The World Health Organization (WHO) recently conducted the Universal Health Coverage (UHC) scoping exercise in the Kingdom of Eswatini from 28 January to 1 February 2019. The exercise was led by the Ministry of Health with participation of other stakeholders. Dr Juliet Nabyonga from Inter- country Support Team for Eastern and Southern Africa, Dr Stanley Midzi from Zimbabwe country office, Dr. Akin. Oyemakinde, a consultant and Dr Khosi Mthethwa, the Health Systems Strengthening focal point in Eswatini WHO country office provided the required technical support for the exercise.

The Kingdom of Eswatini is working towards achieving UHC as highlighted in the National Health Policy 2018 and the National Health Sector Strategic Plan 2014-2018. A country is said to have attained Universal Health Coverage (UHC) when all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need – of sufficient quality and effective delivery, while also ensuring that the use of these services does not expose the user to financial hardships. UHC is also a major focus for the WHO’s General Programme of Work (GPW13) and one of the flagship programmes for the African Region. The aim of WHO is to support and promote the development and implementation of coordinated results-oriented health systems strengthening actions in member states, with a focus on achieving a sustainable and measurable Universal Health Coverage.

The purpose of the scoping exercise was to map the country’s aspirations for UHC and other health related Sustainable Development Goals (SDG) targets, identify the bottlenecks hindering attainment of UHC targets and further negotiate with government, critical actions needed to accelerate movement towards UHC as well as identify the roles expected of WHO in addressing the bottlenecks.  
The exercise focused on the six building blocks of the health systems; leadership/governance, service delivery, health workforce, access to essential medicines, health information systems and financing. Some of the key issues raised from the findings of the scoping team included low satisfaction among users of health services, rising maternal mortality ratio from 320 per 100,000 live births in 2010 to 389 per 100,000 live births in 2016 as well as declining national immunization coverage from 83% in 2014 to 73% in 2016.

 
The country has inadequate health workforce in both numbers and skills. The distribution of health workforce is also skewed in favour of urban areas with some rural health facilities having staffing gaps. Other health workforce challenges include; retention of skilled staff due to frequent rotation of workers especially nurses; and government absorption of donor funded positions. The role of WHO is to support the country to use evidence to inform training needs, planning, recruitment, deployment and retention of staff as well as developing a medium term training plan in line with the diseases burden and also update the staffing norms using Workload Indicators of Staffing Needs (WISN) tool.

There are gaps in the implementation of the Essential Health Care Package (EHCP). The distribution of health facilities and access to essential health services create inequities between rural and urban populations as well as different population groups like the adolescents. Outreach services are not adequately provided to reach populations in remote areas.  It was therefore agreed that WHO assists the Ministry of Health to develop differentiated approach in service delivery, reorient the health system to focus on preventive, promotive, rehabilitative and palliative services, and accelerate actions for the health of adolescents (AA-HA).

 
Decline in Government expenditure on health as a percentage of total government expenditure was noted as well as weak health financing monitoring. WHO will strengthen monitoring for health financing through institutionalisation of National Health Accounts (NHA).

 There is no national data repository with limited capacity to generate analyze and use data for planning and decision making at all levels. The World Health Organization will continue to support the development and dissemination of a Health Information System (HIS) Strategy, ensure interoperability of information systems and put in place a National Health Observatory. 
During a debriefing session with the senior Ministry of Health staff it was noted that more than 80% of the bottlenecks identified were already being addressed and WHO should work with other partners accelerate interventions toward UHC. Funding was identified as a major hindrance to implementation of identified interventions.

 
It would be recalled that the scoping exercise came at an opportune time when the country was developing the extended National Health Sector Strategic Plan II (eNHSSPII). Some of the findings of the scoping process informed the eNHSSP II. WHO will support the Ministry of Health to develop monitoring framework for the eNHSSP II and cost it to attract investments and for ease of implementation.

 
Universal health coverage is a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities in countries. UHC is therefore regarded as a hallmark of the government of Eswatini’s commitment to improving the wellbeing of all people living in Eswatini.