I am writing this as my neighbor’s daughter waits in line at the clinic, hoping there will be antiretroviral drugs available when her turn comes. Six months ago, she would have received a three-month supply. Today, if she’s fortunate, she’ll get enough medication for just four weeks. This is the reality in modern Eswatini, a kingdom where political maneuvering takes precedence over the most basic human need: staying alive.
As a citizen who has watched my country navigate decades of challenges, I find myself both heartbroken and frustrated by our current trajectory. The health crisis gripping our nation isn’t just about medicine shortages or budget gaps. It’s about a fundamental failure of leadership at a moment when we can least afford it.
We emaSwati must confront an uncomfortable reality: for too long, we have allowed our leaders to build a healthcare system on borrowed time and borrowed money. The withdrawal of USAID funding, which once supported programs that saved over 92 million lives globally, has exposed what many of us suspected but few dared say; our health system was never truly ours.
When PEPFAR dollars flowed freely, helping to improve our life expectancy and control HIV in a country where nearly one in four adults lives with the virus, it was easy to celebrate progress. But progress built on external dependency is an illusion of strength, not the real thing. Other African nations understood this. We chose comfort over sustainability.
Today, as patients ration their medications and mothers worry about accessing prenatal care, we’re paying the price for that choice. The health ministry’s budget shortfall of E480 million this year isn’t just a number on a government spreadsheet; it represents lives that could be saved, children who could be immunized, and families who could remain intact.
Prime Minister Russell Mmiso Dlamini’s latest proposal to centralize drug procurement under his office feels like the kind of solution that sounds decisive in a cabinet meeting but crumbles under scrutiny. As someone who has lived through various government initiatives promising to fix our problems, I recognize the pattern: when facing a crisis requiring systemic change, offer a quick administrative reshuffling instead.
The Prime Minister asks us to trust that moving procurement responsibilities from the Ministry of Health to his office, supported by NERCHA and the National Disaster Management Agency, will solve our medicine shortage crisis. But he hasn’t answered the most basic questions any citizen should ask: How will this solve our budget shortfall? Where will the missing E480 million come from? And why should we trust NDMA with drug procurement when its COVID-19 financial management raised serious concerns?
More troubling is how this proposal ignores one glaring structural problem: our entire healthcare system is dangerously centralized around a single person; the Director of Health Services. This one individual is expected to manage everything from procurement to policy implementation, from rural clinics to specialized hospitals, with virtually no other executive support. It’s an impossible task that would challenge even the most capable administrator, yet we’ve built our entire system around this flawed premise.
How exactly will the Prime Minister’s procurement shuffle address this fundamental weakness? Will moving drug purchasing to his office suddenly create the executive capacity our health ministry desperately lacks? Or will it simply add another layer of centralization to an already over-centralized system?
These aren’t abstract policy debates. They’re questions about whether my neighbor’s daughter will have her medication next month, whether pregnant women in rural areas will receive proper care, and whether our children will be protected from preventable diseases.
What troubles me most is how we’ve allowed this crisis to fester in silence, protected by a culture of impunity that shields those responsible. Health crises don’t respect borders; they affect all of us, regardless of our political affiliations or social status. Yet too often, we emaSwati treat healthcare as someone else’s responsibility rather than a collective challenge requiring our active engagement.
The most damning aspect of our current situation isn’t just the medicine shortages or budget gaps; it’s the complete absence of accountability. Despite years of documented mismanagement, expired drugs warehoused while patients go without treatment, and procurement contracts that raise obvious questions, not a single person has been arrested or held criminally responsible for our health crisis.
This culture of impunity extends to the very top. When the Auditor General attempts to fulfill their constitutional mandate by investigating financial irregularities in health spending, they face public insults and political intimidation; including from the Prime Minister himself. What message does this send about our commitment to good governance? How can we expect transparency when those demanding it are attacked rather than supported?
Members of Parliament have rightly questioned the Prime Minister’s proposal, but where is the broader public discourse? Where are the community meetings, the civil society demands for transparency, the citizen committees monitoring health outcomes? If we continue to treat governance as something that happens to us rather than something we participate in, we’ll keep getting the same disappointing results.
The human cost grows daily. Every HIV patient who develops drug resistance because of inconsistent medication supply makes future treatment more complex and expensive. Every mother who can’t access prenatal care risks complications that proper healthcare could prevent. Every child who misses vaccinations puts entire communities at risk.
I’ve watched with both admiration and envy as other African nations have transformed their health systems. Rwanda didn’t achieve its remarkable progress by reshuffling bureaucracies; it made hard choices about fighting corruption, investing in local capacity, and holding leaders accountable for results. Kenya didn’t reduce its aid dependency through emergency measures; it built domestic pharmaceutical manufacturing and strengthened supply chains.
What these countries had that we seem to lack is leadership willing to ask difficult questions and make uncomfortable changes. They recognized that health systems, like democracy itself, require constant nurturing and genuine commitment to succeed.
As a citizen, I don’t want to hear about new procurement arrangements that shuffle responsibilities without addressing fundamental structural problems. I want to see our government create proper executive capacity in the health ministry instead of expecting one Director of Health Services to single-handedly manage our entire healthcare system. I want to see real consequences for corruption; arrests, prosecutions, and asset recovery, not just empty promises of reform.
I want our leaders to stop attacking the Auditor General and other oversight bodies trying to do their jobs, and instead embrace the transparency that good governance requires. I want to see our government honor its health budget allocations instead of consistently disbursing less than promised, and I want transparent reporting on how health funds are used so we can all see where our money goes when lives depend on it.
I want leaders who understand that achieving the African Union’s recommendation of 15 percent health spending isn’t optional; it’s a moral imperative. I want governance reforms that make corruption costly rather than rewarding, with real prosecutions that send a clear message that stealing from our health system will have serious consequences.
Most importantly, I want leadership that treats healthcare as a fundamental right rather than a political favor, that builds proper institutional capacity instead of relying on over-stretched individuals, and that creates sustainable systems rather than perpetually managing crises.
We emaSwati are not naive. We understand that fixing decades of poor governance won’t happen overnight. But we deserve leaders who are honest about the scope of our challenges and committed to addressing root causes rather than symptoms.
The Prime Minister’s procurement proposal may be well-intentioned, but it misses the fundamental point: our health crisis isn’t primarily a management problem; it’s a governance problem. Moving deck chairs doesn’t fix a sinking ship.
If our leaders truly want to serve the people, they need to start by asking harder questions: Why do we consistently fail to meet our health budget commitments? How can we build sustainable financing that doesn’t depend on foreign donors? What systems would ensure that corruption becomes impossible rather than profitable?
These questions don’t have easy answers, but avoiding them has proven far more costly than confronting them would be.
We stand at a crossroads that will define our country’s future. Down one path lies continued dependence on external aid, recurring crises, and the perpetual cycle of emergency measures that never quite solve anything. Down the other lies the difficult work of building strong institutions, demanding accountability from our leaders, and investing in our own capacity for self-reliance.
As I write this, my neighbor’s daughter is walking home from the clinic with one month’s worth of medication; enough to keep her alive until the next crisis. She deserves better. We all deserve better.
The choice before us isn’t really about drug procurement or budget allocations. It’s about what kind of country we want to be: one that manages crises or one that prevents them, one that depends on others’ generosity or one that takes responsibility for its own people’s welfare.
Time is running out for half-measures and political theater. Our leaders need to choose between protecting their own interests and protecting our lives. As citizens, we need to make clear which choice we’ll accept.
My neighbor’s daughter shouldn’t have to worry about whether her medication will be available next month. No emaSwati should. But making that dream a reality requires the kind of honest leadership and citizen engagement we haven’t seen enough of yet.
The question isn’t whether we can afford to change; it’s whether we can afford not to. And that’s a question only we can answer!
Bhekithemba Dlamini writes from Mbabane, Eswatini
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