SERVICE AVAILABILITY MAPPING (SAM)

2006 - 2007

KINGDOM OF SWAZILAND

MINISTRY OF HEALTH AND SOCIAL WELFARE AND MINISTRY OF EDUCATION

IN COLLABORATION WITH

THE WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA

© World Health Organization 2008

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2 Acknowledgements

It was the first time that Service Availability Mapping (SAM) was carried out in Swaziland. This important initiative was possible because of the commitment of senior authorities in the Ministry of Health and Social Welfare. Special gratitude goes to Ms Nomathemba Dlamini, the Principal Secretary, and Mr. Sikelela Dlamini, the Undersecretary of the Ministry of Health and Social Welfare and the Chairman of the SAM Steering Committee, who were very supportive from the beginning of the process.

The effective involvement of various units within the Ministry of Health and Social Welfare was highly appreciated. The contribution of the Swaziland National Programme on AIDS particularly the Monitoring and Evaluation Unit which supervised the whole process from the consultative stakeholders meeting until the finalization of the report was determinant. We particularly would like to thank Sibongile Maseko, former M&E focal point, Sibongile Mndzebele, current M & E focal point in Ministry of Health and Social Welfare, M&E officers Nomsa Mulima, Sandile Dlamini, and Nqaba Nhlebela who actively participated in planning, data collection and analysis.

The contribution throughout the process of the Office of the Surveyor General in the Ministry of Natural Resources, namely Mr. Sidney Simelane, chairman of the SAM Technical Committee, and Mr. Patrick Mkhonta, was very much appreciated. The same goes to the National Emergency Response Council to HIV/AIDS (NERCHA) for their participation in data analysis.

We are grateful to WHO, particularly to Dr David Okello, former WR in Swaziland, and to Dr Edward Maganu, current WHO Representative in Swaziland, for their advice encouragement and support. Our appreciation also goes to Dr Augistin Ntlivamunda, HIV/AIDS Country Officer, Dr Benjamin Gama, National Programme Officer, Mr. Thamsanqa Dlamini, IT Officer, and Mr Phakama Dlamini for the role they played in SAM planning, execution and data analysis.

Special thanks go to Dr Gorge Loth, former WHO/HQ staff and who retired in 2006, and to Shanthi Noriega Minichiello, Service Availability Mapping Focal Point in HQ/Geneva, for the key roles they played in planning and implementation of SAM in Swaziland. Without their determination and technical support, the exercise would not have been possible.

Finally, we acknowledge the valuable financial support from WHO, the collaborative and supportive efforts from the Regional Office in Brazzaville and headquarters in Geneva.

3 Abbreviations and acronyms

ACT Artemisin-based Combination Therapy AIDS Acquired Immunodeficiency Syndrome ANC Antenatal Care ART Antiretroviral Therapy ARV Antiretroviral ASRH Adolescent Sexual and Reproductive Health CDR Crude Death Rate FDI Foreign Direct Investment GDP Gross Domestic Product GPS Global Positioning System HIV Human Immunodeficiency Virus HRH Human Resources for Health HTC HIV Testing and Counseling IMA/ART Integrated Management of Adult Illness/Antiretroviral Therapy IMCI Integrated Management of Childhood Illness IMR Infant Mortality Rate NVP/AZT Neverapine/zidovudin MMR Maternal Mortality Rate MoEPD Ministry of Economic Planning and Development MoH Ministry of Health NCD Non-Communicable Disease ORS Oral Rehydration Salts TB Tuberculosis PDA Personal Digital Assistant PEP Post Exposure Prophylaxis PHU Primary Health Unit PLACE Priority for Local AIDS Control Efforts PLWHA People Living With HIV/AIDS PMTCT Prevention of Mother to Child Transmission PPA Priority Prevention Area PSAM Prevention Service Availability Mapping SAM Service Availability Mapping U5MR Under-Five Mortality Rate VCT Voluntary counselling and Testing WHO World Health Organization

4 Table of contents

1. Background...... 9 1.1 Geography and population ...... 11 1.2 Economic profile ...... 14 1.3 Health profile...... 14 1.4 Education profile ...... 15

2. Service Availability Mapping (SAM)...... 17 2.1 Background...... 18 2.2 Objectives ...... 18 2.3 Methodology ...... 19

3. Results, health services survey ...... 21 3.1 Foreword...... 22

3.2 Executive summary...... 23 3.2.1 Regional results ...... 23 3.2.2 Results from health facilities ...... 23

3.3 Regional results ...... 25

3.3.1 Health infrastructure...... 25 Health facilities...... 25 Laboratory capacity ...... 26 Blood safety services...... 26 Injection equipment ...... 28 Oxygen, indoor spraying and X-ray ...... 28 Communication technology...... 29

3.3.2 Service availability ...... 29 HIV/AIDS treatment ...... 29 Maternal and child health ...... 30 Tuberculosis case management ...... 30

3.3.3 Social marketing programmes ...... 31

3.4 Facility census results...... 32

3.4.1 Health infrastructure...... 32 Health facilities...... 32 Communications...... 34 Water source...... 40 Sterilization...... 42

3.4.2 Human resources...... 43

3.4.3 Basic equipment...... 48 Equipment availability in hospitals ...... 48 Equipment availability in health facilities...... 48

3.4.4 Availability of essential drugs in health facilities...... 50

3.4.5 Laboratory capacity...... 52

3.4.6 Service availability...... 53 Mother and Child health (MCH) ...... 53 HIV/AIDS...... 66 Sexually Transmitted Infections (STIs)...... 76 Tuberculosis case management ...... 79 Malaria...... 82 Non-Communicable Diseases (NCDs)...... 83 Condoms...... 85 Male circumcision ...... 87 Provision of other important services...... 89

3.5 List of annexes...... 90

4. Results, school survey...... 93

4.1 Foreword...... 94

4.2 Results ...... 95

4.2.1 General information ...... 95 School distribution by region, ownership and educational level...... 95 Schools by ownership...... 97 Student population...... 99 Teacher population ...... 104

4.2.2 Prevention services...... 106 Provision of information on HIV/AIDS and other HIV related issues...... 106 Condom promotion and distribution ...... 110 Vulnerable orphans...... 114

4.2.3 Training of teachers and students on HIV/AID issues ...... 117

4.2.4 Visit of schools by health workers ...... 126

4.2.5 School health situation (health issues)...... 128

4.2.6 Commodities...... 146

6 4.3 Annexes ...... 159

5. Results, Prevention Service Availabiltiy...... 160 Mapping (PSAM) Survey ...... 160 5.1 Executive summary...... 161

5.2 Training and preparation...... 163 5.2.1 Specific objective ...... 163 5.2.2 Activities...... 163 5.2.3 Lessons learned...... 164

5.3 Identifiying priority prevention areas in a region ...... 164 5.3.1 Specific objective ...... 164 5.3.2 Activities...... 164 5.3.3 Selection and description of PPAs...... 166 5.3.4 Lessons learned...... 169

5.4 Field visits to assess adequacy of HIV prevention in PPAs...... 170 5.4.1 Specific objectives ...... 170 5.4.2 Activities...... 170 5.4.3 Results of field visits to PPAs ...... 172 5.4.4 Most important venues in each PPA...... 175

5.5 Conclusions and recommendations...... 177

6. Future direction...... 178

7. References ...... 179

7

1. Background

1.1 Geography and population

The kingdom of Swaziland, situated in Southern Africa, is a small land locked country (17 364 km2) with an estimated population of 1 146 050 (2006), of which about 76 % reside in rural areas.

The country is roughly divided into four climatic zones running North to South. The farthest east lays the Lubombo plateau, followed by the lowveld, middleveld and the highveld to the west.

The altitude of the lowveld is 200m, 700m in the middleveld and 1200m in the highveld. Temperatures are highest in the lowveld while rainfall is higher in the highveld.

The country shares borders with South Africa (Kwazulu Natal province in the South and Mpumalanga province in the North and West) and Mozambique in the East.

The highveld is the most humid and cool of all the zones while the lowveld is the driest and hottest. The climates in the middleveld and the Lubombo plateau are moderate. These variations in landscape and climate throughout the country uniquely link certain diseases to specific zones and seasons.

It is important to note that Swaziland is divided into four administrative regions, Hhohho, Lubombo, Manzini and Shiselweni (Figure 1.1), and fifty five Tinkhundla {constituencies} (Table 1.1).

Figure 1.1

Geographical features and bordering countries Table 1.1 Projected population of Swaziland by region and Tinkhundla, 2006

HHOHHO Total LUBOMBO Total Tinkhhundla Tinkhhundla population population

Hhukwini 11410 Lomahasha 27846 Maphalaleni 22290 Mhlume 32965 Lobamba 25066 Matsanjeni North 14949 Mbabane East 45721 Sithobela 32661 Mbabane West 29488 Siteki 12650 Madlangempisi 18863 Siphofaneni 24290 Piggs Peak 24778 Nkilongo 23322 Mhlangatane 30805 Mpolonjeni 23568 Timphisini 11420 Hlane 2689 Ntfonjeni 23918 Dvokodvweni 36850 Nkhaba 17906 Lubuli 17363 Motjane 28259 Mayiwane 19169 Ndzingeni 22640 Total Regional pop. 331734 Total Regional pop. 249153 MANZINI Total SHISELWENI Total Tinkhhundla Tinkhhundla population population Ludzeludze 34185 Lavumisa /Somtongo 7215 Manzini North 33078 Maseyisini 27996 Manzini South 18589 Zombodze 22232 Manzini West (Kwaluseni) 41125 Mbangweni/Shiselweni II 31573 Ntondozi 15909 Matsanjeni 19446 Ngwempisi 35600 Shiselweni I 19308 Nhlambeni 15938 Sigwe 13815 Mkhiweni 27747 Sandleni 18035 Mthongwaneni 19250 Nkwene 8298 LaMgabhi 15118 Mtsambama 23653 eKukhanyeni 20339 Ngudzeni 9661 Mafutseni 15445 Gege 11524 Mahlangatsha 21227 Hosea 19826 Mahlanya/ Lobamba Lomdzala 23906 Kubuta 8784 Mangcongco 10312 Mhlambanyatsi 12480 Total Regional pop. 360248 Total Regional pop. 241365 It is essential to mention that 2.8 % annual population growth rate was used to make the projections, with the 1997 population census serving as the baseline. Using this growth rate, national population is estimated at 1 182 500 for 2006. These data were used for analysis in this report.

12 Table 1.2 Population by age group for the year 2006

Population Population Population aged aged aged Total population < 15 years < 5 years < 1 year

Number of 1 146 050 463 987 180 593 34 882 persons

Percentage of total population 100 % 41 % 16 % 3 %

Source: Central Statistics Population Estimates, 2006 using 1997 Census)

13 1.2 Economic profile

The economy of the country is primarily agriculturally with a growing manufacturing sector. The economy is closely linked to the economy of the Republic of South of Africa. The Kingdom of Swaziland experienced high economic growth levels of 9 % on average in the late 1980s. In recent years economic growth has severely slowed down, reaching an average of 3.4 % in the period 1990-1992. There is evidence of deepening poverty and hunger in the population.

However, the World Bank classifies the country as a lower middle income country with a gross domestic product (GDP) per capita income of US$ 1 387 (1999). Despite having a reasonable resource base compared to many developing countries, the majority of people (69%) in the country are classified as impoverished (2001/2002 SHIES), possibly due to poor distribution of available resources and rising unemployment.

While the country appears to have made significant economical development progress in the past, there is no doubt that these achievements are being curtailed by the effects of the HIV/AIDS epidemic and difficulties in attracting foreign direct investment (FDI).

1.3 Health profile

1.3.1 Health status

Available information shows that previous improvements of the health status are being eroded by the advent of HIV/AIDS. Indeed, life expectancy at birth increased from 44 years in 1966 to 58.8 years in 1997, a 14.4 year increase over 31 years. As a result of HIV/AIDS, however, life expectancy at birth fell to 40 years in 2003, an 18 year decrease over 6 years. Life expectancy continues to decline annually (MoEPD, 2003). 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). In fact, Crude Death Rate per 1 000 population increased from 13 in 1990 to 26.2 in 2005 (World Bank, 2006). Infant Mortality Rate (IMR) per 1 000 live births increased from 94.4 per 1 000 in 1990 to 108 in 2005.

The Maternal Death Review Audit 2001 indicated that out of 16 898 live births that occurred between January and December of 2000, there were 43 maternal deaths in four regional hospitals. Direct obstetric causes of maternal deaths accounted for 48.8% of all the deaths.

Malnutrition is associated with high morbidity and mortality among children under five, with almost 20% of children in the country found to be severely stunted and 5.1% severely underweight in 2004 (MOHSW & WHO, 2004).

14 Tuberculosis (TB) and HIV/AIDS continue to be a challenge in Swaziland. In 2005, 8 350 new confirmed TB cases were reported. The incidence of tuberculosis has increased from 300 per 100 000 people in 1990 to over 1 000 per 100 000 people in 2003 (MOHSW, 2003). It is currently estimated that in Swaziland there are about 230 000 people living with HIV/AIDS (PLWHA) of whom more than 34 500 are in need of ARVs. By December 2006, over 17 000 PLWHA had access to ART. The most recent sentinel surveillance report (2006) on HIV prevalence among TB patients shows that about 80 % of TB patients are coinfected with HIV.

Communicable diseases continue to be a major challenge for the country. According to Health Statistics Reports, respiratory conditions account for more than a quarter of all outpatient visits, having increased from 25.3% in 1995 to 26.4% in 2000. Reasons for admission included pulmonary tuberculosis, malaria, gastro-enteritis, colitis and pneumonia. Mortality was mostly caused by pulmonary tuberculosis, gastro-enteritis, colitis and pneumonia.

1.3.2 Health services

Taking into account private missions and public health services, health infrastructure consists of 7 hospitals, 8 public health units, 12 health centers, 162 clinics and 187 outreach sites. In addition, there are 73 mission health facilities (health centers, clinics and outreach sites), 53 private clinics and 22 industry-supported health centers and clinics. Currently, there is no functional referral system for rationalization of service delivery at the various levels, leading to congestion at the referral facilities.

1.4 Education profile

The education statistics report for 2004 states that there are 546 primary schools and 218,352 pupils (85% net enrolment rate). Slightly more boys (51.7%) than girls attend primary school. A total number of 189 secondary/high schools have a total enrolment of 66824 students (37% net enrolment). Girls in secondary and high schools are slightly more (50.5% and 50.3%) than boys. At university level, males are slightly more (51.9%) than female students. Primary school enrolment stood at 230 000 in 2002 with 82% residing in rural areas. Gender disparities in enrolment are very small. The teacher- pupil ratio was 1:34 at primary school and 1:18 at secondary and high school. Urban schools have a higher pupil-to- teacher ratio than rural schools.

The 1997 census recorded literacy to be 81.3% with males having slightly higher rates (82.6%) than women (80.2%). Literacy levels were estimated much higher (92%) among young who are aged 15 – 24 years compared to older generations of the population.

15

2. Service Availability Mapping (SAM) 2.1 Background

Strengthening national health information systems was identified as a priority in the World Health Organization’s (WHO’s) African Region at the 54th session of the Regional Committee (resolution AFR/54/R3). However, the most basic information on the availability of essential services and health resources is often incomplete.

The aim of SAM is to collect key information on the availability of health resources and interventions and to use the results for operations and strategic planning and management. In Swaziland, some of the information collected by SAM already exists in various formats. The benefits of SAM, however, are its systematic collection procedure and ‘user-friendly’ data presentation. Maps and summary measures generated through SAM provide a complete picture of the level and distribution of Regional resources, as well as highlight gaps in the provision of health services and interventions.

A key goal of health programmes is to make essential health services equally accessible to all individuals and communities in terms of availability, coverage, physical access and utilization. Several health measurement tools provide information on access, use and quality of services. These include household surveys, clinic-based statistics and facility surveys, but none are low cost rapid methods such as SAM.

2.2 Objectives

The objectives of the SAM were to:

ƒ provide national planners and decision-makers with information on the distribution of services within the country; ƒ provide baseline monitoring information for increasing the provision of key services such as antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT) and HIV Testing and Counselling (HTC); ƒ assess whether SAM can become a useful and feasible planning and monitoring tool at national and regional level. The specific objectives of the Priority Prevention Area (PPA) component of the Prevention Service Availability Mapping (PSAM) protocol are to:

ƒ identify PPAs where there is the greatest risk of HIV transmission; ƒ document the need for prevention activities in these areas; ƒ document prevention program coverage; ƒ identify gaps in program coverage using simple program coverage indicators and maps.

18 The PPA component is an adaptation of the first step of the Priorities for Local AIDS Control Efforts (PLACE) protocol. The rationale for the PPA component of PSAM arises from HIV surveillance data and epidemiologic models that show that HIV incidence is higher in areas where there is a concentration of people engaging in high risk sexual behaviour. PPAs are areas where national and regional informants believe that people are most likely to engage in high risk behaviors such as commercial sex and where HIV/AIDS prevention programs are most needed. Examples of PPAs include towns, border crossings, or areas along transportation routes.

2.3 Methodology

SAM is a rapid assessment tool that generates information on the availability of specific health services, health infrastructure and human resources for health in each region. It also determines the availability of HIV prevention interventions within health facilities, schools and communities.

Four brief questionnaires, one for regions, a second for health care facilities, a third for schools and a fourth for PPAs, were programmed into a personal digital assistant (PDA). Each questionnaire consisted of several sections. These questionnaires were designed to explore the availability of and quantify human resources, infrastructure and services in the region as a whole as well as at the facility level. Additionally, the availability of HIV prevention resources and interventions at the school and community levels were evaluated.

Under the supervision of M & E Unit in the Ministry of Health and Social Welfare, the SAM regional questionnaire was applied in Swaziland's four regions: Hhohho, Lubombo, Manzini and Shiselweni. Twenty PPAs were included as part of the HIV prevention component of this exercise. Four teams were established, one for each region. Each team was composed of two data collectors, one supervisor and one driver. The data collection started on 17 July and ended on 11 October 2006.

It is important to state that, regardless of ownership, all hospitals, health centres, public health units and clinics recognized by health regional health authorities were covered during SAM survey. It should also be noted that outreach health facilities, first aid stations as well as clinics run by private practitioners without particular interest in HIV/AIDS interventions were not visited.

It is also important to state that, regardless of ownership, the schools that were not given permission by the regional education boards were not covered during the survey, yet Swazi students are taking classes.

19 Figure 2.1 Data processing procedure

The SAM regional questionnaire was applied in Swaziland's four regions: Hhohho, Lubombo, Manzini and Shiselweni. National level work included facility and school censuses in 55 Tinkhundla. 20 PPAs were also included as part of the HIV prevention component of this exercise.

20

3. Results, health services survey

21 3.1 Foreword

The implementation of SAM in Swaziland was not an easy task. However, with the commitment and determination of the Ministry of Health and Social Welfare and the financial and technical support from the World Health Organization, our goal was fully achieved.

Service Availability Mapping is no doubt a very important and valuable tool in terms of management of health programmes and planning for their improvement. Indeed, Service Availability Mapping is going to facilitate the visualization of inequities between and within regions in terms of availability of key health services based on priorities of the Ministry of Health and Social Welfare.

Its added value is that it offers an easy to use and a simple way of presenting data that is relevant at the national and regional levels. It does combine health and non-health data which impact on health into a single format that facilitates decision-making and promotion of intersectoral collaboration.

In the very near future SAM will be fully integrated into the overall national monitoring and evaluation framework for health at national and regional levels, not only to facilitate decision making and planning processes as has been indicated above, but also to serve as an advocacy tool to development partners. In fact, through SAM, development partners will be fully informed of the performance of our health services, where we are and where we came from, and then define knowingly their contributions to different health programmes they would like to support.

In this regard, I appeal to our international and national partners, including the United Nation Agencies, Multilateral and Bilateral Agencies, National Institutions and NGOs to fully support this initiative that has shown its valuable and determinant role in management of health programmes at all levels. With your support, the Ministry of Health will be able to regularly and effectively monitor and assess our health programmes and take at the opportune moment all necessary corrective measures for their strengthening in order to meet the needs of the population

I would like to take this opportunity to congratulate our health workers for the good work they are doing as it has transpired through this exercise. Since this exercise will be carried out every two years, I encourage them to continue to effectively participate in SAM which constitutes a very good opportunity to show to the world what they are doing in terms of health promotion and care delivery.

Nomathemba Dlamini,

The Principal Secretary

Ministry of Health and Social Welfare

22 3.2 Executive summary

The 2006 Service Availability Mapping (SAM) in Swaziland provides a comprehensive baseline picture of service availability in the regions and health care facilities of the country.

3.2.1 Regional results

The survey has revealed that for some services, there were no differences between regions, whereas for others, disparities between regions were blatant. For example, health facilities (number of hospitals, public health units, and health centres and clinics) per 100 000 inhabitants revealed no significant difference between regions. The number of inpatient beds per 100 000 inhabitants, however, were twice as high (226) in Manzini region compared to Shiselweni region (106). In addition, the Lubombo region had more than twice the number of Community Health Workers per 100 000 population (427) than Shiselweni region (174).

The survey indicated more efforts need to be made in the development of new technology. Only two regions (Lubombo and Manzini) have access to computer services, whereas in all the other regions there is no internet access.

3.2.2 Results from health facilities

Access to safe water needs improvement, particularly in Shiselweni and Lubombo regions where 45% and 25% of health facilities, respectively, had tanker trucks as a source of water.

Swaziland faces a very large challenge regarding human resources for health (HRH). The number of doctors per 100 000 population was estimated at 10, for nurses at 56 and midwives at 64. The HRH crisis is most severe in the Lubombo and Shiselweni regions.

Equiptment shortages were not as alarming as HRH shortages, however, they are noreworthy. Microscopes were found to be present in only 20.1 % of health facilities, microscope slides in 33.1 % of health facilities, suction machines in 26 % of facilities, otoscopes in 44.8 % of health facilities and emergency transport in only 7.1% of health facilities.

In general, the situation of essential drugs was not as extreme as expected. Oral and injectable antibiotics were available in 98.8% and 79.2% of health facilities respectively, folic acid and iron were available in 92.8% of health facilities and vitamin A in 87.6% of facilities. It is important to note that less available medecines included oxytocin, available in 30.5% of health facilities, magnesium sulfate, available in 29.8% of facilities, and artemisin-based combination therapy (ACT), available in only 5.2% of health facilities.

23

The survey indicated that laboratory services need to be strengthened. Few health facilities were able to perform laboratory tests on site. Only 10.4% of health facilities declared having the capacity to perform sputum examination, 13 % had the capacity to carry out Giemsa straining for malaria, 39.6 % were able to measure blood sugar level and 16.9 % of health services had the capacity to perform full blood count.

About 94.1 % of health facilities were offering ANC services and 89.6 % immunization services. Only 35 % of health facilities declared having delivery beds and 20.8 % maternity beds.

HIV/AIDS-related services are offered in various regions of the country. Seventy one percent of health facilities were offering NVP/AZT for PMTCT, 68 % were offering HTC, 14.3 % were offering ART and 13.6 % were offering Post Exposure Prophylaxis (PEP.

With 57.7 % of health facilities meeting the minimum STI case management criteria, STI management seems to be satisfactory across all regions compared to other programmes. It is encouraging to note that about 79 % of health facilities had TB drugs. As expected it appeared that malaria control efforts were being focused to Lubombo region. In fact, whereas about 28.6 % of health facilities in Lubombo region met the minimum criteria for malaria case management, only 5.7 % of health facilities met the minimum criteria in Manzini region. It is also important to note that whereas first line treatment was available in 83.7 % of health facilities, second line treatment was available in only 51.9 %.

While all important commodities for managing hypertension (blood pressure machine, stethoscope, weighing scale for adults and drugs for hypertension) seemed to be available in the large majority of health facilities, only 39.6 % of health facilities declared having the capacity to determine blood sugar level in order to monitor diabetes.

The survey showed that male circumcision services were offered in 7.7% of health facilities during the month preceding the survey, most of them being located in Hhohho region.

24 3.3 Regional results

3.3.1 Health infrastructure

Health facilities

Service Availability Mapping visited 154 health facilities in the country which correspond to 13 facilities per 100 000 inhabitants. Of these, 36 (23.4 %) declared having 1 755 inpatient beds which corresponds to 148 beds per 100 000 inhabitants.

Manzini Region has the highest density of health facilities with 14 facilities per 100 000 inhabitants and Shiselweni the lowest with 11 facilities per 100 000 inhabitants (Table 3.1).

Table 3.1 Number of health facilities and hospital beds per 100 000 inhabitants

Population Total Facilities Number of Number of Number of Region per region number of per 100 000 facilities inpatient inpatient health inhabitants with beds per beds* per facilities inpatient region 100 000 beds inhabitants HHOHHO 331 734 40 12 9 383 115 LUBOMBO 249 153 35 14 9 302 121 MANZINI 360 248 52 14 14 813 226 SHISELWENI 241 365 27 11 4 257 106 TOTAL 1 182 500* 154 13 36 1 755 148 * Estimated population from 1997 census by applying 2,8 as annual population growth

Figure 3.1 indicates the number of beds per 100 000 inhabitants in the 4 regions. With 226, Manzini region has the highest number of beds per 100 000 inhabitants and Shiselweni the lowest with 106 beds.

Figure 3.1 Number of beds per 100 000 inhabitants by region

250 226

200

150 121 115 106 100

50 Number of beds per per beds of Number 100 000 inhabiatants 0 Hhohho Lubombo Manzini Shiselweni Regions

25 Laboratory capacity

From table 3.2, it can be seen that the infrastructure to carry out essential laboratory tests, whether privately or publicly, is very good in all regions. All regions have the capacity to handle tests measuring blood count, blood sugar level, haemoglobin level, liver function, RPR/VDRL, HIV antibody testing, sputum examination and giemsa stain for malaria. CD4 cell count currently cannot be performed in Manzini Region and antibody tests for hepatitis B cannot be performed in Lubombo Region.

Table 3.2 Laboratory capacity, by region

Laboratory tests Regions Hhohho Lubombo Manzini Shiselweni Full blood count Yes Yes Yes Yes Blood sugar level Yes Yes Yes Yes Hemoglobin (Hb) Yes Yes Yes Yes Liver Function Yes Yes Yes Yes CD4 cell count Yes Yes No Yes RPR/VDRL for syphilis Yes Yes Yes Yes HIV antibody test Yes Yes Yes Yes Hepatitis B Yes No Yes Yes Sputum Exam Yes Yes Yes Yes Giemsa Stain for malaria Yes Yes Yes Yes

Blood safety services

All regions have blood transfusion services with no interruptions in supply, as shown in Table 3.3. Blood testing was reported to be done in all regions Blood is voluntarily donated in all regions except in case of emergency, as indicated by regional health oddicers, when blood is collected for transfusion from relatives of the patient.

Table 3.3 Blood services by region

Description of service Regions Hhohho Lubombo Manzini Shiselweni Blood Transfusion services Yes Yes Yes Yes Interruptions in supply Yes Yes Yes Yes Blood testing Yes Yes Yes Yes Blood Donors Yes Yes Yes Yes - Voluntary Yes Yes Yes Yes - Paid No No No No - Relatives Yes Yes Yes Yes

26

27 Injection equipment

Information regarding injection equiptment is summarized in Table 3.4. Most needles used for injection within the country are disposable, as opposed to auto-destruct or reusable needles. The most common sterilization procedure for all regions is autoclave.

Table 3.4 Situation of injection equipment in regions

Region Commonly used Most common sterilization needles procedure Hhohho Disposable Autoclave Lubombo Disposable Autoclave Manzini Disposable Autoclave Shiselweni Disposable Autoclave

Oxygen, indoor spraying and X-ray

Table 3.5 shows that oxygen and X-ray services are provided in all regions in the country. Indoor spraying for malaria is only done in Lubombo where malaria seems to be predominant due to climatic conditions.

Table 3.5 Availability of some specific services in regions

Type of services provided Regions Hhohho Lubombo Manzini Shiselweni Oxygen Yes Yes Yes Yes X-ray Yes Yes Yes Yes Indoor spraying for malaria No Yes No No Indoor spraying for malaria for No Yes No No previous/current season

28 Communication technology

Only two regions (Lubombo and Manzini) reported having functional computers for use by regional health teams, however no regions have computers with internet access. As can be seen in Table 3.6, all regions have landline connections and cellular networks.

Table 3.6 Availability of selected communication equipment, by region

Land line Cellular phone Access to Computers with Region connections networks computers internet access Hhohho Yes Yes No No Lubombo Yes Yes Yes No Manzini Yes Yes Yes No Shiselweni Yes Yes No No

3.3.2 Service availability

HIV/AIDS treatment

At the regional level, the objective of SAM was to have an idea of the availability of key services such as Post Exposure Prophylaxis (PEP), Prevention of Mother to Child Transmission (PMTCT) of HIV, HIV Antibody Testing and Counselling and Antiretroviral Therapy (ART). The issue of training health workers was also looked into with focus to Integrated Management of Adult Illness, including provision of Antiretroviral Therapy (IMAI/ART), HIV testing and counselling (HTC), PEP, and nutrition (within the context of HIV). As summarized in Table 3.7, all regions reported facilities that were able to provide these HIV-related services.

The same table summarizes the percentage of facilities by region that have staff trained in HIV/AIDS related areas. During the last 2 years, more than 50 % of staff had been trained in HIV counselling and testing as well as in PMTCT. More than 50% of staff were trained for IMAI/ART in Lubombo and Manzini, whereas in Hhohho and Shiselweni less than 50% of the staff were trained. Manzini and Hhohho managed to train more than 50% of health workers in HIV testing and counseling. Manzini is the only region where less that 50 % of the staff have been trained in HIV testing. As far as PEP is concerned, only Lubombo and Shiselweni have trained more than 50 % of their staff. Manzini is the only region for which more than 50 % of the staff have been trained in nutrition.

29 Table 3.7 Percentage of facilities by region with staff trained

HIV HIV HIV Regions IMAI/ART counseling PEP PMTCT Nutrition counseling testing and testing Hhohho <50% >50% >50% >50% <50% >50% <50% Lubombo >50% <50% >50% >50% >50% >50% <50% Manzini >50% >50% <50% >50% <50% >50% >50% Shiselweni <50% <50% >50% >50% >50% >50% <50%

Maternal and child health

More than 50% of health personnel in all regions have been trained in Integrated Management of Childhoos Illness (IMCI). All regions excluding Shiselweni indicated more than 50% of staff having been trained in safe motherhood (Table 3.8).

Table 3.8 Percentage of facilities by region with staff trained in IMCI and safe motherhood

Services Regions IMCI Safe motherhood Hhohho >50% >50% Lubombo >50% >50% Manzini >50% >50% Shiselweni >50% <50%

Tuberculosis case management

All regions reported to have tuberculosis (TB) diagnostic laboratory facilities and to provide TB treatment.

Efforts have been made in all regions to train health workers in TB case management regardless of regional variations of the disease.

30 3.3.3 Social marketing programmes

The presence of social marketing programmes in regions was also assessed. These marketing programmes concerned condoms, insecticide-treated bed nets for malaria prevention, and immunization. As indicated in table 3.9, indoor residual spraying marketing programmes were common in the Lubombo region (>50%). In Hhohho, Shiselweni and Manzini coverage was found to be less, with zero coverage in Manzini. Coverage of social marketing programmes for insecticide treated bed nets was found to be more than 50% in Lubombo region and zero in other regions. Social marketing programmes for immunization coverage was greater than 50% in all four regions. All regions have carried out social marketing programmes for condom use.

Table 3.9 Coverage of marketing programmes, by region

Regions Interventions Hhohho Lubombo Manzini Shiselweni Indoor residual spraying for <50% > 50% 0 % <50% Malaria Insecticides treated bed nets - >50% - - Immunization coverage >50% >50% >50% >50% Condom social marketing Yes Yes Yes Yes programmes

Table 3.10 indicates regional differences in user payment for medicines and other commodities in both public and private non-profit facilities. In all regions, ARVs, TB drugs, oral rehydration salts (ORS), delivery kits and oral contraceptives are provided free of charge. However, in Manzini, patients have to pay to access pain relief drugs and medicines to treat opportunisitic infections (OI).

31 Table 3.10 Payment for drugs and commodities (supplies)

Regions Drugs and medical supplies Hhohho Lubombo Manzini Shiselweni TB treatment No No No No Pain relief drugs for No No Yes No HIV/AIDS patients Drugs for treatment of OI’s No No Yes No ARV’s No No No No Antibiotics to treat No No No No pneumonia among children under 5 years ORS’s No No No No Delivery kits No No No No Oral contraceptives No No No No

3.4 Facility census results

3.4.1 Health infrastructure

Health facilities

As already indicated, during the SAM survey a total of 154 facilities were visited nationwide, including 1 national referral hospital, 3 regional referral hospitals, 3 sub- regional hospitals, 6 primary health units, 12 health centers and 129 clinics. It is important to mention that in Hhohho Region, Mbabane Government Hospital plays both roles of National and regional referral hospital. It can be also noted that out of 129 clinics, 44 (34 %) are located in Manzini region (Table 3.11).

Table 3.11 health facilities by region and by type

National Regional Sub Public Public Private Public Private Private Region Ref. Ref. Regional Health Health Health Total Clinic Hospital Clinic Hosp. Hosp. Hosp. Unit Center Center

HHOHHO 1 0 1 2 2 32 2 0 0 40

LUBOMBO 0 1 0 1 1 28 1 3 1 36

MANZINI 0 1 2 2 0 38 1 3 5 52

SHISELWENI 0 1 0 1 2 20 0 0 2 26

Total 1 3 3 6 5 118 4 6 8 154

32

Figure 3.2 shows that there is less than one hospital and one public health unit per 100 000 inhabitants in all regions, however there are at least 10 health centers or clinics per 100 000 inhabitants per region.

Figure 3.2 Number of hospitals, public health units, health centers and clinics per 100 000 inhabitants by region

13 13 14 11 12 10 10 8 6

inhabitants 4 Number of health health of Number 2 0.6 0.8 0.4 facilities per 100 000 per facilities 0.6 0.4 0.4 0.5 0.4 0 Hhohho Lubombo Manzini Shiselweni Regions

Hospitals Public health units Health centres and clinics

Seventy-eight were public facilities, 18 were private for profit, 9 were private non-profit, 34 were mission facilities, and 15 were industry facilities. Whereas there are 5 private non- profit health facilities in Hhohho, there were none in Lubombo region. It should be also noted that there is no industrial health facility in Shiselweni region (table 3.12).

Table 3.12 Health facilities by region and type of ownership

Private non Private for Region Government Mission Industry Total profit profit Hhohho 19 5 11 2 3 40 Lubombo 19 0 8 2 7 36 Manzini 21 2 12 12 5 52 Shiselweni 19 2 3 2 0 26 Total 78 9 34 18 15 154

33 Communications

The majority of facilities have functional land line telephones (84%), and only 70 % have access to cellular phone services. In general, about 21 % facilities have a functional computer and 12 % have access to the internet (table 3.13).

Table 3.13 Communication facilities in health facilities

Regions Facilities Facilities with Facilities with Facilities with Facilities with by region telephone cellular phone computer internet Number % Number % Number % Number %

Hhohho 40 37 93 34 85 7 18 3 8

Lubombo 35 27 77 30 86 8 23 6 17

Manzini 52 42 81 21 40 13 25 8 15

Shiselweni 27 24 89 23 85 5 19 2 7

Total 154 130 84 108 70 33 21 19 12

Referring to regions, whereas the majority of health facilities have access to the telephone, computers are less accessible with 25 % for Manzini (the highest) and 18 in Hhohho (the lowest). For internet, the situation is worse since the percentage of health facilities with access to internet is between 17 % in Manzini region and 7 % in Shiselweni regions (figure 3.3).

34

35

36

37

38

39 Figure 3.3 Percentage of facilities with specific communication facilities per region

100 93 89 77 81 80 60

Percentage 40 25 18 23 19 20 17 15 8 7 0 Hhoho Lubombo Manzini Shiselweni Regions

Telephone Computer Internet

Water source

In all regions the most common source of water was piped water, with 66.8 % of all health facilities surveyed in the country accessing water through this route. The second most common route of water access in all regions is by tanker truck, with 17% of all health facilities accessing water in this way. Approximately 6% oh health facilities reported rain or surface water as their main source of water. There was only one health facility in the country without any specified source of water located in Manzini region (table 3.14).

Table 3.14 Main water source for health facilities by region

Open Covered/ Surface/ Tanker No Region Piped water Rain Total borehole River Truck water well Hhohho 32 1 2 0 1 4 0 40 Lubombo 17 0 3 3 3 10 0 36 Manzini 41 2 4 3 0 1 1 52 Shiselweni 13 0 2 0 11 0 26 Total 103 3 11 6 4 26 1 154

40

41 Figure 3.4 Type of water source (percentage) of health facilities by region

80 80 79 60 48 48 45 40 Percentage 25 20 10 9 9 5 9 4 7 6 7 2.5 2.5 0 0 2 2 0 0 0 0 0 0 0 0 Hhohho Lubombo Manzini Shiselweni Regions

Piped water Open water well Covered borehole Surface/river Rain Tanker Truck No water source

Sterilization

Sterilization by autoclave is the most common method of sterilization in health facilities in Hhohho and Lubombo (35% and 49% respectively), while sterilization by boiling pot is the most common method in health facilities in Manzini (29%). Sterilization by autoclave and "other" methods of sterilization are tied as the most common methods of use in Shiselweni (both 37%). On the national level sterilization by autoclave is the most common method of use (36%), followed by "other" methods (25%), sterilizers (18%), boiling pot (15%) and pressure pot (6%)(Table 3.15).

Table 3.15 Sterilization methods in health facilities by region

Sterilization Method Region Autoclave Sterilizer Pressure Pot Boiling Pot Other Number % Number % Number % Number % Number % Hhohho 14 35 11 28 3 8 6 15 6 15

Lubombo 17 49 7 20 0 0 1 3 10 29

Manzini 14 27 7 13 3 6 15 29 12 23

Shiselweni 10 37 2 7 4 15 1 4 10 37

Total 55 36 27 18 10 6 23 15 38 25

42 3.4.2 Human resources

There were a total of 174 doctors working full time in the health facilities visited during the survey, and, of these, 45 (25.8%) were Swazi nationals. Eleven facilities in Manzini, 9 facilities in Hhohho, 5 facilities in Lubombo and 1 facility in Shiselweni reported having doctors on part-time basis.

There were 44 family nurse health practitioners reported, of which 88.6% were Swazi nationals. Ninety-four percent of the 759 midwives reported were Swazi nationals, 73% of the 197 nurses reported were Swazi nationals and 98% of the 426 nursing assistants reported were Swazi nationals.

Seventy-five percent of the 40 reported laboratory technicians were Swazi nationals. Thirteen laboratory assistants were reported, however their nationalities were not noted.

Hhohho region has a high proportion of the country`s radiographers, physiotherapists, anesthesiologists and nutritionists. The only two psychologists reported to be working in the country are both deployed in Manzini region (Table 3.16).

Table 3.16 Health workers in health facilities by region

Health personnel Hhohho Lubombo Manzini Shiselweni Total categories All Swazi All Swazi All Swazi All Swazi All Swazi Doctors 83 24 24 3 54 15 13 3 174 45 Family nurses 17 14 6 6 9 8 12 11 44 39 Midwives 239 225 127 121 284 266 109 107 759 719 Nurses 73 73 31 22 69 28 24 21 197 144 Nurse assistant 141 137 93 92 129 125 63 63 426 417 Pharmacists 7 6 4 3 5 1 1 1 17 11 Laboratory 11 8 6 6 17 12 6 4 40 30 technicians Laboratory assistant 5 - 4 - 4 - 0 - 13 - Radiographers 12 - 7 - 9 - 4 - 32 - Physiotherapists 6 - 1 - 3 - 0 - 10 - Anesthesiologists 9 - 3 - 4 - 0 - 16 - Nutritionists 3 - 0 - 1 - 0 - 4 - Psychologists 0 - 0 - 2 - 0 - 2 -

In total, 395 HIV/AIDS counselors were reported to be working at health facilities in the country with a high concentration (45.5%) in Manzini region. Shiselweni region reported only 6.8% of the HIV/AIDS counselors to be working in the region. Manzini region also

43 had the highest proportion of health service managers with 56% of the country`s health service managers working in the region.

Regarding community workers, 3 726 were reported of which 35.6% were in Manzini and 11.2% in Shiselweni. It is important to mention that only 14 social workers were reported for the whole county (Table 3.17).

Table 3.17 Other categories of human resources in health facilities by region

Categories Hhohho Lubombo Manzini Shiselweni Total HIV Counselors 87 101 180 27 395 Environmentalists 16 11 9 7 43 Social workers 5 2 6 1 14 Community 913 1 063 1 330 420 3 726 workers Dispensers 14 14 18 9 55 HIS Officers 15 4 9 6 34 Orderlies 122 73 231 146 572 Health service 13 12 41 7 73 managers

Hhohho region had the highest doctor to patient ratio with 25 doctors per 100 000, 1.7 times larger than the national average of about 15 doctors per 100 000 inhabitants.,Manzini`s doctor to patient ratio was the same as the national average with 15 doctors per 100 000 inhabitants. The doctor to patient ratio in Lubombo and Shiselweni regions both fell below the national average, with Shiselweni`s ratio being only one third of the national average at 5 doctors per 100 000 inhabitants (Table 3.18).

The highest ratio of nurses to patients in the country is 70 nurses per 100 000 inhabitants in Hhohho region, followed by Manzini and Shiselweni lingering near the national average of 56 nurses per 100 000 inhabitants. Shiselweni was the least served with 41 nurses per 100 000 inhabitants. All regions reported a total of 759 midwives, a midwife to patient ratio of 64 per 100 000 inhabitants. Manzini reported the highest concentration of midwives with 79 midwives per 100 000 inhabitants. Shiselweni had the lowest reported concentration of midwives at 45 midwives per 100 000 inhabitants (Figure 3.5).

The high concentration of human resources for health, mainly doctors, midwives and nurses, compared to other regions is due to the presence of Mbabane Government Hospital which serves as both a regional and national referral hospital.

44

Table 3.18 Doctors, nurses and midwives per 100 000 population

Doctors Nurses* Midwives Region Population Num Ratio Num Ratio Num Ratio Hhohho 331 734 83 25 231 70 239 72 Lubombo 249 153 24 10 130 52 127 51 Manzini 360 248 54 15 207 57 284 79 Shiselweni 241 365 13 5 99 41 109 45 Total 1 182 500 174 15 667 56 759 64 * Nurses, family nurses and assistants nurses

Figure 3.5 Doctors, nurses and midwives per 100 000 population

80 79 72 70 70 60 57 51 52 50 45 41 40

Number 30 25 20 15 10 10 5 0 Doctors Midwives Nurses

Hhohho Lubombo Manzini Shiselweni

There is not to a sufficient number of community workers for the populations they are supposed to serve. Shiselweni region reported the lowest worker to patient ratio with 174 health workers per 100 000 health workers, just over one-half of the national average of 315 community workers per 100 000 inhabitants. Manzini reported the highest number of community health workers with 427 per 100 000 inhabitants.

45 Figure 3.6 Number of community health workers per 100 000 inhabitants by region

500 427 400 369 300 275 200 174 inhabitants 100 workers per 100 000 per workers Number of community 0 Hhoho Lubombo Manzini Shiselweni Regions

46

47 3.4.3 Basic equipment

Equipment availability in hospitals

All hospitals visited had basic equipment in place such as X-ray machines, oxygen systems, autoclaves, infusion kits and operating theatres.

Other basic equipment which were available in hospitals included anesthesia machines and operating tables, hemocytometers cytoflometers, ambulances, latex gloves, refrigerators, microscopes and microscope slides (Table 3.19).

Table 3.19 Selected basic equipment in hospitals (table to be reviewed)

Type of equipment Region Total Hhohho Lubombo Manzini Shiselweni Cytoflometer 1 1 1 1 4

Haemocytometer 3 2 2 1 8

Anesthesiology machine 4 2 4 1 11

Operating equipment 4 4 5 1 14

Infusion kit 5 4 6 1 16

Autoclave 7 5 3 1 16

Oxygen machine 5 4 6 1 16

X-ray machine 6 4 5 1 16

Equipment availability in health facilities

Table 3.20 and figure 3.7 show that some equipment is present in almost all health facilities. Refrigerators are present in 93.5 % of health facilities, latex gloves available in 96.8 % of facilities, blood pressure machine present in 94.8 % of all health facilities, stethoscope present in 98.1 % of all health facilities, adult weighting scale available in 94.8 % of health facilities, weighting scale for under five present in 89.6 % of all health facilities, tongue depressor present in 90.9 % of all health facilities. However, some equipment is less common in health facilities such as microscopes (available only in 20.1 % of health facilities), microscope slides (available in 33.1 % of health facilities), suction machines (available in 26.0 % of health facilities), otoscopes (available in 44.8 % of health facilities) and emergency transport (available in 7.1 % of health facilities).

48 Table 3.20 Basic equipments in health facilities

Region Total Type of equipment Hhohho Lubombo Manzini Shiselweni Number % Microscope 8 8 11 4 31 20.1 Microscope slides 12 23 10 6 51 33.1 Latex gloves 40 34 50 25 149 96.8 Blood pressure machine 37 32 51 26 146 94.8 Stethoscope 39 35 51 26 151 98.1 Adult weighting scale 38 33 50 25 146 94.8 Weighting scale for < 5 year-old 35 32 45 26 138 89.6 Oral thermometer 38 34 50 26 148 96.1 Physical examination table 40 35 52 25 152 98.7 Speculum 28 26 34 22 110 71.4 Otoscope 16 20 25 8 69 44.8 Tongue depressor 36 34 48 22 140 90.9 Suction machine 10 11 13 6 40 26.0 Refrigerator 38 34 46 26 144 93.5 Emergency transport 4 2 4 1 11 7.1

Figure 3.7 Percentage of health facilities per equipment

Emergency transport 7.1 Refrigerator 93.5 Suction machine 26 Tongue depressor 85.1 Otoscope 44.8 Speculum 71.4 Physical examination table 98.7 Oral thermometer 96.1 Wighting scale for under 5 89.6 Adult weighting scale 94.8 Type of equipment Stethoscope 98.1 BP machine 94.8 Latex gloves 96.8 Microscope slides 33.1 Microscope 20.1

0 20406080100120 Percentage

49 3.4.4 Availability of essential drugs in health facilities

As indicated in Table 3.21 and Figure 3.8, common drugs such as injectable and oral antibiotics and contraceptives, iron, folic acid, vitamin A, antihypertensive drugs, the measles vaccine, ibuprofen/paracetamol and ORSs were available in at least 79% of all health facilities surveyed. First and second line treatment for malaria were present in 83.7% and 53.9% of all health facilities respectively.

TB drugs were available in 79.9 % of all health facilities and ergometrine in 69.5 % of facilities.

Some special drugs such as oxytocin and magnesium sulfate were less prevalent in health facilities with 30.5 % and 29.8 % availability, respectively. Artemisin combination therapy (ACT) for malaria was available in only 5.2 % of facilities.

Table 3.21 Availability of basic drugs in health facilities by region

Region Total Basic drugs Hhohho Lubombo Manzini Shiselweni Number % Injectable antibiotics 40 33 49 25 122 79.2 Oral antibiotics 40 36 50 26 152 98.7 Injectable contraceptive 31 28 42 23 124 80.5 Oral contraceptive 33 31 42 23 129 83.8 Iron 40 34 43 26 143 92.8 Folic acid 39 33 45 26 143 92.8 Vitamin A capsule 35 34 43 23 135 87.6 Measles vaccine 36 34 42 24 136 88.3 Ibuprofen/panadol 35 31 43 23 132 85.7 First line malaria drug 33 32 42 22 129 83.7 Second line malaria drug 22 24 20 17 83 53.9 Artemisin combination therapy 2 1 5 0 8 5.2 Antihypertensive drug 35 36 48 26 145 94.1 Magnesium sulfate 18 7 14 7 46 29.8 Ergometrine 29 25 32 21 107 69.5 Oxytocin 11 6 17 13 47 30.5 Tuberculosis drugs 29 29 39 26 123 79.9 ORS 38 33 49 26 146 94.8

50 Figure 3.8 Percentage of health facilities with specified essential drugs

S 94.8 R O 79.2 s g u r d 30.5 B in T c o t y x 69.5 O e in r t e 29.8 m e o t g a r lf E u s 94.1

s m g iu u s r e d 5.2 n e n g v i io a s t M n a e a 53.9 t n r i ia e b r p la m y a h o i c m 83.7 t a n e i in r A s n a i li l a m d Type of drug Type t m 85.7 r n l A o e o c n d e i a l S t n s a 88.3 r i /p e n F n i e c f c o r a 87.6 v A p u s it e Ib l V s a 92.8 e id M c a c li 92.8 o n F o Ir 83.8 c a tr n o c 80.5 l c a a r r t O n o 98.7 C io j. ib In t n a 79.2 l o a r b ti O n 0 102030405060708090100 A j. In

Percentage

51 3.4.5 Laboratory capacity

In general laboratory capacity seemed to be weak in all regions. Whereas for HIV antibody test about 74 % of all health facilities declared to have the capacity to perform the test on site, only 39.6 % of health facilities were able to perform the test for glucose blood level on site, 32.4 % RPR/VDRL, 26 % the test for hemoglobin, 16.9 % for full blood count, 10.3 % for sputum examination. 7.8 % for hepatitis and 11 % for liver function tests (table 3.22 and figure.3.8)

For health facilities without the capacity to carry out the test on site, samples were sent to the next level for examination and results were received within 7 or 14 days. These health facilities represented about 53.8% for RPR/VDLRL, 24% for HIV antibodies, 81.8% for sputum examination, 83.1 % for liver function, 88.3 % for hepatitis test 77.2% of full blood count and hemoglobin testing. Referring to health facilities that were receiving laboratory results within one week, there were 2.6% for HIV antibodies, 5.2% for full blood count and hemoglobin, 7.1% for hepatitis, 3.2% for blood glucose level, 16.8% for RPV/VDRL, 5.8% for liver function and 8.4% for sputum examination (table 3.22).

Table 3.22 Performance of laboratory tests in health facilities

Laboratory Hhohho Lubombo Manzini Shiselweni Total Test On 7 14 On 7 14 On 7 14 On 7 14 On 7 14 site days days site days days site days days site days days site days days HIV antibodies 31 2 7 30 0 6 33 4 14 20 0 6 114 4 33 Hemoglobin 10 0 30 11 2 23 11 5 31 8 1 17 40 8 101 Full blood 8 1 30 5 2 26 8 5 34 5 0 21 26 8 111 count Hepatitis B 5 2 32 1 3 30 5 5 40 1 1 23 12 11 125 Blood glucose 14 1 24 19 0 17 20 3 27 8 1 17 61 5 85 level Giemsa strain 6 4 27 7 1 19 3 5 37 4 2 17 20 11 100 for malaria RPR or VDRL 8 8 8 12 5 11 15 10 22 5 3 15 50 26 57 Liver function 6 0 33 4 2 26 4 6 38 3 1 22 17 9 119 Sputum 4 1 31 5 3 25 4 7 37 3 2 20 16 13 113 examination

52 Figure 3.9 Percentage of health facilities with capacity to perform some laboratory tests on site

n 10.4 tio ina m a x 11 e tion nc u putum f S r 32.4 ve L R Li D /V R P R 13 laria 39.6 in for ma ra st a 7.8

Giems atitis Blood sugarp level Hae 16.9 ount c 25.9 blood Full globin o 74 Hem s bodie 0 102030405060708090100 nti IV a H

3.4.6 Service availability

Mother and Child health (MCH)

MATERNITY SERVICES

Table 3.23 describes MCH infrastructure availability. Among the 154 health facilities, 54 reported having delivery beds and 32 maternity services. About 35 % of facilities with delivery beds were in Manzini, 33.3 % in Lubombo, 22.2 % in Hhohho and only 9.3 % in Shiselweni. Only 35% of the health facilities surveyed in the country were reported to have delivery beds, and only around 21% were reported to have maternity services. Among the 32 facilities with maternity services, 40.6 % were in Lubombo region, 28.2 % in Manzini region, 21.8% in Hhohho region and 9.4 % in Shiselweni region. Whereas the number of delivery beds reported by the 54 facilities was 105, the number available beds in maternity services as reported by 32 health facilities was 289.

53 Table 3.23 MCH infrastructures by region

MCH Infrastructures

Regions Facilities with delivery beds Facilities with maternity bed Number of Number of beds Number of Number of beds facilities facilities Hhohho 12 27 7 110 Lubombo 18 23 13 61 Manzini 19 34 9 69 Shiselweni 5 3 3 40 Total 54 87 32 280

In terms of percentage of health facilities equipped with beds for delivery and maternity services, Lubombo region was better equipped relative to other regions with 51.4 % and 37.1 % of facilities reported having delivery and maternity beds respectively. Shiselweni region was the least equipped with 18.5 % of health facilities with delivery beds and 11.1 % with maternity beds (Figure 3.10).

Figure 3.10 Percentage of health facilities with delivery and maternity beds by region

60 51.4 50 40 37.1 36.5 30 30 Percentage 17.5 17.3 18.5 20 11.1 10 0 Hhohho Lubombo Manzini Shiselweni Regions

Percentage of facilities with delivery beds Percentage of facilities with maternity beds

54

55 MATERNAL AND CHILD HEALTH GUIDELINES

A majority of health facilities had IMCI guidelines (63.6 %). PMTCT guidelines were available in 91 (59%) of health facilities, pediatric HIV/AIDS care guidelines were available in 67 (43.5 % ) health facilities, whereas only 56 (36.3 %) health facilities declared having guidelines for infant and young child feeding. Only 26.6 % of health facilities declared having all four guidelines.

Table 3.24 Facilities with MCH guidelines by region

Regions Available Guidelines Total Hhohho Lubombo Manzini Shiselweni IMCI 22 25 35 16 98 Paediatric HIV/AIDS 15 18 30 4 67 Infant and Young Child Feeding 18 11 24 3 56 PMTCT 28 25 32 6 91 Facilities with all 4 guidelines per region 10 10 21 0 41

TRAINING OF HEALTH WORKERS IN MCH

There were 56 facilities reporting to have at least one health worker trained on safe motherhood. One hundred and twenty-one health facilities had at least one person trained on PMTCT and at least 79 facilities had one person trained in IMCI. For combined Infant and Young Child Feeding in context of HIV/AIDS and Baby Friendly services, 86 and 58 facilities, respectively, reported to have at least one health worker trained.

IMAI/ART guidelines including pediatric care were reported in 97 health facilities.

Regarding the number of trained staff in the whole country during the last two years (2005 and 2006), about 289 health workers were trained in PMTCT, 185 in IMAI/ART, 179 in Combined Infant and Young Child Feeding in context of HIV/AIDS, 149 in Adolescent and reproductive health and 111 on Baby Friendly services as well as in Safe Motherhood (Table 3.25). Mbabane Government Hospital, which had the highest absolute number of health workers in its capacity as a national referral hospital, could not provide any data regarding the number of trained personnel in different areas of MCH.

56 Table 3.25 Number of facilities with staff trained on MCH interventions

Type of Hhohho Lubombo Manzini Shiselweni Total trainings Number Num. Num Num Num. Numb Num. Num Num. Num of staff facilities staff facilities staff of staff of staff facilities trained trained trained facilities trained facilities trained* IMAI/ART 25 41 21 38 31 64 20 42 97 185

IMCI 21 34 23 41 23 47 12 20 79 142

Safe 17 32 13 23 18 44 8 12 56 111 Motherhood

PMTCT 29 55 31 91 39 88 22 48 121 282

Combined 20 35 22 46 28 68 16 30 86 179 Infant and Young Child Feeding in context of HIV/AIDS

Baby 16 37 13 24 16 30 13 20 58 111 Friendly services

Adolescent 20 37 21 38 25 44 18 30 84 149 and reproductive health

With all the 6 6 6 3 21 above and trained staff * do not include MGH

Figure 3.11 shows the percentage of health facilities with at least one health worker trained in HIV/AIDS related areas as specified. The coverage seems to be better for PMTCT for which the percentage of health facilities with trained personnel is between 75% (Hhohho region) and 86 % (Lubombo region) followed by IMAI/ART between 57 % (Lubombo region) and 78 % (Shiselweni region).

With baby friendly services which seems to have less coverage, the percentage of health facilities with at least one trained personnel is between 48 % (Shiselweni region) and 31 % (Manzini region).

The percentage of health facilities with at least one health worker trained in all specified HIV/AIDS related areas varied between 17 % in Lubombo region and 11 % in Shiselweni region.

57 Figure 3.11 Percentage of health facilities with trained personnel in HIV/AIDS related areas

100

88 80 81 74 76 75 65 65 66 62 Percentage 60 6059 59 60 52 53 50 48 50 48 4444 4546 40 40 37 37 34 30 30 20 IMAI/ART IMCI PMTCT Young child Baby friendly ASRH Safe feeding services motherhood

Hhohho Lubombo Manzini Shiselweni 3-D Column 5

MCH SERVICE AVAILABILITY

Whereas 143 (94.1 %) facilities reported to have ANC services and 138 (89.6 %) to have immunization services, only 17 (11%) health facilities had ANC outreach sites and 35 (22.7 %) immunization outreach sites (Table 3.26).

Table 3.26 Facilities offering MCH services

Regions MCH services Total Hhohho Lubombo Manzini Shiselweni ANC 38 33 49 25 145 Immunization 38 33 42 25 138 ANC outreach 5 4 4 4 17 Immunization outreach 6 15 7 7 35

The national coverage of ANC and immunization services was very good Figure 3.12). In fact, between 95 % (Hhohho region) and 92 % (Shiselweni Region) of health facilities services were offering ANC services. For immunization services, the percentage of health facilities offering these services were between 95 % (Hhohho region) and 80% (Manzini region).

58 Figure 3.12 Percentage of health services offering ANC and immunization services

95 95 95 94 94 94 92 92 90 85 80 80 Percent age 75 70 Hhohho Lubombo Manzini Shiselweni

Regions

Facilities offering ANC services (%) Facilities offering immunization services (%)

59

FAMILY PLANNING

Table 3.27 and figure 3.13 show that, among 154 health facilities, 81 (52.6 %) declared having technical guidelines, 71 (46.1 %) had at least one person trained in family planning during the last two years, 129 (83.8 %) and 124 (80.5 %) had oral and injectable contraceptives respectively.

Minimus standards of family planning involve all three aspects surveryed: presence of guidelines, trained staff, and availability of oral and injectable contraceptives. Only 12 (7.8 %) facilities met the minimum standards. Five facilities meeting minimum standards were reported in Hhohho and Manzizi while only one facility was reported to meet minimum standards in Lubombo and Shiselweni.

Table 3.27 Situation of family planning in health facilities

Number Facilities of Facilities Number Facilities Facilities with which facilities Facilities with with FP of staff with oral oral and meet Region with injectable guidelines trained contraceptive injectable minimum staff contraceptives on FP pills contraceptives standards* trained

on FP Hhohho 24 21 43 33 31 31 5 Lubombo 17 18 38 31 28 27 1 Manzini 28 21 42 42 42 41 5 Shiselweni 12 10 18 23 23 24 1 Total 81 70 141 129 124 123 12 * Presence of guidelines, trained staff, availability of oral and injectable contraceptive.

Figure 3.13 Percentage of health facilities with specific criteria for the provision of family planning services

96 100 86 89 81 83 81 78 77 80 60 55 53 60 48 51 Percentage 44 40 37 40

20 13 3 10 4 0 Technical gudelines Trained personnel Injectable Oral contraceptives All criteria contraceprives

Hhohho Lubombo Manzini Shiselweni

60

61

62 63 Adolescent health

Only 82 (53.2 %) health facilities declared having at least one person trained in adolescent sexual and reproductive health and 59 (38.3 %) declared providing adolescent sexual and reproductive health services.

Young people (girls and boys) aged 10-19 years account for nearly a quarter of the total population of Swaziland (Reproductive Health Needs Assessment Report, 2001) and is a great need for adolescent health services. An average of 20 facilities with youth friendly services per 100 000 adolescents was reported, the highest being 23 in Shiselweni region and the lowest being 17.6 in Lubombo region (Figure 3.14).

Table 3.28 Provision of adolescent and sexual reproductive health services in regions

Number of Density of facilities Adolescent Total facilities with at Facilities that Population per offering ASRH Region population number of least 1 person provide ASRH region services per 100 000 per region facilities trained on services adolescent ASRH Hhohho 331 734 82 934 40 18 15 18 Lubombo 249 153 62 288 35 21 11 17.6 Manzini 360 248 90 062 52 25 19 21.1 Shiselweni 241 365 60 341 27 18 14 23.2 Total 1 182 500 295 625 154 82 59 20.3

Figure 3.14 Number of health facilities with adolescent, sexual and reproductive health services per 100 000 inhabitants by region

25 23.2 21 20 18 17.6 15 10 5.8 5 4.5 4.4 5.2 0 Hhohho Lubombo Manzini Shiselweni Regions

Ratio of health facilities providing ASRH and adolescent population Ration of health facilities ASRH and general population

64 65 HIV/AIDS

PMTCT

Among the 154 health facilities, 143 (92.8 %) were reported to offer PMTCT routine counseling services, 140 (90.9%) infant feeding counseling in the context of HIV/AIDS, 114 (74% ) PMTCT testing, 111 (72 %) NVP/AZT and 21 (13.6 %) post partum services (Table 3.29).

Out of 111 health facilities offering NVP/AZT, 35 (31.5 %) were in Manzini region, 32 (28.8 %) in Hhohho region, 28 (25.2 %) in Lubombo region and 17 (14.4%) in Shiselweni region.

Table 3.29 Availability of PMTCT services

Region Total Number PMTCT services Hhohho Lubombo Manzini Shiselweni of % facilities Routine PMTCT counseling 37 32 49 25 143 93 Infant feeding counseling in the 39 33 45 23 140 91 context of HIV/AIDS PMTCT testing 32 28 35 19 114 74 NVP/AZT 32 28 35 16 111 72 Facilities that offered 7 7 3 4 21 14 Postpartum services

The region with the highest health facility providing NZP/AZT to population ratio is 11.2 facilities per 100 000 inhabitants was found in Lubombo region. Shiselweni region had the lowerst ratio with 6.6 health facilities providing NZP/AZT per 100 000 inhabitants (Figure 3.15).

66 Figure 3.15 Ratio between health facilities providing NVP/AZT and the general population by region

Ratio between health facilities providing NVP/ AZT and the general population by region 12 11.2 10 9.6 9.7 8 6.6 6 4

100 000 population 2 Number of facilities per per facilities of Number 0 Hhohho Lubombo Manzini Shiselweni Regions

67 VOLUNTARY COUNSELING AND TESTING (VCT)

Eighty health facilities were found to have VCT guidelines, the greatest concentration of which is in Manzini region with 33 facilities. The least concentrated region is Shiselweni with 6 facilities.

Of the 154 health facilities surveyed, 105 (68.2%) reported offering HIV testing and counseling services, whereas only 27 (17.5 %) health facilities reported offering counseling services only (Table 3.30).

Table 3.30 HIV testing and counselling in health facilities

Facilities with Facilities Facilities Number of HIV and testing offering HIV Region offering facilities technical testing and counseling only guidelines counseling Hhohho 40 24 27 8 Lubombo 35 17 27 7 Manzini 52 33 34 8 Shiselweni 27 6 17 4 Total 154 80 105- 27

In Manzini and Hhohho regions 63 % and 60 % of health facilities, respectively, declared having VCT technical guidelines. In Lubombo and Shiselweni only 48 % and 22 % of facilities, respectively, reported having VCT technical guidelines.

The majority of health facilities (77 % in Lubombo region, 67% in Hhohho, 65 % in Manzini region and 62% in Shiselweni) were offering HIV Testing and Counseling services whereas 20 % of health facilities in both Hhohho and Lubombo regions were offering only counseling services. In Manzini and Shiselweni, the percentage of health facilities offering counseling only was about 15 % in each region. (Figure 3.16)

68 Figure 3.16 Health facilities with VCT technical guidelines and type of VCT services offered to the population by region

80 77 67 63 65 62 60 60 49 40

Percent age 20 20 22 20 15 15 0 Hhohho Lubombo Manzini Shiselweni Regions

Facilities with guidelines Facilities offering HIV testing and counselling

Facilities offering counselling only

Seventy percent of health facilities had personnel trained in HIV Testing and counseling, and 80 (51.9 %) health facilities had personnel trained only in HIV counseling. Regarding the number of personnel trained in HIV and counseling and rapid testing in all regions, they were 250, those trained in HIV counseling only were 201 and those trained in HIV rapid testing were 161. It is important to note that only 67 (43.5 %) health facilities had health workers trained in HIV testing, HIV counseling and HIV rapid testing (table 3.31).

Table 3.31 Health Workers Trained in HIV Testing and Counseling (HTC)

Training on Training on counseling Training on rapid testing Training on all Total Counseling only and testing only 3 categories number Regions of health number Number Number facilities Facilities Facilities Facilities # of facilities trained trained trained Hhohho 40 18 31 28 54 29 61 16

Lubombo 35 22 60 28 89 29 77 19

Manzini 52 25 44 36 78 36 88 19

Shiselweni 27 15 26 17 37 19 38 13

Total 154 80 161 109 258 113 264 67

Only the Lubombo region had more than 50 % of health facilities with at least one personnel trained in the three VCT related areas (Counseling, HIV Testing and Counseling (HTC) and Rapid Testing). Considering these three training aspects, only 40 % of health facilities in Hhohho region had personnel trained in all three areas. They were 54 % in Lubombo region, 36 % in Manzini region and 48 % in Shiselweni region (figure 3.17)

69 Figure 3.17 Percentage of health facilities with trained personnel on different aspects of VCT by region

90 82 80 80 72 70 70 69 69 70 62 62 60 55 54 50 48 48 45 40 40 36 Per cent age 30

20

10

0 Counselling only HIV testing and counselling Rapid test only All the three

Hhohho Lubombo Manzini Shi se l w e ni

70

71 ART SERVICES IN HEALTH FACILITIES

Whereas 75 (48.7%) health facilities reported having IMAI/ART technical guidelines and 98 (63.6 %) facilities reported having trained personnel on IMAI/ART, only 22 (14.3 %) declared providing ART services. Among the 22 health facilities providing ART services, 7 were in Hhohho, 4 in Lubombo, 8 in Manzini and 3 in Shiselweni. However, it should be noted that only 12 (7.8 %) health facilities met the minimum standards of having technical guidelines, trained personnel and offering ART services (Table 3.32).

Table 3.32 Provision of ART services

Number of Total Health Number of Health health number of facilities with ART staff trained facilities facilities Region health people guidelines on providing meeting facilities trained on IMAI/ART ARVs minimum per region IMAI/ART standards* Hhohho 40 21 25 41 7 5 Lubombo 35 18 21 36 4 1 Manzini 52 30 31 64 8 4 Shiselweni 27 6 20 44 3 2 Total 154 75 98 185 22 12 * Guidelines, trained staff and provision of ARVs-

Fifty-seven percent of health facilities within Manzini region declared having IMAI/ART technical guidelines while only 22% of facilities in Shiselweni region reported having IMAI/ART guidelines. Seventy-eight percent of facilities in Shiselweni had personnel trained in IMAI/ART, while 57 % of health facilities in Lubombo region had trained personnel. The percentage of facilities meeting minimum standards was 13 % in Hhohho region, 8 % in Manzini region and 7 % in Shiselweni region 3 % in Lubombo region (Figure 3.18).

72 Figure 3.18 Percentage of health facilities with IMAI/ART technical guidelines, trained personnel and providing ARVs by region

80 74

70 62 59 57 57 60 53 51

Percentage 50 40

30 22 18 15 20 11 12 11 7 10 7 2 0 Facilities with Facilites with Facilities Facilites meeting guidelines trained personnel providing ARVs standards

Hhohho Lubombo Manzini Shiselweni

73 POST-EXPOSURE PROPHYLAXIS SERVICES

Among the 154 health facilities, 84 (54.5%) had PEP technical guidelines, 106 (68.8 %) had staff trained in PEP and 21 (13.6 %) health facilities were offering PEP services. Only 12 (7.9%) facilities had technical guidelines, trained personnel and were offering PEP services. In the last two years, 165 people had accessed PEP services (Table 3.33).

Table 3.33 Availability of post exposure prophylaxis (PEP) services

Facilities Total Facilities Facilities with number Facilities Number Number of with staff providing guidelines, Region of with PEP of staff PEP trained PEP trained staff health guidelines trained beneficiaries* in PEP services and PEP facilities services Hhohho 40 23 28 49 7 - 6 Lubombo 35 27 29 63 4 18 2 Manzini 52 28 32 64 7 136 3 Shiselweni 27 6 17 35 3 11 1 Total 154 84 106 211 21 165 12

Figure 3.19 Percentage of health facilities with PEP technical guidelines, trained personnel and providing PEP services by region

90 82 80 77 70 70 62 57.5 61 60 53 Percentage 50 40 30 22 17 11 11 20 13 15 10 5 5 3 0 Facilities with guidelines Facilites with trained personnel Facilities providing PEP Facilites meeting minimum standards

Hhohho Lubombo Manzini Shiselweni

Whereas the percentage of facilities with PEP technical guidelines was 77 % in Lubombo, there were only 57 % in Hhohho region. Lubombo had the highest percentage of health facilitieswith personnel trained on PEP as well, however only 11% of facilities were found to provide PEP services. Seventeen percent of health facilities in Hhohho region were found to provide PEP services, the highest concentration in the country (Figure 3.19).

74

75 Sexually Transmitted Infections (STIs)

STI technical guidelines were present in 140 health facilities (90.9 %) and trained personnel in STI management were present in 115 (74.6 %). Male and female condoms were reported to be offered in 139 (90.2 %) and 120 (77.9 %) health facilities, respectively. However, only 89 (57.8%) health facilities met the minimum standards of STI management (presence of technical guidelines, presence of male and female condoms, and availability of oral and injectable antibiotics). STI services were available in 148 health facilities (96.1%), distributed as follows: 34 in Hhohho, 33 in Lubombo, 51 in Manzini and 25 in Shiselweni (Table 3.34).

Table 3.34 STI diagnosis and treatment

Regions Description Total Hhohho Lubombo Manzini Shiselweni Number of facilities 40 35 52 27 154

Facilities with 37 31 45 27 140 technical guidelines

Facilities with trained 31 30 37 17 115 staff on STI management

Number of staff 64 74 77 33 248 trained on STI management

Facilities with male 36 31 48 24 139 condoms

Facilities with female 34 28 37 21 120 condoms

Facilities with oral 40 35 50 27 152 antibiotics

Number of facilities 40 33 49 25 147 with injectable antibiotics Number of health 38 34 51 25 148 facilities offering STI services Facilities meeting 26 23 25 15 89 standards

76 Referring to regions, the figure 3.20 indicates that the coverage of STI services in all regions is satisfactory. Technical guidelines were present in 100 % of health facilities in Shiselweni region, trained personnel between 85 % (Lubombo region) and 62 % (Shiselweni region) of health facilities, male condom between 92 % (Manzini region) and 88 % (Lubombo and Shiselweni regions), oral antibiotics between 100 % (Hhohho, Lubombo and Shiselweni regions) and 96 % (Manzini region) of health facilities.

The percentage of facilities meeting minimum criteria for STI management constituted 65% in Lubombo and Hhohho regions, 55 % in Shiselweni region and 48 % in Manzini region.

Figure 3.20 Provision of STI services by region

100 100 100 100 100 100 93 96 95 9798 89 92 949492 92 90 9088 88 86 85 85 80 80 77 71 77 71 70 65 65 62 Percentage 60 55 50 48 40

30

20

10

0 Guidelines Trained Male condom Female Oral antibio Injectable STI sevices Meeting personnel condom antibio standards

Hhohho Lubombo Manzini Shiselweni

77

78 Tuberculosis case management

Table 3.35 depicts TB management in health facilities. Of the 154 health facilities surveyed, only 52% reported having TB technical guidelines and 44 % TB/HIV technical guidelines.

Ninety-two facilities (59.7 %) and 82 facilities (53 %) had trained personnel in TB and TB/HIV management respectively. In the last two years, 162 and 146 health workers were trained in TB and TB/HIV management respectively.

Only 16 (10.3 %) health facilities had the capacity to perform sputum examination on site.

Table 3.35 Tuberculosis case management in health facilities by region

Description Region Total Hhohho Lubombo Manzini Shiselweni Number of facilities in 40 35 52 27 154 region Facilities with Number 18 22 31 9 80 TB technical guidelines % 45 63 60 33 52

Facilities with Number 15 23 25 5 68 TB/HIV technical guidelines % 38 66 48 19 44 Facilities with Number 23 25 27 16 92 trained staff on TB % 57 71 52 59 60 management Number of trained staff on 46 51 39 26 162 TB management Facilities with Number 23 21 22 16 82 trained staff on TB/HIV management % 58 60 42 59 53

Number of trained staff on 46 45 30 25 146 TB/HIV management Facilities with Number 29 29 39 25 121 TB drugs % 72 82 75 92 79

Facilities with Number 4 5 4 3 16 sputum examination % 10 14 7 11 10.3

79 Whereas more than 50% of health facilities in Lubombo and Manzini regions had TB technical guidelines, only 45% and 33% of health facilities declared having TB technical guidelines in Hhohho and Shiselweni regions respectively. TB/HIV technical guidelines, were present in 38% of health facilities in Hhohho region, 66% in Lubombo, 48% in Manzini and 19% in Shiselweni region.

More than 50% of health facilities declared having at least one health worker trained in TB case management. The situation was more or less similar for training on TB/HIV case management except in Manzini region where the percentage of health facilities with trained personnel was 42%. TB drugs were present in 96 % of health facilities in Shiselweni region, 80 % in Lubombo region, 75 % in Manzini region and 73 % in Hhohho region.

It was also noted that 14 % of health facilities in Hhohho region were able to perform sputum examination on site. They were 11 % in Shiselweni, 10 % in Lubombo and 6 % in Manzini region (Figure 3.21).

Figure 3.21 TB case management by region

100 92 90 82 80 75 72 69 70 66 63 63 60 60 60 60 58 59 52 48 50 45 42 40 38 33 Percentage 30 20 19 14 10 11 10 7 0 TB guidelines TB/HIV guidelines Personnel traind Personnel trained TB drugs Sputum on TB on TB/HIV examination on site

Hhohho Lubombo Manzini Shiselw eni

80

81 Malaria

Ninety-four facilities (61%) declared having malaria technical guidelines. Viewed per region, 88 % in Lubombo, 65 % in Hhohho region, 46 % in Manzini and 48 % in Shiselweni had the technical guidelines.

Regarding the first and second line drugs for malaria treatment, they were available in 129 (83%) and in 83 (53%) facilitieis respectively.

One hundred health facilities declared a total of 225 health personnel trained on malaria diagnosis during the last two years. The number of health facilities meeting minimum standards (guidelines, trained staff, first and second line drugs) were only 22 (14.2 %), 10 being in Lubombo region, 5 in Hhohho, 4 in Shiselweni region and 3 in Manzini region.

Table 3.36 Malaria management in health facilities by region

Health Health of Health Number Health facilities facilities Health Total facilities of staff facilities with with facilities number of with first trained Region with second trained meeting health line anti on Malaria line anti staff on minimum facilities malaria malaria guidelines malaria malaria standards* drugs diagnosis drugs diagnosis Hhohho 40 26 33 22 26 51 5

Lubombo 35 31 32 24 28 70 10 Manzini 52 24 42 20 29 63 3 Shiselweni 27 13 22 17 16 31 4 Total 154 94 129 83 100 225 22 * Guidelines, trained staff, first and second line drugs

Figure 3.22 shows that Lubombo region has a relative advantage in terms of malaria management. In fact, 88 % of health facilities in Lubombo region declared having technical guidelines whereas they were 65 % in Hhohho, 48 % in Shiselweni and 46 % in Manzini.

The first line treatment was available in 91 % of health facilities in Lubombo, 82 % in Hhohho and 80 % in Manzini and 81% in Shiselweni regions. Second line treatment was available in 68 % of health facilities in Lubombo region, 62 % of health facilities in Shiselweni region, 55 % of health facilities in Hhohho region and only 38 % of health facilities in Manzini region. Lubombo had the highest percentage of health facilities with personnel trained in malaria case management. Among the 225 staff trained on malaria diagnosis during the last two years, 70 (31 %) were from Lubombo region, 63 (28 %) from Manzini region, 51 (22 %) from Hhohho region and 31 (13 %) from Shiselweni region.

82 Twenty-two health facilities met minimum standards for malaria case management, 10 (45 %) of which were located in Lubombo region, 5 (22 %) in Hhohho, 4 (18 %) in Shiselweni and 3 (13 %) in Manzini.

Figure 3.22 Malaria case management by region

100 88 91 80 82 80 81 80 68 65 62 65 59 60 55 55 46 48 40 38 28.6 Percentage 20 13 15 6 0 Guidelines First line Second line Trained Meet treatment treatment personnel standards

Hhohho Lubombo Manzini Shiselw eni

Non-Communicable Diseases (NCDs)

Whereas 146 (94.8 %) health facilities had blood pressure machines, 151 (98 %) had stethoscopes, 146 (94.8%) had adult weighing scales and 145 (94.1 %) had antihypertensive drugs. Only 61 (39.6 %) health facilities declared having the capacity to perform testing for blood sugar.

Five essential elements of NCD management make up the minimum standards for case management: testing for blood sugar level, availability of blood pressure machines, stethoscopes and adult weighing scales and availability of antihypertensive drugs). Only 47 (30.5%) health facilities met these minimum needs for NCD management.

83 Table 3.37 Management of non-communicable dieases in health facilities by region

Health Health Health Health facilities Health Total facilities facilities facilities with facilities Facilities number with with with Region Test for with that meet of health Blood Adult Antihyper- blood Stetho- standards* facilities pressure weighting tensive sugar scopes machines scales drugs level Hhohho 40 14 37 39 38 35 9 Lubombo 35 19 32 35 33 35 16 Manzini 52 20 51 51 50 48 15 Shiselweni 27 8 26 26 25 27 7 Total 154 61 146 151 146 145 47 *Health facilities with test for blood sugar level, blood pressure machine, stethoscope, adult weighting scale and antihypertensive drugs

Lubombo region was found to be the only one where more than 50 % of health facilities were able to perform blood sugar level tests (38 % in Manzini, 35 % in Hhohho and 30 % in Shiselweni). Blood pressure machines and stethoscopes were available in over 90% of the health facilities.

Antihypertensive drugs were available in all health facilities in both Lubombo and Shiselweni regions, in 92 % of health facilities in Manzini region and in 88 % of health facilities in Hhohho region.

Only 46 % of health facilities met the minimum standards for NCD case management in Lubombo region, 29 % in Manzini region, 22 % in Hhohho region and 26 % in Shiselweni region.

Figure 3.23 Non-communicable disease (NCD) management in health facilities by region

10 0 10 0 10 0 96 96 94 96 100 92 97 98 95 96 9188 92 87 80

60 54

Percentage 38 45 40 35 29 28 22 25 20

0 Blood Sugar Stethoscope Antihypertensive level drugs

Hhohho Lubombo Manzini Shiselweni

84 Condoms

Of all health facilities visited, 90.2 % had male condoms and 77.9% had female condoms in stock. Shiselweni region had the highest number of facilities with both male and female condoms with 88 % and 77% respectively (Table 3.38 and Figure 3.24).

The number of both male and female condoms in stock was estimated at 335 030, of which 91.7 % were male condoms and 8.3 % female condoms.

Table 3.38 Condom availability in health facilities

Facilities with male condoms Facilities with female condoms Total Number Number Number of number % of Number % of Region of of male female of health health of health health health condoms condoms facilities facilities facilities facilities facilities in stock in stock Hhohho 40 36 90 78 856 34 85 10 915 Lubombo 35 31 88 62 538 28 80 4 392 Manzini 52 48 92 94 602 37 71 7 279 Shiselweni 27 24 88 70 137 21 77 5 311 Total 154 139 90 307 133 120 78 27 897

Figure 3.24 Male and female condom availability in health services by region

90 92 90 85 88 88 80 77 80 71 70 60 50 40 30

Percentage 20 10 0 Hhohho Lubombo Manzini Shiselweni Regions

Male Condom Female Condom

85

86 Male circumcision

Among the 154 facilities, only 12 (7.8 %) declared having performed male circumcision during the previous month of which 5 were in Hhohho, 4 in Manzini, 2 in Lubombo and 1 in Shiselweni (Table 3.39).

Table 3.39 Facilities offering male circumcision per region

Percentage of Number of Number of facilities facilities health offering male Region offering male Names of Health facilities facilities in circumcision circumcision region services services

Hhohho 40 5 12.5 Flaps, Mbabane, MGH, Medisun Mbabane clinic Lubombo 35 2 5.7 GSH, Ubombo Company Hospital Manzini 52 4 7.7 Manzini clinic, RFM, Philani clinic, MKGH Shiselweni 27 1 3.7 HGH Total 154 12 7.8

87

88 Provision of other important services

Regarding blood transfusion and emergency caesarian services, 11 (7.1 %) health facilities indicated that they offer both services of which 4 were in Hhohho Region, 4 in Manzini Region, 2 in Lubombo Region and 1 in Shiselweni region (Table 3.40).

Table 3.40 Other important services offered in health facilities by region

Number of Blood transfusion Emergency caesarian health Number of Number of Region Percentage Percentage facilities in the health health (%) (%) region services services Hhohho 40 4 10.0 4 10.0 Lubombo 35 2 5.7 2 5.7 Manzini 52 4 7.8 4 7.8 Shiselweni 27 1 3.7 1 3.7 Total 154 11 7.1 11 7.1

89 3.5 List of annexes

1. Regional data base 2. Facility data base 3. Regional questionnaire 4. Facility questionnaire 5. List of facilities not visited 6. List of supervisors and data collectors 7. List of tables 8. List of figures 9. List of maps

90 91

4. Results, school survey 4.1 Foreword

The devastating impact of HIV/AIDS is being experienced throughout our society. AIDS is now the major cause of illness and death in all sectors and at all levels. It is depriving families, communities and the entire nation of the young and productive people. HIV/AIDS impacts negatively on the supply of education and the demand for education by learners. It is for this reason that the Ministry of Health & Social Welfare, in collaboration with the Ministry of Education engaged in the service availability mapping SAM) exercise which serves as an important step in scaling up the national response. The Service Availability Mapping is no doubt a very important and valuable tool in terms of management of health interventions in schools and planning for their improvement. Indeed, the Service Availability Mapping is going to facilitate the visualization of inequities between and within regions in terms of availability of key health services in schools based on priorities of the Ministry of Education.

Its added value is that, it offers an easy to use and a simple way of presenting data that is relevant at national and regional levels. It combines school health and non-health data which impact on health education into a single format that facilitates decision-making and promotion of intersectional collaboration with relevant stake holders.

It is in this regard that I appeal to our international and national partners, including the United Nation Agencies, Multilateral and Bilateral Agencies, National Institutions and NGOs to fully support this initiative that has shown its valuable and determinant role in the availability and management of school health programmes in schools. With the support of relevant stake holders, the Ministry of education will be able to regularly and effectively monitor and assess our efforts in the implementation of health programmes within schools, and take at the opportune moment all necessary corrective measures for their strengthening in order to meet the needs of the school going youth within the country.

I would like to take this opportunity to congratulate the Ministry of Health for the collaborative efforts with the Ministry of education for their continued good work that they are doing, as it has transpired through this exercise. Since this exercise will be carried every two years, I encourage them to continue effectively to participate in SAM which constitutes a very good opportunity to show to the world what they are doing in terms of health promotion and care delivery.

Goodman Kunene

The Principal Secretary

Ministry of Education

94 4.2 Results

4.2.1 General information

School distribution by region, ownership and educational level

Regarding ownership, about 63.1 % are classified as Public schools, 33.0 % as private with non profit and 3.9 % as private for profit (Figure 4.1). Twelve (42.9 %), 9 (32.1 %) and 7 (25 %) school are classified as private for profit in Hhohho, Manzini and Lubombo regions respectively. There is no school for profit in Shiselweni Region.

The distribution of schools per region shows that 29.4% of schools are located in Manzini region, 25.7% in Hhohho region, 24.2% in Shiselweni region and 20.6% in Lubombo region.

Table 4.1 School ownership by region

95 Ownership Private non profit Region Public Private for profit Total (Mission) Number % Number % Number % Number % Hhohho 111 23.5 70 28.3 12 42.9 193 25.7

Lubombo 113 23.9 34 13.8 7 25.0 154 20.6

Manzini 138 29.2 73 29.6 9 32.1 220 29.4

Shiselweni 111 23.5 70 28.3 0 0 181 24.2

Total 473 100 247 100 28 100 748 100

Figure 4.1 School ownership (percentage), Swaziland, 2006

4% 33%

63%

Public Private with non profit Private with profit

Taking into account the population in each region, on overall, Shiselweni region seems to be in a better position with 75 schools per 100 00 population. For Manzini and Lubombo, the overall number of schools per 100 000 population is 61 and 58 respectively.

96 Schools by ownership

97

Table 4.2 Number of schools per 100 000 population by region

Primary High and technical Secondary schools Total schools schools

Region Population Total Schools Total Schools Total Schools Total Schools number per number per number per number per of 100 000 of 100 000 of 100 000 of 100 000 schools population schools population schools population schools population

Hhohho 331 734 139 42 3 1 51 15 193 58

Lubombo 249 153 108 44 8 3 38 15 154 62

Manzini 360 248 159 44 9 2 52 14 220 61

Shiselweni 241 365 131 54 6 2 44 18 181 75

Total 1 182 500 537 45 26 2 185 16 748 63

School levels by region are shown in Table 4.3 and Figure 4.2. Among the 748 schools, 537 (71.7 %) are classified as primary schools, 176 (23.5 %) as high schools and 26 (3.5 %) as secondary schools. It is important to mention that 2 Sebenta schools and the University campus at Kwaluseni (UNISWA) were also visited.

Table 4.3 Number of schools by level of education

Level of education Region Primary Secondary High Technical Total Hhohho 139 3 49 2 193 Lubombo 108 8 37 1 154 Manzini 159 9 47 5 220 Shiselweni 131 6 43 1 181 Total 537 26 176 9 748

98

Figure 4.2 Number of schools by level of education and by region

159 160 139 140 131 120 108 100

80

60 49 47 43 40 37

20 8 9 6 3 2 1 4 1 0 Hhohho Lubombo Manzini Shiselw eni Re gion

Primary Secondary High Technical

Student population

Tables 4.4a, 4.4b, 4.4c, 4.4d, and 4.4e describe student population in schools at different levels. In primary schools, the population was estimated at 223 481 students, 3 155 students for secondary schools, and 72 660 in high schools. In Technical or vocational schools, the population was estimated at 2 034 students.

Table 4.4 Student population by level of education and by region

Region Primary Secondary High Technical Sebent school Hhohho 61 470 465 22 469 600 3 000 Lubombo 43 691 822 13 103 66 16 Manzini 68 315 1 201 20 794 1 026 0 Shiselweni 50 005 667 16 294 342 0 Total 223 481 3 155 72 660 2 034 3 016

Table 4.4a shows that, across all levels of education, the distribution of gender is fairly equal. In fact, in primary schools, the percentage of boys was 51.3% and girls 48.7 %. In high schools and secondary schools, the percentage of boys was 49.2 % and 50.9 % respectively whereas for girls, the percentage was about 50.8 % and 49.1 % respectively

99 (ttables 4.4b and 4.4c). It is important to mention that for the University campus of Kwaluseni the percentage of males is about 48.7 % and 51.3 % for females. (Figure 4.3).

Table 4.4a Student school enrolment in primary schools

Gender Region Male Female Total

Number Percentage Number Percentage Number Percentage

Hhohho 28 819 50.1 28 661 49.9 57 480 100

Lubombo 22 387 51.8 20 794 48.2 43 181 100

Manzini 33 509 51.1 31 938 48.9 65 581 100

Shiselweni 24 771 52.1 22 729 47.6 47 500 100

Total 109 486 51.3 104 122 48.7 213 608 100

Table 4.4b Student school enrolment in secondary schools

Sex

Region Male Female Total

Number Percentage Number Percentage Number Percentage

Hhohho 215 46.2 250 53.8 465 100

Lubombo 431 52.3 393 47.7 824 100

Manzini 630 52.4 571 47.6 1201 100

Shiselweni 330 49.5 337 50.5 667 100

Total 1 606 50.9 1 551 49.1 3 157 100

100 Table 4.4c Student school enrolment in high schools

Sex

Region Male Female Total

Number Percentage Number Percentage Number Percentage

Hhohho 11 006 48.8 11 534 51.2 22 540 100

Lubombo 6 466 50.0 6 462 50.0 12 928 100

Manzini 9 603 48.9 10 050 51.1 19 653 100

Shiselweni 7 846 49.6 7 986 50.4 15 832 100

Total 34 921 49.2 36 032 50.8 70 953 100

Table 4.4d Student school enrolment in technical or vocational schools

Sex

Region Male Female Total

Number Percentage Number Percentage Number Percentage

Hhohho 300 50.0 300 50.0 600 100

Lubombo 48 72.7 18 27.3 66 100

Manzini 549 53.5 477 46.5 1 026 100

Shiselweni 136 39.8 206 60.2 342 100

Total 1 033 50.8 1 001 49.2 2 034 100

101 Table 4.4e University enrolment

Sex

Region Male Female Total

Number Percentage Number Percentage Number Percentage

Hhohho 0 0 0 0 0 100

Lubombo 0 0 0 0 0 100

Manzini 2 735 48.7 2 885 51.3 5 620 100

Shiselweni 0 0 0 0 0 100

Total 2 735 48.7 2 885 51.3 5 620 100

Figure 4.3 Distribution of student population by gender and education levels

Percentage 60

51.3 49.2 50.8 50.9 50.8 51.3 48.7 49.1 49.2 50 48.7

40

30

20

10 Primary High Secondary Technical University Level of education Boys Girls

The tables 4.5a, 4.5b and 4.5c, show the number average of number of students in primary, secondary and high schools. In primary schools, the average number of students per classroom is 24, whereas in secondary schools, the average number of students per classroom is 25. In high schools, the average number of students per classroom is 25.

102 Table 4.5a Average number of students per classroom and by region in primary schools

Average number of Number of Region Number of students students per classrooms classroom Hhohho 2 578 61 470 24 Lubombo 1 820 43 691 24 Manzini 2 755 68 315 25 Shiselweni 2 156 50 005 23 Total 9 316 223 481 24

Table 4.5b Average number of students per classroom and by region in secondary schools

Average number of Number of Region Number of students students per classrooms classroom Hhohho 15 465 31

Lubombo 31 824 26

Manzini 49 1201 26

Shiselweni 29 667 23

Total 124 3 157 25

Table 4.5c Average number of students per classroom and by region in high schools

Average number of Number of Region Number of students students per classrooms classroom Hhohho 853 22 469 26

Lubombo 555 13 463 24

Manzini 789 19 964 25

Shiselweni 670 16 818 25

Total 2 867 72 714 25

103 Table 4.6 indicates the number of classrooms per region and ownership. The large majority of classrooms are public, followed by private not-for-profit and private for-profit.

Table 4.6 Number of classrooms per reigon by ownership of school

Region Level of Private for-Profit Private Public Education Classrooms not-for-profit Classrooms Classrooms

Primary 63 732 715 Hhohho High School 50 196 624

Primary 54 373 806 Lubombo High School 40 61 494

Primary 87 681 1 078 Manzini High School 33 252 553

Primary 0 630 811 Shiselweni High School 0 235 463

Teacher population

In primary schools the majority of teachers are women (74.2%), whereas in high schools they constitute of 48% (tables 4.7a and 4.7b).

Table 4.7a Number of primary school teachers

Sex

Region Male Female Total

Number Percentage Number Percentage Number

Hhohho 433 25.6 1 256 74.4 1 689

Lubombo 379 27.0 1 023 73.0 1 402

Manzini 516 24.5 1 594 75.5 2 110

Shiselweni 470 26.8 1 285 73.2 1 755

Total 1 798 25.8 5 158 74.2 6 956

104 Table 4.7b Number of high school teachers

Sex

Region Male Female Total

Number Percentage Number Percentage Number

Hhohho 626 49.9 628 50.1 1 254

Lubombo 434 55.7 344 44.3 778

Manzini 584 50.7 592 49.3 1 176

Shiselweni 522 53.3 462 46.7 984

Total 2 166 52.0 2 026 48.0 4 192

Table 4.7c Number of school teachers tertiary/vocational lecturers

Sex

Region Male Female Total

Number Percentage Number Percentage Number

Hhohho 44 64.7 24 35.3 68

Lubombo 4 80 1 20 5

Manzini 97 59.5 66 40.5 163

Shiselweni 16 45.7 19 54.3 35

Total 161 59.4 110 40.6 271

105 4.2.2 Prevention services

Provision of information on HIV/AIDS and other HIV related issues

Table 4.8 below shows that all the HIV prevention aspects are covered in the school curriculum by over 70% of the schools in all regions except HIV/ AIDS counselling which is covered by 49.5% of schools in Hhohho, 37.2% in Lubombo, 46.6% in Manzini and about 50% in Shiselweni. Life skills and HIV/AIDS transmission and symptoms are each covered by over 95% of the schools in each region.

Table 4.8 Number of schools with HIV prevention aspects covered in school curriculum by region

HIV prevention Region aspects Hhohho Lubombo Manzini Shiselweni

Life skills 191 (98.5%) 152 (97.4%) 219 (99.1%) 180 (99.4%)

Reproductive 186 (95.9%) 139(89.1%) 216 (97.7%) 174 (96.1%) health

STI Signs and 179 (92.3%) 141 (90.4%) 213 (96.4%) 171 (94.5%) symptoms

HIV/AIDS 190 (98%) 151 (96.8%) 221 (100%) 176 (97.3%) transmission and symptoms

HIV/AIDS 96 (49.5%) 58 (37.2%) 103 (46.6%) 92 (50.8%) counselling and testing

Care for PLWHA 156 (80.4%) 104 (66.7%) 174 (78.7%) 151 (83.4%)

Rape and sexual 173 (89.2%) 134(85.9%) 199 (90.0%) 159 (87.8%) abuse

Career 127 (65.5%) 90(57.7%) 138 (62.4%) 83 (45.9%) Development (Counselling and Testing)

Other 36 (18.6%) 32 (20.5%) 31 (14.0%) 41 (22.7%)

106

107 HIV voluntary counselling and testing information is frequently disseminated to pupils by most primary and high schools (71.3% and 75.4% respectively) as shown in Table 4.9. Discussion and promotion of condom use, however, is covered by less than half of the total number of schools in the country. The same applies for the distribution of condoms where an average of 2.3% of schools reported condom distribution. Approximately 7% of high schools in Manzini region reported having condoms accessible to teachers and students.

Table 4.9 Number of schools with provision of HIV prevention services in primary and high schools

Regions Provision of HIV information and services

HIV voluntary counselling and Discuss and promote condom Distribution of testing information use condoms

Pr. High Pr. High Pr. High

Hhohho 94 (67.6%) 38 (73.1%) 64 (46.0%) 23 (44.2%) 3 (2.2%) 2 (3.8%)

Lubombo 75 (68.2%) 37 (80.4%) 37 (33.3%) 25 (54.3%) 2 (1.8%) 0 (0%)

Manzini 115 (71.95%) 39 (69.6%) 68 (42.5%) 21 (37.5%) 4 (2.5%) 4 (7.1%)

Shiselweni 102 (77.3%) 39 (79.6%) 24 (18.2%) 17 (34.7%) 1 (0.8%) 1 (2.0%)

Total 386 (71.3%) 153 (75.4%) 193 (35.7%) 86 (42.4%) 10 (1.8%) 7 (3.4%)

Figure 4.4 Schools providing HIV testing and counselling information

100 80.4 79.6 73.1 77.3 80 67.6 68.2 71.9569.6 60 40

Percentage 20 0

o i i h bo in en h m z w ho o an el H ub M is L Sh Region Prim ary High School Vocational /Tertiary

108

109 Condom promotion and distribution

Less than 50% of schools of all levels reported to be engaged in the promotion of condoms. Even fewer schools reported to be engaged in condom distribution. The highest level of condom distribution in schools is in Manzini region (7.1%) (Figure 4.6).

Figure 4.5 Schools discussing and promoting condoms

60 54.3

50 46 44.2 42.5 37.5 40 33.3 34.7

30 18.2 20 Percentage 10

0

o o ni i hh b zi en o om an lw Hh b M e Lu is Sh Region

Primary High School Vocational /Tertiary

Figure 4.6 Condom distribution in schools

10 9 8 7.1 7 6 5 3.8 4 2.2 2.5 3 1.8 2 2 Percentage 0.8 1 0 0

i i ho bo in n h m z e o o an lw Hh b M se Lu hi Region S

Primary High School Vocational /Tertiary

110

111

112

113 Vulnerable orphans

Table 4.10 and figures 4.7 and 4.8 illustrate the presence of orphans in primary and high schools. All of the regions have a large orphan population, ranging from 24% in Lubombo primary schools to 29% in Shiselweni primary schools. Taking into account the population in each region, Shiselweni has the highest proportion of orphans with 8 969 orphans per 100 000 inhabitants in primary schools and 2 872 orphans per 100 000 inhabitants in high schools.

Table 4.10 Education for orphans by level of education

Number of orphans per 100 Total number of orphans Region Population 000 inhabitants Primary High Primary High Hhohho 331 734 14 550 6 380 4 386 1 923 Lubombo 249 153 18 047 5 734 7 243 2 301 Manzini 360 248 21 429 6 050 5 948 1 679 Shiselweni 241 365 21 647 6 933 8 969 2 872 Total 1 182 500 75 673 25 097 6 399 2 122

Figure 4.7 Percentage of orpheans in primary schools by region

19% 29% Hhohho Lubombo Manzini 24% Shiselweni 28%

Figure 4.8 Percentage of orpheans in high schools by region

24% 28%

24% 24%

Hhohho Lubombo Manzini Shiselweni

114 Table 4.11 Number of vulnerable children per region in primary and high schools per 100 000 inhabitants

Total number of vulnerable Total number of vulnerable Region Population children children per 100 000 Primary High Primary High Hhohho 331 734 3 471 1 406 1 046 424 Lubombo 249 153 502 350 201 140 Manzini 360 248 957 488 266 135 Shiselweni 241 365 1 110 301 460 125 Total 1 182 500 2 545 6 040 215 512

Hhohho region has the highest vulnerable children to population ratio at 1 046 vulnerable children per 100 000 inhabitants in primary schools and 424 vulnerable children per 100 000 inhabitants in high schools (Table 4.11)

Figure 4.9 Percentage of vulnerable children in primary schools by region

17% Hhohho Lubombo 16% Manzini 59% Shiselweni 8%

Hhohho accommodates an overwhelming 55% (1451) of the national total of vulnerable children, while Shiselweni accommodates the least with 11% of the national total (Figure 4.10).

Figure 4.10 Percentage of vulnerable children in high schools by region

11% Hhohho 19% Lubombo

55% Manzini 15% Shiselw eni

115 Table 4.12 indicates that only a minority of primary and high schools have health clubs that focus on HIV prevention lessons (30%). The situation is even more alarming for number of schools with programmes specifically focused on HIV prevention for teachers and those involving parents. Only 15% of schools have programmes that link with the community to reach out of school youth. Extra curriculum activities are provided by most schools in the country (81%). Very few schools have additional financial resources to support HIV prevention. Only one school in Shiselweni reported the resources to do so.

Table 4.12 Schools with provision of HIV prevention

Regions Total HIV Hhohho Lubombo Manzini Shiselweni prevention in schools PR. HIGH V/T PR. HIGH V/T PR. HIGH V/T PR. HIGH V/T Number %

Health club with focus 30 24 0 54 20 0 30 32 1 20 17 0 228 30% on HIV prevention HIV prevention 8 2 0 9 2 0 10 4 0 12 2 0 49 6% for teachers HIV prevention 10 6 0 9 3 0 27 6 0 30 4 0 94 12% involving parents Programmes that link with community to reach 14 8 0 19 7 0 35 6 1 25 3 0 118 15% drop out/out of schools youth Extra curriculum 137 45 0 103 37 0 152 47 1 65 25 0 612 81% activities Additional financial resource to 10 3 0 4 0 0 2 3 1 0 1 0 24 3% support HIV prevention

116 4.2.3 Training of teachers and students on HIV/AIDS issues

Of all schools visited, 76.2% had at least one teacher trained in HIV prevention. Shiselweni reported having the highest number of schools with at least one trained teacher (78.6%). Only 37.0% of the schools reported having teachers trained in career guidance, and 17.3% of schools had trained peer educators (student to student) (Table 4.13).

117 Table 4.13 Number of schools with at least one person trained on HIV prevention and other related programmes by region including Sebenta and University

Schools Schools Schools Schools with at with at with at with at Total least 1 least 1 least 1 least 1 number Region person % person % person % person % of trained on trained on trained trained in schools HIV special in career peer prevention counselling guidance education Hhohho 193 148 76.3 110 57.0 80 41.2 23 11.9

Lubombo 154 120 76.9 88 56.4 55 35.3 39 24.7

Manzini 220 162 73.6 89 40.3 56 25.3 39 17.6

Shiselweni 181 142 78.5 106 59.2 87 48.1 30 16.5

Total 748 572 76.2 393 52.5 278 37.0 131 17.3

Figure 4.11 Schools with at least one person trained on HIV programmes

100

76.3 77.4 78.5 80 73.3

60 56.7 56.8 58.6 48.1 40.3 41.2 40 35.5

PERCENTAGE 25.3 24.2 17.6 16.6 20 11.9

0 HIV Prevention Special counseling Career Guidance Peer education

Hhohho Lubombo Manzini Shiselweni

Table 4.14 and Figure 4.12 show the number of schools with adequate HIV prevention strategies. To meet the criteria a school must have at least one teacher trained in HIV prevention, a career guidance teacher, curriculum materials and trained peer educators (student to student). Of all schools visited, 8% of primary schools and 9% of high schools met these criteria. Only one tertiary institution was qualified.

118

119 Figure 4.12 Schools with adequate HIV prevention strategies

16 14.5

12.2 11.5 12 8.9 8 6.9 6.5 6.1 4.3 4

0 Percentage of Schools o o i i h b in en h m z w ho o an el H ub M is L Sh Region

Primary High School

Table 4.14 Schools with adequate HIV prevention strategy

Level of education Region Primary Adequate Sec/high Adequate Tertiary Adequate Hhohho 139 9 (6.5%) 52 6 (11.5) 3 Lubombo 108 16 (14.5%) 45 2 (4.3%) 2 Manzini 159 11 (6.9%) 56 5 (8.9%) 5 1 Shiselweni 131 8 (6.1%) 49 6 (12.2%) 1 Total 537 44 (8.1%) 202 19 (9.3%) 11 1

Schools were asked if teachers were trained in HIV programmes. and 10.5% were trained on HIV prevention, 6% on special counselling, 4% on career guidance. It can also be noted that there is fewer number of students trained on peer education. Table 4.15 below reflects that on average, there are 441 students enrolled in schools per peer educator, though Manzini shows a significant shortage of peer educators, 1 peer educator: 621 students. The table also shows that there are more female peer educators, (56%) than their male counterparts.

120

121 Table 4.15 Number of persons trained on HIV prevention in schools by region

Teachers Student Peer Educators Total Number of number Ratio Female Male HIV Special Career Peer persons of peer: peer peer Prevention counselling guidance educators trained students student educators educators enrolled Hhohho 320 180 127 87 503 163 1:537 91 72 Lubombo 346 184 94 59 875 251 1:239 142 109 Manzini 351 143 91 94 417 152 1:621 83 69 Shiselweni 263 194 159 69 854 140 1:498 78 62 Total 1280 701 471 311 649 706 1:441 394 312

122

123

124

125 4.2.4 Visit of schools by health workers

In terms of nurse visit to schools, Table 4.16 indicate that only 20% of schools reported having been visited by a nurse in the past 3 months. Hhohho schools were the most frequently visited with 38% of schools having received a nurse visit within the past 3 months.

Table 4.16 Frequency of nurse visits by region

Total Nurse visiting % Nurse visiting % Frequency of number of within past 3 per within past 6 per nurse visits schools months region months region Hhohho 193 74 38.1 17 8.7 Lubombo 154 18 12.0 17 10.8 Manzini 220 28 12.6 20 9.0 Shiselweni 181 30 16.5 8 4.4 Total 748 150 20.0 62 8.2

126 127 4.2.5 School health situation (health issues)

Only 86% of schools in Hhohho region have a functional water source. Seventy-one point six percent of schools in Lubombo, 85.9% in Manzini and only 56.4% in Shiselweni have functioning water sources. Even fewer schools have functioning water sources throughout the entire year.Only 70.4% of schools in Hhohho, 68.6% in Manzini, 43.2% in Lubombo and 30.4% in Shiselweni have available water sources throughout the entire year (Table 4.17).

Table 4.17 Number of schools with availability of functioning water source by region (excluding Sebenta and University)

Regions Total Hhohho Lubombo Manzini Shiselweni Total Schools Total Schools Total Schools Total Schools

Number with Number with Number with Number with % % % % of water of water of water of water Schools available Schools available Schools available Schools available Have functional 568 193 166 86.0 154 111 71.6 220 189 85.9 181 102 56.4 water source (76%) Have functional water source 409 193 136 70.4 154 67 43.2 220 151 68.6 181 55 30.4 throughout (54.4%) the yer

Out of 751 schools in the country (including Sebenta and University), only 386 (51%) were found to have piped water supply. The majority of schools in Hhohho (72.7%) and in Manzini (53.8%) had access to piped water supply system, whereas Lubombo and Shiselweni only had 38.7% and 36.5% respectively. Nationally, an additional 119 schools (15.8%) were reported to obtain water from covered wells or boreholes. This means a third of the schools have either no water or have an unreliable water supply.

Table 4.18 Number of schools with different types of water source by region

Regions Type of main water Hhohho Lubombo Manzini Shiselweni Total source Number % Number % Number % Number %

386 Piped Water 141 72.7 60 38.7 119 53.8 66 36.5 (51%) Water from covered 119 13 6.7 33 21.3 45 20.4 28 15.5 well or borehole (15.8%) 42 Rain water 6 3.1 10 6.5 3 1.4 23 12.7 (5.6%) 13 Open water well 0 0.0 5 3.2 7 3.2 1 0.6 (1.7%) 53 River/spring water 7 3.6 9 5.8 19 8.6 18 9.9 (7%) 97 Tanker water 24 12.4 33 21.3 19 8.6 21 11.6 (12.9%) 13 Dams 0 0.0 4 2.6 5 2.3 4 2.2 (1.7%) 28 No water 3 1.5 2 1.3 5 2.3 18 9.9 (3.6%)

Table 4.19 Number of schools with hand washing facilities (including Sebenta and University)

Type of Hhohho Lubombo Manzini Shiselweni facility Number % Number % Number % Number % Sink 42 21.6 16 10.4 41 18.6 9 5. Tap 67 34.5 46 29.9 61 27.7 39 21.5 Basin 71 36.6 82 53.2 105 47.7 103 56.9 None 14 7.2 10 6.5 13 5.9 30 16.6 Total 194 100 154 100 220 100 181 100

About 16.6% schools in the Shiselweni region were found to be without hand washing facilities. Seven point two percent of schools in Hhohho, 6.5% in Lubombo and 5.9% in Manzini were reported to be lacking hand washing facilities. (Table 4.19).

Over 97% of schools reported separate toilet facilities for boys and girls in all regions (98.9% in Hhohho, 99.3% in Lubombo, 97.7% in Manzini and 98.3% in Shiselweni)(Table 4.20). 133

Table 4.20 Number of schools with separate toilet facilities for boys and girls per region and levels of education

Total Hhohho Lubombo Manzini Shiselweni Level of education number of schools Number % Number % Number % Number % Primary 537 139 25.9 109 20.3 159 29.6 130 24.2 Secondary 26 3 11.5 8 30.8 9 34.6 6 23.1 High and technical 185 49 26.5 37 20.0 47 25.4 42 22.7 schools Total 748 191 25.5 154 20.6 215 28.7 178 23.8

Table 4.21 Number and type of toilet facilities by region (including Sebenta and University)

Hhohho Lubombo Manzini Shiselweni

Number of % Number of % Number of % Number of % Sanitation type Schools Schools Schools Schools using toilet using toilet using toilet using toilet type type type type

Pit Latrines 143 74.1 128 83.1 166 75.5 170 93.9

Flush Toilets 49 25.4 25 16.2 52 23.6 11 6.1

Bush 1 0.5 1 0.6 2 0.9 0 0

Total 193 100.0 154 100.0 220 100.0 181 100.0

The majority of schools in the country were found to depend on pit latrines for sanitation (Table 4.21).

Figure 4.13 Availability of toilets by type per region

100 94.4 82.3 80 74.2 75.2 60 Percentage 40 25.3 23.9 17.1 20 5.6 0 0.5 0.6 0.9 0 Hhohho Lubombo Manzini Shiselweni Region Pit Latrines Flush Toilets Bush

137

Table 4.22 Health screening in school by level of education

Regions Frequency of health Hhohho Lubombo Manzini Shiselweni screening P S H T P S H T P S H T P S H T

Within the past 3 months 107 3 27 137 79 5 19 103 22 0 4 26 76 2 11 89

Within the past 6 months 5 0 2 7 7 0 4 11 7 0 2 9 5 1 5 11

Tables 4.22 and Figure 4.13 describe the availability of school related services for students by level of education. Whereas schools are doing well with tuck shops and de-worming (more than 76% and 74% of schools are providing these services respectively), only 16% of schools reported providing sanitary towels. With first aid supply and gloves, only 42% of schools are up to standard (table 4.23 and figure 4.14).

Table 4.23 Availability of other school related services by level of education

Hhohho Lubombo Manzini Shiselweni

P S H Total % P S H Total % P S H Total % P S H Total %

Number of schools providing first aid 49 1 24 74 38.3 30 8 38 57 37.0 85 2 42 129 58.6 38 1 17 56 30.9 supply and gloves

Number of schools providing sanitary 28 0 14 42 21.8 8 1 8 17 11.0 21 2 15 38 17.3 15 0 5 20 11.0 towels

Number of schools that have tuck 99 3 44 146 75.6 76 6 35 117 76.0 109 7 45 161 73.2 98 5 39 142 78.5 shops within or nearby

Number of schools that have de worming 82 1 24 107 55.4 80 4 23 106 68.8 138 8 35 181 82.3 114 6 40 161 89.0 programme during the last 6 months

Figure 4.14 Availability of various services in schools

100% 82% 75% 75% 78% 79% 80% 68% 73% 58% 60% 55% 38% 37% 40% 31% 22% Percentage 17% 20% 11% 11%

0% Hhohho Lubombo Manzini Shiselweni

Regions

No. of schools providing first aid supply and gloves No of schools providing sanitary towels No. of schools that have tuck shops within or nearby No. of schools that have de worming programme during the last 6 months

143

144

145 4.2.6 Commodities

Table 4.24 Number of schools with resource materials for HIV prevention by region and level of education

Regions Type of Hhohho Lubombo Manzini Shiselweni educational material Technical/ Technical/ Technical/ Technical/ Primary High Primary High Primary High Primary High Vocational Vocational Vocational Vocational

Adolescent health/HIV peer 11 5 0 5 9 0 20 15 0 4 5 0 education training manual Any book on reproductive 80 46 2 23 21 0 68 35 0 15 13 0 health for students Any book on HIV/AIDS/STI 85 37 2 35 28 0 77 32 0 26 19 0 for students HIV prevention material such 0 0 0 0 0 0 0 0 0 0 0 0 as posters, pamphlets for students STI prevention materials 0 0 0 0 0 0 0 0 0 0 0 0 such as posters and pamphlets Figure 4.15 Number of schools with resource materials for HIV prevention by type of material

140 120 100 80 60 40

No. of schools of No. 20 0 Adolescent HIV prevention HIV/AIDS/STI STI prevention Reproductive health/HIV peer mater ial book mater ial health books edu. Type of educational material

Hhohho Lubombo Manzini Shiselweni

Figure 4.16 Percentage of schools with source materials per region

70 63.9 66 60 50.9 50 48.2 39.9 40 27.8 30 24.7 24.7

Percentage 20 17.1 8.2 8.9 10 4.9 0 0 0 0 0 0 0 0 0 Hhohho Lubombo Manzini Shiselweni Regions

Adolescent health/HIV peer education training manual Any book on reproductive health for students Any book on HIV/AIDS/STI for students HIV prev ention material such as posters, pamphlets for students STI prevention materials such as posters and pamphlets

Figure 4.17 Percentage of schools with resource materials for HIV prevention to total number of schools per region

Hhohho Lubombo Manzini Shiselweni

70.0

60.0

50.0

40.0

30.0

20.0

10.0 Percent schools with resource 0.0 Adolescent HIV/AIDS/STI book Reproductive health health/HIV peer edu. books Type of material

The most available electronic equipment is television with 25.8% of schools having reported access in Hhohho, 26.6% in Lubombo, 24.3% in Manzini and 18.1% in Shiselweni (Table 4.27 and Figure 4.18).

148 149

150 Table 4.25 Percentage of schools with equipment for educational activities by region

Availability of electronic equipment Hhohho Lubombo Manzini Shiselweni Radio 10.3 6.3 12.2 3.8 Video 18.6 22.2 20.3 9.3 Television 25.8 26.6 24.3 18.1 Film projector 5.2 3.2 3.2 1.1 LCD-projector 4.1 4.4 4.5 1.6 Overhead projector 18.0 13.9 15.8 5.5

Figure 4.18 Percentage of schools with equipment for educational activities by region

30

25

20

15 Percentage 10

5

0 Hhohho Lubombo Manzini Shiselweni Regions

Radio Video Television Film projector LCD-projector Overhead projector

151

152

153 Figure 4.19 Percentage of schools with equipment for educational activites by region

Availability of electronic equipment

30.0

25.0

20.0

15.0

10.0

5.0 Percentage of schools by region 0.0 Radio Video Television Film LCD- Overhead projector projector projector Type of equipment

Hhohho Lubombo Manz ini Shiselw eni

From Table 4.27 above, of the 748 schools in Swaziland, 9% had a functional radio facility from which students could have access to HIV educational programmes. A functional video and television accounted for 18% and 24% respectively, however a functional film and LCD projector both accounted for the lowest ratio of 3%.

The charts show numbers as well as percentages of schools having the equipment by region.

154 Table 4.26 Number of schools where condoms were available by region and by level of education

Regions Condom availability Hhohho Lubombo Manzini Shiselweni and distribution P S H T P S H T P S H T P S H T Condom available in 2 3 2 7 0 0 0 0 5 1 3 9 0 2 0 2 schools for students Condom available for 5 3 2 12 5 2 0 7 12 4 3 19 1 3 0 4 teachers

Figure 4.20 Number of schools where condoms are available by region

Condom availability in schools Condom availability for students and teachers in schools indicated 3% and 5% respectively. It may 10 be worth noting that the Shiselweni region had the 8 lowest percentage in terms of condom availability in schools. 6

region 4

2

Percentage of schoolsper 0 Hhohho Lubombo Manzini Shiselw eni Region

For students For teachers

157

158 4.3 Annexes

List of supervisors and data collectors

List of tables

List of Figures

159

5. Results, Prevention Service Availabiltiy

Mapping (PSAM) survey

160 5.1 Executive summary

This report has 3 sections:

ƒ training and preparation for field work;

ƒ identifying priority prevention areas (PPAs) in each district;

ƒ field visits to assess adequacy of HIV prevention programs in PPAs.

5.1.1 Review of questionnaires

Information for this part of the report was obtained from meetings with regional key informants, key informants in Priority Prevention Areas and from interviewers who walked through PPAs and visited key locations in the PPAs. Information for each PPA was recorded on a questionnaire. The questionnaire was divided into two parts and had a total of 8 sections.

Part I

Part I of the PPA Questionnaire was completed during a Regional Key Informant Meeting after the key informants had reached a consensus on the identification of 5 priority prevention areas in their district. Key informants who were knowledgeable about the region attended this meeting which was conducted by a member of the national level team. A guideline for how to select PPAs is contained in the PSAM PPA guide. In the first part of the meeting, the key informants identified the geographic areas where HIV transmission is most likely to occur based on epidemiologic data and contextual information. These are areas where prevention programs are most needed and are called Priority Prevention Areas (PPAs). After the areas were identified, the group selected five priority areas in their region that would receive a field visit.

After those areas were identified, the meeting continued with a group interview using Part I of PPA questionnaire. Part I was completed for each PPA selected by regional key informants. A group setting was used. The interviewer read the questions and marked the answer reached by consensus in the group. Part II of the PPA questionnaire was completed during a visit to the PPA.

Part I of the questionnaire was completed for each PPA. Part I of the questionnaire has three sections:

ƒ information about the name and location of the PPA and contact information for key informants in the PPA;

161 ƒ characteristics of PPA such as its size, whether it is located next to a transportation route and other characteristics useful for planning prevention programs in the PPA;

ƒ characteristics of prevention services and human resources in the PPA.

Part II

Part II was completed during a visit to the PPA by the (P) SAM team. The team met with 3 - 5 persons who were identified during the regional meeting as PPA key informants. During the meeting, Sections 4-6 were completed. The group identified the three most important venues in the PPA. At the close of this meeting, the team visited the two most important venues (or sites within the PPA where people go to meet sexual partners) and determined if prevention services were available at or nearby those venues. Information about prevention services at the 2 most important venues was recorded in section 8.

162 5.2 Training and preparation

5.2.1 Specific objective

ƒ To prepare for implementation of the PPA component of PSAM.

5.2.2 Activities

In order to prepare for field work, the following activities described in table 5.1 were undertaken:

1. National stakeholder meeting 2. Local adaptation of questionnaires and forms 3. Organization of PSAM teams 4. Preparation of the PDA and GPS 5. PDA & GPS Training 6. Interviewer Training 7. Setting up regional interviews 8. Distribution of fieldwork materials

Table 5.1 Activities implemented

Date Step Activity Implementation Notes and Outputs Achieved February 2006 1 National stakeholder Stakeholders supported the initiative meeting April 2006 2 Local adaptation of A workshop was organised for questionnaire questionnaires and adaptation with participation of key stakeholders forms including the MOHSW and NERCHA June 2006 3 Organize PSAM In the presence of the MOHSW (M & E Unit) data teams collectors and supervisors were trained for 4 days June 2006 4 Prepare the PDA PDA and GPS were prepared with WHO consultant and GPS support

June 2006 5 PDA & GPS Training Data collectors and supervisors were trained on PDA and GPS use for one day August 2006 6 Interviewer Training August 2006 7 Setting up regional The Identification of key informants was done key informant successfully in collaboration with HIV/AIDS regional interviews coordinator August 2006 8 Distribution of field The field work materials were done just before key work materials important interview

163 5.2.3 Lessons learned

ƒ The objectives of PPA exercise were clear, however, more time was needed.

ƒ The concept of a PPA was clear. However, it was not always applicable in Swaziland in terms of delimitation of the area and defining the population.

ƒ Each form (part 1 and part 2) were understandable. However, there were some overlaps in part I and II and this created some confusion.

ƒ It was not easy to identify key informants and sometimes, those identified did not have all required information. In fact, some information that was not obtained at the regional level and was collected instead in each of the selected PPAs.

ƒ It was recommended in future that more time to be allocated to the identification of key format with whom more interaction will be absolutely essential for proper preparation and implementation of PSAM.

5.3 Identifiying priority prevention areas in a region

5.3.1 Specific objective

1. To identify and describe the Priority Prevention Areas (PPAs) in the region.

5.3.2 Activities

Priority Prevention Areas were identified in each region in a meeting that included the regional HIV/AIDS coordination and key informants who are the following:

The specific activities included:

1. meeting with region key informants to identify PPAs; 2. interviews of region key informants to characterize PPAs in terms of type of PPA and setting; 3. interviews of region key informants to more specifically characterize the PPAs; 4. collection of information needed to locate each PPA so that the PSAM team could visit. These activities are summarized in the table 5.2.

164 Table 5.2 Activities to identify and describe priority prevention areas

Step Activity Implementation 1 PSAM team met with • PSAM team discussed the definition of a PPA and reached region key informants consensus with the region key informants on the operational in 4 regions to identify definition of a Priority Prevention Area in the region. A PPA could be and select 5 PPAs a section of a city such as the night life area or area surrounding a per region for a total large employer such as a factory, a mining area, an area along a of 20 PPAs transportation route, a trading centre, a mining area or other well- defined area. • The PSAM team and the region key informants brainstormed a list of potential PPAs using maps and available epidemiologic and contextual data, reports and information. • The group discussed the criteria for identifying the 5 most important PPAs and applied criteria to the list of potential PPAs to identify 5 most important PPAs.

2 PSAM team Using the PPA Questionnaire Part 1, section 2, PSAM team members interviews of region obtained information on the contextual risk factors for each PPA, key informants to including: obtain background • Proximity to a major transportation route information about • Proximity to an international border crossing each selected PPA • Presence of a large transient or migrant population • High male to female ratio among resident or migrant population • Known centre for sex work or short-term casual sexual relationships • Area with many out of school youth • Centre for tourism • Information showing evidence of HIV/ STI and TB clustering in PPA

3 More specific At the end of the meeting to identify PPAs, the protocol required the information about PSAM team to ask region key informants very specific additional PPA requested questions about each PPA selected for the study using the PPA Questionnaire Part 1, sections 2 and 3. These sections included questions to:

• Estimate the number of households in the PPA (Section 2). • Assess whether a range of prevention services can be found in the PPA including a local HIV/AIDS committee, program for condom distribution, VCT, STI youth services, posters, billboards, and radio programs (Section 2). • Assess the availability of male and female condoms (Section 3). • Assess the extent to which human resources are available for prevention programs, specifically the number of female and male peer educators (Section 3).

4 Information on Information so that the PPA can be located was also obtained: location of PPA • Name of PPA obtained • District (Tinkhundla) where PPA is located • Directions to the PPA

165 5.3.3 Selection and description of PPAs

Selection of PPAs

Each of the four Swaziland regions selected five Priority Prevention Areas. In Shiselweni, all of the PPAs chosen were urban. Other regions selected a range of types of PPAs in urban, semi-urban, and rural settings. Overall, half of PPAs selected were urban and half were either semi-urban or rural (Table 5.3)

Table 5.3 Identification, setting and size of priority prevention areas

Region Names of selected priority Setting Number of prevention areas households Hhohho WHY NOT DISCO & NIGHT CLUB Urban N/A LUCKY'S RESTAURANT Urban 1000 NGWENYA BORDER GATE Semi-Urban 500 MBUTFO BAR Rural 500 PHOLANI BAR Urban 800 Lubombo SIPHOFANENI TOWN Rural 100 TIO ZE Rural N/A LOMAHASHA BORDER Semi-Urban N/A BIG BEND INN Semi-Urban 2000 MAPHIVENI Rural 80 Manzini MAHHALA Urban N/A MOZAMBIQUE RESTAURANT Urban N/A NKOSELUHLAZA STREET Urban N/A INALA WINE AND MALT Semi-Urban N/A BHUNYA CLUB Semi-Urban 600 Shiselweni NHLANGANO FIRM SITE Urban N/A LAVUMISA BORDER AREA Urban N/A ASSEGAI INN Urban N/A CITY CENTRE Urban N/A PHOENIX HOTEL Urban N/A

166 Characteristics of PPAs

Most PPAs were characterized as having a high prevalence of HIV and STI. Table 5.4 below shows additional characteristics of the 20 PPAs selected by key informants. The PPAs varied in type, setting and size. PPAs included bars, clubs, hotels, border areas, streets, and a city centre. Settings ranged from urban to peri-urban to rural. A majority of PPAs were parts of a city or town. 75% contained rest points for long distance drivers and 45% were on a highway linking commercial centres, cities or countries. Out of school youth were common at 19 of 20 PPAs and 17 of 20 PPAs had large numbers of people who travel within the country. Herd boys were named as a group needing prevention services in 5 of 20 PPAs. Sex work and alcohol consumption were common in almost all of the PPAs. Injecting drug use and settings where men have sex with men were identified but not common.

Table 5.4 Characteristics of PPAs

Infrastructural Number % PPA is part of a city or town 14 70.0 PPA contains a squatter area 7 35.0 PPA is located on a highway linking commercial centres, cities, or 9 45.0 countries PPA contains a rest point for long distance truck drivers 15 75.0 PPA is on an international border 3 15.0 PPA contains a major tourist attraction 6 30.0* Population Number % PPA has large number of people who have recently returned from 14 70.0* South Africa or who routinely visit South Africa PA has large numbers of people who travel within the country 17 85.0* including migrant workers, traders, and truck drivers PPA has many out of school youth 19 95.0* PPA has herd boys who need prevention programs 5 25.0* PPA has more men than women 16 80.0* Activities Number % PPA contains an area with nightlife, including alcohol, music, and 18 90.0 dancing PPA contains an area with sex workers 18 90.0* PPA contains an area where injecting drug use is common 1 5.0* PPA is a social centre for surrounding areas 17 85.0 PPA contains locations where men go to meet men for sex 4 20.0 PPA contains locations where older men meet young women 15-24 19 95.0* for sex Population health Number % PPA residents have a known high HIV prevalence** 12 60.0 PPA residents have a known high STI prevalence** 12 60.0 PPA residents have a known high TB prevalence** 5 25.0

167 Prior to visiting the PPAs, questions were asked of the key informants about the availability of prevention programs in the PPA. These findings are summarized in Table 5.5 below. Over half of the PPAs had had HIV prevention sessions but only 45% had had sessions in the past 3 months and only 40% had “Know your status” campaigns in the past 3 months. Only 4 of the 20 PPAs had had a TV or radio program devoted to HIV in the past 3 months and only 8 of the 20 PPAs had had a condom social marketing program. Most PPAs had condom outlets in or nearby the PPA but few had voluntary counselling and testing services or STI treatment services. Fewer than half of the PPAs had an HIV Committee in or around the PPA.

Table 5.5 Availability of prevention programmes in PPAs

Prevention programmes Number % Community based HIV/AIDS prevention sessions 11 55.0* Community based HIV/AIDS prevention session held in past 3 months 9 45.0* “Know your HIV status” campaign in past 3 months 8 40.0* HIV-related radio or TV show in past 3 months 4 20.0 Other HIV-related activities in past 3 months 15 75.0* Condom social marketing program in past 3 months 8 40.0*

Prevention facilities available: In the PPA Near the PPA No Services “Don’t (%) (%) (%) Know” (%) VCT Site… 3 (15.0) 12 (60.0) 5 (25.0) 0 (0.0) STI Services 3 (15.0) 12 (60.0) 5 (25.0) 0 (0.0) Male Condom Outlets 16 (80.0) 4 (20.0) 0 (0.0) 0 (0.0) Female Condom Outlets 8 (40.0) 2 (10.0) 7 (35.0) 3 (15.0)

Condom availability Information from kiosks, shops or guest houses in PPA Number % Male condoms easily available during the daytime 18 90.0 Male condoms easily available during the night time 16 80.0* Female condoms easily available during the daytime 9 45.0* Female condoms easily available during the night time 3 15.0

Condom availability timeframe This month 2 months ago No data Date male condoms were last available in PPA 3 2 15 Date female condoms were last available in PPA 4 2 14

Condom distribution statistics 400-500 3 000 No data Average no. male condoms distributed per month in PPA 4 1 15 Average no. female condoms distributed per month in PPA 4 1 15

Human Resources for Prevention Number % HIV/AIDS Committee in or around PPA 8 40.0* HIV/AIDS Committee met in past 3 months (11 PPAs) 3 15.0 Peer educators available in PPA 12 60.0*

168 Number of peer educators in each PPA Mean (Min, Max) No. PPAs with no data Total (male and female) among PPAs with data 15.8 (3, 60) 14 Number of male peer educators among PPAs with 8.4 (0, 35) 15 data * Information not known for 1-4 PPAs ** All other PPAs had an unknown prevalence; no PPAs had a known low prevalence

5.3.4 Lessons learned

ƒ It was not quite easy to identify PPAs in all regions specifically those where sex workers wait for clients in streets without any defined structure.

ƒ The delimitation of PPAs was in some cases a challenge which made the numbering of household more difficult

169 5.4 Field visits to assess adequacy of HIV prevention in PPAs

5.4.1 Specific objectives

To document the need for prevention services in the PPA by visits to the PPA to:

ƒ estimate the number of venues in each PPA where people meet new sexual partners; ƒ estimate the size of the socializing population attending these venues; ƒ document whether prevention programs are established in the PPA.

5.4.2 Activities

1. Interviews with PPA key informants

2. Mapping the centre of each PPA and describing its geographic boundaries in words

3. PSAM team walk-through of the PPA

4. PSAM team visits the two most important venues where people meet new sex partners in the PPA

5. Data consolidation workshop

6. Tabulation of interview data

7. Review of map data and creation of maps

170 Table 5.6 Assessing the adequacy of prevention services in PPAs

Step Activity Implementation

1 PSAM team met with PSAM team used the PPA Questionnaire Part 2, section 6 to obtain knowledgeable persons characteristics of the PPA from individuals in the PPA.. These included in each PPA to obtain questions to: more information about • Assess whether a range of prevention services can be found in the each PPA. PPA including a local AIDS committee, program for condom distribution, VCT, presence of a “know your HIV status campaign”, STI services, television or radio programs about HIV/AIDS, male and female condom availability, and any other HIV-related activities (Section 5). • Report the extent to which human resources are available for prevention programs, specifically the number of female and male peer educators (Section 5). • Estimate the number and size of venues in each PPA where people go to socialize and meet new sexual partners. The key informants are asked the number of each of 11 different types of venue, e.g., number of bars, hotels, taxi stands, brothels, and the total is summed (Section 6). Names of the three most important venues are identified.

2 Mapping Coordinates PSAM members used GPS units to obtain coordinates (PPA obtained Questionnaire Part 2, Section 4).

3 Walk-Through PSAM team members walk through the PPA towards 2 of the 3 most important venues identified in Section 6. The team walks through the PPA using PPA Questionnaire Part 2, Section 7, to observe if any of the following are visible: • Visible HIV prevention billboards or posters • Visible VCT billboards or posters • Visible condom use billboards or posters

4 Visiting Venues The PSAM team visits two of the three most important venues identified in Section 6 to determine if prevention services are available at each venue or nearby. In Swaziland, a total of 36 venues were visited, because in four PPAs, only one venue was visited. A knowledgeable respondent at each venue is interviewed using PPA Questionnaire Part 2, Section 8, to determine: • Whether people meet new sexual partners at the venue • The number of men and women at the venue during the busiest time • Whether there have been any HIV/AIDS prevention activities in the past 3 months • Condom availability in the past year • Presence of condoms today • Whether a condom can be obtained within 10 minutes of the venue at night

5 Data consolidation Data consolidation was done taking into account the information collected during the exercise

6 Tabulation of data Tabulation of data was made according to data available in database

7 Maps created Maps were created by region

171 5.4.3 Results of field visits to PPAs

Each PPA was characterized by the PSAM team in the PPA. The questionnaire covered background information, characteristics of the PPA, availability of prevention programs, and characteristics of venues where people socialize and meet new sex partners. (Table 5.7 below.) Some information on availability of prevention programs obtained at the regional level was asked again in the PPA to confirm the reports from the regional level. There was fairly good agreement, however the extent of prevention program activity reported at the PPA level was slightly higher than at the regional level. For example, at the regional level, 3 VCT sites were reported and at the PPA level, 4 VCT sites were reported. A notable exception was the number of peer educators. Regional key informants reported a higher number than that reported in the PPAs.

There were a very large number of venues reported in many PPAs. In 8 PPAs, over 100 venues where people meet new sexual partners were reported. Even though this information needs further verification, it does indicate that the spread of HIV in Swaziland is quite easy and rapid which may explain the current high prevalence of HIV/AIDS in the country.

Table 5.7 Results from interviews with people in PPAs during field visits

Prevention Programs Available in PPA Number %

Community based HIV/AIDS prevention sessions (11 PPAs) 8 40.0*

Community based HIV/AIDS prevention session held in past 3 months 9 45.0

“Know your HIV status” campaign in past 3 months 10 50.0*

HIV-related radio or TV show in past 3 months 3 15.0*

Special HIV/AIDS prevention events in past 3 months 10 50.0*

Other HIV-related activities in past 3 months 5 25.0

Condom social marketing program in past 3 months 11 55.0*

Prevention facilities Near the PPA “Don’t Know” In the PPA (%) No Services (%) available: (%) (%) VCT Site 4 (20.0) 11 (55.0) 5 (25.0) 0 (0.0) STI Services 5 (25.0) 9 (45.0) 6 (30.0) 0 (0.0) Male Condom Outlets 19 (95.0) 1 (5.0) 0 (0.0) 0 (0.0) Female Condom Outlets 6 (30.0) 2 (10.0) 12 (60.0) 0 (0.0)

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Condom Availability from kiosks, shops or guest houses in PPA Number % Male condoms easily available during the daytime 18 90.0 Male condoms easily available during the night time 15 75.0 Female condoms easily available during the daytime 8 40.0 Female condoms easily available during the night time 5 25.0

Condom availability timeframe This month 2 nonths ago No data Date male condoms were last available in PPA 3 0 17 Date female condoms were last available in PPA 2 1 17

Condom distribution statistics 400-500 3 000 No data (72; Average no. male condoms distributed per month in PPA 685.5 14 2,000) Average no. female condoms distributed per month in PPA 1.0 (0; 6) 14

Human Resources for prevention Number % HIV/AIDS Committee in or around PPA 9 45.0* HIV/AIDS Committee met in past 3 months 5 25.0* Peer educators available in PPA (15 PPAs) 1 5.0*

Visible signs of programmes Number % HIV prevention posters/billboards/flyers visible 5 25.0* VCT posters/billboards/flyers visible 17 85.0* Condom Use posters/billboards/flyers visible 17 85.0*

Number of venues in PPA Number % 0-9 4 20.0 10-19 4 20.0 20-49 2 10.0 50-99 2 10.0 100-499 3 15.0 500+ 5 25.0

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Number of each type of venue where people meet Mean Median Min, Max new sexual partners Hotels, Casinos, Guest Houses Big (More than 500 Patrons) 0.2 0 (0, 4) Medium (100-499 Patrons) 0.15 0 (0, 2) Small (25-99 Patrons) 4.1 0 (0, 75) Very Small (Less than 25 Patrons) 1.05 0 (0, 20) Brothels Big (More than 500 Patrons) 0.05 0 (0, 1) Medium (100-499 Patrons) 0.05 0 (0, 1) Small (25-99 Patrons) 0 0 (0, 0) Very Small (Less than 25 Patrons) 0.7 0 (0, 14) Bars, Discos, Bottle shops, Shebeens Big (More than 500 Patrons) 87.75 0 (0, 745) Medium (100-499 Patrons) 76.25 2 (0, 499) Small (25-99 Patrons) 22.15 1 (0, 300) Very Small (Less than 25 Patrons) 10 0 (0, 200) Border Crossing, Truck, Taxi and Transportation Centres Big (More than 500 Patrons) 25.2 0 (0, 500) Medium (100-499 Patrons) 17.7 0 (0, 350) Small (25-99 Patrons) 12.05 0.5 (0, 150) Very Small (Less than 25 Patrons) 5.35 0 (0, 90) Restaurants, Shopping Plazas, Social gathering places Big (More than 500 Patrons) 40.6 0 (0, 800) Medium (100-499 Patrons) 0.8 0 (0, 9) Small (25-99 Patrons) 1.5 0 (0, 10) Very Small (Less than 25 Patrons) 0.05 0 (0, 1) Markets Big (More than 500 Patrons) 0.1 0 (0, 1) Medium (100-499 Patrons) 0.35 0 (0, 3) Small (25-99 Patrons) 0.2 0 (0, 2) Very Small (Less than 25 Patrons) 0 0 (0, 0) Streets, Parks Big (More than 500 Patrons) 0.1 0 (0, 1) Medium (100-499 Patrons) 0 0 (0, 0) Small (25-99 Patrons) 0 0 (0, 0) Very Small (Less than 25 Patrons) 0 0 (0, 0) Prisons Big (More than 500 Patrons) 0.1 0 (0, 1) Medium (100-499 Patrons) 0.05 0 (0, 1) Small (25-99 Patrons) 0.21 0 (0, 2) Very Small (Less than 25 Patrons) 0.65 0 (0, 12) Police, Military Barracks Big (More than 500 Patrons) 0.45 0 (0, 3) Medium (100-499 Patrons) 0.45 0 (0, 5) Small (25-99 Patrons) 0.25 0 (0, 3) Very Small (Less than 25 Patrons) 0 0 (0, 0) Schools Big (More than 500 Patrons) 0.55 0 (0, 6) Medium (100-499 Patrons) 0.05 0 (0, 1) Small (25-99 Patrons) 0.35 0 (0, 6) Very Small (Less than 25 Patrons) 0 0 (0, 0) Churches Big (More than 500 Patrons) 1.05 1 (1, 2) Medium (100-499 Patrons) 2.25 2 (1, 3) Small (25-99 Patrons) 1.05 1 (1, 2) Very Small (Less than 25 Patrons) 1 1 (1, 1)

174 5.4.4 Most important venues in each PPA

There were a large number of venues in the PPA, however, PPA informants were asked to identify the two most important venues in the PPA. A total of 36 venues were identified from the 20 PPAs. The characteristics of these venues are described in the table below. Over half of the venues were bars or bottle store and over half were places where female sex workers solicited clients. Half of the sites had over 100 persons visiting at the busiest time of the day. The information from these important venues is quite informative about whether the PPA has succeeded in delivering intervention services to the places that need it the most. About half of the sites reported having had a condom promotion program in the last three months and that condoms were always available at the site, however condoms were only seen by interviewers at six of the 36 sites.

Table 5.8 Characteristics of two most important venues in each PPA

Venue type Number % Bar, Bottle Store 20 55.6 Hotel, Motel 5 13.9 Restaurant 3 8.3 Shop 2 5.6 Truck Stop 2 5.6 Working Site for many young people 1 2.8

Respondent position at the venue Number % Owner, manager, staff 30 83.3 Patron 4 11.1

Verification of sexual activity at the venue Number % People meet new sex partners at the venue 32 88.9 Female sex workers solicit clients at the venue 20 55.6

Number of people at venue at busiest day and time Number % More than 500 persons 10 27.8 100 – 499 persons 17 47.2 25-99 persons 8 21.2 Less than 25 persons 1 2.8

175

Availability of HIV/AIDS prevention services Number %

HIV/AIDS prevention activities in last 3 months 13 36.1

HIV/AIDS educational talks in last 3 months 5 13.9

Peer health education program in last 3 months 1 2.8

Condom promotion program in last 3 months 18 50.0

HIV/AIDS posters or leaflets available in last 3 months 10 27.8

Condoms available within 10 minutes walk at night 26 86.1

Always Sometimes Never Condom availability in past year (%) (%) (%)

28 4 4 In the past year, how often have condoms been (77.8) (11.1) (11.1) available?

Always Sometimes Never Condom availability today (%) (%) (%)

6 23 7 Are there any condoms here today and can I see (16.7) (63.9) (19.4) one?

* Information not known for 1-4 PPAs

176 5.5 Conclusions and recommendations

The PPA survey revealed that Priority Prevention Areas can be identified at the regional level. Visits to the PPAs confirmed that the PPAs were areas with many venues where people meet new sexual partners. Since a high rate of new sexual partner acquisition is a key determinant of the HIV epidemic, it is reasonable to prioritize some venues for prevention program outreach including condom promotion and distribution.

ƒ Organize a workshop in each region for Inn owners and Hotels (tenants) on HIV/AIDS. The objective of the workshop will be to brief them about the HIV/AIDS situation in the country, HIV prevention strategies and to define the role they should play and their responsibility as well as contribution to HIV control as members of the Swazi community.

ƒ Organize regular meetings for Bar and hotel owners to give them the opportunity to exchange their experience and to discuss solutions to problems they may encounter in exercising their responsibility in the area of HIV prevention.

ƒ Define information package that could be easily delivered to sex workers and identify the best way to do it with their active participation.

ƒ Define the HIV prevention package to deliver to truck drivers and identify the best way to do it (including location).

ƒ Elaborate and implement a program targeting PPAs in each region in collaboration with regional administrative and health authorities with involvement of regional NGOs.

177 6. Future direction

Service Availability Mapping (SAM) has been perceived as a very useful tool in terms of school health programme management. In addition, SAM provides insight for the needed improvement particularly in HIV/AIDS education among in-school youth. For these reasons, SAM should at least be carried out every two years to assess progress made. SAM can be extended to other services in terms of HIV care and prevention., identify gaps and to devise solutions.

SAM exercise in Swaziland was quite challenging. It was the first time that Swaziland had undertaken this initiative with all anticipated risks to encounter. However, SAM has been a rewarding initiative, and the experience gained and lessons learnt will serve not only to improve the process, but also to expand the exercise to other education aspects that were not included this time. In terms of funds mobilization, all efforts will be made to involve other partners of whom some have manifested some interest so that SAM can be extended to other services in terms of HIV care and prevention.

To capture properly, the information to be used for decision making for planning process, the questionnaire should further be adapted in collaboration with regional education officers and school heads who are supposed to know the prevailing situations in their schools.

Particular attention need to be paid to the selection of data collectors. Experience has shown that the use of data collectors who have a medical background improves understanding of the questionnaire and extraction of accurate information whatever working environment and circumstances. In this regard, the use of students from the faculty of health sciences is an interesting option to be explored. Therefore, timing of further SAM exercises should be guided by the availability of these students.

It is hoped that, for the next SAM exercise , new population estimates through the national census will be available to allow more appropriate interpretation and analysis of the collected information and, therefore to make better projections in terms of improvement of accessibility to health education by the population in need.

178 7. References

1. NERCHA; National Strategic Plan, 2006 2. MOH&SW; Reproductive Health Needs Assessment Report, 2001 3. MOH&SW; 9th Sentinel Surveillance Report, 2002 4. SHIES 5. World Bank Report, 2006 6. MOHSW, sentinel Surveillance Report, 2006 7. MOHSW; Health Statistics Report 8. WHO; AFR/54/R3 9. Population census report, 1997

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