CASE STUDY

Eight months in Lubombo: a story of change

at Good Shepherd Hospital, Swaziland
Good Shepherd Hospital (GSH) is
the regional hospital for Lubombo,
the poorest and most rural region of
Swaziland. Serving a population of
approximately 220,000, the hospital
operates in an extremely
challenging local and national
context.

The highveld near Manzini in Swaziland

The Kingdom of Swaziland is a land-locked lower

middle-income country located between South
Africa and Mozambique.
Although a beautiful country, Swaziland is also a
place of extreme inequalities, with around 60%
of the population considered rural poor.
Health services are overburdened and underresourced. Among the Swazi population of
around 1 million, it is doubtful that there is a
single person untouched by the HIV and TB
co-epidemics.

Swaziland: key health facts

Map of Swaziland
showing the region
of Lubombo and
the approximate
position of Good
Shepherd Hospital

In Swaziland, 26% of adults in the 15-49

age group are HIV positive - the highest
estimated prevalence of HIV infected adults
in the world1.
Swazilands tuberculosis (TB) incidence is
the highest in the world and 80% of TB
patients are co-infected with HIV1.
Multi-drug resistant TB (MDR-TB) is
increasing2 .
44% of the population is younger than 15
and just under one quarter (23%) of
children aged 18 or younger are orphans
(defined as loss of one or both parents)3.
Non-communicable diseases (such as
cardiovascular disease, hypertension and
diabetes) also present huge challenges in
Swaziland.

Eight months in Lubombo - a story of change at Good Shepherd Hospital, Swaziland

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Future hopes and the key role of GSH

of care. This represents a huge step forward.

Yet, against this rather bleak picture, there are

signs of hope. Not least there now appears to be
real political commitment to address HIV and TB,
with both declared national emergencies by the
King of Swaziland.

In Lubombo there is GSH, considered one of the

leading hospitals in Swaziland. As a COMDIS-HSD
partner, the hospital has led the way in:

International donors and local partners continue to

invest in the health system. Antiretroviral therapy is
now widely available and free of charge at the point

establishing a decentralised service delivery

model for multi-drug resistant TB diagnosis and
treatment; and
achieving earlier diagnosis of HIV and TB
through better case finding.

A Swazi man in the rural poor Lubombo region

Children in a poorly-ventilated Lubombo home with an

indoor stove

Implementing an HIV/TB screening

programme for health workers

screening programme. It also served as a great

vehicle to introduce an infection prevention and
control (IPC) agenda into hospital working
practices. To ensure the sensitisation sessions
were as effective and relevant as possible, they
were designed to be inclusive, detailed and
tailored.

Anyone familiar with HIV or Africa will know that

testing for HIV and TB is an extremely sensitive
issue. Fear and stigma associated with diagnosis
are real concerns. Apathy and a feeling of
inevitability are also barriers. There are also major
economic disincentives for being diagnosed. Staff
with active TB and MDR-TB are not permitted to
work and can go without pay or receive reduced
pay for long periods. In addition, there are
implications for the organisation; it is not good for a
hospital to be seen to have a problem with TB.
Rolling out the programme at GSH:
At GSH, the management team had already
approved a sensitisation and screening programme
for hospital staff. The next step was to roll these
out. The sensitisation programme was used to
maximise acceptability and therefore uptake of the

Everyone from doctors to support staff were

invited.
The sessions lasted half a day for each group
and covered a range of issues including general
information about HIV and TB, the rationale of
the screening programme, its optional nature
and assurances about how confidentiality would
be maintained.
The sessions were offered in different formats to
match the needs of different audiences. Some
were in English and used presentation materials,
others were offered in Siswati and were purely
discussion based.

Eight months in Lubombo - a story of change at Good Shepherd Hospital, Swaziland

www.comdis-hsd.leeds.ac.uk

The presentations and discussions were Figure 1:

led by Thokozani Dlamini (sister in charge
of the GSH Wellness Team) and took
place every day for 3 weeks. The
screening at the GSH Wellness Clinic
followed immediately after for 10 weeks.
Uptake and results summary:

Of 356 staff, 253 (60%) attended the

sensitisation sessions.
247 (59%) of high-risk and lower-risk
groups attended screening (attendance
being optional).
Among these, there were79 positive
TB screenings, with 2 cases of active
TB detected. These individuals were
promptly commenced on therapy.
Just over half (127) of those attending
for screening opted for HIV testing.
Of these, 2 staff were newly diagnosed
with HIV.

The screening programme is now run

annually at GSH.

We managed to secure a supply of isoniazid for the programme;

sufficient to offer all staff TB chemoprophylaxis, regardless of their
HIV status. TB chemoprophylaxis is used to prevent TB infection
from developing into active disease. The decision to offer it to all
staff was made in partnership with the Swaziland National
Wellness Programme and reflected the generally high-risk
environment at GSH at that time. 133 staff (54% of those
screened) took it up, with a 70% completion rate at six months.

TB ward renovation: before and after

Conditions on the TB ward were pretty much
perfect for developing hospital-acquired TB
transmission. The facilities, mostly built in the
1950s and 1960s (before the HIV epidemic), were
simply not fit for purpose. For example:

Patients were not effectively grouped together.

The nurses station was located along the
corridor from the TB wards so patients moved in
and out without restrictions, mixing with other
non-TB inpatients (most of these HIV positive).
Bathrooms for female TB patients were located
across the main hospital corridor.
Airbricks allowed the transfer of airbornesuspended TB from TB to non-TB patient areas.
There was no dedicated TB in-patient nursing
team (nurses divided their duties between

all-male or all-female medical in-patients). As a

result, TB patients received less attention than
other in-patients, impacting on length of stay and
exacerbating the situation.
Imagine being a Swazi nurse on duty for this ward
As you venture through the door there are a
number of patients with TB lying on beds close
together. The room is dark and very poorly
ventilated.
The ward is sectioned off into three parts; there is
no window to the outside in two of the three
sections, including the one you have walked into.
The patients are sick, many of them dying. Some of
them need to be washed. You are wearing the N95
face mask that you have been issued for the month
(in the UK nurses get a new face mask every day).
Your colleague recently got MDR-TB.
Now imagine doing that day after day

Eight months in Lubombo - a story of change at Good Shepherd Hospital, Swaziland

www.comdis-hsd.leeds.ac.uk

Making the new TB ward happen

One of the biggest challenges we faced in
improving care for TB patients at GSH was lack of
money. Although HIV and TB have mobilised the
global community, TB infection control has been
largely neglected in policy and practice.
Infrastructure projects tend not to appeal to
international donors. This may be because they
perceive certain risks with these projects, such as
lack of design expertise and potential issues of
ownership.
It was clear we would have to rely on local
donations and the budget was likely to be very low.
In addition, any new design would have to fit into
the existing hospital infrastructure, as there would
certainly not be enough money for a purpose-built
facility.

How we found the funds

Working with the in-house hospital maintenance

team, we came up with a provisional budget while

ensuring that our plans remained realistic.
We presented the plan to the GSH management
team who were very enthusiastic. We then
approached Themba Dlamini, head of the National
TB Programme and a valued supporter. He had
been increasingly concerned about the problems of
workplace TB infection and promised to allocate
some funds.
We gained the support of the national infection
control and quality assurance teams, who
inspected the site and plans in person and
promised to help facilitate the project.
Potential donors were approached, including the
Ministry of Health. The fundraising culminated in
an appearance on stage at the World TB Day
celebrations to receive a cheque from the
Honourable Minister of Health for the Kingdom of
Swaziland. Our total budget was 280,000 Swazi
Emalangeni (then around 18,800).

1:The existing veranda at GSH

2:Professional, pro-bono input
The hospital veranda
was well-elevated and
in the sun most of the
day. Natural ventilation
(using wind-driven
turbines) could be
maximised, to
overcome the problem
of an unreliable
electricity supply.

Pro-bono support
from UK healthcare
architects, Apex4d
and Bowman Riley,
meant the plans
could be simulated
and modified
remotely from the
UK. (Pic courtesy of
Bowman Riley)

3:Construction underway
Knocking down 4 walls opened up
the TB ward. The extended unit
was sealed off from the rest of
the hospital. A new entrance and
a nurses' station ensured TB
patients would be grouped
together and would not come into
contact with non-TB in-patients.

Eight months in Lubombo - a story of change at Good Shepherd Hospital, Swaziland

www.comdis-hsd.leeds.ac.uk

Open for business: the new TB ward at Good Shepherd Hospital

Introducing infection prevention and control

training
Better IPC had been a long-standing issue at GSH.
However, a neonatal sepsis outbreak and
problems with MDR-TB had pushed it to the fore.
Together with Dr Samson Haumba, Country
Director of the University Research Company (a
global organisation dedicated to improving the
quality of health care, social services and health
education worldwide) we organised and ran
training sessions for around 220 hospital staff.

We also used the infection control training

sessions to boost IPC capacity and recruit focal
nurses for IPC in all hospital departments

There were big challenges. Unlike in the UK, hand

washing was not part of routine accepted practice.
If youve never been taught the importance of good
hand hygiene and hand hygiene technique, and
there are few well-maintained hand basins, why
would you practice good hand hygiene?
The training was well received by GS staff. The
highlight was a 5-minute talk given at the
beginning of every session by a member of staff
who had been affected by MDR-TB. They would tell
their colleagues about their experiences and urge
them to act to protect themselves. You could see
sleepy eyes suddenly focus.

One of the IPC posters created and displayed around

the hospital. It says in Siswati: Are they clean?
Washing hands stops microbes spreading

Eight months in Lubombo - a story of change at Good Shepherd Hospital, Swaziland

www.comdis-hsd.leeds.ac.uk

The bigger IPC picture and scaling up

Clearly the IPC problem was bigger than the issues
faced by GSH or Lubombo. There were significant
gaps at national level in terms of communicable
disease control, particularly around infectious
disease surveillance and response.
We approached Chikwe Ihekweazu, a consultant
epidemiologist seconded to the South African
National Institute of Communicable Disease (NICD)
in Johannesburg, to advise us on IPC. NICD has a
remit to provide communicable disease support for
the Southern African region. It has international
funding, excellent laboratory facilities and, most
importantly, it was willing to help.
After a short but fruitful meeting with Dr Simon
Zwane, the Director of Health Services for
Swaziland, it was clear that the Swazi Ministry of
Health was also open to potential collaboration with
the NICD.
Working together, both organisations agreed to
share resources and establish joint projects to

protect the health of the populations of both

countries. Specifically, NICD would provide
additional training and expert support to help the
Ministry of Health build capacity in:

infectious disease surveillance

epidemiology

outbreak response

laboratory diagnostics, and

public health research.

This agreement has been included in a

memorandum of understanding between the
governments of South Africa and Swaziland.
The Good Shepherd Hospital Tuberculosis
Infection Prevention and Control Policy was
published in December 2014. The policy builds
on this early work and provides detailed
information on what hospital staff can do to
protect themselves and others from infection.

Note on the author:

References:

Dr James Elston is an infectious disease physician and

one of the public health registrars to have completed a
secondment to Good Shepherd Hospital as part of the
COMDIS-HSD research programme. Read more about our
work to increase TB and HIV case-finding in Swaziland.

1. Centres for Disease Control and Prevention. (2013) CDC in

Swaziland factsheet. Atlanta
2. Kingdom of Swaziland Ministry of Health. (2012) TB
Program annual report. Swaziland
3. Central Statistical Office. (2008) Swaziland Demographic
and Health Survey 2006-07. Swaziland

10/15

This project has been funded by

UK aid from the UK government

COMDIS-HSD is a Research Programme Consortium funded until the end of 2016 by UK aid from the UK government.
Working with partner NGOs in 7 low and middle income countries, we carry out research and, using our findings, provide
evidence to policymakers to help them improve the way they deliver health services to their populations. Together with our
partners, our aim is to improve the quality of prevention and care services for common diseases, as well as making these
services easier for people to access, especially in underserved populations.
Eight months in Lubombo - a story of change at Good Shepherd Hospital, Swaziland

www.comdis-hsd.leeds.ac.uk