- Swaziland's sugar-dependant Lubombo Province is experiencing the trickle-down effects of impending reforms in the European Union's sugar industry that are having negative consequences for the region's HIV-positive population.
The sugar industry has provided much of the province's infrastructure, from roads and housing to schools and hospitals, but with the industry in decline, companies are already cutting back on these services. The Royal Swaziland Sugar Corporation (RSSC), the biggest player in the industry, has closed one of its four clinics and merged two others, while Ubombo Sugar Limited is also planning belt-tightening measures.
Dr Tim Nunn, Ubombo's chief medical officer, told PlusNews that the company-funded hospital, the only one in the district, would probably be downgraded to a clinic before the end of the year. "Because of the EU reforms, we're told that healthcare is non-core business," he said. "But we've made it core business by putting HIV/AIDS at the forefront of every agenda."
Nunn predicted that losing staff and hospital facilities would compromise their ability to treat and monitor HIV/AIDS patients with serious opportunistic infections or drug complications. "The alternative for those people is a government unit 70 kilometres up the road that is understaffed and over-utilised. The care they would get is not anywhere near what they would get here."
Company-funded medical facilities are available to employees and their dependants, and community members who can afford them. But falling sugar prices and rising production costs mean that an increasing number of small-scale cane growers can barely afford to maintain their small plots and feed their families, let alone pay for medical fees.
Profits from Twana Dlamini's family sugar cane plot in the small farming community of Vuvulane used to cover the 600 Emalangeni (US$80) monthly cost of her antiretroviral (ARV) medicine. The drugs are now freely available at the government hospital in Siteki, but Dlamini, 33, and mother of two, stopped taking them last April when monthly trips to the hospital became unaffordable.
Despite being bed-ridden after a stroke, she has not seen a doctor in over a year and her elderly mother is struggling to support the family. "We have no money for food, especially with the problem of the sugar cane price," Dlamini said.
An employee testing campaign by the RSSC in 2002 put the region's HIV prevalence on a par with the national rate of 38.8 percent, the world's highest.
Dr A. Phillip, chief medical officer at Good Shepherd hospital in Siteki, Lubombo's only public hospital, said the loss of breadwinners to AIDS and the cost of caring for sick or orphaned family members had already reversed much of the economic gains made when growing sugar was more profitable.
Between 150 and 250 people a day crowd into Good Shepherd's small HIV clinic; many more do not come because even the nominal fee the hospital charges is beyond their means. The next challenge facing those who begin ARV treatment is how to take the pills on an empty stomach.
Job losses in the sugar industry are contributing to the vicious cycle of poverty and HIV/AIDS. Community Services and Development Manager for the RSSC, Faith Motsa, pointed out that retrenchments have major implications in communities where one breadwinner often supports 10 or more people: "If you lose one income-earner, it affects a whole extended family that often already have diminished resources because of HIV/AIDS."
Outsourcing functions previously carried out by RSSC employees is another cost-saving measure with devastating consequences, particularly for those affected by HIV. According to Motsa, employees "lucky enough" to be rehired by the new service providers often find salaries cut by half, and no benefits like free access to company clinics. Some employees have accepted voluntary "ill-health" retrenchment packages in return for larger life insurance payouts for their families. She conceded that "probably we've shortened the lifespan of that individual, who could walk to the clinic and access prompt treatment before."
Retrenchments have had other side effects. "We have not altered any of our voluntary counselling and testing (VCT) services, but you find that people's attention gets diverted by retrenchments and utilisation drops a bit, as people are distracted by uncertainty about their future," Motsa commented.
Pressure on public health facilities is increasing, while the loss of revenue from sugar exports is likely to impact on the government's ability to increase spending on health and other services previously subsidised by sugar companies. The Global Fund to Fight AIDS, Tuberculosis and Malaria is paying for ARV drugs in Swaziland, but according to the Fund's Portfolio Manager for Swaziland, Tatjana Peterson, the lack of a fully functioning patient and drug management system, and a shortage of healthcare workers is hampering the national ARV rollout and affecting the quality of treatment.
Good Shepherd, with just one doctor and two nurses managing an HIV clinic that serves a regional population of 200,000, is no exception. In April six regional clinics began distributing ARVs, relieving some of the pressure on Good Shephard and giving hope to patients like Twana Dlamini. Nevertheless, said Phillip, "We are struggling here to take care of all this."
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