JOINT EXTERNAL EVALUATION
OF IHR CORE CAPACITIESof the
KINGDOM OF ESWATINI

Mission report:
9-13 April 2018

JOINT EXTERNAL EVALUATION
OF IHR CORE CAPACITIESof the
KINGDOM OF ESWATINI

Mission report:
9-13 April 2018

WHO/WHE/CPI/2018.27© World Health Organization 2018
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Acknowledgements-------------------------------------------------------------------------------------------------v
Acronyms and abbreviations-------------------------------------------------------------------------------------- vi
Executive summary------------------------------------------------------------------------------------------------- 1
Swaziland scores and priority areas for action----------------------------------------------------------------- 2

PREVENT—————————————————————————— 4of IHR Core Capacities of the Kingdom of Eswatini

Contents

National legislation, policy and financing----------------------------------------------------------------------- 4
IHR coordination, communication and advocacy-------------------------------------------------------------- 6
Antimicrobial resistance------------------------------------------------------------------------------------------- 8
Zoonotic diseases--------------------------------------------------------------------------------------------------12
Food safety----------------------------------------------------------------------------------------------------------15
Biosafety and biosecurity-----------------------------------------------------------------------------------------17
Immunization-------------------------------------------------------------------------------------------------------20

DETECT————————————————————————— 23
National laboratory system---------------------------------------------------------------------------------------23
Real-time surveillance---------------------------------------------------------------------------------------------25
Reporting------------------------------------------------------------------------------------------------------------28
Workforce development------------------------------------------------------------------------------------------31

RESPOND———————————————————————— 33
Preparedness-------------------------------------------------------------------------------------------------------33
Emergency response operations---------------------------------------------------------------------------------35
Linking public health and security authorities-----------------------------------------------------------------37
Medical countermeasures and personnel deployment-------------------------------------------------------39
Risk communication-----------------------------------------------------------------------------------------------41

OTHER IHR-RELATED HAZARDS AND POINTS OF ENTRY—————— 44
Points of entry------------------------------------------------------------------------------------------------------44
Chemical events----------------------------------------------------------------------------------------------------47
Radiation emergencies--------------------------------------------------------------------------------------------51

Appendix 1: JEE background————————————————— 54

iii

The WHO JEE Secretariat would like to acknowledge the following, whose support and commitment
to the principles of the International Health Regulations (2005) have ensured a successful outcome
to this JEE mission:•

The Government and national experts of the Kingdom of Eswatini for their support of, and work in,preparing for the JEE mission.

•

The Governments of Botswana, Ghana, Sweden (Public Health Agency of Sweden), Uganda and theUnited States of America (Centers for Disease Control and Prevention), for providing technical experts
for the peer-review process.

•

The Food and Agriculture Organization of the United Nations (FAO) and the World Organization for
Animal Health (OIE), and the United Nations Institute for Training and Research (UNITAR) for theircontribution of experts and expertise.

•

The following WHO entities: the WHO Country Offices of Ghana, South Sudan, the Intercountry
Support Team for Eastern and Southern Africa, Headquarters, and the WHO Regional Office for Africa
who sent experts.

•

The Global Health Security Agenda Initiative for its collaboration and support.

•

The Governments of Germany, Finland and the United States of America for their financial support tothis mission.

of IHR Core Capacities of the Kingdom of Eswatini

ACKNOWLEDGEMENTSv

Joint External Evaluationvi

Acronyms and abbreviations
ACSCARAMR Containment Strategic Plan to Combat Antimicrobial Resistance (2017–2021)

AEFI

Adverse events following immunization

ALARA

As low as reasonably achievable

AMR

Antimicrobial resistance

CMS

Central Medical Stores

CVL

Central Veterinary Laboratory

DHIS

District Health Information System

DHMT

District health management team

DVLS

Department of Veterinary and Livestock Services

EDCU

Epidemiology and Disease Control Unit

EMS

Emergency Medical Services

EOC

Emergency operations centre

EPI

Expanded Programme on Immunization

EPRU

Emergency Preparedness and Response Unit

FAO

Food and Agricultural Organization of the United Nations

FETP

Field Epidemiology Training Program

HMIS

Health Management Information System

HP&E

Health Promotion and Education Department

HCAI

Health care-associated infection

HPAI

Highly-pathogenic avian influenza

HR

Human resources

IAEA

International Atomic Energy Agency

IDNS

Immediate Disease Notification System

IDSR

Integrated Disease Surveillance and Response

IHR

International Health Regulations

ILO

International Labour Organization

IPC

Infection prevention and control

INFOSANInternational Food Safety Authorities Network

ISO

International Organization for Standardization

MCM

Medical countermeasures

MoA

Ministry of AgricultureMemorandum of Understanding

NDMA

National Disaster Management Agency

NFP

IHR National Focal Point

NGO

Nongovernmental organization

NRL

National Reference Laboratory

OIE

World Organisation for Animal Health

PHEIC

Public health emergency of international concern

PoE

Points of entry

PVS

Performance of Veterinary Services (evaluation)

RRT

Rapid response team

SADC

Southern African Development Community

SADCASSouthern African Development Community Accreditation Services

SEA

Swaziland Environmental Agency

SEPI

Swaziland Expanded Programme on Immunization

SOP

Standard operating procedure

SRA

Swaziland Revenue Authority

SWASA

Swaziland Standard Authority

TB

Tuberculosis

UNICEF

United Nations Children's Fund

USDF

Umbutfo Swaziland Defence Force

VAC

Vulnerability Assessment Committee

WAHIS

World Animal Health Information System

WHO

World Health Organizationof IHR Core Capacities of the Kingdom of Eswatini

MoU

vii

Eswatini has fortunately not experienced any large-scale emergencies recently. An acute emergency,
however, can occur at any time. Cognizant of this fact, the Government of Eswatini volunteered to undertake
the Joint External Evaluation (JEE) to identify its gaps in emergency preparedness, detection and response
and improve on its strengths/capacities for health security. This is highly commendable. The external peerto-peer review of Eswatini's capacities in 19 technical areas of the International Health Regulations (IHR)
commenced on 9 April 2018.

of IHR Core Capacities of the Kingdom of Eswatini

Executive summary

The country was found to have various strengths including the implementation of IHR through theIntegrated Disease Surveillance and Response (IDSR), a good sample/specimen transport system withdedicated vehicles managed by staff trained in specimen referral and laboratory testing systems for priority
diseases. Among the strengths identified during the field visits is the national emergency hotline, the tollfree 977-telephone number used throughout the country, which could be considered a best practice. The
staff managing the hotline are extremely well trained and organized, utilizing an electronic system for data.
The system is also used by health staff to report cases (e.g. cholera), which activates communication withall appropriate stakeholders to mount a response.
A lot of work has been done in the area of developing plans and strategies which were shared during
the peer-to-peer review. Many of these documents however were in draft form, and had not yet received
formal endorsement or enactment by ministers or parliament. Consequently, in order to maintain the
integrity of the JEE tool, a number of scores assigned were lower than expected. It is important to notethat in such instances, the country can quickly increase its scores by formally ratifying/enacting the plans,such as the draft National Multi-Hazard Contingency Plan, which is currently only awaiting the signatureof one minister in order to be formally adopted. Once complete, the country will have a strategy to address
multiple hazards with all relevant stakeholders, and work can begin on operationalizing work plans. It will
also quickly result in an increase in the country's score in the technical area of national legislation.
Eswatini is not a large country; its area is 17,364 km2, with a population of just over 1 million. For that andother reasons, officials in the country have made use of informal communication and ways of working thathave worked in the past—however, due to their informal nature, several processes are not documented.
Documentation of protocols and standard operating procedures was found to be lacking in a number of thetechnical areas assessed. This does not mean, however, that the capacity of the country is necessarily absent
or lacking in certain technical areas. Using IHR coordination as an example, it is clear that strong relationships
exist between staff of the Ministries of Health and Agriculture for example; however there are no formal
standard operating procedures that outline coordination mechanisms among all key sectors.
Another overarching area in which Eswatini needs to focus is the provision of adequate resources to address
the gaps identified in each technical area by investment in building the necessary skills and competencies.
For example it was found during the visit to the ground crossing that staff were not sensitized to the IHR
requirements and requested further training to adequately perform their duties. Additional resources areneeded to bring the points of entry (PoE) to the level that fulfils the requirements outlined by IHR.
While biosafety issues are catered for, another point brought out by the review is the lack of structures toaddress biosecurity systems. So it is imperative to incorporate biosecurity elements in the biosafety plan.
This will improve the scores in this technical area.
During the review national and international colleagues worked tirelessly to accurately determine the stateof the emergency preparedness and response capacity in Eswatini. It is clear that the strong political willobserved can be harnessed to quickly address the gaps identified by the JEE; that political will is needed tomobilize the resources to implement the national action plan for health security. This will allow the country
to achieve more sustained capacities for health security.

1

Joint External Evaluation

Eswatini scores and priority areas for action
Indi- Indicator description
Technical area cators
Nationallegislation, policy
and financing
IHR coordination,communication
and advocacy

Antimicrobial
resistance

Zoonotic diseases

Legislation, laws, regulations, administrative requirements, policies or other government instruments in place are sufficient for implementation of IHR (2005)
The State can demonstrate that it has adjusted and aligned its domestic legislation,
policies and administrative arrangements to enable compliance with IHR (2005)

2

P.2.1

A functional mechanism is established for the coordination and integration of
relevant sectors in the implementation of IHR

1

P.3.1

Antimicrobial resistance detection

1

P.3.2

Surveillance of infections caused by antimicrobial-resistant pathogens

1

P.3.3

Health care-associated infection (HCAI) prevention and control programmes

1

P.3.4

Antimicrobial stewardship activities

1

P.4.1

Surveillance systems in place for priority zoonotic diseases/pathogens

3

P.4.2

Veterinary or animal health workforce

4

Mechanisms for responding to infectious and potential zoonotic diseases are
established and functional
Mechanisms for multisectoral collaboration are established to ensure rapid
response to food safety emergencies and outbreaks of foodborne diseases

2

P.1.1
P.1.2

P.4.3

2

2

Food safety

P.5.1

Biosafety andbiosecurity

P.6.1

Whole-of-government biosafety and biosecurity system is in place for human,
animal and agriculture facilities

1

P.6.2

Biosafety and biosecurity training and practices

P.7.1

Vaccine coverage (measles) as part of national programme

P.7.2

National vaccine access and delivery

1
3
2

D.1.1

Laboratory testing for detection of priority diseases

4

D.1.2

Specimen referral and transport system

4

D.1.3

Effective modern point-of-care and laboratory-based diagnostics

2

D.1.4

Laboratory quality system

D.2.1

Indicator- and event-based surveillance systems

2
4

D.2.2

Interoperable, interconnected, electronic real-time reporting system

2

D.2.3

Integration and analysis of surveillance data

D.2.4

Syndromic surveillance systems

4
4

D.3.1

System for efficient reporting to FAO, OIE and WHO

1

D.3.2

Reporting network and protocols in country2

Immunization

Nationallaboratory system

Real-timesurveillance

Reporting

2

Score

Workforce
development

Preparedness

Emergency
response
operations

Linking publichealth and security
authorities
Medicalcountermeasuresand personnel
deployment

Risk
communication

Points of entry

Chemical events

Radiation
emergencies

Score

D.4.1

Human resources available to implement IHR core capacity requirements

2

D.4.2

FETP1 or other applied epidemiology training programme in place

1

D.4.3

Workforce strategy

1

R.1.1

National multi-hazard public health emergency preparedness and response planis developed and implemented

2

R.1.2

Priority public health risks and resources are mapped and utilized

1

R.2.1

Capacity to activate emergency operations

2

R.2.2

EOC operating procedures and plans

1

R.2.3

Emergency operations programme

3

R.2.4

Case management procedures implemented for IHR relevant hazards

2

R.3.1

Public health and security authorities (e.g. law enforcement, border control,
customs) are linked during a suspect or confirmed biological event

2

R.4.1

System in place for sending and receiving medical countermeasures during apublic health emergency

1

R.4.2

System in place for sending and receiving health personnel during a publichealth emergency

1

R.5.1

Risk communication systems (plans, mechanisms, etc.)

R.5.2

Internal and partner communication and coordination

R.5.3

Public communication

R.5.4

Communication engagement with affected communities

R.5.5

Dynamic listening and rumour management

1
2
3
1
2

PoE.1

Routine capacities established at points of entry

1

PoE.2

Effective public health response at points of entry

1

CE.1

Mechanisms established and functioning for detecting and responding tochemical events or emergencies

2

CE.2

Enabling environment in place for management of chemical events

2

RE.1

Mechanisms established and functioning for detecting and responding to radiological and nuclear emergencies

1

RE.2

Enabling environment in place for management of radiation emergencies

1of IHR Core Capacities of the Kingdom of Eswatini

Indi- Indicator description
Technical area cators

Scores: 1=No capacity; 2=Limited capacity; 3=Developed capacity; 4=Demonstrated capacity; 5=Sustainable capacity.
1

FETP: Field epidemiology training programme3

Joint External Evaluation

PREVENTNational legislation, policy and financing
Introduction

PREVENTThe International Health Regulations (IHR) (2005) provide obligations and rights for States Parties. In someStates Parties, implementation of the IHR (2005) may require new or modified legislation. Even if a newor revised legislation may not be specifically required, states may still choose to revise some regulations
or other instruments in order to facilitate IHR implementation and maintenance in a more effective
manner. Implementing legislation could serve to institutionalize and strengthen the role of IHR (2005) andoperations within the State Party. It can also facilitate coordination among the different entities involvedin their implementation. See detailed guidance on IHR (2005) implementation in national legislation at
http://www.who.int/ihr/legal_issues/legislation/en/index.html. In addition, policies that identify national
structures and responsibilities as well as the allocation of adequate financial resources are also important.

TargetAdequate legal framework for States Parties to support and enable the implementation of all their
obligations, and rights to comply with and implement the IHR (2005). New or modified legislation insome States Parties for implementation of the IHR (2005). Where new or revised legislation may not be
specifically required under the State Party’s legal system, States may revise some legislation, regulations orother instruments in order to facilitate their implementation and maintenance in a more efficient, effective
or beneficial manner. States Parties ensure provision of adequate funding for IHR implementation throughthe national budget or other mechanism.

Eswatini's level of capabilities
Eswatini is a signatory to the 2005 International Health Regulations (IHR) and is committed tostrengthening its core capacities including surveillance, laboratory, preparedness and response. The indepth self-assessment of the core capacities conducted in 2010 resulted in the development of the IHR
implementation plan and the adoption of the Integrated Diseases Surveillance and Response (IDSR) as avehicle for the implementation of IHR.
The country has a number of legislative instruments and documents that govern public health surveillance
and response. These include the Animal Diseases Act (1965), the Public Health Act (1969), Environmental
Health Policy (2002), Disaster Management Act (2006), National Health Policy (2007), the Veterinary Public
Health Act (2013), the National Health Sector Strategic Plan (2014–2018) and the Medicines and Related
Substances Control Act (2016). Eswatini is also signatory to a number of cross-border agreements on malaria
involving Mozambique, South Africa and Eswatini and acute flaccid paralysis involving Eswatini, Lesothoand South Africa. The Government however recognized the need to update some of these documents toaccommodate the legal framework to support and enable the implementation of all the IHR (2005).
The legislative and regulative framework for health review was undertaken in 2015 for the purpose ofundertaking the existing relevant laws for public health, which resulted in the amendment of the Public
Health Act (1969) and Medicines and Related Substances Control Act (2016) and drafting of the HealthBill. This bill is awaiting finalization and various processes before final approval by parliament. For animal
health, an assessment of existing legislation was conducted as part of the 2015 Performance of Veterinary
Services (PVS) evaluation. The recently-adopted Veterinary Public Health Act (2013) was found to cover4

•Finalize the Health Bill which addresses gaps identified in the Public Health Act (1969) and other IHR
related legislation (chemical, radiation, etc.) and submit them through the processes for enactment.

•

Establish a budget line for funding IHR activities as outlined in the IHR implementation plan.

•

Compile list of laws that are relevant for IHR according to priority and update them to conform to IHR(2005).

•

Establish an inter-ministerial legal committee that regularly meets to operationalize the legal
requirements of IHR.

PREVENT

Recommendations for priority actionsof IHR Core Capacities of the Kingdom of Eswatinithe main pillars of the IHR (2005), albeit through compliance with OIE standards. Despite the assessmentsof these pieces of legislation, the exercise to prioritize respective IHR-related laws to be updated isoutstanding. Active engagement and training of the legal counsels of the relevant ministries on IHR (2005)
is needed to conduct this exercise.

Indicators and scores
P.1.1 Legislation, laws, regulations, administrative requirements, policies or other government
instruments in place are sufficient for implementation of IHR (2005) – Score 2

Strengths/best practices• Eswatini has several laws, policies and administrative procedures that speak to components of IHR.
•

There is a draft Health Bill nearing completion that includes several clauses that address IHR compliance.

•

IDSR is being implemented at all levels and has been identified as the channel for operationalizing IHR.

Areas which need strengthening/challenges• Enforcement of existing laws addressing IHR is inadequate.
•

A mechanism for financing the steps needed to operationalize IHR is not clearly delineated.

•

While for some diseases such as malaria there are cross-border agreements, no such agreements withneighbouring countries exist for public health emergencies.

P.1.2 The State can demonstrate that it has adjusted and aligned its domestic legislation,
policies and administrative arrangements to enable compliance with the IHR (2005) – Score 2

Strengths/best practices• Assessment of relevant laws to IHR has been conducted and adjustment needs identified•

Findings from the assessment of IHR legislation and documents have informed the development of theVeterinary Public Health Act (2013) and the draft Health Bill.

Areas which need strengthening/challenges• There is inadequate collaboration among the legal counsels in the different ministries relevant to IHR
to oversee the implementation of the legal requirements of IHR.
•

There are some laws in other ministries relevant to IHR that are yet to be updated to comply with IHR.

5

Joint External Evaluation

IHR coordination, communication and advocacy
Introduction
The effective implementation of the IHR requires multisectoral/multidisciplinary approaches throughnational partnerships for efficient and alert response systems. Coordination of nationwide resources,
including the designation of a national IHR Focal Point, which is a national centre for IHR communications,is a key requisite for IHR implementation.

PREVENT

TargetMultisectoral/multidisciplinary approaches through national partnerships that allow efficient, alert andresponsive systems for effective implementation of the IHR (2005). Coordinate nationwide resources,
including sustainable functioning of a national IHR Focal Point – a national centre for IHR (2005)
communications which is a key requisite for IHR (2005) implementation – that is accessible at all times.
States Parties provide WHO with contact details of national IHR Focal Points, continuously update andannually confirm them.

Eswatini's level of capabilities
Coordination, communication and advocacy related to the IHR in Eswatini are implemented in the context
of Integrated Disease Surveillance and Response (IDSR). Following a One Health approach it brings together
Ministries of Health, Agriculture and Environmental Services as well as nongovernmental organizations(NGOs) and the private sector. A fully staffed IHR National Focal Point (NFP) Secretariat has been establishedand operates continuously. Lines of communication between the NFP and both veterinarian and publichealth sectors are operational; the NFP reports promptly to WHO (within 24 hours) as prescribed in the IHR.
The National Epidemic Task Force provides leadership to the Epidemic Task Force (ETF) and rapid response
team (RRT) structures and collaborates with and provides coordination for multiple Ministry of Health(MoH) units, external agencies and NGOs involved in a large-scale response. However, these surveillance
and response mechanisms are currently restricted to infectious diseases epidemics under IDSR as these are
the principal hazards in Eswatini. In order to meet IHR requirements the existing coordination mechanisms
would have to be expanded to address all multi-hazard public health threats as stipulated in the IHR (2005).
In the event of a major emergency or disaster, there is a fully operational National Disaster Management
Agency (NDMA), which can coordinate all the relevant sectors and actors to implement a response to theemergency, including a public health emergency of international concern (PHEIC).
The MoH has prioritized its commitment to IHR as evident from investment in human and operational
resources but it will be necessary to advocate beyond the health sector for an all-government, comprehensive
engagement in order to comply with IHR requirements. National policies encourage government ministries
to work together but the current level of collaboration is insufficient to comply with IHR core capacities
and requires more formalization. All stakeholders will need to be sensitized to ensure action-oriented
preparedness systems are put into place. It will be critical to communicate that IHR is an obligation of theGovernment of Eswatini as a whole, not just the work of the NFP or even the MoH.
There is a need for formal multisectoral coordination structures and mechanisms, which cut across all thetechnical areas being assessed in the Joint External Evaluation. Although this applies across all technicalareas, those that were identified as particular challenges are: preparedness, emergency response operations;linking public health and security authorities and risk communication.

6

•

Establish and operationalize formal, regular coordination mechanisms with other key sectors (via a task
force or committee) through finalized standard operating procedures (SOPs) to address all hazards andcore capacities described in the IHR.

•

Conduct annual internal assessments for IHR and after-action evaluations of public health events
across multiple sectors to document lessons learned and strengthen collaboration between sectors for
future events.

•

Advocate for and mobilize necessary resources from government and other stakeholders for
implementation of IHR-related activities.

of IHR Core Capacities of the Kingdom of Eswatini

Recommendations for priority actions

Indicators and scores

PREVENT

P.2.1 A functional mechanism established for the coordination and integration of relevant
sectors in the implementation of IHR – Score 1

Strengths/best practices• Functional National and Regional Epidemic Task Forces exist for multisectoral coordination when
responding to disease outbreaks using RRTs.
•

The MoH has established a secretariat for the NFP, which is available continuously and has a functioning
communication system.

•

Informal mechanisms for intersectoral coordination exist and the NDMA has the authority for national
coordination in the event of a major crisis.

Areas which need strengthening/challenges• A formal multisectoral and multidisciplinary IHR coordination mechanism, through a task force orcommittee, is required to engage all the relevant sectors. This mechanism should function both during
and outside an emergency and include established communication channels, collaboration on joint
activities, access to decision-makers, and documentation of cooperation through meeting reports,
plans and evaluations. Expansion of the scope of the existing task force for IDSR to include hazards
outlined in IHR would achieve this objective.
•

Development and implementation of appropriate SOPs and guidelines are needed for coordination of
IHR activities at all levels and across all sectors for preparedness and response to public health threats,
particularly to enable the One Health approach.

7

Joint External Evaluation

Antimicrobial resistanceIntroduction
Bacteria and other microbes evolve in response to their environment and inevitably develop mechanisms toresist being killed by antimicrobial agents. For many decades, the problem was manageable as the growthof resistance was slow and the pharmaceutical industry continued to create new antibiotics.

PREVENTOver the past decade, however, this problem has become a crisis. Antimicrobial resistance is evolving at an
alarming rate and is outpacing the development of new countermeasures capable of thwarting infections
in humans. This situation threatens patient care, economic growth, public health, agriculture, economic
security and national security.

TargetSupport work coordinated by FAO, OIE and WHO to develop an integrated global package of activities tocombat antimicrobial resistance, spanning human, animal, agricultural, food and environmental aspects (i.e.
a One Health approach). Each country has: (i) its own national comprehensive plan to combat antimicrobial
resistance; (ii) strengthened surveillance and laboratory capacity at the national and international levels
following international standards developed as per the framework of the Global Action Plan; and (iii)
improved conservation of existing treatments and collaboration to support the sustainable development of
new antibiotics, alternative treatments, preventive measures and rapid point-of-care diagnostics, including
systems to preserve new antibiotics.

Eswatini's level of capabilities
In Eswatini the detection of antimicrobial resistance (AMR) in microbial pathogens is done in three publiclaboratories. For the microbial pathogens isolated from community and hospital acquired clinical specimens,
AMR detection is done at the National Reference Laboratory (NRL) and Raleigh Fitkin Memorial Hospital
Laboratory, whereas AMR detection in microbial pathogens from the animal health sector is done at theCentral Veterinary Laboratory. In addition, two private laboratories i.e. Lancet and Ampath laboratories, arealso engaged for antibiotic susceptibility testing of AMR pathogens. The respective laboratories conduct
external quality assurance programmes to ensure the validity of the AMR testing. The public laboratories arein the process of officially subscribing to an institute for international standards on AMR testing guidelines(Clinical Laboratory Standards Institute Guidelines), and are committed to attaining accreditation for the
NRL and the other public health laboratories.
In accordance with the IHR (2015) requirements, there must be an endorsed “National Action Plan” that
describes activities and surveillance systems for the AMR detection and surveillance, HCAI detection,
surveillance and management, and antimicrobial usage and stewardship. It is commendable that Eswatinifinalized their national “AMR Containment Strategy to Combat Antimicrobial Resistance (2017–2021)”
in December 2017. It has been signed by two of the ministers from the three relevant ministries: Ministryof Health (signed), Ministry of Agriculture (signed) and awaiting the signature of the Minister of Natural
Resources and Energy.
This document identifies interventions that are required in Eswatini for the development of a robust
surveillance system for AMR and HCAIs, optimal antimicrobial usage and antimicrobial stewardship. The
next essential step is for the country to develop an implementation plan that describes specific activities
and the associated costs, timelines, risks and mitigation measures for each of the respective interventions
stated in the Antimicrobial Resistance Containment Strategic Plan. This important step will facilitate
effective implementation of AMR and HCAIs surveillance nationwide.

8

As the finalization of the national action plans (i.e. on AMR, HCAI, IPC, antimicrobial use and stewardship)
is conducted, it will be important to recall that since AMR affects the public health, animal health andenvironmental health sectors, an important requirement of IHR (2005) is to ensure that establishedsurveillance systems are integrated across all sectors (One Health approach). So where required, a multisectoral team may be valuable for respective efforts during this process.

of IHR Core Capacities of the Kingdom of Eswatini

Eswatini has comprehensive and commendable Infection Prevention Control (IPC) 2014 guidelines, which
intricately describe the country's various IPC procedures. In addition, there are designated trained IPC
personnel in respective healthcare facilities in the public system and healthcare personnel benefit from
IPC training. However, since the IPC guidelines were published in 2014 they will need to be reviewed andupdated according to recent WHO guidelines implemented in 20162. These may then be incorporated into
the national implementation plan for AMR (and HCAIs) or incorporated into a separated national action
plan for IPC procedures.

•

Complete the approval process of the AMR Containment Strategy to Combat Antimicrobial Resistance[ACSCAR] (2017–2021) by obtaining the remaining signature from the Minister of Natural Resources
and Energy.

•

Develop an implementation plan that includes AMR detection and surveillance, HCAI detection,
surveillance and management and antimicrobial usage and AMR stewardship, with a relevant
monitoring and evaluation framework (or incorporate these points into the current draft plan). Note:
while the draft ACSCAR is comprehensive it only describes interventions. An implementation plan that
describes action/work to be done in the short, mid and long term, inclusive of a budget for the planned
actions, would be valuable.

•

Review and update the IPC guidelines (2014) according to the WHO guidelines published in 2016.
These may then be incorporated into a separate "National action plan for IPC" or incorporated into
the implementation plan of the ACSCAR (2017–2021), as suggested above.

•

Update the Standard Treatment Guidelines (2012) to include a multisectoral (One Health) approachand engage the relevant stakeholders to enforce legislation for the requirement of prescriptions for
antibiotics in both the public health and animal health sectors.

•

Upgrade existing isolation units in tertiary hospitals and put in place isolation units in regional publichealth hospitals, at least one per region.

PREVENT

Recommendations for priority actions

2 Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level.
Geneva: World Health Organization; 2016 (http://apps.who.int/iris/bitstream/handle/10665/251730/9789241549929-eng.pdf,
accessed 27 April 2018).

9

Joint External Evaluation

Indicators and scores
P.3.1 Antimicrobial resistance detection – Score 1

PREVENT

Strengths/best practices• The ACSCAR (2017–2021) document identifies strategic areas of work for AMR in the following
six areas: awareness; surveillance and research; reducing infections through IPC, biosafety; use of
antimicrobial medicines in humans and animals; research and development (R&D); and governanceand stewardship.
•

Antibiotic susceptibility testing is conducted at National Reference Laboratory (NRL), Raleigh Fitkin
Memorial Hospital, the Central Veterinary Laboratory and two private laboratories: Lancet and Ampath.

•

The laboratories conducting antibiotic susceptibility testing are enrolled in external quality assurance
programmes.

•

The animal health sector is guided by global AMR initiatives through WHO, FAO and OIE.

Areas which need strengthening/challenges• Although the AMR Containment Strategy to Combat Antimicrobial Resistance (2017–2021) has beendeveloped, the implementation plan including an M&E framework needs to be developed.
•

Subscription to an institute for International standards and guidelines for AMR testing (ClinicalLaboratory Standards Institute guidelines) needs to be finalized.

•

Sentinel sites for AMR surveillance need to be designated and international tools for AMR surveillance(GLASS3; AGISAR4 and ATLAS5) need to be adopted and implemented.

•

Established systems must allow for the integration of AMR detection and surveillance in both the
public health and animal health sectors.

P.3.2 Surveillance of infections caused by antimicrobial-resistant pathogens – Score 1

Strengths/best practices• There is a plan is to set up AMR sentinel surveillance in four regional hospitals•

The central veterinary laboratory monitors anti-microbial resistance and submits monthly reports to theoffice of the Director of Veterinary and Livestock services

Areas which need strengthening/challenges• The national implementation plan should also include the surveillance of the infections caused by AMR
pathogens.
P.3.3 Health care-associated infection (HCAI) prevention and control programmes – Score 1

Strengths/best practices• Infection Prevention and Control (IPC) guidelines (2014) are available.
•

IPC personnel are present in healthcare facilities across the public health system; IPC SOPs have beendeveloped and healthcare workers are trained on IPC procedures.

3 Global Antimicrobial Resistance Surveillance System (GLASS)
4 WHO Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR)
5 Antimicrobial Testing Leadership and Surveillance (ATLAS)

10

Existing isolation units in the tertiary hospitals need to be upgraded; establishing isolation units inother hospitals is also a need (i.e. at least one per region).

P.3.4 Antimicrobial stewardship activities – Score 1

Strengths/best practices• There are some national documents on medicines and antimicrobials which are approved and in use
i.e. Standard Treatment Guidelines to Regulate and Promote Rational Use of Antibiotics (2012), and the
Medicines and Related Substances Control Act (2016).
•

Importation and distribution of antimicrobials for the animal health sector is done by the Department
of Veterinary Services in the Ministry of Agriculture and is governed by the Animal Diseases Act (1965).
This allows regulatory authority for the control and distribution of veterinary medicines.

Areas which need strengthening/challenges• A national implementation plan for antimicrobial use and stewardship has not yet been developed.
•

Monitoring of the prescription and use of antimicrobials needs to be strengthened, at pharmacies byhealthcare workers and as a follow up with patients.

•

Prescriptions are a requirement for the acquisition of antibiotics used in the public health and animal
health sectors but it is possible for antibiotics to be purchased without the presentation of a prescription.
The legislation that requires having a prescription to purchase antibiotics needs to be enforced by therelevant regulatory authorities within the country.

PREVENT•of IHR Core Capacities of the Kingdom of Eswatini

Areas which need strengthening/challenges• The national implementation plan for the country's IPC programme does not include surveillance andmanagement of HCAIs.

11

Joint External Evaluation

Zoonotic diseases
Introduction
Zoonotic diseases are communicable diseases that can spread between animals and humans. Thesediseases are caused by viruses, bacteria, parasites and fungi carried by animals, insects or inanimate vectorsthat aid in its transmission. Approximately 75% of recently emerging infectious diseases affecting humans
is of animal origin; and approximately 60% of all human pathogens are zoonotic.

PREVENT

TargetAdopted measured behaviours, policies and/or practices that minimize the transmission of zoonotic
diseases from animals into human populations.

Eswatini's level of capabilities
Eswatini conducts surveillance of several zoonotic diseases, i.e. bovine spongiform encephalopathy, brucellosis,
cysticercosis, echinococcosis, rabies, Rift Valley fever, salmonellosis and tuberculosis. However, not all of these
diseases are perceived as being of domestic public health concern. For example, tuberculosis surveillance indairy cattle focuses on M. bovis, while corresponding surveillance in public health focuses primarily on M.
tuberculosis. When conducting surveillance for avian influenza, animal health surveillance focuses on all typesof influenza, some not shown to be transmissible to humans. Therefore, whereas epidemiological surveillanceon zoonosis is conducted on the side of the Ministry of Agriculture (MoA) at sometimes an advanced level,
there is a mismatch with some of the priorities of the Ministry of Health. This may be due to a perceived lack offormal cooperation, such as through an inter-ministerial mechanism or One Health platform. Such a platform
could go a long way in streamlining surveillance of zoonoses between the two entities (agreeing on a shortlistof zoonoses of interest to both the public health and the animal health security). An informal comparison ofsuch priorities – conducted during the plenary session – only produced a clear match for rabies, tuberculosis
and avian influenza (but with the caveats mentioned above).
The best illustrative practice in terms of joint zoonotic disease collaboration is rabies, for which there isa mechanism for the joint investigation and management of bite-incidents, which offers prospects forthe elimination of dog-mediated rabies by 2030, as promoted by WHO, FAO and OIE. The well-qualified
veterinary and (para-professional) workforce is regarded as an important asset in the country.

Recommendations for priority actions

12•

Strengthen and formalize the collaboration between the Ministry of Agriculture and the Ministry of
Health on zoonotic disease surveillance and control through the One Health approach (e.g. throughMoUs).

•Develop or extend a continuing education programme to enhance the technical capabilities oftechnical staff to manage zoonotic diseases, with particular emphasis – for veterinary staff – on issuesof biosecurity and (personal) biosafety when dealing with outbreaks of suspected emerging or reemerging zoonotic diseases in animals.

•

Improve and prioritize funding of zoonotic animal health disease control/prevention programmes, withparticular emphasis on the funding of risk mitigation measures that result from surveillance outcomes(i.e. rabies and brucellosis/tuberculosis control).

Strengths/best practices• Several surveillance systems (both passive and active) are in place for priority diseases (refer to theabove list).
•

There is regular reporting on animal diseases to regional, continental and international bodies (SADC,
AU-IBAR, OIE) and a list of notifiable diseases. Legislation is in place for the control of animal diseases(and foodborne diseases from animal products). Refer to the list under “relevant documentation”
below. This includes an official list of notifiable animal diseases (for which declaration to the veterinary
authority is mandatory).

•

Due to its demanding foot-and-mouth disease free status and export-accreditation to the European
Union (beef), the country maintains stringent controls of importation of livestock and livestock
products and border inspections of these products. These products are audited by both the OIE andthe European Commission’s Food and Veterinary Office.

Areas which need strengthening/challenges• Collaboration needs to be strengthened between all stakeholders involved in zoonotic diseases
surveillance and control, in particular between the MoH and the MoA, but also with civil society
organizations (consumers), animal welfare organizations (rabies) and environmental authorities(wildlife).
•

The Veterinary Public Health Act, adopted in 2013, still needs to be implemented to its full capacity,
including through the adoption of further secondary legislation.

•

To fully meet the capacity requirements of P.4.1. score 4, the following capacities must be strengthened:
full alignment of surveillance for formally identified and prioritized zoonotic diseases between theMoH, MoA and relevant other stakeholders for at least five zoonotic diseases of national public healthconcern.

PREVENT

P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens – Score 3

of IHR Core Capacities of the Kingdom of Eswatini

Indicators and scores

P.4.2 Veterinary or animal health workforce – Score 4

Strengths/best practices• There are trained personnel for the control of animal diseases:❍❍

Veterinarians at national level❍❍

Veterinarians at regional level❍❍

Veterinary para-professionals (veterinary assistants) at sub-regional level❍❍

Community-based animal health workers (Dip Tank Assistants) at community level

Areas which need strengthening/challenges• The country in general lacks a structured and institutionalized system of continuing education orcontinuous professional development of its technical staff to improve technical capabilities on existing,but especially emerging and re-emerging zoonotic diseases, such as e.g. Rift Valley fever or new highlypathogenic avian influenza (HPAI) strains.

13Joint External Evaluation

P.4.3 Mechanisms for responding to infectious and potential zoonotic diseases establishedand functional – Score 2

Strengths/best practices• The above-mentioned challenges in respect to rabies vaccination capacity are in part overcome bygood cooperation with the public health authorities which collaborate even at the community level.
Areas which need strengthening/challenges• Budgetary constraints limit the implementation of response mechanisms for some of the surveillance
programmes in place.

PREVENT•

14

A mechanism for coordinated response to outbreaks of zoonotic diseases by public health, animal
and wildlife sectors will have to be established, at least through agreed joint standard operatingprocedures (SOPs).

Food- and water-borne diarrhoeal diseases are leading causes of illness and death, particularly in lessdeveloped countries. The rapid globalization of food production and trade has increased the potential
likelihood of international incidents involving contaminated food. The identification of the source of an
outbreak and its containment is critical for control. Risk management capacity with regard to control
throughout the food chain continuum must be developed. If epidemiological analysis identifies food as
the source of an event, based on a risk assessment, suitable risk management options that ensure theprevention of human cases (or further cases) need to be put in place.

TargetSurveillance and response capacity among States Parties for food- and water-borne disease risks or eventsby strengthening effective communication and collaboration among the sectors responsible for food safety,
and safe water and sanitation.

PREVENT

Introductionof IHR Core Capacities of the Kingdom of Eswatini

Food safety

Eswatini's level of capabilities
Disease outbreaks related to food safety rarely occur in Eswatini, but it is possible that outbreaks are
occurring but are not being detected, since faecal specimens from diarrhoeal cases are not always analysed
and there is no chemical, toxicological and microbiological monitoring of food from farm to fork. There isno surveillance system in place for prioritized foodborne illnesses, which may be the reason why Eswatini
rarely reports food safety-related events. There is therefore a need to improve the national food safetysurveillance system. While a lot is being done by dedicated professionals from various ministries, monitoring
and control is very fragmented.
The Ministry of Health and the Ministry of Agriculture are both responsible for food safety in the country
and in practice they share this responsibility with several other actors like the Ministry of Commerce,
Industry and Trade, the Regulatory & Quality Infrastructure Development, Licensing Section, the Ministryof Education (Home Economics Section), the Eswatini Standard Authority (SWASA), the Eswatini NutritionCouncil, the Eswatini Dairy Board, the National Marketing Board, the Eswatini Consumer Association andthe Eswatini Consumer Forum. Responsible focal points from the various ministries know each other welland strive to keep food as safe as possible, but they work through informal procedures that only work
because they know each other.
Most of the food used in Eswatini is imported from South Africa and Eswatini relies a lot on the controlsthat South Africa (or other countries) implement before exporting. During outbreaks or other food safetyrelated incidents the focal points manage to reduce risks and even find sources, but the legal backgroundfor necessary control measures is lacking. In March 2018 some processed meat products originating fromSouth Africa were found to be contaminated with Listeria Monocytogenes. In the absence of a robust
surveillance system for foodborne illnesses, Eswatini was only able to passively respond to the emergency– responding to recalls coming from the companies in South Africa that produced the meat and relying on
information received from the Ministry of Health of South Africa. Direct and successful measures were taken
to recall the contaminated products and the International Food Safety Authorities Network (INFOSAN) was
officially informed. No further incidents occurred and the measures taken, including recall of implicatedproducts and inspections of food establishments seem to have been successful. However, it could not be
definitively stated that there were no cases of the implicated Listeria strain present in Eswatini – until

15

Joint External Evaluationlaboratory tests of implicated food items and stools are undertaken. Informal links are working, but are no
guarantee for a sustainable and transparent food safety control programme in Eswatini.

Recommendations for priority actions•

Develop a coordinated intersectoral food safety policy and enact legislation specific to food safety.

•

Develop standard operating procedures (SOPs) for operational links and roles of responsibility between
the focal points from various ministries and agencies responsible for the daily activities and decisions
regarding food safety.

•

Establish a formalized multisectoral food safety coordination network and a network between alllaboratories in the country that deal with food safety.

PREVENT

Indicators and scores
P.5.1 Mechanisms for multisectoral collaboration established to ensure rapid response tofood safety emergencies and outbreaks of foodborne diseases – Score 2

Strengths/best practices• Inspectors from the Ministry of Health, Ministry of Agriculture (including animal health and plant
health), National Marketing Board and the Eswatini Dairy Board are available in all the designated
Points of Entry for control of export and import of commodities.
•

Food safety-related forums are available in the Ministries of Agriculture and Health such as the National
Codex Committee (NCC) and the National Sanitary and Phytosanitary Committee (comprising Animal
Health OIE; Plant Health; International Plant protection Convention (IPPC) and food safety, Codex
Alimentarius).

•

There are weekly live and pre-recorded slots for health issues including food safety on the national
radio station.

•

The Environmental Health Department is represented in the IHR National Focal Point.

Areas which need strengthening/challenges• Food safety policies and legislation are inadequate.

16•

Collaboration and communication with other ministries or other organizations responsible for foodsafety could be improved (i.e. formalized).

•

Chemical, toxicological and microbiological monitoring of food from farm to fork needs strengthening.
At this moment the Ministry of Agriculture carries out chemical and microbiological analysis for meat
export, and municipal governments (Mbabane and Manzini) conduct microbial monitoring of foods intheir municipalities.

•

Consumer awareness campaigns need to be strengthened.

It is vital to work with pathogens in the laboratory to ensure that the global community possesses arobust set of tools – such as drugs, diagnostics, and vaccines – to counter the ever-evolving threat of
infectious diseases.
Research with infectious agents is critical for the development and availability of public health andmedical tools that are needed to detect, diagnose, recognize and respond to outbreaks of infectious
diseases of both natural and deliberate origin. At the same time, the expansion of infrastructure andresources dedicated to work with infectious agents have raised concerns regarding the need to ensure
proper biosafety and biosecurity to protect researchers and the community. Biosecurity is important inorder to secure infectious agents against those who would deliberately misuse them to harm people,
animals, plants or the environment.

PREVENT

Introductionof IHR Core Capacities of the Kingdom of Eswatini

Biosafety and biosecurity

TargetA whole-of-government national biosafety and biosecurity system with especially dangerous pathogens
identified, held, secured and monitored in a minimal number of facilities according to best practices;biological risk management training and educational outreach conducted to promote a shared culture of
responsibility, reduce dual-use risks, mitigate biological proliferation and deliberate use threats, and ensure
safe transfer of biological agents; and country-specific biosafety and biosecurity legislation, laboratory
licensing and pathogen control measures in place as appropriate.

Eswatini's level of capabilities
Eswatini acceded to the Biological and Toxic Weapon Convention (BWC) in 1991 and is also party to the
Cartagena Protocol on Biosafety and to the Convention on Biological Diversity.
Eswatini’s Biosafety Act of 2012 has recently amended a draft Biosafety Regulations in 2017. This Act
empowers the Eswatini Environment Authority to be the national focal point for biosafety. This act alsoestablishes a Biosafety Advisory Committee to provide guidance to relevant stakeholders.
Some elements of biosecurity have been incorporated into the biosafety regulations. However, the focus isprimarily limited to agricultural interests.
Biosafety levels of containment are in place at the National Reference laboratory and Central Veterinary
Laboratory. Physical security is used in laboratories in both sectors: both laboratories utilize locks, and the
National Reference Laboratory utilizes biometrics in addition to prevent access to biological specimens byunauthorized people.
Both the public health and animal health laboratories work with the environmental health sector to
manage biological waste.
During the plenary, capacity of this technical area was discussed at length. It was agreed that a score of 1
would not capture the entire capacity of this indicator in the country, but to be true to the JEE tool, 1 wasscored here due to the lack of a biosecurity element in the plans and system in place. It was noted that theSuppression of Terrorism Act No.3 of 2008 might provide further information about Eswatini's (planned)
capacity in the area of biosecurity, but review of that Act did not occur during the mission.

17

Joint External Evaluation

Recommendations for priority actions•

Develop biosecurity plan or incorporate biosecurity plan elements into the biosafety plan.

•

Conduct inventory of public health and veterinary facilities and the pathogens stored in those facilities.

•

Develop national legislation that addresses biosecurity and law enforcement as a whole-of-government
system.

•Develop biosecurity training for both public health and animal health sectors, which establishes anannual review of policies and procedures.

Indicators and scores

PREVENT

P.6.1 Whole-of-government biosafety and biosecurity system in place for human, animal andagriculture – Score 1

Strengths/best practices• Memorandums of Understanding (MoUs) exist between the Eswatini Environmental Agency (SEA) &MoH (Environmental Health (Port Health), the Eswatini Revenue Authority (SRA) and Royal Eswatini
Police Service.
•

Biometrics for entry into key laboratory areas are in place at the National Reference Laboratory. Security
cameras are in use in sensitive areas of the national laboratory.

•

There is awareness of policies and best practices related to genetically-modified organisms (GMOs) in
the agriculture sector.

Areas which need strengthening/challenges• It is not clear which ministries are the custodians of the Biological Weapons Convention and Suppressionof Terrorism Act (2008) in Eswatini; MoH collaboration with the respective ministries is needed toenhance coordination on biosecurity.

18•

Awareness and understanding of the international definition of biosecurity and related terminology
and standards is inadequate.

•

A framework that outlines a system for pathogen biosecurity is lacking.

•

There is a challenge with coordination of biosecurity activities for public health and veterinary
laboratories.

•

Coordination of the existing working groups which cover aspects of biosafety and biosecurity e.g. the
National Codex Committee, and National Sanitary and Phytosanitary Committee (comprising Animal
Health OIE; Plant Health; International Plant protection Convention (IPPC) and food safety, biosafety)
is a challenge.

•

Incorporating biosafety and biosecurity issues across relevant sectors and government departments isneeded.

•Documentation on biosafety best practices is available at both the national laboratory and the officesof public health units.

•

Information on GMOs is being incorporated into training curricula.

Areas which need strengthening/challenges• Training on biosafety and biosecurity is not available to all laboratory staff (public health and animal
health), including management and support staff.
•

The Biosafety Act does not currently address biosecurity concepts or reference the Biological Weapons
Convention.

•

The country lacks a biosecurity strategy and action plan.

PREVENT

Strengths/best practices• Training on biosafety is conducted at the national laboratory level and within public health units.

of IHR Core Capacities of the Kingdom of Eswatini

6.2 Biosafety and biosecurity training and practices – Score 1

19

Joint External Evaluation

Immunization
Introduction
Immunizations are estimated to prevent more than two million deaths a year globally. Immunization is oneof the most successful global health interventions and cost-effective ways to save lives and prevent disease.

TargetA national vaccine delivery system – with nationwide reach, effective distributions, access for marginalized
populations, adequate cold chain and ongoing quality control – that is able to respond to new disease threats.

PREVENT

Eswatini's level of capabilities
The Eswatini Expanded Programme on Immunization (SEPI) was established in 1980 as one of the components
of primary health care provision in Eswatini; it is governed by health sector legislation and WHO-adaptedand adopted strategies and policy guidelines. Immunization services are provided free of charge to theentire population at all facilities, both private and public. The EPI is integrated into primary health services.
Vaccinations have been mandatory and the enactment of the Children Protection and Welfare Act (2012)
has also focused on overcoming religious and traditional objections. Bacille Calmette-Guérin (BCG) andpoliomyelitis vaccines are administered to all newborns at maternity facilities. EPI technical staff are trained
annually on conducting disease surveillance, vaccine and cold chain management and monitoring targeted
diseases through weekly and monthly reporting systems. Acute flaccid paralysis, measles, neonatal tetanus(NT) and adverse events following immunization (AEFIs) are reported immediately through the Immediate
Disease Notification System (IDNS), which is supplemented by weekly and monthly reports that are sent to
WHO global programmes after internal approval. All data are managed electronically within EPI as part of
the Health Management Information System (HMIS) of the MoH.
The national laboratory handles diagnostics for some vaccine-preventable diseases and a courier system
is in place for transportation of specimens to the laboratory. Technical support is available from WHO
and UNICEF and vaccines under the routine immunization schedule are procured and 100% funded
directly by the government. For supplementary campaigns and special events funds are made available
from WHO and UNICEF. Successful introduction of new vaccines has taken place in the past three
years: rotavirus, inactivated polio vaccine (IPV) and measles-rubella vaccine. The country has a system
in place to monitor three diseases targeted for elimination/eradication – poliomyelitis, measles andneonatal tetanus – and a committee to oversee poliomyelitis eradication and another for review of
AEFIs. Rabies vaccines for animals/dogs are annually administered by veterinary services within the
Ministry of Agriculture. Post-exposure prophylaxis for potential rabies exposure of humans is provided
by the MoH through the Central Medical Stores (CMS).
Since 2013 there has been a decline in national routine immunization coverage. The indicator to measurenational coverage is the coverage of measles vaccine administered to children aged 9 months or below
the age of 12 months; this indicator has been below the target of 90% and in 2017 was 79% (a planis in place to reach 90% in the next three years). Logistics and supplies management problems have led
to vaccine stock-outs, which subsequently affect vaccination coverage rates; activities are now in place
to overcome this challenge.

20

of IHR Core Capacities of the Kingdom of Eswatini

Although community-based surveillance exists to ensure that every child is protected from vaccinepreventable diseases, deaths of infants aged under 3 months often are not recorded or reported. Data
management within the programme is a fundamental problem because there are no dedicated data
managers in the EPI programme and staff are “borrowed” from other departments. There are also
challenges in ensuring accuracy and completeness of facility-level (134 facilities) data as well as stock
management within the CMS system. Full integration between the Integrated Disease Surveillance
and Response (IDSR) and EPI strategic and operational plans is also a gap that the country would
like to address. Most importantly, staff shortages at national and regional level hinder programmatic
success overall.
Access to yellow fever vaccine is only on demand for travellers (not in routine immunization because it is
not endemic in Eswatini) but vaccine supplies are centralized rather than being available at designatedpoints of entry – the country is working on resolving this gap.

•

Implement a clear plan for strengthening HR capacity within the EPI programme by strengthening
national and regional EPI (including training of clinical supervisors and focal persons on adverse events
following immunization), as well as community-based disease surveillance.

•

Resolve issues within the EPI programme on data management, particularly the newly-implemented
Client Management Information System (CMIS), which aims at: (1) facility-level data accuracy, (2)better interoperability with CMS for real-time stock management; and (3) reporting from private clinics
conducting immunizations and following AEFIs is enhanced.

•

Enhancing data quality within HMIS.

•

Pursue the procurement of vaccines through UNICEF Supply Division mechanisms, which would be lesscostly thereby avoiding supply problems and stock-outs.

•

Gazette the Eswatini National Immunization Technical Advisory Group (SWANITAG) so that it canguide the EPI programme on all areas of work, particularly ensuring the EPI programme includes all
vaccines used for epidemic response.

•Strengthen and reinforce appropriate linkages between EPI and IDSR for surveillance, reporting andresponse for vaccine-preventable diseases as well as including all national vaccines under EPI (additional
to the routine EPI vaccines), such as yellow fever and rabies.

PREVENT

Recommendations for priority actions

Indicators and scores
P.7.1 Vaccine coverage (measles) as part of national programme – Score 3

Strengths/best practices• Eswatini has an effective, government-funded EPI programme that covers the population of the entire
country through free-of-cost provision of vaccines provided through both public and private sector
clinics.
•

Training is provided to staff annually; electronic systems are used for reporting immunization data andfor managing vaccine supplies and stocks; and committees oversee poliomyelitis eradication efforts
and reported AEFIs.

•

The SWANITAG will shortly be gazetted so it can provide overall guidance to EPI.

21

Joint External Evaluation

Areas which need strengthening/challenges• Challenges for the EPI programme to reach the target for measles coverage of 90% include a lack of
dedicated human resources at national and regional levels.
•

Vaccine stock-outs due to forecasting and procurement issues (see next indicator) is a challenge.

•

Community-based reporting for EPI programme parameters is a challenge.

P.7.2 National vaccine access and delivery – Score 2

PREVENT

Strengths/best practices• The EPI programme has good capacity at all levels in cold chain equipment and maintenance to ensure
national vaccine access and delivery at the health facility level. The cold chain functions best at the newCentral Vaccine Stores for all procured vaccines and work is planned to strengthen and expand the cold
chain at all levels with dedicated government investment.

22

Areas which need strengthening/challenges• Supply chain stock management systems are still in development, which is why there are challenges inreaching required measles vaccine coverage levels.
•

Real-time management of vaccine stock is currently a challenge (currently being addressed throughinteroperability with the system used by CMS).

•

Procurement of some vaccines is a challenge (efforts are ongoing to explore pooled procurement
mechanisms through UNICEF).

•

Technical staff to look at cold chain equipment.

National laboratory system
Introductionof IHR Core Capacities of the Kingdom of Eswatini

DETECT

Public health laboratories provide essential services including disease and outbreak detection, emergency
response, environmental monitoring and disease surveillance. State and local public health laboratories
can serve as a focal point for a national system, through their core functions for human, veterinary andfood safety including disease prevention, control and surveillance; integrated data management; reference
and specialized testing; laboratory oversight; emergency response; public health research; training andeducation; and partnerships and communication.

TargetReal-time biosurveillance with a national laboratory system and effective modern point-of-care andlaboratory-based diagnostics.

The National Reference Laboratory (NRL) has commendable expertise and facilities. It currently conducts
IHR core tests for six priority diseases/conditions: malaria, measles, meningitis, food poisoning, typhoid andcholera. There is an excellent designated transport system for clinical specimens within the country. Howevertransportation of specimens outside the country (i.e. to South Africa) for advanced diagnostic testing has
been dependent on WHO financial support, which will be ending in the near future. So measures will need
to be taken that will enable sustainability of the transport system internationally (e.g. apportioning funds
from the country's annual budget).

DETECT

Eswatini's level of capabilities

The Central Veterinary Laboratory (CVL) conducts five of the IHR core tests: tuberculosis, highly-pathogenic
avian influenza, brucellosis, salmonellosis and rabies. During plenary there was debate about the immediate
public health interest of some of those species (i.e. bovine tuberculosis, avian influenza, salmonella spp.).
There is no dedicated transport system in place for veterinary specimens like that used for public healthfacilities. This is partly due to differences in the operational systems in the animal health sector as comparedto the public health sector (i.e. farm visits are done by veterinarians who then return with the samples to
the CVL). This system has worked to now, as vehicles have been available to collect samples; however a
designated transport system would be preferable.
Both the NRL and the CVL engaged in quality assurance through external proficiency testing programmes:
the CVL conducts proficiency testing for rabies through the Onderstepoort Veterinary Institute (ARC-OVI),
which is the OIE Reference Laboratory for rabies. In addition, the CVL is in the process of acquiring ISO
17025 accreditation and the NRL has applied for accreditation from the Southern African Development
Community Accreditation Services (SADCAS).
It was noted during plenary that management of medical waste is a challenge, despite the use of autoclaves
and incinerators for medical waste in the public health sector.

Recommendations for priority actions•

Include all the laboratory core tests into an EQA programme at both the Central Veterinary Laboratory
and National Reference Laboratory.

23

Joint External Evaluation•

Secure funds for service contracts for maintenance of laboratory equipment.

•

Ensure the sustainability of the transport system, by establishing dedicated funds explicitly for specimens
destined for testing internationally (as support from WHO will be ending shortly).

•

Finalize the applications for accreditation for the Central Veterinary Laboratory and the National
Reference Laboratory with selected accreditation bodies.

•

Create a national body in charge of licensing, inspection and certification of laboratories.

Indicators and scoresD.1.1 Laboratory testing for detection of priority diseases – Score 4

Strengths/best practices• Both the CVL and the NRL are conducting core tests for more than five of the IHR priority diseases.
Areas which need strengthening/challenges• Some of the core tests are currently not performed in NRL. These should be incrementally included as
the expertise and required consumables and assays become available

DETECT

D.1.2 Specimen referral and transport system – Score 4

Strengths/best practices• The National Sample Transport System provides an efficient transport service for specimens and resultsfrom intermediate/district level laboratories to the national referral laboratories and vice versa. This
enables laboratories to meet the stipulated turnaround times for release of validated results to patientsor applicable stakeholders.
Areas which need strengthening/challenges• The transport system for samples sent internationally (to South Africa) needs to have a dedicated budget
to ensure its sustainability.
D.1.3 Effective modern point-of-care and laboratory-based diagnostics – Score 2

Strengths/best practices• The NRL system has point-of-care diagnostic tests for malaria, HIV and cholera.
Areas which need strengthening/challenges• Tier specific diagnostic testing strategies for the use of point-of-care tests are not well documented.
D.1.4 Laboratory quality system – Score 2

Strengths/best practices• The national laboratories for both the public health and animal health sectors are enrolled in quality
assurance systems for some of the core tests that are currently conducted.
Areas which need strengthening/challenges• Some laboratory core tests (of both the CVL and NRL) are not included in external quality assessment
programmes (all the core tests that are conducted need to be enrolled in quality assurance programmes).

24•

Service contracts for maintenance of all laboratory equipment is needed. Currently contracts for larger
equipment are in place but generally contracts for "smaller" equipment (e.g. micropipettes) have notbeen finalized.

•

CVL and NRL applications for accreditation with selected accreditation bodies need to be finalized.

•

There is currently no national body in charge of licensing, inspection and certification of laboratories inEswatini.

Introduction
The purpose of real-time surveillance is to advance the safety, security and resilience of the nation byleading an integrated bio-surveillance effort that facilitates early warning and situational awareness of
biological events.

of IHR Core Capacities of the Kingdom of Eswatini

Real-time surveillance

TargetStrengthened foundational indicator- and event-based surveillance systems that are able to detect
events of significance for public health, animal health and health security; improved communication andcollaboration across sectors and between sub-national, national and international levels of authority
regarding surveillance of events of public health significance; improved country and intermediate level
regional capacity to analyse and link data from and between strengthened, real-time surveillance systems,
including interoperable, interconnected electronic reporting systems. This would include epidemiologic,
clinical, laboratory, environmental testing, product safety and quality and bioinformatics data; andadvancement in fulfilling the core capacity requirements for surveillance in accordance with the IHR andOIE standards.

In 2012 Eswatini adopted the IDSR strategy with an aim to use this strategy as a way of operationalizing
the IHR. A primary emphasis of IDSR is on harmonizing multiple surveillance systems into a unified,coordinated effort at every level of the health system.

DETECT

Eswatini's level of capabilities

Indicator and event based surveillance systems are operational for both animal health and public healthsectors at all levels in Eswatini. The event-based surveillance system relies on a morbidity register, patient carefiles, department daily reports, a client management information system (CMIS), a laboratory information
system, health workers and members of the public. It makes use of the immediate disease notification
system, which utilizes the toll-free number 977. When a clinician suspects and the case presenting fits
the IDSR cases definition, he/she dials 977, which sends a text message to responders, thus activating
response from the appropriate epidemic task forces. For indicator-based surveillance, reliable sources ofdata are used; health workers compile these data from morbidity registers and send summaries monthly
to the regional Health Management Information System (HMIS) offices. Regional HMIS officers aggregate
data from facilities and submit them to the national office.
In public health there are 15 notifiable diseases and three of those are zoonotic in nature (Influenza
subtypes, suspected Rift Valley fever and suspected human rabies). The animal health sector relies on an
entirely paper-based reporting system (with the exception of the Eswatini Livestock Identification andTraceability System, SLITS6, a system relying on both paper and electronic data). Data from this sector comefrom more than 900 dipping tank areas7, 28 sub-regional offices, four regional offices and the national
level epidemiology unit, which also integrates data coming from meat inspections, laboratory services,quarantine stations and points of entry. From there the data are reported to the continental (African Union)
and international (OIE) reporting authorities.
There is regular informal collaboration between the epidemiology unit in the animal health sector andthe corresponding unit within the MoH, the Epidemiology and Disease Control Unit (EDCU). The bulletin
6
7

https://www.icar.org/wp-content/uploads/2015/09/Mdluli.pdf
Dipping tanks are where animals such as cattle are treated to remove/prevent ticks from spreading disease to animals.

25

Joint External Evaluation

produced by the EDCU on a monthly basis covers only three zoonoses, i.e. Rift Valley fever, avian influenza(s)and human rabies, which does not entirely match the priorities of the veterinary surveillance system (which
does not conduct surveillance for Rift Valley fever for example). More collaboration between the publichealth and animal health sectors is therefore needed.

Recommendations for priority actions•

Develop an electronic reporting system for the animal health sector.

•

Develop the list of priority zoonotic diseases for both the animal health and public health sectors.

•

Institutionalize collaboration between human health, animal health and environmental sectors (e.g.
MOUs between the sectors).

•

Institutionalize integration of surveillance system, data validation, data analysis and sharing of
information between relevant sectors.

Indicators and scoresD.2.1 Indicator- and event-based surveillance systems – Score 4

DETECT

Strengths/best practices• IDSR has been implemented since 2012.
•

Indicator and event based surveillance system is in place for both human health and animal healthsectors.

•

A nationally available toll-free number is established, which triggers SMS to stakeholders, alertingthem about reported health events so a response can be launched.

•Weekly and monthly epidemiological surveillance bulletins are published and circulated.

Areas which need strengthening/challenges• Regular training of health workers in surveillance is needed at all levels.
•

Information sharing between sectors still has challenges.

D.2.2 Interoperable, interconnected, electronic real-time reporting system – Score 2

Strengths/best practices• Surveillance reporting is done electronically for the public health sector.
•

CMIS, an electronic reporting system for public health, is being used.

Areas which need strengthening/challenges• The reporting system in the animal health sector is still paper-based.

26•

Reporting systems of public health and animal health sectors are not interconnected or interoperable.

•

Poor internet connectivity negatively affects the real-time data collection of the CMIS which is not fully
adopted.

•Information sharing between the human health and animal health surveillance systems is poor.

Strengths/best practices• Case-based forms are standardized and include a laboratory component.
•

The public health sector produces bulletins to share information.

•

Data analysis is done at the national level.

Areas which need strengthening/challenges• Data analysis at all levels is inadequate.
•of IHR Core Capacities of the Kingdom of Eswatini

D.2.3 Integration and analysis of surveillance data – Score 4

Capacity of staff to analyse data in both the public health and animal health sectors needs to be
increased.

D.2.4 Syndromic surveillance systems – Score 4

Strengths/best practices• Syndromic surveillance exists for acute flaccid paralysis, acute influenza and acute diarrhoea withdehydration, which serve as early warning indicators for a potential disease outbreak.
•Diarrhoea is one of the four diseases/conditions monitored among children aged under 5 years througha sentinel surveillance system and the production of weekly reports.

•

Coordination by the EDCU of the EPI surveillance systems (that monitors acute flaccid paralysis) and thelaboratory surveillance system (that monitors acute watery diarrhoea as a proxy for rotavirus, cholera,etc.) is inadequate.

DETECT

Areas which need strengthening/challenges• Feedback on the outcome of suspected cases to health facilities and other stakeholders is inadequate.

27

Joint External Evaluation

ReportingIntroduction
Health threats at the human–animal–ecosystem interface have increased over the past decades, as
pathogens continue to evolve and adapt to new hosts and environments, imposing a burden on humanand animal health systems. Collaborative multidisciplinary reporting on the health of humans, animals andecosystems reduces the risk of diseases at the interfaces between them.

TargetTimely and accurate disease reporting according to WHO requirements and consistent coordination with
FAO and OIE.

DETECT

Eswatini's level of capabilities
The National IHR Focal Point (NFP) within the Ministry of Health (MoH) is designated as the national
authority responsible for decision-making and initial risk assessment with respect to PHEICs and reporting.
Information on PHEICs is handled by the NFP with subsequent notification to WHO through official
documents. The NFP in the country is located within the Office of the Senior Medical Officer under the
Directorate for Public Health of the MoH and consists of the following five functions: Senior Medical
Officer, Public Health Epidemiologist, Deputy Chief Environmental Health Officer, Representative ofLaboratories and Program Manager for Emergency Preparedness and Response. The core team of the NFP
is complemented by an epidemiologist from the Epidemiology and Disease Control Unit (EDCU) and an
expert from the Health Promotion Unit.
The MoH reporting flow is organized in two ways: daily reporting happens through the Immediate Disease
Notification System (IDNS) while monthly reporting is through the Health Management Information System(HMIS), resulting in weekly and monthly bulletins, respectively. For case identification, a standard immediate
disease notification system (IDNS) form has been developed; health facilities/practitioners are required tofill this in and thereafter call the 977 hotline to report to the IDNS database and consult on further steps
to be taken. The information fed into the INS database is then communicated to the relevant task forces
and units, such as the Regional Epidemic Task Force (RETF), Emergency Preparedness and Response Unit
(EPRU), the Health Management Information System (HMIS) and the Epidemiology and Disease Control
Unit (EDCU) under the MoH.
Subsequently, in accordance with Annex II of the IHR (2005), the NFP in Eswatini decides if a case needs tobe reported to WHO and consult with WHO informally in line with Article 8 of the IHR (2005). At the timeof the JEE in Eswatini, the most recent case that was formally reported to WHO under the IHR (2005) was
leprosy in August 2017, while an informal consultation with WHO preceded the recent recall of products
from the Swazi market related to a listeria outbreak that originated in South Africa in March 2018.
While the NFP is operational, it relies largely on informal communications at the national level. This ismainly attributable to the relatively small size of the country and the professional community dealing
with IHR relevant hazards and outbreaks. The same informal networks apply in relation to the reporting of
zoonotic diseases and collaboration between the NFP and OIE Delegate.
The OIE Delegate is located in the Ministry of Agriculture and is supported in reporting by the Focal Points
for Animal Disease Notification (WAHIS Focal Point), Aquatic Animal Diseases and Wildlife Surveillance inEswatini. While the OIE Delegate and all other categories of Focal Points have undergone training for her/28

Recommendations for priority actions•

Train IHR NFPs using the formal learning packages and incorporate IHR/IDSR training in pre-service
and in-service training.

•

Develop protocols and standard operating procedures (SOPs) for reporting to WHO, FAO and OIE in
accordance with national regulations and legislation and international standards.

•

Conduct regular simulation exercises on reporting zoonoses (possibly including cross-bordercollaboration) in order to facilitate multisectoral collaboration and reporting between the NFP, OIE
Delegate and World Animal Health Information System (WAHIS) Focal Point.

of IHR Core Capacities of the Kingdom of Eswatini

his specific role, the NFP has not been linked to learning packages. The ministries of Health and Agriculturein the country are currently reporting independently to authorities, i.e. the MoH reports to WHO while the
Ministry of Agriculture reports to OIE.

Indicators and scores
D.3.1 System for efficient reporting to FAO, OIE and WHO – Score 1

Strengths/best practices• The NFP and OIE Delegates are operational and Eswatini has demonstrated some capability in reportingto WHO, FAO and OIE.
•The OIE Delegate and the Focal Point for Animal Disease Notification (WAHIS Focal Point) are welltrained on this specific role.

•

There have been informal consultations with WHO.

DETECT

In order to improve the D.3.1 capacity level, Eswatini needs to ensure that the NFP has access to pre-service
and in-service training as well as learning packages on reporting to facilitate rapid notification of events.

Areas which need strengthening/challenges• The persons within the NFP need to be adequately trained to understand their roles and fulfil their
responsibilities most efficiently.
•

There is a lack of mechanisms for the exchange of information between the NFP and the OIE Delegate,
and thus collaboration between public health and animal health, which can lead to delays in reportingto the external bodies, as reporting is done independently.

•

Eswatini has demonstrated some capability in reporting to WHO, FAO and OIE, however timeliness andcase accuracy leave room for improvement.

D.3.2 Reporting network and protocols in country – Score 2

Strengths/best practices• The country has adopted Annex 2 of the IHR (2005) into the IDSR.
•

The country has conducted informal consultations with the WHO Country Office on various aspects as
per Article 8 of IHR (2005).

•

Reporting to OIE through the OIE Delegate within the Ministry of Agriculture is well established andembedded in regulations and standards formulated by OIE.

29

Joint External Evaluation

DETECT

30

Areas which need strengthening/challenges• There is a lack of formalized processes and protocols for the NFP and thus documentation on thedecision-making process at the national level whether to report a case to WHO.
•The Ministry of Health and the Ministry of Agriculture report via different channels and therefore
integration is a challenge. The different methods of reporting need to be harmonized by formulating
standard methods and systems for data collection and reporting in order to prevent inconsistencies in
the information shared.

•

Eswatini`s annual simulation exercises under the auspices of NDMA have so far not tested the country`s
capability to report to WHO, FAO, and OIE under IHR (2005).

•

There is minimal collaboration for reporting with other countries, as there is a need of MoUs, strategies
and legislation that facilitates collaborations between government ministries and other countries.

Introduction
Workforce development is important in order to develop a sustainable public health system over time bydeveloping and maintaining a highly qualified public health workforce with appropriate technical training,
scientific skills and subject-matter expertise.

of IHR Core Capacities of the Kingdom of Eswatini

Workforce development

TargetStates Parties with skilled and competent health personnel for sustainable and functional public healthsurveillance and response at all levels of the health system and the effective implementation of the IHR (2005).

Eswatini's level of capabilities

The country’s health sector has a total of 6,665 health workers excluding staff from the central Ministryof Health (MoH), regional health offices and vertical programmes (approximately half of this number are
in non-clinical cadres). There are 208 medical doctors and 2,420 nursing and midwifery staff giving aworkforce density of 1.64 per 1000 population. The country has only three epidemiologists operating
at national level who offer health emergency-related support as and when necessary. Though there isno establishment for biostatistics in the public sector, the MoH is able to access such support from theCentral Statistics Office and as such three statisticians have been seconded to the MoH. There are healthinformation officers at the national and intermediate levels (and in some hospitals) who provide dataand information management support. Laboratory human resource capacity is available at the regionaland facility levels especially hospitals and health centres. The country has established standing nationaland regional emergency task forces with both regular MoH and seconded staff from other sectors. Of the
498 staff that work in the animal health sector, only 15 are Veterinary Officers and 45 are Animal HealthInspectors. There are no veterinary practitioners that support zoonosis-related work at the MoH.

DETECT

Eswatini has some multi-disciplinary human resource capacity at all the levels of service delivery for IHR
implementation: an analysis of health worker staffing norms was carried out in selected health facilities
in February 2017 and the findings were used to determine staffing norms for 18 priority cadres including
medical officers, nurses/midwives, pharmacist and laboratory staff. The staffing norm analysis however did
not cover cadres that provided public health surveillance and response services such as community healthworkers and epidemiologists or staff in the animal health and agriculture sectors.

The MoH has a draft workforce development strategy that includes public health professions but does
not address the veterinary and environmental workforce. Though there is poor distribution of staff and ahigh attrition rate, a human resource information database was established in 2013 to facilitate tracking
movement of staff. This database needs to be updated to incorporate more variables and to be linked
with the payroll dataset.
Most health staff have received some basic epidemiology training as part of their pre-service programmes.
There is no Field Epidemiology Training Program (FETP) or other applied epidemiology training programmes
in the country. The national health training division occasionally supports individuals to pursue similar
programmes in other countries per the national in-service training arrangements. The MoH has a wellcoordinated in-service training programme for health workers through the central ministry (Ministry of
Public Service). The local university offers bachelor’s degree programmes in nursing, laboratory sciences,animal science, agronomy and crop production.

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Joint External Evaluation

Recommendations for priority actions•

Conduct human resource analysis in the animal health and environmental health sectors, andincorporate findings in the human resources strategy; finalize and disseminate the resulting document toall stakeholders in the context of One Health and advocate for buy-in by donors/partners to implement
a strategy to address the gaps discovered.

•

Establish a network with neighbouring countries for Field Epidemiology and Laboratory Training
Programs.

•

Develop collaboration mechanisms with the private sector, especially to prepare for response to publichealth emergencies.

•

Extend the scope of the health resources information system and veterinary and environmental workforce
to facilitate effective management, including tracking of movement of staff.

Indicators and scores
D.4.1 Human resources available to implement IHR core capacity requirements – Score 2

DETECT

Strengths/best practices• The country has some multidisciplinary workforce capacity in terms of medical officers, nurses/midwifes,
laboratory scientists, information officers and community health workers at all service delivery points.
Areas which need strengthening/challenges• Key epidemiological positions for surveillance and response to health emergencies at sub-national levels
is lacking.
•

There are no mechanisms in place to facilitate collaboration (i.e. secondment of staff) between theprivate and public sector for surveillance and response to health emergencies.

D.4.2 FETP or other applied epidemiology training programme in place – Score 1

Strengths/best practices• A local university offers pre-service and advance-level programmes in nursing, laboratory sciences,animal science, agronomy and crop production, and could potentially offer some elements of FETP.
•

The MoH has a well-coordinated in-service training programme for health workers.

•

The ministry of public service and training, through their in-service unit, has the ability to support
individuals to pursue IHR-related programmes outside the country.

Areas which need strengthening/challenges• There is a need to develop an FETP training course in the country or create agreements to train humanresources in an FETP in nearby countries.
•

In-service training in IHR-related areas is currently insufficient.

D.4.3 Workforce strategy – Score 1

Strengths/best practices• A draft health sector human resources development strategy exists.
Areas which need strengthening/challenges• The draft human resources development strategy does not currently include animal and environmental
health aspects.

32•

The human resources strategy is currently not implemented.

•

The system to monitor/track human resources in the country is currently not fully up to date.

Preparedness
Introductionof IHR Core Capacities of the Kingdom of Eswatini

RESPOND

Preparedness includes the development and maintenance of national, intermediate and community/
primary response level public health emergency response plans for relevant biological, chemical,
radiological and nuclear hazards. Other components of preparedness include mapping of potential
hazards, the identification and maintenances of available resources, including national stockpiles andthe capacity to support operations at the intermediate and community/primary response levels during apublic health emergency.

TargetDevelopment and maintenance of national, intermediate (district) and local/primary level public healthemergency response plans for relevant biological, chemical, radiological and nuclear hazards. This covers
mapping of potential hazards, identification and maintenance of available resources, including national
stockpiles and the capacity to support operations at the intermediate and local/primary levels during apublic health emergency.

Eswatini's level of capabilities

Eswatini has conducted a series of assessments to evaluate its capacity including the Eswatini National
Vulnerability Assessment, service availability mapping, Comprehensive Health & Nutrition Assessment
Report on the Impact of El Niño, and the Disaster Risk Reduction, Emergency Preparedness and Response
Capacity Assessment Report. These assessments continuously influence review of national plans. The
country has adopted the Integrated Disease Surveillance and Response (IDSR) strategy and establishedepidemic task forces at national and regional levels including rapid response teams.

RESPOND

Eswatini has a National Disaster Management Agency (NDMA) established by the Disaster Management
Act, 2006 and an Emergency Preparedness and Response Unit (EPRU) within the MoH, which is guided by
the Emergency Preparedness and Response strategy 2017–2020. In addition, the National Health Policy,
the National Health Sector Strategic Plan and the National Multi-Hazard Contingency Plan are also in place.

It is important to note that the National Multi-Hazard Contingency Plan does not incorporate all thehazards referenced by the IHR (biological, chemical, radiological and nuclear) including points of entry(PoE). In addition, Eswatini is yet to conduct a national multi-hazard multisectoral risk assessment, including
resource mapping. These needs have necessitated the scores given for this technical area.

Recommendations for priority actions•

Conduct a multi-hazard, multisectoral risk assessment.

•

Complement the National Multi-Hazard Contingency Plan by incorporating the PoE and other IHRrelated hazards.

•

Roll out EPR plans at regional, facility, and community levels.

•

Update and endorse Eswatini's emergency response standard operating procedures (SOPs).

33

Joint External Evaluation

Indicators and scores
R.1.1 National multi-hazard public health emergency preparedness and response plandeveloped and implemented – Score 2

Strengths/best practices• The country has established an Emergency Preparedness & Response department, which includes:
❍❍
❍❍

❍❍

❍❍

emergency medical services (which responds to all public health emergencies);a national emergency communication centre (which the public can access for all health-related
issues);disaster risk management (which capacitates, maps, and mobilizes resources to mitigate andrespond to natural disasters);
Epidemics (deals with epidemic hazards and response).

•

Policies and legislation that support preparedness are in place, including strategic documents andguidelines such as the National Multi-Hazard Contingency Plan and Environmental Health Strategy.

•

National simulations are conducted annually, which test preparedness and include a review of policies.

•

There is a mechanism that coordinates the approach to emergencies, which includes epidemic task
forces at national and regional levels and inter-sectoral collaboration (e.g. Ministry of Agriculture andnational programmes share regional resources, such as skilled personnel, medical supplies, etc.).

RESPOND

Areas which need strengthening/challenges• Policies and legislation enabling emergency preparedness and response are fragmented; there is a need
to formulate policies and legislation to coordinate preparedness and response plans and activities.
•

Preparedness and response strategies are not implemented at different levels of service delivery (e.g.
human resource training is limited, preparedness and response documents are not readily available andsimulations conducted at the local level are limited).

•

Coordination and collaboration between the Ministry of Health, UN agencies and stakeholders in othersectors (e.g. among religious groups) is weak.

•

The country's research agenda for preparedness needs to be operationalized.

R.1.2 Priority public health risks and resources mapped and utilized – Score 1

Strengths/best practices• Public health risks were mapped by the Vulnerability Assessment Committee (VAC) report; itsvulnerability assessment exercise (conducted annually) addresses some health hazards.
•

A service availability and readiness assessment has been completed, which targets and maps facilities'
capabilities.

•

Service availability mapping report was published in 2013.

•

Ministry of Health has allocated a budget for emergency preparedness and response.

Areas which need strengthening/challenges• Limited resource and funds are available to strengthen response activities and assess their effectivenessagainst the international benchmark; there is a need to conduct a national resource mapping.

34•

There are no stockpiles of supplies at the local level.

•

While annual simulation exercises take place at the regional level, this is not occurring at the national
and intermediate levels, hence affecting the level of preparedness.

Introduction
A public health emergency operations centre is a central location for coordinating operational information
and resources for strategic management of public health emergencies and emergency exercises. Emergency
operations centres provide communication and information tools and services, and a management system
during a response to an emergency or emergency exercise. They also provide other essential functions to
support decision-making and implementation, coordination and collaboration.

of IHR Core Capacities of the Kingdom of Eswatini

Emergency response operations

TargetCountry with public health emergency operations centre (EOC) functioning according to minimum
common standards; maintaining trained, functioning, multisectoral rapid response teams and “real-time”
biosurveillance laboratory networks and information systems; as well as trained EOC staff capable ofactivating a coordinated emergency response within 120 minutes of the identification of a public healthemergency.

Eswatini's level of capabilities•

Incident support – the provision of resources and/or strategic guidance, authorizations, and specificdecision-making support. This support may be provided to an incident management team at a site orin limited circumstances, to another EOC.

•

Essential services and continuity of operations – this function ensures that essential services aremaintained, including where possible, in the areas impacted by the emergency.

The EOC is linked to a call centre (national toll-free 977 telephone number) with trained staff available
at all times to guide response. In addition, the country has trained rapid response team that can deploy
regionally, with a functioning ambulance system.

RESPOND

Eswatini has established an EOC within the Ministry of Health (MoH), which is responsible for the following
functions:

The National Disaster Management Agency (NDMA) was established in 2015 to guide emergency response
operations and collaboration of all nine sectors in the country, including health. The country has conducted aseries of assessments to evaluate capacities and various risks, including the Eswatini National Vulnerability
Assessment, service availability mapping, Comprehensive Health & Nutrition Assessment Report on the
Impact of El Niño, and the Disaster Risk Reduction, Emergency Preparedness and Response Capacity
Assessment Report.

Recommendations for priority actions•

Review EOC manual, procedures and plans to incorporate biosurveillance laboratory networks andinformation systems.

•

Strengthen the links between MoH EOC and other EOCs, i.e. NDMA, Fire department, etc.

•

Train staff on EOC procedures, plans and surge capacity.

•

Formally endorse the EOC plan.

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Joint External Evaluation

R.2.1 Capacity to activate emergency operations – Score 2

Strengths/best practices• There is an established EOC within the MoH.
•

Capacity exists to activate emergency response operations.

•

During an emergency, the MoH EOC is used to coordinate response.

•

Staff working in the MoH EOC are trained in emergency response.

Areas which need strengthening/challenges• There is weak coordination between public health and animal health sectors.
•

Surge capacity training is still weak.

•

Links are weak to other response parties, such as the Fire department, the Royal Eswatini Police
Service and the Umbutfo Eswatini Defence Force (USDF).

R.2.2 EOC operating procedures and plans – Score 1

Strengths/best practices• An EOC manual and emergency management dispatch standards (toll–free telephone number) havebeen developed and are in use.
•

Capacity exists to activate emergency response operations.

Areas which need strengthening/challenges• Links are weak to other response parties, such as the fire department, the Royal Eswatini Police Service
and the USDF.
R.2.3 Emergency operations programme – Score 3

RESPOND

Strengths/best practices• Capacity exists to activate emergency response operations.
•

Table-top exercises have been conducted to test the systems in place.

Areas which need strengthening/challenges• There is weak coordination between public health and animal health sectors.
•

EOC is not fully functional.

R.2.4 Case management procedures implemented for IHR relevant hazards – Score 2

Strengths/best practices• Standard Treatment Guidelines (2012) and the Essential Medicines List of Common Medical Conditionsin the Kingdom of Eswatini 1st edition (2012) are available.
•

EOC staff have been trained in case management as part of the national and regional rapid response
teams.

Areas which need strengthening/challenges• SOPs for management and transportation of people potentially exposed to infectious/transmittablehazards (e.g. chemical contamination) are not available.

36Introduction
Public health emergencies pose special challenges for law enforcement, whether the threat is manmade(e.g. the anthrax terrorist attacks) or naturally occurring (e.g. flu pandemics). In a public health emergency,
law enforcement will need to quickly coordinate its response with public health and medical officials.

of IHR Core Capacities of the Kingdom of Eswatini

Linking public health and security authorities

TargetCountry conducts a rapid, multisectoral response in case of a biological event of suspected or confirmed
deliberate origin, including the capacity to link public health and law enforcement, and to provide and/or
request effective and timely international assistance, such as to investigate alleged use events.

Eswatini's level of capabilities

While there is no MoU in place between public health and security authorities in Eswatini, public healthcoordinates with the Ministry of Agriculture, Ministry of Home Affairs (border control) and the RoyalEswatini Police Service as well as the customs officials at points of entry. In the event of a public healthemergency, security authorities need to coordinate their response with public health in an efficientmanner. While this is not formalized as of yet, annual simulation exercises and joint trainings are taking
place, for example by simulating various infectious disease outbreaks (e.g. Ebola virus disease) and therole of relevant actors in the response to these public health events. In May 2018, a simulation exercise
will take place in Botswana, including the whole Southern African Development Community (SADC)
region, as well as the military. Furthermore, in Eswatini, protocols for communication do exist but areas yet not formalized.

RESPOND

In Eswatini, the authority of the Royal Eswatini Police Service falls under the Prime Minister, and there is a
Director for health under the police services. Responsibility for the army is under the Ministry of Defence,with an entity for military health. The interaction between medical officers in the army and with the police
is informal however, and a Memorandum of Understanding (MoU) would streamline the collaboration
between public health and security authorities. The Public Health Act, 1969 does provide some legal basis
to engage security authorities in public health issues.

Recommendations for priority actions•

Set up formal collaboration mechanisms (MoUs and SOPs) between public health and security
authorities.

•

Finalize synchronization of the different call centres, in order to improve public health emergency
response.

•

Develop a joint training programme on topics related to information sharing and joint investigations/
responses, and evaluate the effectiveness of this programme.

37

Joint External Evaluation

Indicators and scores
R.3.1 Public health and security authorities (e.g. law enforcement, border control, customs)
linked during a suspect or confirmed biological event – Score 2

Strengths/best practices• Informal points of contact during events are established and utilized.
•

Leaders from public health and security authorities have participated in annual simulations.

•Preparedness and response training courses have been conducted jointly between health and security
forces.

•Synchronization of the different call centres is in process, in order to improve public health emergency
response.

RESPOND

Areas which need strengthening/challenges• Development and implementation of frameworks (e.g. MoUs) outlining roles, responsibilities and bestpractices for sharing information between public health, animal health and security authorities needs
to be done.

38•

Joint training exercises for public health and security authorities on topics related to information sharing
and joint investigations/responses should be conducted.

•

SOPs for coordination of joint response to public health and other emergencies need to be developed.

Introductionof IHR Core Capacities of the Kingdom of Eswatini

Medical countermeasures and personnel
deployment

Medical countermeasures are vital to national security and protect nations from potentially catastrophic
infectious disease threats. Investments in medical countermeasures create opportunities to improve overallpublic health. In addition, it is important to have trained personnel who can be deployed in case of a publichealth emergency for response.

TargetNational framework for transferring (sending and receiving) medical countermeasures, and public healthand medical personnel from international partners during public health emergencies.

Eswatini's level of capabilities
Provision of medical countermeasures (MCM) is the responsibility of the Central Medical Stores (CMS)of the Ministry of Health for public health and the Ministry of Agriculture for animal health, especiallydistribution of vaccines at central, regional and local levels.

The Medicines and Related Substances Control Act (2016) is legislation that has provisions for the controlof medicines and related substances in the country; this includes the registration of products. The country,
however, has no system in place for personnel deployment during emergencies.
It was noted during plenary that a regulatory authority overseeing medical countermeasures is in theprocess of being established.

RESPOND

There is a dedicated supply infrastructure (warehouse and transport fleet) with permanent staff to run
the supply chain system for MCM. In addition, there is a dedicated procurement unit that is responsible
for the procurement of MCM, quantification is the responsibility of Central Medical Stores working incollaboration with relevant programmes and departments. An established routine system is in place forsending and receiving medical countermeasures, but there is no documentation showing its efficacy.

Recommendations for priority actions•

Develop and adopt a plan for sending and receiving medical countermeasures in line with theregulations under the Medicines and Related Substances Act (2016).

•

Test the plan through a simulation exercise that includes all relevant stakeholders and Southern African
Development Community (SADC) countries.

•

Develop and adopt a plan, which includes establishing regional and international agreements such as
MoUs, for sending and receiving MCM and personnel for support during a public health emergency.

39

Joint External Evaluation

Indicators and scores
R.4.1 System in place for sending and receiving medical countermeasures during a publichealth emergency – Score 1

Strengths/best practices• There is a budget for procuring medicines and supplies during emergencies – framework contracts for
emergency supplies exist at the Central Medical Stores.
•

The warehouse facilities are adequate to handle emergency supplies in addition to the routine supplies.

•

The management of commodities at central level is electronic; however the internal management of
supplies at most facilities is still manual even though a digital system is being developed.

Areas which need strengthening/challenges• There is a lack of documentation (standard operating procedures/protocols) of the existing system ofsending, receiving and distributing medical countermeasures, including donations during a public healthemergency. The system should be documented and shared with all sectors and relevant beneficiaries.
•

There are no formal agreements/MoUs with neighbouring countries (i.e. the Southern African
Development Community) and regional/international organizations (e.g. the Global Outbreak Alert andResponse Network) to ensure timely mutual cross-border aid (personnel and medical countermeasures).

•

The system of sending, receiving and distributing medical countermeasures during a public healthemergency needs to be strengthened, to ensure that this can occur at any time.

•

There are currently barriers to acquiring MCM quickly during an emergency, including products thatfall outside the routine supply chain of the country (i.e. that address issues such as product registrationand potentially lengthy customs procedures).

RESPOND

R.4.2 System in place for sending and receiving health personnel during a public healthemergency – Score 1

Strengths/best practices• Some stakeholders such as the EPR/IHR focal point are aware of an informal system for sending andreceiving health personnel during a public health emergency even though there is no documentation.
Areas which need strengthening/challenges• There is no policy or protocol that directly addresses regulatory and licensure concerns of receiving
health personnel from outside Eswatini during a public health emergency.
•

40

There is no specific documentation protocol or standard operating procedures (SOPs) guiding
deployment of national personnel/health workers internationally during a public health emergency.

Introduction
Risk communications should be a multilevel and multifaceted process which aims at helping stakeholders
define risks, identify hazards, assess vulnerabilities and promote community resilience, thereby promoting
the capacity to cope with an unfolding public health emergency. An essential part of risk communicationis the dissemination of information to the public about health risks and events, such as disease outbreaks.
For any communication about risk caused by a specific event to be effective, the social, religious, cultural,political and economic aspects associated with the event should be taken into account, including the voiceof the affected population.

of IHR Core Capacities of the Kingdom of Eswatini

Risk communication

Communications of this kind promote the establishment of appropriate prevention and control action
through community-based interventions at individual, family and community levels. Disseminating theinformation through appropriate channels is essential. Communication partners and stakeholders in the
country need to be identified, and functional coordination and communication mechanisms should beestablished. In addition, the timely release of information and transparency in decision-making are essential
for building trust between authorities, populations and partners. Emergency communications plans shouldbe tested and updated as needed.

Eswatini’s level of capabilities
The Health Promotion and Education (HP&E) Department in the Ministry of Health (MoH), is responsible forhealth promotion and community engagement. Generally, risk communication activities are ad hoc and not
well coordinated at all levels in Eswatini. There is neither a national risk communication strategy nor any
formal agreements that guide officers when they carry out such activities. The department and technicalworking groups implement risk communication activities during outbreaks and emergencies. Membershipof the working groups is limited but includes health care workers and representatives from civil society
organizations, partners, the private sector and other non-state actors. The Prime Minister is the one who
declares a state of emergency. In case of an emergency the ministries and/or directorates responsible forthose specific public health emergencies are designated to be the key spokespersons for initial information
dissemination to the public about health risks and events, working in collaboration with the National
Disaster Management Agency (NDMA).

RESPOND

TargetState Parties use multilevel and multifaceted risk communication capacity. Real-time exchange of information,
advice and opinions between experts and officials or people who face a threat or hazard (health or economic
or social wellbeing) to their survival, so that informed decisions can be made to mitigate the effects of thethreat or hazard and protective and preventive action can be taken. This includes a mix of communication andengagement strategies, such as media and social media communications, mass awareness campaigns, healthpromotion, social mobilization, stakeholder engagement and community engagement.

Risk communication is included in disease-specific preparedness and response guidelines and plans (e.g.
malaria, human papilloma virus and influenza). The HP&E oversees some risk communication materials
to ensure they are clear and factually correct. No formalized systems exist for monitoring and addressing
media, rumours and other misinformation. Mechanisms for surge staff for risk communication during
emergencies are ad hoc. Information is disseminated through mass media such as radio, television andprint. Messages are in both languages (SiSwati and English).

41

Joint External Evaluation

There is very little funding available for HP&E, and it was noted during plenary that one of the obstacles todisseminating information via television is the high cost of airtime. One of the priority actions, therefore,
addressed cultivating stronger relationships with the media to enhance collaboration.

Recommendations for priority actions•

Develop a communication strategic plan, which includes a monitoring and evaluation (M&E) frameworkand standard operating procedures (SOPs).

•

Develop and implement coordination mechanisms for internal and multi-sectoral (One Health) routine
and emergency response communications.

•

Institute measures for effective rumour monitoring and feedback at all levels.

•

Identify and foster strong partnerships with media personnel on principles and reporting of IHRactivities.

Indicators and scores
R.5.1 Risk communication systems (plans, mechanisms, etc.) – Score 1

Strengths/best practices• There is a dedicated department within the MoH responsible for risk communications.
•

Risk communication is incorporated in some disease-specific preparedness and response plans (e.g.
malaria)•

Some partners support risk communication activities of the MoH during emergencies, in collaboration
with the NDMA.

RESPOND

Areas which need strengthening/challenges• There is no national risk communication strategy or plan in place with standard operating procedures.
•

There is low capacity at national and sub-national levels to effectively implement risk communicationinterventions.

•

There is no dedicated budget for emergency response risk communication, however there is a dedicatedbudget for emergencies which is open for all technical areas to access.

R.5.2 Internal and partner communication and coordination – Score 2

Strengths/best practices• There are agreements between the MoH and some partners for endorsing risk communication
messages.
Areas which need strengthening/challenges• The membership of technical working groups is not regularly reviewed; and coordination andcollaboration mechanisms between the MoH and all relevant agencies involved in risk communication(routinely and during emergencies) are not formalized.
•

42

Inadequate mechanisms exist for sharing new strategies with partner organizations to continually
improve communication response.

Strengths/best practices• The Prime Minister is involved in the coordination of risk communication to the public during outbreaks
and emergencies.
•

A nationwide toll-free telephone number (977) enables anyone to call and report emergencies,
suspected cases of disease, or ask questions.

•

The Government uses cell phone messages, radio, television and social media to reach the community
with educational messages (e.g. the NDMA has a Facebook page).

•Media activities during an emergency are shared in both official languages.

of IHR Core Capacities of the Kingdom of Eswatini

R.5.3 Public communication – Score 3

Areas which need strengthening/challenges• There are no formalized SOPs for public communications within the MoH media and communications
department.
•

There is a lack of operational research on communication methods to effect behavioural change during
emergencies.

R.5.4 Communication engagement with affected communities – Score 1

Strengths/best practices• Social mobilization and health promotion activities occur in the community, which support interventions
during some disease outbreaks.
Areas which need strengthening/challenges• There is no systematic mechanism for continuous assessment and provision of feedback to at-risk oraffected populations and agencies implementing response activities in the community.

Strengths/best practices• A toll-free telephone number (977) is available, with dedicated staff to receive and advise community
members on health and related issues.
Areas which need strengthening/challenges• There is no system in place responsible for listening and rumour management in the community on apermanent basis.

RESPOND

R.5.5 Dynamic listening and rumour management – Score 2

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Joint External Evaluation

OTHER IHR-RELATED HAZARDS AND POINTSOF ENTRY
Points of entry
Introduction
All core capacities and potential hazards apply to “points of entry” and thus enable the effective applicationof health measures to prevent international spread of diseases. States Parties are required to maintain corecapacities at designated international airports and ports (and where justified for public health reasons,a State Party may designate ground crossings), which will implement specific public health measuresrequired to manage a variety of public health risks.

TargetStates Parties designate and maintain core capacities at international airports and ports (and where
justified for public health reasons, a State Party may designate ground crossings) that implement specificpublic health measures required to manage a variety of public health risks.

Eswatini's level of capabilities

OTHER

Eswatini is a landlocked country and utilizes road, railway (for goods only) and air to connect withneighbouring countries Mozambique and South Africa. Of the total 16 points of entry (PoE) (13 groundcrossings, two airports and one inland clearance depot), seven are designated PoE: two of the designatedborder crossings are to Mozambique and the remaining five to South Africa.
The responsibility for establishment of capacity at PoE lies with the Department of Environmental Health, under
the Ministry of Health (MoH). The West Africa Ebola virus disease outbreak in 2014 catalysed an increase incapacity at PoE in Eswatini, whereby port health officers were deployed and other assessment equipment suchas thermal scanners was installed in some PoE. During plenary however, it was noted that there is a lack ofappropriate medical services including diagnostic facilities at most designated PoE. The main border crossings(Ngwenya and King Mswati III International airport) have excellent capacities to respond to public healthemergencies, appropriate to the scale and size of these PoE. It was suggested that Eswatini revise the numberof IHR-designated PoE, in order to focus efforts to crossings most used both for animals and import/export aswell as for humans. Having fewer designated PoE in Eswatini would therefore allow the country to focus its
resources on ensuring IHR requirements are met in all designated PoE.
Since 2014, Eswatini has never had a confirmed case of a public health event at a point of entry, andonly one known suspected occurrence, which was during the Ebola virus disease outbreak. Two of thedesignated PoE have access to medical facilities for the prompt assessment and care for ill travellers. The
remaining five designated PoE are served by the nearby health facilities (ranging from 3 to 31 km awayfrom PoE), supported by national Emergency Medical Services (EMS) with ambulances. The current National
Multi-Hazard Contingency Plan does not contain a specific sector to respond to public health threats at
PoE, but there is a specific contingency plan for emergencies at the King Mswati III International Airport.

44

•

Incorporate a section on preparedness and response to public health threats at PoE into the National
Multi-hazard Contingency Plan.

•

Develop guidelines and standard operating procedures (SOPs) for IHR-designated PoE.

•

Provide equipment for prompt assessment of ill travellers including facilities for isolation in all IHRdesignated PoE.

•

Develop programmes and train personnel for the control of vectors and reservoirs as well as theinspection of conveyances and cargo available at IHR-designated PoE.

•

Review the IHR designated PoE to determine if all seven need to remain as designated.

•

Create posts for port Health.

of IHR Core Capacities of the Kingdom of Eswatini

Recommendations for priority actions

Indicators and scores
PoE.1 Routine capacities established at points of entry – Score 1

Strengths/best practices• The King Mswati III international airport has an onsite health clinic and isolation unit with designatedstaff in addition to the Environmental Health Officers.
•

The main border crossing to South Africa (Ngwenya) has onsite medical services, including diagnostic
facilities for the prompt assessment and care of ill travellers.

•

PoE without onsite medical facilities have access to other government-owned medical facilities withina radius of 3 to 31 km.

•

Designated PoE provide access to equipment and personnel for the transport of ill travellers to an
appropriate facility, via the EMS and ambulances nationwide.

•

Five out of the seven designated PoE do not have equipment for prompt assessment and facilities for
isolation (but they do have access to government-owned medical facilities nearby).

•

There are no programmes for control of vectors and reservoirs in place, except for a pest control
programme at King Mswati III International Airport.

•

PoE personnel are a borrowed workforce from the Department of Environmental Health within the
MoH; there are no dedicated personnel for PoE.

•

Training of personnel for inspection of conveyances and cargo at PoE needs to be undertaken. It
was noted during plenary that the Environmental Health Officers at the designated PoE could becapacitated to do these inspections.

OTHER

Areas which need strengthening/challenges• The Inland clearance depot has no monitoring and no PoE activities established (though there is no
human traffic through this PoE).

45

Joint External Evaluation

PoE.2 Effective public health response at points of entry – Score 1

Strengths/best practices• Standard operating procedures (SOPs) for designated PoE are under development and are expected tobe ready by April 2019.
•

Eswatini has a comprehensive and updated National Multi-Hazard Contingency Plan, which is nearing
official endorsement.

•

A specific emergency order for the international airport (King Mswati III International Airport) isendorsed and indicates the responsibilities and actions by appropriate partners in the event of various
hazards.

•

A referral system and transport for the safe transfer of ill travellers to appropriate medical facilities isin place.

OTHER

Areas which need strengthening/challenges• The National Multi-Hazard Contingency Plan does not contain a specific section on responding to
public health emergencies occurring at PoE.

46•

Facilities for assessing contaminated/infected travellers and animals onsite or facilities for theassessment and quarantine of suspect travellers are not available for most designated PoE.

•

Evaluation of effectiveness in responding to public health events at PoE, through either simulation
exercises or actual events, has not been done (though no actual public health events have been notedat a PoE since 2014).

Introduction
State parties should have surveillance and response capacity for chemical risk or events. It requires
effective communication and collaboration among the sectors responsible for chemical safety, industries,
transportation and safe disposalof IHR Core Capacities of the Kingdom of Eswatini

Chemical events

TargetState parties should have surveillance and response capacity for chemical risk or events. It requires
effective communication and collaboration among the sectors responsible for chemical safety, industries,
transportation and safe disposal.

Eswatini's Level of Capabilities
Chemicals are extensively used in Eswatini (particularly in the agro-pastoral, health and domestic sectors
and some use in industry and mining), but they are currently inadequately managed or their use is addressedin a piecemeal fashion (i.e. there is no one plan discussing all chemicals; different plans and pieces oflegislation cover different chemicals, yet frameworks to manage chemicals exist). Chemicals are mainly
imported from South Africa for which the South African Registration System to Control Chemical Imports
is accepted. Agrochemicals will subsequently be controlled through the Pesticides Management Act, 2018.

Pharmaceuticals are regulated under the Medicines and Related Substances Control Act (2016). A national
chemicals profile giving the administrative infrastructure for management of chemicals with an inventoryof chemicals used in the country was prepared in 2015. National implementation plans follow theStrategic Approach to International Chemicals Management (SAICM), and some multilateral environmental
agreements have been prepared. Eswatini has ratified the Basel, Minamata, Rotterdam and Stockholm
Conventions, and participates in the International Conference on Chemicals Management. However,capacity building is needed to ensure the implementation of multilateral environmental agreements. The
implementation of the Globally Harmonized System of Classification and Labelling of Chemicals is being
undertaken in the context of SADC.

OTHER

Legislation for management of chemicals is currently covered under the Environmental Management
Act (2002), the Waste Regulations (2000) and Water Pollution Control Regulations (2010). However, thecomplementary regulations for control of chemicals and hazardous substances produced intentionally orunintentionally is lacking, and existing legal measures do not address the whole life cycle of chemicals.
Exposure to humans and a comprehensive approach will be covered in the Sound Management of Chemicals
Bill, which is currently being drafted for submission to parliament. An inter-ministerial coordinating
mechanism for consultation among stakeholders and for management of chemical events exists and will
be formalized through the Sound Management of Chemicals Bill.

The ILO conventions 170 and 174 are not in force. Some guides and procedures for sound chemicals
management have been elaborated but are only partially implemented. There is some access to international
databases relating to chemicals (e.g. WHO and IPCS/INCHEM8). Environmental monitoring of air and waterand surveillance for chemicals in other media is provided by the Ministry of Tourism & Environmental Affairs
through laboratories in South Africa. There is no monitoring of products destined for consumer use. Capacity
in the region to monitor chemical contamination of food is being sought through the Codex Alimentarius.
8 International Programme on Chemical Safety.

47

Joint External Evaluation

The Ministry of Health lacks toxicological capacity for chemicals monitoring and health exposure monitoring.
Coordination with other IHR sectors is partial and communication of chemical risks needs strengthening.
There remains a lack of awareness concerning chemical risks and chemical events and a poor appreciationof the implications for response to chemical emergencies by decision-makers. Educating the public andawareness concerning chemical risks is lacking.
Further training of human resources in chemicals risk assessment and communication is desirable, as is thestrengthening of existing training for response to chemical events both by first responders and the medical
professions (often medical professionals have an inadequate knowledge concerning the diagnosis andpatient management of diseases of chemical etiology).
The laboratory capacity to detect and respond to chemical events is low. Standard operating procedures(SOPs) do not exist and analytical toxicology capacity for diagnosis and treatment of exposed patientsremains weak at the country’s health facilities. The existing laboratory capacity for identifying viral andbacteriological diseases could be expanded, however, for some toxicological testing. In addition, ensuring
access to pharmaceuticals and medical supplies for chemical emergency response is not in place.
A well-developed national centre for toxico-vigilance and pharmacovigilance does not exist; urgent
consideration should be given to whether it is adequate to rely on South Africa for this function. Capacity
for identification and surveillance of chemical risks from chronic exposure, with the potential of becoming
chemical events, needs to be developed.
Some small capacity exists for identifying chemical risks associated with contamination of food, although
there is a need to strengthen capacity for analysis of clinical toxicological samples. While the health sector
cooperates with the emergency services (coordinated through the MoH) for preparedness and response tochemical events and their notification, there is lack of systematic harmonized data collection and exchange
of information on chemical events occurring throughout the country, and on their management.
Financial resources are not available for mobilization for a chemical event response. Industrial installations
are required, through their environmental impact assessment, to have their chemical emergency
preparedness and response plans for the periphery as well as the interior of the installation. However,this may not adequately cover small- and medium-sized installations, lacking technical reporting capacity.
There is a partial system for tracking important hazardous chemical consignments entering the country, andcapacity to register and track consignments needs to be strengthened.

OTHER

Several chemical incidents have occurred (e.g. the Mhlumeni, Illovo and Malagwane caustic soda spills;
Texray benzine fumes; Bhunya Phenols and USA Distillers molasses), and the management of these eventswas not satisfactory. Comprehensive chemical emergency plans are lacking and need developing with
SOPs; these should be regularly tested and improved through simulation exercises.
It was noted during plenary that an additional barrier with respect to chemicals procured from othercountries (outside Africa) included directions for use in foreign languages and mislabelled products. It wasalso indicated that a national risk assessment of chemicals would be done in 2018.

Recommendations for Priority Actions

48•

Advocate among all relevant stakeholders to endorse the enactment of the Sound Management ofChemicals Bill and the promulgation of relevant regulations.

•

Encourage each ministry to include chemical incident-emergency response in their relevant sector plans.

•Promote capacity building (infrastructure, technical capabilities and trained human resources) ofcompetent authorities for effective surveillance and enforcement of regulations related to chemicals
management.

Review the need to establish a national poison information centre and related medical and analyticalfacilities that operates at all times.

Indicators and Scores
CE.1. Mechanisms are established and functioning for detecting and responding to chemical
events or emergencies – Score 2

Strengths/best practices• Legislative frameworks are in place.
•

There are chemical profiles, inventories and national implementation plans in place.

•

National Competent Authorities exist, and are mandated with sound management of chemicals (albeit
limited capacities and resources).

•

Monitoring and inspection systems are partially in place, i.e. Memorandum of Understanding (MoU)
between SEA & MoH (Environmental Health (Port Health); MoU between Eswatini Environmental
Agency (SEA) & Eswatini Revenue Authority (SRA); and an MoU between SEA & the Royal Eswatini
Police Service.

of IHR Core Capacities of the Kingdom of Eswatini•

Areas which need strengthening/challenges• The Sound Management of Chemicals Bill is not yet enacted, and the Pesticide Management Act is not
yet fully implemented (including the promulgation of accompanying regulations).
•

Infrastructure and capacity development for assessment of chemical emergencies in the country needs
to be strengthened.

•

Awareness about sound management of chemicals needs to be raised at all levels, and across sectors
and government departments.

•

Capacity for surveillance and detection of chemical events is lacking; such capacity could be promoted
through establishment of a poisons information centre and related medical and analytical facilities
operating continuously with systematic data collection.

•

Analytical toxicology laboratory facilities need strengthening, building on the existing laboratory
services for other IHR areas, with the creation of a regional network of accredited laboratories. Capacity
should also be strengthened to test for chemicals in food and environmental media.

•

Laboratory capacity, qualified human resources and financing remain insufficient.

Strengths/best practices• Legislation for emergency response defining the roles and responsibilities of main stakeholders has
been enacted.
•

Inventories of facilities using chemicals exist.

•

Simulation exercises for health emergencies have been conducted, which include some potential
chemical events.

OTHER

E.2 Enabling environment is in place for management of chemical events – Score 249

Joint External Evaluation

OTHER

50

Areas which need strengthening/challenges• A comprehensive public health plan for preparedness and response to chemical incidents/emergencies
has yet to be developed.
•

Surveillance guidelines for chemical events do not exist.

•

Public awareness on chemical safety needs to be improved.

•

There has been no training of medical personnel (including first responders) in diagnosis andmanagement of chemicals events, and there are no guidelines on the subject or routinely scheduled
simulation exercises.

•

Access to pharmaceuticals and essential equipment for patient management needs to be increased.

Introduction
State parties should have surveillance, assessment, notification, reporting and response capacities forradiological public health hazards, events or emergencies of international concern. This requires effective
collaboration and communication among the state organizations with responsibilities in radiation
emergency management.

of IHR Core Capacities of the Kingdom of Eswatini

Radiation emergencies

TargetStates Parties should have surveillance and response capacity for radio-nuclear hazards/events/emergencies.
This requires effective communication and collaboration among the sectors responsible for radio-nuclear
management.

Eswatini's level of capabilities

Eswatini does not have a radiation control authority, a strategic plan for radiation safety, or a complete
legislative infrastructure for control of radiological hazards and response to nuclear and radiologicalemergencies. While the country has a signed radiation safety act (Control of Radio-active Substances
Act, 1964), there is no emergency response plan for radiation emergencies. A comprehensive inventory
has not been made of potential sources of emergencies or of the magnitude of these hazards, but the
Ministry of Natural Resources and Energy is currently making a survey of equipment and radiologicalsources for medical use. In the event of a radiological/nuclear emergency the National Disaster
Management Agency would respond.
There is no monitoring of consumer products (e.g. foodstuffs and goods) regarding radiation hazards.
There are no procedures for risk assessment in radio-nuclear surveillance/monitoring, to trigger/mount a
response of suitable composition and magnitude. There is no laboratory capacity or access to laboratory
capacity available for systematic analysis. Current human and financial resources are not sufficient to meetthe needs for radiation safety. There is no existing inventory of reference health care facilities for radiation
emergencies. There are no protocols/guidelines for case management regarding radio-nuclear hazards.
Procedures on emergency response need to be developed for the involved organizations. Intersectoral
coordination is regulated by the Ministry of Natural Resources and Energy.

OTHER

The highest level of radiation hazard in Eswatini is category II sealed sources used in hospitals (medical
equipment) and industrial applications that could require on-site protective actions. These are monitored
on a regular basis using radiation dosimeters for measurement of radiation received by radiation workers
provided by the South African Bureau of Standards (SABS). Since June 2016 dosimeters are inspected
every three months. Medical imaging staff use lead-based protective devices and employ the "as low asreasonably achievable" (ALARA) principle to protect themselves and the public from harm. With correct
use of such equipment the hazard of exposure is low; but there remain the risks associated with misuseand criminal diversion as well as uncontrolled disposal of obsolete equipment and radioactive materials
that might be dumped illegally. There is no nuclear power generation in Eswatini or nuclear reactors. Somefood stocks are imported from a region of South Africa that is close to a nuclear power station. A potential
major concern is transit of radioactive material through Eswatini.

Eswatini is not yet a party to the Convention on Assistance in the Case of a Nuclear Accident or Radiological
Emergency, or the Convention on Early Notification of a Nuclear Accident, among other importantconventions and treaties concerning the safe and peaceful use of nuclear energy. There is no focal point for51

Joint External Evaluation

the WHO Radiological Emergency Medical Preparedness and Assistance Network (REMPAN). Eswatini is nota party to the Treaty on the Non-Proliferation of Nuclear Weapons, nor has it acceded to the International
Atomic Energy Agency (IAEA) Convention on the Physical Protection of Nuclear Material (CPPNM) plus its
amendment protocol.
National laboratory facilities for identifying and measuring samples for detecting radioactivity, used forenvironmental safety and consumer product control, as well as on monitoring of the radiation exposed
workforce need to be developed. Qualified technical experts need to be trained by IAEA. Further, arrangements
need to be put in place for national and international transport of radioactive materials, samples and waste.
Obsolete materials and equipment should be required to be returned to the manufacture for disposal.
As it was noted during plenary that the country is challenged by its storage of medical (particularly
radiological) waste, it is suggested that a storage facility be created for confiscated materials andequipment. Training of medical radiation personnel has been provided in South Africa and the United
Republic of Tanzania. Coordination and cooperation mechanisms need to be formalized between national
authorities responsible for radiological and nuclear events with the Ministry of Health and the IHR National
Focal Point (NFP). A review needs to be made of the medical facilities that could be developed to manage
patients contaminated with radioactive substances and patients with overexposure. Standard operatingprocedures (SOPs) for management of radiation emergencies need to be developed and guidelines
established for undertaking live drills and simulation exercises with all stakeholders to test emergency
response effectiveness. Finally, a system should be introduced for preparing a real-time inventory of transitsof radioactive materials, which would allow the following of consignments to their destination.

Recommendations for Priority Actions•

Explore the requirements for Eswatini to adhere to International mechanisms with regards to radiation
safety, such as through the IAEA.

•

Develop a health policy for the detection of and response to radiation emergencies.

•

Develop standard operating procedures for the management of radiation emergencies including the
responsibilities for public health assessments and response regarding radiation emergencies.

•

Develop a Radiation Safety Bill for the health sector, which includes the establishment of a nationalradiation monitoring authority or agency.

Indicators and scores

OTHER

RE. 1 Mechanisms are established and functioning for detecting and responding toradiological and nuclear emergencies – Score 1

52

Strengths/Best practices• Medical radiation monitoring with analytical support from South Africa is being conducted.
•

The country has ratified the radiation safety treaty of the Control of Radio-active Substances Act, 1964.

•

An Intersectoral coordination committee regarding radiation safety is regulated by the Ministry of
Natural Resources and Energy.

•Pre-service training of radiographers is in place.

•

Medical Imaging staff use lead-based protective devices and employ the ALARA principle.

•

Infrastructure of public facilities meets the basic requirements in terms of radiation protection.

•

A zero draft of a Nuclear Regulatory Bill has been written.

•

Only trained personnel operate radiation-emitting devices.

•

There are no SOPs for organizations that utilize and those that monitor radiation.

•

International radio-nuclear conventions are not adhered to, e.g. General Safety Requirements (GSR)
Part 3 and International Basic Safety Standards (BSS).

•

Government budget allocation for oversight control and prevention needs strengthening.

•

Development of SOPs for interoperable efficiency is required.

•

Bio-radio health care expertise needs to be developed.

•

Maintenance of nuclear instruments done outside the country at high cost is a challenge.

•

There are no satellite offices to respond immediately should an emergency occur at the peripheries.

•

The Radiation Safety Bill has not yet been enacted into law; as a result there is no regulatory andlicensing authority for medical devices or for monitoring radiation in the country.

•

Quality management systems in medical use of radiation need to be strengthened.

of IHR Core Capacities of the Kingdom of Eswatini

Areas which need strengthening/challenges• Radiation events are not systematically documented.

RE.2 Enabling environment is in place for management of Radiation Emergencies – Score 1

Strengths/Best practices• Pre-service training of radiographers is available.
Areas which need strengthening/challenges• SOPs for interoperable efficiency in the management of radiation emergencies need to be developed.
Procedures and guidelines for scheduled emergency plan review, live drills and simulation exercises
need to be developed.

OTHER

•

53

Joint External Evaluation

Appendix 1: JEE background
Mission place and dates
Mbabane, Eswatini 9 – 13 April, 2018

Mission team members:•

Sally-Ann Ohene, World Health Organization, Ghana (Team lead)•

Issa Makumbi, Ministry of Health, Uganda (Co-Lead)•

Franklin Asiedu-Bekoe, Ministry of Health, Ghana•

John A Haines, United Nations Institute for Training and Research•

Naledi Mannathoko, Ministry of Health, Botswana•

Kim Brolin Ribacke, Public Health Agency of Sweden•

Basego Mothowaeng, Ministry of Health, Botswana•

HendrikJan Ormel, Food and Agriculture Organization of the United Nations•

Asheena Khalakdina, World Health Organization, Geneva•

Patrick Bastiensen, World Organization for Animal Health•

Susan Hiers, Centers United States Centers for Disease Prevention and Control•

Romina Stelter, World Health Organization, Geneva•

Gertrude Avortri, World Health Organization, Zimbabwe•

Roland K. Wango, World Health Organization, Senegal

Objective
To assess Eswatini’s capacities and capabilities relevant to the 19 technical areas of the JEE tool for
providing baseline data to support Eswatini’s efforts to reform and improve their public health security.

The JEE process
The JEE process is a peer-to-peer review. The entire external evaluation, including discussions around thescores, the strengths, the areas that need strengthening, best practices, challenges and the priority actions
should be collaborative, with JEE team members and host country experts seeking full agreement on all
aspects of the final report findings and recommendations.
Should there be significant and irreconcilable disagreement between the external team members and the hostcountry experts, or among the external, or among the host country experts, the JEE team lead will decide theoutcome; this will be noted in the final report along with the justification for each party’s position.

54

•

Prior to the visit, there was email communication with the AFRO, assessment team members, theEswatini WHO Country Office to review the agenda, responsibilities and logistics.

•

Workshops were held over the period of 29th December 2017 to 8th March 2018 to provide
information to national stakeholders on the JEE process including guidance on the self-assessment andassignment of responsibilities for making presentations during the JEE.

Limitations and assumptions•

The evaluation was limited to one week, which limited the amount and depth of information that could
be managed.

•

It was indicated that the results of this evaluation will be publically available.

•

The evaluation is not just an audit. Information provided by Eswatini was not be independently verified
but discussed and the evaluation rating mutually agreed to by the host country and the evaluation
team. This was a peer-to-peer review.

of IHR Core Capacities of the Kingdom of Eswatini

Preparation and implementation of the mission

Key host country participants and institutions
Eswatini lead representative:NAME

POSITIONORGANIZATION

Dr. Njabulo Lukhele (Team Lead)
Mr. Nhlanhla Nhlabatsi
Mr. Masitsela Mhlanga
Mr. Sipho Shongwe
Gugu Maphalala
Vusie Lokotfwako
Bongani Tsabedze
Bongiwe Dlamini
Dr Kevin Makadzange
Dr Sihle Mdluli
Dr. Zizwe Cindzi

Senior Medical Officer
Senior Epidemiologist
Emergency Preparedness & Response Manager
Deputy Chief Environmental Health Officer
Chief Laboratory Technologist
Epidemiologist
Epidemics Officer
Senior Health Promotion Officer
Health Promotion Officer
Veterinary Epidemiologist
Veterinary Officer

Ministry of Health
Ministry of Health
Ministry of Health
Ministry of Health
Ministry of Health
Ministry of Health
Ministry of Health
Ministry of HealthWHO, Eswatini
Ministry of Agriculture
Ministry of Agriculture

Participating institutions:•

Eswatini Ministry of Health•Eswatini Ministry of Agriculture•

Eswatini Ministry of Tourism & Environmental Affairs•

National Disaster Management Agency•

Eswatini Civil Aviation Authority•

Eswatini Environment Authority

55

Joint External Evaluation

List of Participants
NAME

ORGANIZATIONEMAIL

Phinda Khumalo
Zandile Dhlamini
Nhlanhla Nhlabatsi
Sifundo Zwane
Dr. Thembi Ndlangamandla
Funwako Dlamini
Bongani Nkabindze
Xolisiwe Dlamini
Gugu Maphalala
Bongani Tsabedze
Vusie Lokotfwako
Mduduzi Loktfwako
Dr. Njabulo Lukhele
Sibongile Mabuza
Bongiwe Dlamini
Bongmusa Makhubu
Bianca Dlamini
Thobile Seyama

MoH, Epidemiology and Disease Control Unit
MoH
MoH, Epidemiology and Disease Control Unit
MoH
Ministry of Agriculture
MoH, Environmental Health Department
Swaziland Environment Authority
MoH, EPI
MoH, NRL
MoH, EPR
MoH, Epidemiology and Disease Control Unit
MoH, EPR
MoH
MoH, Central Medical Stores
MoH, Health Promotion
Swaziland Civil Aviation Authority
Swaziland Environment Authority
MoH, TB Hospital

phindagkhumalo@yahoo.com
zandimkwanazi@yahoo.com
ntini0064@gmail.com
sifundozwane@yahoo.com
tndla14@yahoo.com
fedlamin@yahoo.com
bongani@sea.org.sz
xolisiwedlamini@yahoo.com
gpmaph@gmail.com
tsabedzebt@gmail.com
vusielokza@gmail.com
lokotfwakomduduzi@gmail.com
lomavy@yahoo.com
sibongile.mabuza@yahoo.com
bdlaminiwork@gmail.com
bongumusa@swacaa.co.sz
bhdlamini@sea.org.sz
seyamatls@gmail.com

Supporting documentation provided by host country
National legislation, policy and financing•

Public Health Act (1969)•

Animal Diseases Act (1965)•

Veterinary Public Health Act (2013)•

Medicines and Related Substances Control Act (2016)•

The National Health Policy (2007)•

The National Health Sector Strategic Plan 2014-2018

IHR Coordination, communication and advocacy

56•

Annual report of the International Health Regulations in Swaziland, 2013•

Disaster Management Act (2006)•

National Strategic Plan for Epidemiology and Disease Control Unit (EDCU) 2016–2020•

Swaziland drought rapid assessment report, 2016•

National Drought Mitigation and Adaptation Plan (NERMAP) 2016–2022•

MDG report for the Kingdom of Swaziland, 2015•

Draft National Multi-Hazard Contingency Plan 2015–2017

National Multi-Hazard Contingency Plan 2017–2018•

National Health Sector Strategic Plan 2008–2013•

The second National Health Sector Strategic Plan 2014–2018•

Comprehensive drought health and nutrition assessment report, 2016•

MoH Ebola (Haemorrhagic Fever) Preparedness and Response Plan 2014/15•

Integrated Disease Surveillance and Response In the Kingdom of Swaziland, 2014•

Mid-term review and lessons on implementing the National Emergency Response Mitigation and
Adaptation Plan 2016–2022•

Draft emergency response standard operating procedures, 2018•

Composition and terms of reference of national and regional epidemic task force teams and rapid
response teams in Swaziland, 2016of IHR Core Capacities of the Kingdom of Eswatini•

Antimicrobial resistance•

The AMR Containment Strategy to Combat Antimicrobial Resistance (2017–2021)•

Infection Prevention Control guidelines, 2014•

Medicines and Related Substances Control Act (2016)•

Standard Treatment Guidelines to Regulate and Promote Rational Use of Antibiotics, 2012

Zoonotic diseases•

Veterinary Surgeons Act (1997)•

The Stock Disease (amendment) Regulation (2007) List of Notifiable Diseases. Amendment to theAnimal Diseases Act (1965)•

Swaziland National Avian flu Preparedness Plan Draft 5, Ministry of Agriculture and Cooperatives(MoAC) & Ministry of Health (MoH), 2007•

The Veterinary Public Health Act (2013)•

Guidelines for National Veterinary Services (2013)•

OIE – PVS Gap-Analysis mission report – Kingdom of Swaziland (2015)

Food safety•

Public Health Act (1969)•

Public Health (Food hygiene) Regulations, 1973•

Swaziland food related standards developed by the Swaziland Standard Authority

Biosafety and biosecurity•

Swaziland National Biosafety Manual•

The Biosafety Act (2012)•

Draft biosafety regulations, 201757

Joint External Evaluation

Immunization•

WHO/UNICEF Joint Reporting Form, 2017•

Draft Swaziland National Immunization Technical Advisory Group Procedure Manual, 2017•

Expanded Programme on Immunization Comprehensive Multi-Year Plan 2017–2021•

Expanded Programme on Immunization policy, 2012•

Swaziland measles rubella catch-up campaign report, 2016•

Swaziland comprehensive EPI review report, 2016•

Introduction plan for rotavirus vaccine in Swaziland, 2014•

Addis Declaration on Immunization•

Swaziland Expanded Programme on Immunization Annual Report, 2016•

Swaziland Expanded Programme on Immunization Annual Report, 2017

National laboratory system•

Mbabane Government Hospital Laboratory – Biosafety Manual, 2014•

Mbabane Government Hospital Laboratory – SOP for CSF Analysis, 2015•

Mbabane Government Hospital Laboratory – SOP for EIA for detection of rubella IgM, 2016•

Ijaz, K. et al. International Health Regulations—What gets measured gets done. Emerging Infectious
Diseases. 2012; 18(7):1054–7.

•

Guidelines for National Veterinary Services, 2013•

OIE – PVS evaluation follow-up mission report – Kingdom of Swaziland (2015)•

OIE – PVS gap-analysis mission report – Kingdom of Swaziland (2015)•

CVL annual report (2014)•

Regional inter-laboratory proficiency testing for rabies diagnosis. Southern Africa, Congo basin andother selected African countries. April 2013. Technical and financial report (confidential) CDC, ARC,
OIE

Real time surveillance

58•

Weekly Disease Notifiable bulletins•

Monthly Disease Notifiable bulletins•

Listing of core syndromes indicative of public health emergencies•

STI management guidelines at SNAP Swaziland National AIDS Programme•

IDSR Assessment Reports•

National Strategic Plan for Epidemiology and Disease Control Unit (EDCU) 2016–2020•

National Integrated Disease Surveillance and Response Strategy•

OIE reports (World Animal Health Information System – WAHIS)•

Ministry of Agriculture reports

•

Various Swaziland monthly epidemiological bulletins•

Various immediate disease notification weekly summary reports 2018•

ISDS 2018 Conference Abstracts: Malaria risk assessment through remote sensing and multi-criteria
evaluation in Madagascar•

CMIS connect – Client Management Information System news, 2017of IHR Core Capacities of the Kingdom of Eswatini

ReportingWorkforce development•

Annual budget performance report F/Y 2017–2018•

Service availability mapping report, 2013•

Analysis of human resources for health in Swaziland, 2017•

Ministry of Health staffing norms. Human Resources Unit of the Ministry of Health, 2016

Preparedness•

Emergency Preparedness and Response strategy 2017–2020•

National Health Sector Strategic Plan•

The Second National Health Sector Strategic Plan 2014–2018•

Annual vulnerability assessment & analysis report 2014•

Swaziland comprehensive health & nutrition assessment report on the impact of El Niño•

Disaster risk reduction, emergency preparedness and response capacity assessment report, 2013•

Swaziland national vulnerability assessment, 2006•

Ebola Preparedness Plan•

National Multi-Hazard Contingency Plan, 2017•

Emergency response SOPs•

Service availability mapping (SAM) report , 2013

Emergency response operations•

Matsapha Simulation & Commemoration of the International Day for Disaster Risk Reduction Report,
November 2017•

Natural simulation report 2014•

Disaster Management Act (2006)•

National Emergency Response, Mitigation and Adaptation Plan 2015–2020 (NERMAP), January
2016 to March 2022•

National Multi-Hazard Contingency Plan, 2017•

The Second National Health Sector Strategic Plan 2014–2018•

Annual vulnerability assessment & analysis report 2014•

Swaziland comprehensive health & nutrition assessment report on the impact of El Niño•

Disaster risk reduction, emergency preparedness and response capacity assessment report, 2013

59

Joint External Evaluation•

Swaziland National Vulnerability Assessment, 2006•

Service availability mapping (SAM) report, 2013•

Standard Treatment Guidelines to Regulate and Promote Rational Use of Antibiotics, 2012•

Essential Medicines List of Common Medical Conditions in the Kingdom of Swaziland 1st edition,
2012

Linking public health and security authorities•

Public Health Act (1969)

Medical countermeasures and personnel deployment•

Medicines and Related Substances Control Act (2016)•

Swaziland Donation Guidelines

Risk communication•

The ACSM Implementation Plan•

Introduction Plan for Inactivated Polio Vaccine (IPV) in Swaziland, 2014•

Advocacy, Communication and Social Mobilization Plan for introduction of HPV vaccine, 2017•

Communication and advocacy strategy on avian and human influenzas•

Draft communication and advocacy strategy for the Department Of Veterinary And Livestock Services,
2017•

National Multi-Hazard Contingency Plan 2012 to 2013•

National Health Promotion Strategy 2018–2022•

Malaria Epidemic Preparedness and Response National Guidelines, 2009

Points of entry•

National Multi-Hazard Contingency Plan 2017–2018•

Memorandum of Understanding between the Swaziland Civil Aviation Authority and the Swaziland's
Government Ministry of Health•Sikhuphe International Airport Emergency Orders, 2014

Chemical events

60•

Environment Management Act (2002)•

Waste Management, part VI of the Environment Management Act (2002) – management ofchemical waste, which also domesticates the Basel Convention.

•

Draft Chemicals Management Bill•

Pesticide Management Act (2018)•

Ratification of international treaties and dependence on their compliance mechanisms•

Public Health Act (1969)•

Agricultural Chemicals and Control Act (2006)

Globally Harmonized System of Classification and Labelling of Chemicals –(including Safety Data
Sheets)•Stockholm Convention•

Rotterdam Convention•

Swaziland National Chemicals Management Profile, 2015•

Waste Regulations (2000)•

Water Pollution Control Regulations (2010)of IHR Core Capacities of the Kingdom of Eswatini•

Radiation emergencies•

Radiation Safety Act (draft)•

Draft Zero National Nuclear Regulatory Act 2017•

The Second National Health Sector Strategic Plan 2014–2018•

Control of Radio-active Substances Act (1964)61

WHO/WHE/CPI/2018.27