South Africa: Health and Education Collapsing in Eswatini

12 September 2019
analysis

A government directive preventing departments from hiring or creating new posts is leaving them understaffed and overworked to the point that children aren't being taught and people are dying.

The cash-strapped Kingdom of eSwatini has attempted to be "cost effective" by issuing a directive to all ministries and departments that "all vacant posts including creation of new posts and promotions across government be frozen", according to circular no. 3 of 2018, which had to be implemented from 1 August last year.

In a nutshell, the circular meant that if a government employee dies, resigns, retires or is transferred, vacant posts will simply not be filled. Civil servants have described the decision as "suicide". The heavily indebted and understaffed departments of health and education were hit hardest by the directive and have since collapsed as they "no longer serve their purpose of existence".

Too little state funding

Previously, parents of learners in eSwatini had to pay school fees from primary to secondary school, and sometimes up to tertiary level. In 2010, the government announced that parents will no longer pay for primary education. According to the eSwatini Ministry of Education and Training, there are 12 560 teachers in 600 primary schools with an enrolment of 239 793 learners. When free education was implemented, the enrolment of learners from grade 1 to 7 jumped to 242 037 from 230 242 the previous year.

The government spends between R650 and R725 a year for each learner. Parents only pay for secondary education. The state takes care of orphaned and vulnerable children in secondary schools through grants paid to the schools. But parents who can afford it pay between R3 400 and R8 000 in school fees whereas the government pays R1 905 to R2 500 for orphaned and vulnerable learners between grades 8 and 12.

The money received from the government "is a mini-skirt, and usually finishes around October", says Siphasha Dlamini-Madonsela, 52, a school administrator at Sigcaweni High School, which is heavily dependent on the grants for orphaned and vulnerable learners. Her school has 217 pupils, the majority of whom fall into this category. Only 20 of the school's learners have parents who can afford to pay school fees, but they aren't always able to pay on time.

Primary and secondary schools are now struggling to pay their operational costs. This has led to thousands of children from impoverished backgrounds being robbed of a better future as schools have turned into "daycare centres instead of educational institutions".

A bleak future

Dlamini-Madonsela says that since schools have started running out of money, some teachers are expected to teach as well as scout for donations so the schools can continue to function. "Most of the time we improvise. We've been turned into beggars because we go to businesspeople to ask for donations," Dlamini-Madonsela says. "You are committing suicide if you keep a nation uneducated. You are saying there's no future in the country if you don't invest in education of the citizens."

Swaziland National Association of Teachers secretary general Sikelela Dlamini says some schools can no longer pay for the basics, such as electricity bills, and that support staff such as librarians, secretaries and cooks have not been paid since the start of the year.

"In terms of improvement and maintenance of the physical schools, it means there can be a broken window and it will remain so the whole year because the teacher has to prioritise between the structure and the imminent needs of a learner," Dlamini says. "There are kids who normally have their first and last meal at school. This means that the teacher has to make sure there's food to be eaten by the kids. The situation is bad."

Teachers and other stakeholders worry that the quality of education in the country has dwindled significantly.

"Swaziland was ranked as one of the highest in terms of education, but now it's not. The rich teach their children outside the country. But the painful part is that the average citizens' children are forced to stay here because they can't afford to take their children to other countries where the quality of education is high," says Dlamini-Madonsela.

Aside from permanently employed educators, Dlamini says only a third of the 4 000 contracted teachers in eSwatini have had their contracts renewed since the freezing of government posts. This has resulted in a shortage of teachers for some learners since the beginning of the year, despite being expected to start writing trial exams in September.

Dlamini says there are more than 100 teachers in the country that need debt counselling and psychological help because their salaries, as civil servants, have not been adjusted for the past three years despite an inflation hike of 20% in the country over that period. "The effects are far-reaching and negative on both learners and teachers ... It is dangerous to keep a sick teacher at school," Dlamini says, commenting that ill educators are forced to continue working because schools are understaffed.

The teachers in need of psychological aid are suffering a double blow as they, along with others in eSwatini who are critically ill, cannot rely on health centres and hospitals in the country as they have become "slaughter houses" instead of lifesaving medical institutions.

Shortage of medications

There are five heavily understaffed government hospitals and six health centres in eSwatini, which have to accommodate a population of about 1.3 million people.

At the Nhlangano Health Centre, about 130km from the capital city of Mbabane, there are three crucial and frequently used antibiotic medications that haven't been available for the past two months. These injected medications include ceftriaxone, which is used to treat a wide range of bacterial infections, the cloxacillin injection is commonly used to treat infections of the skin, bone, heart valves, blood and lungs, and the amoxicillin injection is for treating ailments such as pneumonia, bronchitis, tonsillitis and ear infections.

Other medications that have been out of stock include a broad-spectrum antibiotic called fortified penicillin, plaster of Paris used to mould plaster casts to immobilise broken bones and catheters for draining urine from the bladder.

"There was a woman who was crying that she can't hold herself as urine was burning her bladder. We told her we can't help her because we don't have catheters of all sizes at the centre," says one Nhlangano Health Centre nurse who spoke to New Frame on condition of anonymity.

It's not only medication and injections that are unavailable, sometimes there is no food for patients as the hospital kitchens have not received funds to buy ingredients. Additionally, the cooks contracted by the government haven't been paid since October last year. In June, the administrator of the Nhlangano Health Centre had to buy food for the patients over a weekend from his own pocket after the cooks ran out of supplies.

The situation at the Mbabane Government Hospital, one of the biggest referral hospitals in the country, is equally menacing. Late in November and again in June, the hospital experienced patient food shortages for two weeks. In August, there was a shortage of simple things such as requisition forms, which patients have to sign before X-rays can be done, prescription notepads and several vital medications.

According to senior staff at the hospital, the government has been redirecting medication from rural health centres to the Mbabane hospital to try and prevent people in the city from noticing that there is a shortage.

Health workers in the country say the government has prohibited them from disclosing the direness of the situation to patients. "You are caught in a dilemma, to tell the truth or a lie. If you tell the truth, you might find yourself losing your job. But because you took an oath to save lives, you then tell that person the truth. If you see that this person can afford, we tell them in confidence that in order to get healed, get such and such medication," says one of the senior staff members at the hospital.

Understaffed nurses and doctors

Apart from the shortage of medications, the challenging working conditions and being understaffed contributes to the inability of medical professionals in the country to effectively attend to patients. At the Nhlangano Health Centre, at least seven staff members have left since 2017 and only one person has been hired, says the nurse from the facility.

In 2016, a maternity ward was completed at the Nhlangano centre that needed at least 44 staff members to run it. To date, it hasn't been opened. In February, eSwatini Minister of Health Lizzy Nkosi came to the centre to command the hospital staff to open the ward despite being notified that this wasn't possible owing to the shortage of staff.

Mbabane Government Hospital is similarly affected by understaffing issues. Since June, there has been a vacant sonographer post for someone who specialises in the use of ultrasonic imaging devices to produce diagnostic images and scans. The sonographer who left the hospital specialised in examining and diagnosing pregnant women, by ultrasound, and vital organ conditions.

"She was being overworked and she ended up resigning as she'd attend to about 800 patients per month," says the senior staff member at the hospital, adding that pregnant women who have to undergo ultrasound examination are transferred to the Mankayane Government Hospital 57km away, where they are put on a three-month waiting list.

"If the ultrasound examination is required for urgent purposes due to a life-threatening illness, there is a high chance that she will lose her life even if she'd have survived," says the senior staff member. "It's more frustrating and so depressing to see someone die knowing very well you'd have saved that life. [Not so long ago] there was a shortage of oxygen, and we lost a baby."

The Mbabane Government Hospital's outpatient department has one medical doctor and two interns who attend to about 400 patients daily. "The doctor is not coping. It's become that instead of thoroughly diagnosing a patient, you are pushing to finish the queue because if you take 10 minutes on one client, the ones waiting outside will start complaining," says the senior staff member.

Hospitals have become 'slaughter houses'

The shortage of staff and medication has led to a high rate of fatalities. In a year, the Mbabane Government Hospital loses two infants on average in the first month after birth, which is "a serious concern". But in June, the hospital lost 10 infants in this timeframe to neonatal sepsis, a bacterial infection of the blood affecting babies up to 28 days old. This level of fatalities has never before been recorded in the history of the hospital. Every month, the hospital contributes directly to the deaths of at least 100 patients, says the senior staff member.

In June, at least four older patients died because of the shortage of hypertension medication at the Nhlangano Health Centre. In July, 66 children were diagnosed with diarrhoea and six of them died. "A lot of under-five children are dying, yoh!" says the nurse from the health centre.

"The health system has collapsed. If you're no longer doing your purpose of existence, you are dead. We save lives. But now we can't save lives, why we are still existing?" asks the senior staff member from Mbabane.

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