral facilities.

Health workforce

There have been some remarkable improvements over the past two years with regard to the employment of medical doctors in health facilities country wide as shown in table 4.1 below. A total of 241 doctors/physicians were identified to be working in the country in 2010 compared to 201 in 2008. Similarly, the doctor to patient ratio increased from 19.7 in 2008 to 23.0 in 2010 reflecting a 3.3% increase.

Nurses form a significant majority of the overall health sector human resource and by such play a very critical role in the day to day management of patients in health facilities. While 2008 Service Availability Mapping (SAM) found a total number of 1778 nurses practicing in the country of which 1531 were Swazi, the 2010 SAM found a total of 1911 nurses practicing in the country 1714 of which were locals.

Due to the bureaucratic recruitment and management procedures, the MOH is committed to setting up a Health Service Commission to perform the functions of recruitment, selection, promotion and development of health professionals, as stated in the HR Policy document. The law required to set this up has been drafted and is currently under discussion.

Medical products, vaccines, infrastructures and equipment

The Ministry of Health has promulgated a new National Pharmaceutical Policy 2011 which aims at positively contributing to improving the health of the Swazi population by ensuring equitable access to, and rational use of efficacious, high quality essential medicines, and medical supplies and devices at affordable cost particularly for vulnerable populations.

The department is headed by the Chief Pharmacist who is responsible for organizing and directing all pharmaceutical activities in the country as well as formulating and providing policy advice and guidance to the Ministry of Health. Other functions include ensuring regular medicine supply to the public sector, technical supervision of national referral and regional hospitals and the overall implementation of the Swaziland National Pharmaceutical Policy.

The office of the Chief Pharmacist also plays the role of regulatory authority, an unsatisfactory situation which requires the urgent creation of a formal regulatory body. The limited administrative capacity of the national pharmaceutical services poses high inefficiency risks in the inefficiency risks in the management and control of pharmaceutical services.

General country health policies

The Ministry of Health promulgated a National Health Policy, 2007 in pursuit of the health sector vision. The vision of the sector is that by 2015, the sector shall have developed an efficient and effective system that will contribute to a healthy population that lives longer and has socially fulfilling lives.

The policy addresses seven thematic areas namely, organization and management, coordination, human resources, quality assurance, health financing, infrastructure development and equipment maintenance and service provision (public health and clinical services). The policy is being implemented through the National Health Strategic Plan 2008 -2013.

The national health sector strategic plan is linked to the PRSAP. This linkage turns the PRSAP into concrete MDG-based long-term results-oriented health plan. The essence of the national health sector strategic plan is to reposition the health sector to capitalise on its strategic competencies and redefine its approach to improving quality of health care.

Universal coverage

Health care service delivery is set out to be in an integrated manner in all health facilities, ranging from treatment of common ailments to disease control, antenatal care, care of the sick child to immunization and other preventive care. It was meant to ensure that there would be no missed opportunities.

This has presented special challenges in terms of the need for health workers with generalist skills, especially at health centre and regional levels. The eight kilometre radius set out to promote universal access to health care has been achieved in the country but the accepted WHO standard of five kilometres has not been reached.

Specific Programmes and Services
HIV/AIDS

HIV and AIDS continue to be an overwhelming crisis in the country, rapidly spreading and profoundly impacting on the socio-economic and cultural spheres of life. The rising HIV prevalence has had a positive and a negative effect on the healthcare system.

Positively, it drew political attention once again as a sector that needs to be prioritised and negatively, had been enormously been pressurised and over-stretched by the consequences of HIV and AIDS. Hospital wards are heavily congested with over half of hospital beds occupied by patients with HIV and AIDS-related illnesses. As previously alluded HIV and AIDS is among main contributors of the high mortality rates prevalent in the country. According to the Swaziland Demographic and Health Survey (DHS) 2006/07, the prevalence of HIV in the reproductive age population (15-49) is 26 per cent.

Due to the diverse, vigorous interventions pursued in the health sector the epidemic is stabilizing, albeit at an unacceptably high level. Besides the stabilization being observed in the fight against the epidemic the national response is yet to generate actual reversal in epidemiological trends. New infections in adults are projected to slightly decrease from 12,281 in 2009 to 11,381 in 2015.

Tuberculosis

Tuberculosis constitutes a one of the major public health problems currently confronting the Kingdom of Swaziland. Compared to a 1990 level of 267 all forms of TB cases per 100,000 population, the incidence of the disease has increased five-fold (Fig 1). Within the same period, the incidence of infectious sputum smear positive TB cases has more than tripled. Currently tuberculosis accounts for about 10% of in-patient morbidity in the country.

The country is among those with an estimated TB incidence of 1,198 per every 100,000 population. TB-related mortality has increased from 76 per 100,000 in 1990 to the current level of 317 per 100,000 populations. This mortality figure translates to about 2,780 deaths annually due to TB alone; and an estimated 17,000 TB-related deaths by 2015 if drastic actions are not taken. Current MOH statistics show that 20% of in-patient deaths are attributable to tuberculosis.

Malaria

Malaria in Swaziland is very responsive to control interventions. Malaria reached a peak in 1995-96 when 9700 confirmed cases and over 38000 clinical cases were reported nationwide. At present, wide scale use of IRS in the Lowveld has reduced the reported number of laboratory confirmed malaria cases to 478 during the 2010-2011 transmission season, with 3 malaria-related deaths.

Frequent commuting between Swaziland and Mozambique further complicates the pinpointing of the exact localities where people get infected. A good understanding of malaria epidemiology in the various transmission foci and of their physical characteristics will be critical for targeting the elimination program activities in Swaziland and bordering areas of Mozambique, and for advancing towards zero transmission in a safe, cost-effective and efficient manner.

The government financial commitment has sustained large scale program implementation over the years. The implementation of cross border collaboration through the Lubombo Spatial Development Initiative has been very successful and stands as a best practice in the African Region. The success of the Swaziland malaria program over the last decade has raised expectations for malaria elimination.

Immunization and vaccines development

Swaziland achieved high routine immunization coverage until the late 1990s provided through the existing health service delivery structures including outreach services. Since 2001, a fluctuation in DPT3 coverage has been experienced. The key challenge is how to increase and sustain high routine immunization to acceptable levels. The Reaching Every District (RED) approach and Child Health Days (CHD) were adopted as remedies to improve immunization coverage.

Figure 4.4.1: DPT/HepB/Hib3 and Measles Coverage, 2001 to

Child and adolescent health

The National Nutrition Survey Report 2008 indicates that the prevalence of acute wasting in Swaziland is 1.1 per cent and there are no significant differences between rural and urban settings. Similarly, the prevalence of acute malnutrition was estimated at 1.1 per cent for 0-59 months old. This situation might change though due to a number of socio-economic factors, such the increase in the number of child headed households and the prevalence of significant food poverty.

While acute malnutrition has remained at reasonable low levels over the years, prevalence of chronic malnutrition has shown at steady rise from routine nutrition monitoring systems. At national level 40.4 per cent of children under five are stunted, while the proportion of severely stunted is 12.6 per cent. From the survey it could be inferred that stunting is more prevalent in rural areas than urban areas. The prevalence of underweight children was estimated at 7.2 per cent in 2008 and the prevalence of severely underweight children was 1.1 per cent.

These figures show that there is a considerable problem of malnutrition among children in the country. The National Youth Policy defines youth as young women and men aged 15 to 35 years. The current census figures indicate that young people aged 10-24 years constitute 37 per cent of the population in Swaziland. This is significant in that a majority of these are not married yet they are sexually active and without the benefit of contraception.

Maternal and newborn health

The MDG goal is to reduce maternal mortality ratio by 75 per cent between 1990 and 2015. In Addis Ababa early 2009, the Heads of States launched a Campaign of Accelerated Reduction of maternal mortality in Africa (CARMMA). In Swaziland, the campaign has been adapted to CARMMS, to be coordinated by the Ministry of Health at national level and coordinated and implemented by the Regional Health Management Teams in the regions. At community level, the committees shall be formed to look into issues of maternal and child health financing during obstetric emergencies.

As shown by table 4.6.1 the figures for maternal mortality ratio between 1995 and 2011 showed a decline up to 1997 then an upward trend. The upsurge of maternal mortality has been attributed largely to HIV /AIDS and declining health systems. Pregnant women in Swaziland continue to die from four major preventable causes; severe postpartum haemorrhage, obstetric infections, hypertensive disorders, unsafe abortion and obstructed labour.

HIV prevalence among pregnant women has been estimated at 41 per cent. HIV/AIDS predisposes to sepsis and haemorrhage the two commonest causes of maternal deaths in the country. In the context of the ICPD and the MDGs, the country has the task of reducing the MMR from the baseline figure of 370 (in 1992) to 92 by 2015.

Gender and women's health

Swaziland has shown encouraging signs of commitment to addressing gender equality. Momentous strides have been made in the inclusion of an equality clause in the National Constitution 2005 and ratification of the Convention on the Elimination of All Forms of Discrimination against Women in 2004. The ratio of girls to boys in primary education has remained almost constant, averaging 0.93 since, highlighting that there are more boys enrolled in primary school than girls. It should be noted though that, there are more girls of school-going age than boys.

On the other hand, secondary education statistics show that there are slightly more girls enrolled than boys, with a ratio that is greater than one. However, given the population demographics of the country, in which there are more girls of secondary-school age than boys, girls are still disadvantaged at this level. This is due to high incidences of early pregnancy, sexual abuse, poverty and the impact of HIV and AIDS.

In the country approximately 31 per cent of the population is employed, representing 40 per cent of males and 24 per cent females. Most women are found in the informal sector, mainly in micro-enterprises and in the agricultural and food production sector. Participation of women in non-agricultural wage employment remains low.

Epidemic and pandemic-prone diseases

For the past two decades disaster management in Swaziland has been conducted in an ad hoc manner through the National Disaster Task Force. This culminated to the enactment of the Disaster Management Act, 2006 which formed the base legal standing for attending disasters in the country. However this piece of legislation is not able to comprehensively take care of Health Emergencies due to issues of technicality of the subject that need careful attendance by specialized personnel with clear legal mandate.

The Ministry of Health established a Department for Emergency Preparedness and Response Unit with wide responsibilities in health emergencies in the country. The Unit is a public health arm and serves as the directing and coordinating authority for health emergencies. It is responsible for providing leadership and coordination on health emergencies/disasters, providing Emergency Medical Services (National Ambulance Service), shaping the health emergency research agenda, setting norms and standards, articulating evidence-based policy options for disaster risk management for health, monitoring disease outbreaks and assessing performance of health system during emergencies.

To achieve it overall objective the Ministry of Health has developed a Health Emergency Preparedness and Response Strategy in 2008. The strategy outline a sector coordinated response actions in times of emergencies or disease out breaks in the health sector.

Neglected tropical diseases
Non-communicable diseases and conditions

There is an increasing burden of non-communicable diseases in the country, which adds to the continuing burden of communicable diseases, perinatal and nutritional disorders. A comprehensive analytical description of the magnitude of the burden of increasing of non-communicable diseases is hindered by lack of accurate and reliable information.

Available data suggest an increasing prevalence of non-communicable risk factors. Available records from hospitals and health facilities in the country show that non-communicable diseases comprise the top five reasons for hospitals admissions. The MOH/WHO 2009 survey attempted to determine the prevalence of diabetes mellitus among the Swaziland population. The report suggested a general increase in prevalence of diabetes mellitus with increase in age and a higher prevalence in women than in males (Fig. 10.1).

Fig. 10.1 Prevalence of Diabetes Mellitus

Key Determinants
Risk factors for health

There are a number of attributes, characteristics and/or exposure of individuals which increases the likelihood of developing a disease or injury. In the country there are a few risk factors which mainly accounts for non-communicable diseases. These include unhealthy diets, tobacco use, harmful alcohol consumption, physical inactivity, overweight and obesity raised blood pressure and raised blood glucose.

A survey conducted by WHO in 2009 on Non- Communicable disease risk factors surveillance reported an average of 7.9% prevalence of smoking among the 55 – 64 years age group, followed by 7.3% among the 45-54 years age group. In Swaziland, tobacco consumption seems to increase with age and males were six times likely to use tobacco products than females.

Similarly males were more likely to have consumed alcohol as compared to females. While the association of alcohol consumption oesophageal cancer, liver disease, homicide, epileptic seizures, and motor vehicle accidents globally Swaziland is no exception.

The physical environment

According to Swaziland Country Environmental Profile (2006), ecosystem biodiversity is threatened by lack of protection and land conversions, which are projected to halve the area of potential protection-worthy ecosystems. In addition, the country is projected to see the introduction of a very dry tropical forest type of ecosystem in the eastern part of the country, replacing half of the current subtropical ecosystem as a result of climate change.

Housing conditions vary greatly in rural and urban areas. More than two-thirds of households have access to improved water sources, and three in four households are within 15 minutes of their drinking water supply. About 73 per cent of urban households have water piped into their dwellings or yards, while about 23 per cent of rural households have direct piped water. Rural households also rely on public taps, surface water and dug-protected wells for their drinking water.

The SDHS (2007) also shows that in the urban area alone, sustainable access to improved water sources increased slightly from 89 per cent in 1997 to 91.9 per cent in 2007. The latest study by the Swaziland Water Services Corporations (SWSC) reveals that access to improved water stands at 95 per cent in 2009.

Food safety and nutrition

Swaziland is primarily an agrarian economy and the right to adequate food is seen as a basic human right. This basic right however, has been constantly under threat in the past two decades. The decline is attributable to a number of factors which includes successive years of drought in the context of rain dependence food production; utilization of inappropriate agricultural technologies, limited understanding of the impact of climate change and the multidimensional impacts of HIV and AIDS. Maize production as a stable food and the most dominant crop has declined over the years as shown in figure 5.3.1.

figure 5.3.1.

Social determinants

The health outcomes of individuals, family and communities are influenced by the social and economic conditions in which people are born, grow, live, work and age, and the systems put in place to deal with illness, disability and premature deaths. However, it is self-evident now that the drivers (cause-of-the-causes) of these health conditions exist outside the domain of the health sector and therefore require multi-disciplinary and multi-sectorial approaches to tackle them.

The finds herself facing a huge burden of communicable diseases and non- communicable conditions as well as high maternal and child morbidity and mortality caused by social, economic, political, environmental and behavioural factors. The non-communicable health conditions namely diabetes, high blood pressure, road traffic injuries and cancer, among others, pose a major public health threat. There is no cure but require both lifestyle and structural interventions across the sectors.



References