Facilities and staff are being stretched beyond capacity as Swaziland's public healthcare system buckles under a surge of HIV/AIDS patients, leaving many with home-based care (HBC) as the only alternative, says a new report.

"At health centres and hospitals, health workers reported increased patient loads attributed to HIV and AIDS, and noted that the HIV and AIDS cases were often sicker and more complex to manage than others, placing a major strains on services, which were already weakened by staff shortages," said a study commissioned by the ministry of health and social welfare.

"HIV and AIDS has approximately doubled our case load since the 1990s," one doctor said in the Study of the Health Service Burden of HIV and AIDS and the Impact of HIV and AIDS on the Health Sector in Swaziland.

"I cannot give a patient my undivided attention because of the long queue which also needs to be attended to; this impacts on system performance," said another.

"The hospital is always packed and there are no benches; people are very weak; there is not enough staff. This place is not conducive to healing," a hospital matron commented.

The report also noted a "substantial increase" in tuberculosis cases since 1990. "TB treatment completion rates have dropped to 34 percent, far below the 85 percent generally required to control TB. Ongoing difficulties in improving the rates are attributed to increasing death rates due to HIV and AIDS among TB patients, as well as strain on services."

A healthcare worker told researchers: "If patients consistently see other patients die, they have no faith in the system."

Home-based care the only alternative

Out of necessity, more and more patients are now receiving treatment at home. "At all hospitals and most PHC [primary health care] facilities visited, health workers reported significant growth in the numbers of outpatients," the report noted.

"Some patients just never come to the clinic until they are identified and referred by HBC groups ... mainly because they have given up and think clinics cannot do anything for them," a clinic nurse said.

"We need to scale up, particularly in care and support. If you look at the treatment of HIV/AIDS, we need foremost to improve skills; there is a huge challenge of skills," Khanya Mabuza, Project Officer for the National Emergency Council on HIV and AIDS (NERCHA), told IRIN.

"We cannot continue to do things 'business as usual'. We need to come up with a better way of service: community based, using a grassroots community approach, using lay people as caregivers. Already we are ... 'offloading' the hospitals and moving patients into the community," she added.

"Human resources are the huge challenge. Family members must be trained. If you have the money from donors, it is not enough if you haven't the people to operate machinery and distribute drugs," Mabuza said.

The health ministry report acknowledged the role of HBC but described it as "very weak, and without adequate coverage".

"Major concerns were frequently expressed about quality and sustainability, and some of the underlying problems for HBC include fragmentation and lack of coordination, thinly stretched capacity at all levels, limited training and support, and unreliable HBC supplies."

The coping capacity of families and communities was also questioned. "Many families wait until late in the night to bring relatives with AIDS to casualty. They know that if it is late they are less likely to send the patient home, even if the ward is full," a hospital nursing manager said in the report.

"So the patients spend the night ... sometimes the family stays away and does not pick them up, just to get a bit of rest from caring."

Personnel shortages worsened this week: seven of the 21 doctors employed by the health ministry quit their jobs at government hospitals because they had not been paid on-call allowances for over a year. The doctors, expatriates engaged in specialised tasks like surgery and radiology, have hired a lawyer to sue the ministry of health. Some have left the country.