Coronavirus? Be Afraid Swaziland, be very afraid!

The world closed 2019 on a high. We were all unaware that what seemed like a localized outbreak of a coronavirus in China would, 3 months later, become a global pandemic.

On January 30, 2020 the World Health Organisation (WHO) declared the outbreak of the novel virus— officially called COVID-19 —a Public Health Emergency of International Concern (PHEIC). Already ‘boasting’ of 417 348 confirmed cases and a further 18 595 already dead, the virus has surely left the world in a panic. The economic impact of the virus even scarier, especially for us living in developing countries in the global South.

Rolling updates on the status of the outbreak by the WHO show that on the 50th day since the outbreak was first reported, cases in China had surged by 89% while many others in Europe showed to be going up in true domino effect style.

By March 23 at 00:00 GMT, COVID-19 has shut the world down, clocking about 380 000 cases, 16500 deaths in over 151 countries. The WHO has continuously offered daily feed on the status of the pandemic and considers it on High-risk status worldwide. 

The COVID-19 has awakened us to a catastrophe not seen before in contemporary times. The world’s best health systems have come crumbling down and we all watched helplessly as highly developed nations wrestle this pandemic.

Italy, in particular, is the worst-hit country in Europe, (they have overtaken China on risk status) despite boasting one of the best functional public health systems in the world. By the time of compiling this article, Italy had tallied about 69 176 cases and 6 820 deaths.

The world health governing body has requested all health systems to be on high alert leading to many European countries like Spain, Norway, France, Germany, Finland, Portugal and UK engaging in lockdown in a bid to contain the spread of the virus. 

Meanwhile, in Africa we have seen the least number of cases of this virus. This could be a blessing in disguise because we now have a head start to prepare for and pick lessons from countries like China and Italy. 

However, the growing number of confirmed positive cases in neighbouring South Africa has caused enough panic in Swaziland especially given the known capacity (or lack thereof) of our health system.

Seeing the infection toll rising to above 60 in one week in South Africa, considered by far the most economically capable country by Africa standards — economically and otherwise — has forced even the most hardcore of denialist to admit that it is now only a matter of time before  Swaziland is hit too.

           Why our public health system is not ready for the virus

Not so long ago, Swaziland was brought to its knees by HIV/AIDS. 40 years later the country is still licking wounds caused by a disease that had the best chances of being prevented through simple behaviour change. Today we talk of a highly contagious virus with no hope of treatment on sight. Logically, an outbreak of such a virus will lead to a nightmare of biblical proportions for little Swaziland.

The immediate challenge for us as a country is that we do not have the testing facilities and rely on South Africa which itself is soon going to be overwhelmed. Promises that we will soon start testing locally have come a little too late. In fact, the vibes we receive from our leaders and their indecisiveness plus lack of political leadership in this time of crisis has led us to believe that indeed our public health system is not battle-ready for this virus.

The starting point in understanding if we are ready for Coronavirus is to access the state of our public health system. What then is a public health system in the first place? The Centre for Disease Control (CDC) describes Public health as a science of protecting and improving the health of people and their communities.

Contrary to clinical professionals like doctors and nurses, who focus primarily on treating individuals after they become sick, public health focuses on disease prevention, limiting health disparities as well as responding to infectious diseases.

The capacity of public health to function as a system rests on the political will of the government to fund its critical components equivalent to the needs of the population. A question that begs an answer then is; does Swaziland have a (functional) public health system. If so is the government willing to fund it?

In fact, Swaziland’s Health sector continues to receive the highest share of external aid for both recurrent and capital funding. It is interesting to learn that all the little that the health system achieves owes to outside funding either through PEPFAR, Global Fund, the Republic of China (Taiwan) and the UN Agencies.

Even the most decorated health personnel in the country is dominated by expatriates.  UNICEF Swaziland in its commentary of the 2017 budget posited that although donor contribution is crucial for Swaziland, its unpredictability raises funding sustainability concerns hence the need for increased domestic resource-mobilisation efforts.

Reads the UNICEF 2017 report in part: “The Second National Health Sector Strategic Plan (2014-2018) target ratio for 2017 in terms of trained nurses and midwives per 10,000 people, was 2.4, and the targeted ratio of medical staff (doctors, nurses and midwives) to 10,000 people, was 2.3, compared to the WHO threshold of 25 medical staff per 10,000 people. For a middle-income country, this could be considered as a human resource crisis affecting the health delivery system’s capacity to deliver better health outcomes. Hence the need for improved budgetary investments in developing human resources for health.” 

The Immunisation Unit, for example, received a budget of E38.11 million in the 2017/18 budget. This was a 33.4% decline from the E57.22 million allocated the previous fiscal year. This amount was obviously not sufficient for the health needs of our nation yet it was still slashed.

With one in every four Swazi children not receiving full immunisation, more resources are needed to ensure countrywide coverage. In 2018 E2 billion was allocated to health, a deficit of 200 million from the previous budget allocation.

The figures themselves show how health budget allocations have gone down over the years in the country and the big question is where is the money spent if not to the health the majority of Swazis’ especially as we are badly afflicted by HIV/AIDS?

This alone should show that there is no political will on the side of the government to prioritise public health in the country especially given the comments of UNICEF as quoted above.

A patient waits for his pills as he meets with a nurse at Nhlangano health centre on October 28, 2009. According to the international medical aid organisation Doctors Without Borders (MSF), 80 percent of TB patients in Swaziland also have HIV, placing severe pressure on the small kingdom’s public health system.

Last year the budget allocation was E2.2 billion and saw a marginal increase to E2.3 billion this financial year. This money has always been earmarked for ‘priority projects’ in the ministry of health, none of which relates to public health interests.

Amongst other projects, the money has been used to subvert numerous health institutions partnering with Government, operationalising new clinics, construction of health facilities but not a cent has been directed to disease surveillance and emergency preparedness.

Whilst governments around the world are recalling retired health workers as means to strengthen their health force our government is waiting for the health system to be overwhelmed instead of using this time to re-train them and ensure they are battle-ready should we face Italy type of infections.

Some countries have even gone to the extent of provisionally hiring students in their last 2 years of health science education. Again here Swaziland has about 300 graduate unemployed nurses who survive through piece jobs who could be hired to assist the already understaffed nurses.

Some of these nurses have been actively looking for jobs for the past 3 years. An injection of these nurses into strengthening the national health team can go a long way in reducing the burden in our already exhausted health care workers.

Currently, the country was excluded by WHO from assistance to combat the COVID-19 because the country has a Monarchy that lives large with no regard to our collapsed health system. Why would WHO help a country which has prioritised the gluttony and greed of the king and his criminal extended family instead of the nation?

Medical practitioners who we bank on as our first line of defence against this virus complain daily that they have no protective gear even as they are among the most at-risk group to get the virus. This is but one of our many problems yet we hope to defy the odds and emerge unscathed from a pandemic that has humbled the strongest health systems in the world. Little Swaziland should think twice.

The COVID-19 scare and the present-day government’s response finally exonerates those of us who long called for the total overhaul of our health system. The current and failed health system is designed to respond to health problems instead of putting preventive measures proactively. This reactive approach is not only expensive but also fuels the silent health genocide in the country. 

One then wonders why five decades post the Alma Atta declaration on primary health care the country’s health still uses the out of date biomedical model approach. This model alone is problematic because it disregards the other determinants of health.

This is why when a patient with diarrhoea consults medical practitioners they recommend HIV testing, prescribe Oral Rehydration salt etc, without considering other external issues that could have caused the ailment like safe drinking water, hygiene and sanitation which are at the core of a functional public health system and primary health care in the first place. 

Part 3 of the Alma Ata declaration of 1978 says Primary Health states that “education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs”.

I argue therefore that central to the prevention of the coronavirus spread in Swaziland means social distancing, proper hand hygiene and a functional public health system as a basis of all other interventions. None must be treated without considering the other.

Not so long ago the national psychiatric hospital was out of water and ablution facilities were inaccessible for prolonged periods. As a health worker myself I have witnessed this grim reality first hand.

        

King Mswati III in full traditional gear. The writer says Swazis must choose whether to fund his luxurious lifestyle of upgrade the public health system of the entire country

In the final analysis, the problems of our health system cannot be isolated from the national problem. The national problems remains a greedy king, a rotten political system and clueless hand-picked government.

It is a collective shame that the entire country is compromising its health only to fund the nice life and good time of the royal family and the greedy king. Coronavirus is only here to expose us and force us to choose whether we want to fund the king and his criminal royal family or the needs of the about 1.2 Million Swazis.

Such a choice means sacrificing the interests of the royal family for that of the nation. The failure to localise the Alma Atta Declaration on Primary health and Ottawa Charter on Health promotion is a deliberate trade-off, prioritising royal opulence over the nation’s health.

NB: Thabo Dlamini is a professional Nurse and a former leader of the Swaziland National Union of Students. He is now a Masters student at the University of Bergen.

Thabo Tach

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