7

CHAPTER
ACCESS TO HEALTHCARE FOR
PERSONS WITH DISABILITIES IN
ESWATINI: A TRIADIC EXPLORATION
OF BARRIERS

Khetsiwe P Masuku,* Juan Bornman** & Ensa Johnson***

Summary

Eswatini ratified the United Nations Convention on the Rights of Persons with
Disabilities (CRPD) and its Optional Protocol in 2012, subsequently developing the
National Disability Policy. Regardless of this ratification and the best intentions of
the National Disability Policy, healthcare disparities still exist between persons with
and without disabilities. This study aims to describe the barriers experienced by
persons with disabilities when accessing healthcare services by focussing on the
accounts of persons with disabilities themselves, caregivers of persons with
disabilities and healthcare professionals. A further aim was to propose
recommendations to address these identified barriers. A qualitative case study
approach utilising focus groups was employed. Participants for the three focus
groups were purposively selected. Data was analysed using a framework approach,
employing Nvivo 1.5 qualitative analysis software. Findings revealed that access to
healthcare for persons with disabilities was a challenge in Eswatini due to the
unavailability of resources in the form of rehabilitation healthcare practitioners and
assistive devices; lack of reasonable accommodation especially for persons with
visual and communication impairments; stigma and discrimination;
transportation costs as a result of the distance of healthcare services; and the lack of
social support grants. Recommendations from this study propose an urgent need for

* PhD Graduate, Centre for Augmentative and Alternative Communication, University of

Pretoria, Lecturer, University of the Witwatersrand, PhD (University of Pretoria), MPH
(MEDUNSA); BCommunication Pathology (University of Pretoria). Email:Khetsiwe.
masuku@[Link]
** Professor, Centre for Augmentative and Alternative Communication, University of Pretoria,
PhD (University of Pretoria); M (Communication Pathology) (University of Pretoria);
BLogopaedica (University of Pretoria) Email: [Link]@[Link]
*** Senior lecturer, Centre for Augmentative and Alternative Communication, University of
Pretoria, PhD (University of Pretoria), MA (University of Pretoria), BA Hons (University of
Pretoria), BPrim Ed (University of Pretoria). Email: ensajohnson65@[Link]

KP Masuku, J Bornman & E Johnson ‘Access to healthcare for persons with disabilities in Eswatini:
A triadic exploration of barriers’ (2021) 9 African Disability Rights Yearbook 138-159
[Link]

138
 Access to healthcare for persons with disabilities in Eswatini 139

Eswatini to be deliberate in implementing initiatives such as disability

conscientisation programmes to address stigma and discrimination and to create an
awareness of especially communication and visual disabilities. Intersectoral
involvement, community engagement projects as well as addressing policy gaps are
essential if Eswatini intends to mitigate these barriers.

1 Introduction

Persons with disabilities account for approximately 15 per cent of the

global population with almost 80 per cent of all persons with disabilities
living in low-and-middle income countries (LMICs).1 In Eswatini the
prevalence of disability is 16 per cent.2 Women constitute the majority of
persons with disabilities in Eswatini as they make up 58 per cent of the
population of persons with disabilities. In total, 82 per cent of persons with
disabilities in Eswatini reside in rural areas. Despite having the same
healthcare needs as persons without disabilities, persons with disabilities
may require additional healthcare as a result of their impairments or the
consequences of their impairments.3 However, access to healthcare
continues to be a challenge for this population.4 As a result, persons with
disabilities experience unmet healthcare needs.5 LMICs such as Eswatini
account for the majority of persons with disabilities who experience unmet
healthcare needs.6 These unmet healthcare needs are further compounded
in persons with disabilities who reside in rural areas, engulfed by poverty
and who have limited access to information, education and healthcare.7

Access to healthcare is a broad and complex phenomenon with no

single generally acceptable definition.8 Hence it is unsurprising that
various scholars interpret access to healthcare differently. It could be
argued that the interpretation of access to healthcare is also influenced by
context. For the purpose of this study, access to healthcare is defined using
Peters et al’s four dimensions framework, as it was developed within the

1 World Health Organisation ‘World Report on Disability’ (2011) 2.

2 Deputy Prime Minister’s Office ‘Swaziland National Disability Policy’ (2013) 12;
S Mavundla ‘Country report: Swaziland’ (2015) 3 African Disability Rights Yearbook 245
at 247.
3 See generally T Shakespeare et al ‘Access to healthcare for persons with disabilities’
(2018) [Link]%2Fdocuments%Issues%2FDisability%@FStandardHealth%2F
BackgroundDoc_EGM_Righttohealth (accessed 12 November 2020).
4 See generally JAK Harrison et al ‘Access to healthcare for people with disabilities in
rural Malawi: What are the barriers?’ (2020) 20 BMC Public Health 833.
5 Shakespeare et al (n 3).
6 World Health Organisation ‘Human rights and health’ (2017) [Link]
en/news-room/fact-sheets/detail/human-rights-and-health (accessed 27 December
2021).
7 J Neille & C Penn ‘Beyond physical access: A qualitative analysis into the barriers to
policy implementation and service provision experienced by persons with disabilities
living in a rural context’ (2015) 15 Rural and Remote Health 3332.
8 See generally B Jacobs et al ‘Addressing access barriers to health services: an alytical
framework for selecting appropriate interventions in low-income Asian Countries’
(2012) 27 Health Policy and Planning 288.
140 (2021) 9 African Disability Rights Yearbook

LMIC context. In Peters et al’s9 framework it is proposed that access to

healthcare is the judicious use of amenities according to the needs of the
individual and that access encompasses four dimensions, namely
availability, acceptability, financial accessibility and geographical
accessibility. Peters et al10 further emphasise that quality of care is a
fundamental element of each of the four dimensions of their framework.

2 Evolution of healthcare rights through human

rights frameworks

Access to basic healthcare is an essential and non-progressive human right

that every living human being should enjoy throughout their lifespan,
regardless of race, gender, religion, political beliefs, economic and social
conditions.11 This declaration by the World Health Organisation therefore
creates a legal obligation for global, regional and national structures to
ensure that the right to healthcare for everyone – most importantly those
who have been previously excluded from such services – is protected and
upheld. It was thus inevitable that the focus on access as a human rights’
issue would be actioned through the development of copious global
policies and conventions. For example, in the eighties, the United
Nations12 through the Standard Rules on the Equalisation of
Opportunities for Persons with Disabilities declared that disability should
be approached from a human rights perspective. Subsequently, access to
healthcare for all African citizens is advocated for and emphasised in
several articles of the African Charter on Human and People’s Rights on
the Rights of Persons with Disabilities.13 Articles 15 and 16 of the Draft
Protocol of the African Charter on Human and People’s Rights14 provide
for access to healthcare and rehabilitation for persons with disabilities. It is
also declared in the draft protocol of the African Charter on Human and
People’s Rights that, every person with a disability has the right to
healthcare and it further mandates states to ensure that appropriate and
effective measures are put in place to ensure that persons with disabilities
have access to these services on an equal basis with others.15

9 DH Peters et al ‘Poverty and access to health care in developing countries’ (2008) 1136
Annals of the New York Academy of Sciences 161.
10 Peters et al (n 9) 167.
11 World Health Organisation (n 1).
12 UN Department of Economic and Social Affairs ‘Standard rules on the equalisation of
opportunities for persons with disabilities’ (1993) [Link]
desa/disabilities/standard-rules-on-the-equalization-of-opportunities-for-persons-with-
[Link] (accessed 27 December 2021).
13 African Union ‘Draft Protocol on the African Charter of Human and People’s Rights’
adopted by the Organisation of African Unity on 27 June 1981, entered into force
21 October 1986.
14 African Charter of Human and People’s Rights (n 13).
15 As above.
 Access to healthcare for persons with disabilities in Eswatini 141

The development of the Convention of the Rights of Persons with

Disabilities (CRPD) in 200616 was a momentous landmark in the
recognition of human rights for persons with disabilities globally. The
CRPD is arguably the most important international human rights’
document ever ratified on behalf of persons with disabilities.17 This is
partly because the CRPD outlines and delineates the complete array of
human rights that apply to all human beings and centres them in the
context of the core existence of persons with disabilities.18 The purpose of
the CRPD is to ‘promote, protect and ensure the full enjoyment of all
human rights and fundamental freedoms by persons with disabilities and
to further promote respect for their inherent dignity’.19 Articles 25 and 26
pertain to the rights of access to health and rehabilitation for persons with
disabilities respectively.20

3 Healthcare rights framework in Eswatini

Eswatini ratified the CRPD and its Optional Protocol in 2012.21 To

enforce the CRPD, Eswatini developed the National Disability Policy of
Eswatini in 2013.22 Subsequently, the National Disability Bill of Rights
and the National Disability Plan of Action were developed in 2014 and
2015 respectively.23 It is important to mention that to date, the National
Disability Bill of Rights is yet to be passed as law which has direct
implications for the implementation of the National Disability Policy.24

Access to healthcare for persons with disabilities is specifically

addressed in sections 4.9 and 4.10 of Eswatini’s National Disability
Policy.25 In an analysis of the National Disability Policy,26 it was
established that the policy document had promised access to healthcare to
persons with disabilities at primary, secondary and tertiary levels of care.
A detailed analysis and findings on the policy analysis is described in
Masuku et al.27 In particular, the policy is committed to ensure the
availability of free comprehensive healthcare, assistive devices,
rehabilitation and counselling by qualified healthcare personnel at all

16 UN General Assembly, Convention on the Rights of Persons with Disabilities (2007)

UN Doc A/RES/61/106 (24 January 2007) [Link]
disabilities/[Link] (accessed
27 December 2021).
17 See generally M Perlin ‘International human rights and institutional forensic
psychiatry: The core issues’ (2016) American Psychological Association 9.
18 As above.
19 Arts 25 & 26 of the CRPD.
20 As above.
21 Mavundla (n 2).
22 Mavundla (n 2) 255.
23 Mavundla (n 2) 264.
24 As above.
25 Deputy Prime Minister’s Office (n 2) 41-44.
26 KP Masuku et al ‘Analysing Eswatini’s national disability policy reforms: Access to
healthcare implications for citizens with disabilities’ (2020) (accepted).
27 As above.
142 (2021) 9 African Disability Rights Yearbook

levels of state healthcare to persons with disabilities and their families, with
reference to affordable healthcare in private healthcare facilities.28 In the
National Disability Policy, specific emphasis was placed on the availability
of sexual and reproductive health services for persons with disabilities
because historically persons with disabilities in Eswatini have not had
access to information and accessibility to services which would enable
them to make informed decisions on their sexuality and reproductive
health.29 Community awareness and community mobilisation regarding
health promotion to prevent disabilities was further promised in the
National Disability Policy. Acceptability was also pledged in the National
Disability Policy through advocating for accommodating persons with
disabilities such as making alternative communication methods such as
sign language available, providing health information in accessible formats
and ensuring physical access, for example, wheelchair ramps to buildings.

Prior to Eswatini’s ratification of the CRPD, the protection of the

rights of every citizen of the country was committed to in the Constitution
of the Kingdom of Eswatini.30 Section 30 of the Constitution particularly
focuses on the upholding of the rights of persons with disabilities.
Moreover, in section 60 the provision of basic healthcare for every citizen
of the country was committed to.31 Although Eswatini’s Constitution does
not necessarily make specific reference to access to healthcare for persons
with disabilities, it does, however, commit to establishing laws that will
ensure that persons with disabilities live productive and meaningful lives
in Eswatini.32

There is evidence to suggest that globally, there are compliance

challenges with the mandates of the CRPD as domestic laws and policies
developed and implemented by signatory states in an attempt of
domesticating the CRPD, are often not transferred into practice.
Ultimately, the vision of the CRPD for persons with disabilities is currently
not fulfilled in Eswatini. This challenge is not unique to Eswatini, as other
LMICs such as South Africa33 and Malawi34 are also struggling with
achieving access to healthcare for persons with disabilities. There has been
a call for global research targeted towards the CRPD implementation
process in LMICs.35 The results of the lack of implementation of disability

28 Deputy Prime Minister’s Office (n2).

29 As above.
30 Constitution of the Kingdom of Swaziland, 1996 (as set out in sec 29 (20) of the
Citation of Constitutional Law Act 2006)
31 Sec 60 of the Constitution of the Kingdom of Swaziland.
32 Sec 30 of the Constitution of the Kingdom of Swaziland.
33 See generally M Hussey, M MacLachlan & G Mji ‘Barriers to the implementation of
the health and rehabilitation articles of the United Nations Convention on the Rights of
Persons with Disabilities in South Africa’ (2017) 6 International Journal of Health Policy
and Management 207.
34 Harrison et al (n 4).
35 See generally B O’Hare, D Devakumar & S Allen ‘Using international human rights
law to improve child health in low income countries: A framework for healthcare
professionals’ (2016) 16 BMC International Health and Human Rights 11.
 Access to healthcare for persons with disabilities in Eswatini 143

legal frameworks in LMICs are observed in healthcare challenges.

Therefore, despite the ratification of the CRPD, healthcare accessibility
remains a challenge for persons with disabilities in Eswatini. To our
knowledge, the experiences of persons with disabilities when accessing
healthcare services in Eswatini from their own perspective, have not been
previously explored. As such, it is important to determine how persons
with disabilities, caregivers of persons with disabilities and healthcare
professionals experience the access to healthcare for people with
disabilities in Eswatini in order to create a triadic understanding of the
barriers faced by persons with disabilities.

4 Methods

Consistent with the aim of determining the experiences of persons with

disabilities when they access healthcare services in Eswatini, a qualitative
case study research design was employed.36 Three focus groups
comprising of participants from a range of backgrounds and with varied
experiences of disability – specifically in relation to healthcare – were
utilised. Focus groups were deemed appropriate to achieve the aim as it
encourages engagement, explanations and reasoning about the subject at
hand. In this case, access to healthcare for persons with disability, bringing
both agreements and differences to the fore.37 The current study was
approved by the Research Ethics Committee of the Faculty of Humanities,
University of Pretoria (reference GW20160721HS). The research team
comprised of the first author and a MSc student (research fieldworker) who
had training in qualitative methods and has experience of living and
working in Eswatini.

4.1 Participants

Participants were eligible to participate in the study if they were 18 years

and older, were either persons with disabilities, caregivers of persons with
disabilities or healthcare professionals who had knowledge and/or
experience with healthcare access for persons with disabilities. Participants
were purposively recruited from three different groups, namely persons
with disabilities, caregivers of persons with disabilities and healthcare
professionals to allow for a diversity of views (Table 1). Moreover, these
diverse groups were purposely selected as it was believed that their
experiences, understanding and interpretation of access to healthcare for
persons with disabilities may differ. In total, 25 participants (15 females
and 10 males) with a mean age of 40.6 years (range 30-50 years) were
recruited to participate in one of the three focus groups (see Table 1). The

36 K Hammarberg, M Kirkman & S de Lacey ‘Qualitative research methods: When to use

them and how to judge them’ (2016) 31 Human Reproduction 498.
37 R Barbour Doing focus groups (2008).
144 (2021) 9 African Disability Rights Yearbook

first focus group comprised of five persons with disabilities; the second
group comprised of six caregivers of persons with disabilities who cared for
and accompanied persons with disabilities to healthcare facilities; and the
third group of 14 healthcare professionals who treated persons with
disabilities on a day to day basis at healthcare facilities. In order to
accommodate the large number of healthcare professionals, two separate,
but similar focus groups were conducted. The research team which
conducted the focus groups were not acquainted with any of the
participants.

Table 1: Characteristics of focus group participants

Focus Total Gender Mean age Years of Focus group 1 and

Group N years experience 2 - Type of
(Sample) (range) with disability Disability;
Focus Group 3 -
Profession
Persons with 5 3 Males; 44.6 1=50 years; 3=Visual disability
disabilities 2 Females (40-50) 1=35 years; 2=Physical
1=20 years; disability
1=19 years;
and
1=18 years
Caregivers of 6 2 Males; 41.8 1=15 years; 3=Physical
persons with 4 Females (35-50) 1=10 years; disability
disabilities 1=8years; 2=Communication
2=7 years; and disability
1=5 years 1=Intellectual
disability
Healthcare 14 3 Males; 38.7 (30- 2=0-5 years 3=Occupational
professionals 11 Females 54) 3=6-10 years Therapists
3=11-15 years 2=Speech
3=16-20 years Therapists and
3=20-25 years Audiologists
3=Physiotherapists
1=Social Worker
1=Orthopeadic
technician
3=Medical officers
1=Nurse

4.2 Recruitment

After ethics approval and permission from the relevant authorities were
obtained, persons with disabilities and caregivers of persons with
disabilities were recruited using the data base of the national disability
organisation and healthcare professionals via a public tertiary state
hospital. The study information letter which included an invitation for
 Access to healthcare for persons with disabilities in Eswatini 145

participants to take part in the study, was shared with the president of the
national disability organisation as well as the director of health and the
superintendent of the hospital. Potential participants then directly
contacted the research assistant telephonically to indicate their interest to
participate in the study.

4.3 Procedure

The focus groups with persons with disabilities and caregivers of persons
with disabilities were conducted at a dedicated space at the Mbabane
National Library, while the focus group with healthcare professionals was
conducted in the hospital boardroom. The first author acted as the
moderator and facilitated each of the focus groups. Each group began with
the participants’ completion of a consent form and a demographic
questionnaire. Participants were then issued name tags and given an
option to use a pseudonym. The moderator welcomed participants and
introduced herself and the research fieldworker. Participants were asked to
introduce themselves. The researcher gave a detailed background of the
study and explained the purpose of the focus groups. The rules of the
discussion were outlined and agreed upon by all participants. The
researcher used a self-developed focus group script, asking one question at
a time. Each participant was afforded an opportunity to respond. The
research fieldworker used a project chart to highlight key discussion points.
After the discussion of each question, the researcher captured and
summarised the main points and asked participants to confirm the
correctness of their responses (namely, member checking). After all the
questions had been completed and participants agreed that they had
nothing further to add, the moderator thanked the participants for their
time and constructive participation and the focus groups ended. Transport
and lunch stipends were provided to the two groups of participants
comprising of persons with disabilities and caregivers of persons with
disabilities, while lunch was offered to the healthcare professional
participants. A focus group procedural checklist was followed for all
groups to ensure procedural reliability. Reliability was checked by the
research fieldworker and was found to be 98 per cent across all three focus
groups. Each focus group lasted approximately one hour (ranging between
51.43 minutes and 125 minutes). Focus groups were audio-recorded and
transcribed verbatim by the first author and checked by the research
fieldworker.
146 (2021) 9 African Disability Rights Yearbook

4.4 Data analysis

A framework approach to data analysis was employed in this study,38

using NVivo 1.5 qualitative data analysis software to manage the data and
to label and explore themes.39 In accordance with the framework
approach, the data analysis steps proposed by Gale et al40 were employed
to identify, analyse and report on patterns that existed within the data,
ultimately described as themes. The first step involved the first author
familiarising herself with the data through replaying and re-reading the
transcripts to immerse herself in the data. In the second step, the transcripts
were subjected to line by line collaborative coding by the first and last
author in order to identify patterns in the data. Ultimately a code book was
developed. The third step involved searching for themes by combining
codes with similar contents. The fourth step entailed refining themes and
further dividing them into sub-themes, with excerpts from participants to
support the themes. The fifth step involved relabelling themes using short
phrases. A theme was accepted if it had several quotes from the data to
support it. The final step involved mapping the themes obtained from the
data onto the Peters et al41 access to healthcare framework, namely:
availability, acceptability, geographical accessibility and financial
accessibility.

4.5 Rigour

This study applied the trustworthiness strategies proposed by Shenton,42

namely credibility, transferability, dependability and confirmability.
Furthermore, to ensure trustworthiness, triangulation of data from three
data sources was used and member checking was done by going through
participants’ responses after each question to check for accuracy of
reporting. Collaborative coding also ensured credibility as did peer
scrutiny via online and onsite PhD forums as well as through a conference
presentation where a part of the findings of the study was presented.
Trustworthiness was further ensured through providing an in-depth
description of the study methodology, which is also available through an
audit trail and a detailed reflection journal as well as through
representation of a specific inclusion and exclusion criteria facilitated
transferability. The three groups recruited from diverse backgrounds
ensured that multiple perspectives were obtained.

38 NK Gale et al ‘Using the framework method for the analysis of qualitative data in
multi-disciplinary health research’ (2013) 13 BMC Medical Research Methodology 117.
39 C Brandão ‘P Bazeley & K Jackson Qualitative data analysis with NVivo (2nd ed)’ (2015)
12 Qualitative Research in Psychology 492.
40 Gale et al (n 38).
41 Peters et al (n 9).
42 AK Shenton ‘Strategies for ensuring trustworthiness in qualitative research projects’
(2004) 22 Education for Information 63 at 73.
 Access to healthcare for persons with disabilities in Eswatini 147

5 Findings

The findings and discussion of the study are presented according to the
four dimensions of the access to healthcare framework as described by
Peters et al.43 The specific themes conceptualised under each of the four
dimensions are discussed below.

5.1 Availability of healthcare services as a barrier

Two different themes which are related to availability were

conceptualised. They are discussed separately.

5.1.1 Availability of assistive devices

In Eswatini, there appears to be inconsistency with the issuing and

maintenance of assistive devices. With the lack of a budget dedicated to the
procurement and maintenance of assistive devices by state hospitals,
persons with disabilities acquired assistive devices from various sources.
Assistive devices were received from donations arranged by community
members, donations from non-governmental organisations and sometimes
from the national health fund (the Phalala fund), as explained by Caregiver
#3: ‘I eventually got courage to speak up [at a community meeting] and
I got help because they gave me a wheelchair, even though the wheelchair
is not in use now’. Healthcare professional #2 stated: ‘[P]ersons with
disabilities do receive assistance from the Phalala fund to get prosthetic
limbs from South Africa once-off. The challenge comes when the
prosthetics need to be repaired’. However, Healthcare Professional #11
painted a bleaker picture: ‘There are no assistive devices and other
communication aids’.

5.1.2 Availability of rehabilitation facilities and healthcare professionals

The distribution of healthcare professionals varied across the different

healthcare facilities, with the majority of comprehensive healthcare
services located in tertiary hospitals. The location of rehabilitation services
in referral hospitals presented with access challenges due to the fact that
referral hospitals are situated in major cities, far removed from the rural
areas where the majority of persons with disabilities reside. Healthcare
Professional #6 explained it as follows: ‘Mbabane is probably the only
hospital that has all the health services together under one roof, if you
would go to hospitals in the periphery, you would find maybe medical and
nursing with a physio being the only rehabilitation professional’. Caregiver
#4 expressed the same concern: ‘They [healthcare professionals] say that

43 Peters et al (n 9).
148 (2021) 9 African Disability Rights Yearbook

they have these services, but the problem is that these services are
centralised to referral hospitals, yet the people who need these services are
[on] the outskirts of town and it’s not easy for them to come through to
town’.

Of specific concern was the reported shortage of rehabilitation services

due to the general shortage of professionals in this sector as highlighted by
Healthcare Professional #11: ‘There is a limited number of allied
professionals especially speech language therapists’. Healthcare
Professional #6 attributed this to the fact that rehabilitation posts are not
prioritised or budgeted for: ‘Basically, there is no budget line allocated
towards rehab services and this facility has to find a way of making or
being able to procure stuff for their department’.

5.2 Acceptability of persons with disabilities in healthcare

facilities as a barrier

Only one theme, namely the lack of reasonable accommodation was

conceptualised under the construct acceptability.

5.2.1 Lack of reasonable accommodation

Although it appears as if the Department of Healthcare in Eswatini has

made significant strides in making physical access to healthcare facilities
through the enactment of wheelchair ramps and wider waiting area
passages, this was not consistent across all healthcare facilities. Person
with Disabilities #3 explains: ‘At the dispensary, there is a step that makes
it difficult for [a] person on a wheelchair to get closer to the medicine
counter when one wants to collect medication. When I get my medication
sometimes, I need to shout for the attention of the person at [the]
dispensary window’.

Communication and health information consideration were also

lagging behind. As a result, persons with communication and visual
difficulties still experience challenges when consulting with healthcare
professionals as well as when they attempt to make sense of health
information given to them as can be seen in the following statements from
2 respective participants: ‘When you get to the dispensary, sometimes you
find that the tablets that are given to you have instructions that are not
written in braille’ (Person with Disability #1); and ‘[t]hey just give you the
medication without asking and knowing whether you can read or not or
whether you understand what is written on the pills or not’ (Person with
Disability #2). Healthcare Professional #3 was also aware of this fact:
‘There are no braille signs for the visually impaired to be able to navigate
around the facility’.
 Access to healthcare for persons with disabilities in Eswatini 149

Futhermore, Healthcare Professional #6 noted similar challenges for

deaf persons: ‘There are nurses and some of us here that have been trained
in sign language, but the challenge, I am sure my colleagues will agree with
me, that you attend the sign language training, but when you come back
you do not use it and then lose it’.

Discrimination was the challenge most frequently mentioned by

participants across all three groups. Stigma and discrimination seemed to
be prevalent within families of persons with disabilities and their
communities, mostly as a result of how communities understand disability
and its causes. Healthcare professionals could be seen as an extension of
the community that still views disability from a negative perspective.
Furthermore, some healthcare professionals harbour negative stereotypes
which ultimately influence how they treat persons with disabilities in
healthcare facilities, as explained by Healthcare Professional #10: ‘Lack of
knowledge of all disability conditions amongst us’, and Healthcare
Professional #11: ‘Lack of awareness and experience of healthcare
workers/professionals with persons with disabilities’.

Participants particularly mentioned self stigma, wherein caregivers of

children with disabilities hid their children away from their communities
for fear of judgement as evident in the following statement by Caregiver
#4: ‘Some of us hide our children with disabilities because we don’t want
our communities and community health workers to know about them.
They lock the children in the houses’. Caregiver #1 confirmed barriers
related to stigma: ‘So, you don’t want people to know that you had the bad
luck of having a disability or having a child with a disability so because you
don’t want the community to know, you just hide the child’.

Participants also mentioned that persons with disabilities were

excluded by healthcare professionals from certain health programmes,
especially those related to sexual and reproductive healthcare as
mentioned by Caregiver #4 in the following statement: ‘Even if you do get
there [hospital], there is now the struggle with attitude. They will ask you
“Mummy how many children do you have?” You will say that this is my
fourth. They will tell you that the reason why you ended up with a child
with a disability is because you kept giving birth’. Person with Disability
#5 further confirmed this finding: ‘Yes, the nurse will ask you what you
were doing when you fell pregnant. You feel embarrassed because you feel
like nothing, like you have committed a sin’.

5.3 Financial accessibility of healthcare services as a barrier

Inconsistency in the allocation of social support grants was the theme

conceptualised under financial accessibility.
150 (2021) 9 African Disability Rights Yearbook

5.3.1 Inconsistency in allocation of social support grants

Persons with disabilities often depend on social support grants which they
normally receive on a monthly basis for their livelihood. In Eswatini, the
allocation of social support grants is not a consistent standard procedure as
is the case in other LMIC countries. It was reported by participants that
some persons with disabilities were receiving social support grants while
others did not. In cases where persons with disabilities were receiving these
grants, they did not receive the grants consistently. Caregiver #1 explained
it as follows: ‘We [persons with disabilities] have been placed under the
public assistance [social grant] as a by the way, because it has always been
a secret and not everyone has been aware of it. It [social grant] has been a
hidden thing and the criteria for receiving is still not clear’.

Apart from the inconsistency of the provision of social grants, there

was also a lack of clarity on whether or not healthcare services were free
for persons with disabilities despite being promised as such in the National
Disability Policy. This was explained by Healthcare Professional #5 in the
following statement: ‘Persons with disabilities would not pay for health
services, I heard that the ministry would provide free healthcare services’.
Healthcare Professional #6 also confirmed this: ‘Free health services for
persons with disabilities has not yet been implemented’.

As a result, persons with disabilities experience financial challenges

when accessing healthcare as can be seen in the following statements from
Caregiver #5 and Healthcare Professional #11: ‘Because we live under
difficult financial conditions, we don’t have the money to go up and down
to and from the hospital because as a mother I also have other children to
look after’ (Caregiver #5); ‘Inaccessibility to public transport, such as
having to pay extra for wheelchairs, or paying for the person
accompanying the disabled person’ (Healthcare Professional #11).

5.4 Geographical accessibility of healthcare services as a

barrier

Transportation needs was the theme conceptualised under geographical

accessibility.

5.4.1 Transportation needs

Due to specific impairments experienced by persons with physical

disabilities which render them unable to walk to healthcare facilities, the
majority of participants reported the need for transportation to access
healthcare. Furthermore, participants stated that rehabilitation healthcare
services in primary and community healthcare were not easily accessible
to them as most were far from their place of residence as reported by
 Access to healthcare for persons with disabilities in Eswatini 151

Caregiver #5 in the following statement: ‘You will go to the hospital and

after assessing your child, they will tell you to come once or twice a month
for review, but because the hospital is far you can’t keep appointments’.

It was also mentioned that outreach services were not available to

persons with disabilities. Transportation is costly for persons with physical
disabilities because they have to pay transport for themselves and for their
caregivers. Furthermore, they have to pay extra for their wheelchairs to be
transported. Negative attitudes of public transport drivers unfortunately do
not make the process of taking public transportation easier for persons with
disabilities and their families. The following statements from Caregiver #5
explain this more clearly: ‘As mothers, these children become heavy and it
becomes a challenge to have to carry them on your back. Especially when
you have one with cerebral palsy such as mine’; and ‘Because even with
the wheelchairs, you have to leave it at home sometimes because it causes
a problem on the bus. You have this insensitive bus conductor complaining
about your wheelchair’.

6 Discussion

This study aimed to describe the barriers experienced by persons with

disabilities when they access healthcare services from a triadic perspective
and also aimed to propose recommendations to address these identified
barriers. Findings from this study indicate that, despite it having been eight
years since the inception of the National Disability Policy of Eswatini,
persons with disabilities still experience substantial barriers that hinder
them from accessing healthcare services adequately. A large scale study
conducted by Eide et al44 in four LMICs, namely Sudan, Namibia,
Malawi and South Africa with the aim of identifying the magnitude and
impact of specific barriers for persons with disabilities to accessing
healthcare, obtained similar findings to those of the current study. Eide et
al45 specifically revealed that 10-40 per cent of persons with disabilities do
not get to access general healthcare when they need it.

Findings from the study at hand reveal that barriers to accessing

healthcare in Eswatini were as a result of the unavailability of healthcare
resources – in particular human resources and assistive devices. Human
resources, specifically, rehabilitation healthcare professionals such as
occupational therapists, speech language therapists, audiologists,
physiotherapists and social workers do not have a dedicated budget for
their posts. As a result, Eswatini has a limited number of rehabilitation
professionals, with the majority of services located in referral hospitals
which are in larger towns which are situated far away from rural areas

44 AH Eide et al ‘Perceived barriers for accessing health services among individuals with
disabilities in four African countries’ (2015) 10 Plos One e0125915.
45 Eide et al (n 44).
152 (2021) 9 African Disability Rights Yearbook

where many persons with disabilities reside – a finding also reported by

Bright et al.46 In 2011, the World Health Organisation reported that only
a small percentage of persons with disabilities had access to basic
rehabilitation services when they needed them, a finding confirmed by the
research of Sherry47 and Hussey et al,48 respectively. It is concerning that
a decade later similar experiences are still being reported by persons with
disabilities. Health rehabilitation is regarded as an important prerequisite
for access to all other rights.49 Therefore, the significant contribution of
rehabilitation healthcare professionals in addressing and overcoming
participation barriers through different interventions which can be
focussed on the environment, and on individuals and/or their families,
cannot be over emphasised.50

Consistent with findings from studies conducted in similar LMIC

contexts such as Malawi, South Africa, Namibia and Sudan by Eide et
al;51 Harrison et al;52 and Matter and Eide,53 the findings from the current
study also revealed that Eswatini did not have a dedicated budget for the
issuing and maintenance of assistive devices. As such, persons with
disabilities have no option but to seek assistive devices from community
members or from non-governmental organisations. A national fund called
‘Phalala fund’ was mentioned as having been instrumental in assisting
with assistive devices. However, it was stated that these assistive devices
referred to are devices such as prosthetics which could only be obtained in
South Africa. Where devices were obtained through this fund, maintaining
them remained a constant challenge due to the lack of a dedicated budget
for this purpose.

The accommodation of persons with physical disabilities with the

provision of wheelchair ramps and the widening of waiting area spaces –
even though this was not the case for all hospitals – was noted in Eswatini.
Regrettably, findings revealed that the needs of persons with
communication, hearing or visual impairments were not accommodated
when accessing healthcare in Eswatini. This could be attributed to the fact
that communication disorders, including hearing impairments, are viewed
as invisible disabilities.54 In a South African audit, Hanass-Hancock and

46 T Bright et al ‘A systematic review of strategies to increase access to health services

among children in low and middle income countries’ (2017) 17 BMC Health Services
Research 252.
47 K Sherry ‘Disability and rehabilitation: Essential considerations for equitable accessible
and poverty-reducing healthcare in South Africa’ (2014) 1 South African Health Review.
48 Hussey, MacLachlan & Mji (n 33).
49 Sherry (n 47).
50 As above.
51 Eide et al (n 44).
52 As above.
53 RA Matter & AH Eide ‘Access to assistive technology in two Southern African
countries’ (2018) 18 BMC Health Services Research 792.
54 N Tye-Murray Foundations of aural rehabilitation: Children, adults and their family members
(2009).
 Access to healthcare for persons with disabilities in Eswatini 153

Alli55 confirmed these findings where it transpired that half of the facilities
in South Africa’s KwaZulu-Natal province had essential features such as
ramps, doors and toilets that provided wheelchair access, but almost none
provided information in braille or offered sign language interpretation. The
lack of reasonable accommodation for these populations, not only
impacted on persons with disabilities’ right to access healthcare with
autonomy, dignity, privacy and confidentiality, but also had the potential
to have life-threatening consequences especially where instructions
pertaining to medication were not adequately explained to persons with
disabilities in understandable ways. It is not possible to address a person’s
right to healthcare without considering the important role of language in
fulfilling this right.56 Therefore, it is proposed that healthcare information
should be provided in a simplified format and where necessary with visual
support or in an auditory format. These findings are echoed in studies
conducted by Masuku et al;57 and Orrie and Motsohi.58

With regard to geographical accessibility, there was a general

dissatisfaction with the distance of healthcare services in Eswatini,
especially the concentration of rehabilitation services in referral hospitals
situated in major towns. This finding is supported by Bright et al,59 who
revealed that in LMIC’s such as Eswatini, healthcare facilities were mostly
situated in urban areas making it difficult and expensive for most people
especially those residing in rural areas to access these services.
Transportation to healthcare facilities from where persons with disabilities
reside, to the facility is thus inevitable. The further the distance is from the
healthcare facility, the higher the transportation fare for public transport.
As confirmed by Hussey et al,60 the distance to healthcare facilities does
impact on persons with disabilities’ financial accessibility of these services.
The negative attitudes of public transport drivers towards persons with
disabilities further compounded transportation difficulties. In a study titled
‘“You must carry your wheelchair” – Barriers to accessing healthcare in a
South African rural area’, the challenges of transportation as they relate to
both cost and attitudes was also stressed.61

55 J Hanass-Hancock et al ‘“These are not luxuries, it is essential for access to life”:

Disability related out-of-pocket costs as a driver of economic vulnerability in South
Africa’ (2017) 6 African Journal of Disability 280
56 HJ Haricharan et al ‘Can we talk about the right to healthcare without language? A
critique of key international human rights law, drawing on the experiences of a Deaf
woman in Cape Town, South Africa’ (2013) 28 Disability and Society 54.
57 KP Masuku, N Moroe & D van der Merwe ‘“The world is not only for hearing people –
It’s for all people”: The experiences of women who are deaf or hard of hearing in
accessing healthcare services in Johannesburg. South Africa’ (2021) 10 African Journal of
Disability 1.
58 S Orrie & TS Motsohi ‘Challenges experienced by healthcare workers in managing
patients with hearing impairment at a primary health care setting: A descriptive study’
(2018) 60 Official Journal of the South African Academy of Family Practice/Primary Care 39.
59 Bright et al (n 46).
60 Hussey, MacLachlan & Mji (n 33).
61 R Vergunst et al ‘“You must carry your wheelchair” - Barriers to accessing healthcare in
a South African rural area’ (2015) 8 Global Health Action.
154 (2021) 9 African Disability Rights Yearbook

The fact that, globally, persons with disabilities still do not experience
the same access to work opportunities, could lead to a large proportion of
them being unemployed.62 With a national unemployment rate of 41 per
cent and a poverty rate of 63 per cent in Eswatini,63 the unemployment
rate for persons with disabilities in Eswatini is further compounded. This
therefore implies a need for social support from the state to support persons
with disability financially in their quest to access healthcare services.
However, it was found in the current study that there is an inconsistency
with the allocation of social support grants in Eswatini, with some persons
with disabilities receiving social support and some not. One of the
participants mentioned that the social grant: ‘Has always been a secret and
not everyone has been aware of it’ (Caregiver #4). Where social support
grants were received, they were not on a month-to-month basis. This
inconsistency of providing social support grants in Eswatini is contrary to
findings from other countries. For example, in South Africa grants are
allocated to persons with disabilities to improve their financial situation.64
Although social grants may be offered to persons with disabilities in other
countries, it is also important to keep in mind that these grants may not be
sufficient, considering that in some cases it may be the only source of
income as a result of high unemployment and poverty.65

To conclude this discussion, the South African Human Rights

Commission (SAHRC)66 argues that discrimination remains the biggest
disability. The statement of the SAHRC also rings true for Eswatini as
negative beliefs and stereotypes about the causes of disability continue to
perpetuate stigma and discrimination of persons with disabilities when
they access healthcare services. Stigma and discrimination are experienced
at a personal and a community level as well as at healthcare facilities.
Negative attitudes from healthcare professionals, in part because of the
lack of knowledge on disability, was confirmed by Eide67 as well as in a
study by Hussey et al,68 where all participants cited stigma and negative
perceptions towards persons with disabilities in South African society as
being the major underlying barrier to health and rehabilitation. Trani et
al69 argued that negative stereotypes regarding disability and towards
persons with disabilities by healthcare professionals and members of the
community, for example public transport providers, stemmed from
socialisation and cultural factors resulting in how they treated persons with

62 S Bonaccio et al ‘The participation of people with disabilities in the workplace across

the employment cycle: Employer concerns and research evidence’ (2020) 35 Journal of
Business and Psychology 135.
63 United Nations Office for the Coordination of Humanitarian Affairs (2020) Annual
Report.
64 Sherry (n 47).
65 Hanass-Hancock (n 55).
66 Sherry (n 47).
67 Eide et al (n 44).
68 Hussey, MacLachlan & Mji (n 33).
69 JF Trani, E Ballard & J Pena ‘Stigma, social exclusion and mental distress of persons
with disabilities in Afghanistan’ (2016) 153 Social Science and Medicine 258.
 Access to healthcare for persons with disabilities in Eswatini 155

disabilities. It is therefore important to propose some recommendations to

address access for persons with disabilities in Eswatini.

7 Recommendations

Three overarching recommendations are made to address the challenges

mentioned in this study.

7.1 Addressing stigma and discrimination

Whether conscious or sub-conscious, stigma and shame are the core

catalysts in societies that impede persons with disabilities’ ability to access
their rights, including their right to basic healthcare. Stigma and shame
regarding disabilities are rooted in the manner in which our cultures and
contexts have socialised individuals to perceive disability and ultimately
view persons with disabilities and how the community judge what they are
capable and incapable of. It tends to manifest itself in the way in which
persons with disabilities are viewed and how their value in society is
perceived by others. Stigma ranges from the subtle forms of rejection that
persons with disabilities experience – sometimes from their own families,
such as being hidden from the public eye – to more crude forms of
discrimination experienced within communities – such as exclusion from
opportunities enjoyed by persons and families without disabilities. As
alluded to earlier in this study, healthcare professionals are socialised in
holding similar beliefs to those of communities, which results in the
perpetuation of stigma and discrimination in healthcare facilities too.
Ndlovu70 terms the African view of disability as ‘ambivalent’ in that it
depicts disability and persons with disabilities in both a positive and
negative light. On the one end, disability is portrayed as burdensome and
as a result of an affliction, a punishment, an embodiment of sin, as the
works of witchcraft and/or as ancestral anger. While on the other end the
African principle of Ubuntu that encapsulates ‘humanness’ dictates that
everyone, regardless of social standing should be treated with the dignity
that they deserve.71 Initiatives to address access to healthcare for persons
with disabilities therefore cannot be done independently of addressing
stigma and discrimination.

There is a need for disability conscientisation amongst communities in

Eswatini, if attitudes and perceptions about disabilities are to change.
Programmes aimed at conscientising communities on disability rights
need to be implemented at community level. Communities need to be
made aware of the rights of persons with disabilities. At a healthcare level,

70 HL Ndlovu ‘African beliefs concerning people with disabilities: Implications for

theological education’ (2016) 20 Journal of Disability and Religion 29.
71 As above.
156 (2021) 9 African Disability Rights Yearbook

healthcare practitioners need to be trained on disability rights with specific

reference to healthcare rights. Likewise, McConkey et al72 recommend
that communities should be educated to understand what causes disability,
how to assist persons with disabilities and also highlights that persons
without disability should spend time with persons with disabilities, in
order for them to realise how similar they are – so called ‘heart knowledge’.

Figure 1 is an example of access to healthcare guidelines that were

developed to highlight the core rights to healthcare for persons for
disabilities in Eswatini.73 These guidelines were developed for display in
healthcare settings to empower persons with disabilities on their right to
access healthcare.

72 R McConkey et al ‘Promoting better health for persons with intellectual disabilities through
community-based inclusive development’ (2018) Disabilities Innovations Africa Series 6.
73 Masuku et al (n 26).
 Access to healthcare for persons with disabilities in Eswatini 157

Figure 1: Access to healthcare guidelines from Masuku et al74

Masuku, 2020.

74 K Masuku ‘Access to healthcare for persons with disabilities in Eswatini’ PhD thesis,
University of Pretoria, 2020.
158 (2021) 9 African Disability Rights Yearbook

7.2 Intersectoral involvement addressing the social

determinents of healthcare

Persons with disabilities are amongst the poorest in most LMIC,75 yet
social influences play a significant part in perpetuating poor and decreased
quality of healthcare services. Access to healthcare for persons with
disabilities across the lifespan is a systemic challenge that is influenced by
social determinants of health. It therefore becomes imperative to address
social determinants such as access to early life experiences, education,
employment, social support, shelter, employment security and community
engagement for persons with disabilities76 if healthcare is to be an
achievable goal.

Addressing social determinants of healthcare implies the need for an

intersectoral involvement as it cannot be the responsibility of the
Department of Healthcare or the Department of Social Development
alone. For example, to address the geographical and financial accessibility
barriers brought about by the location of rehabilitation services in referral
hospitals, the government of Eswatini may want to consider a service
delivery model whereby such services are brought closer to communities.
The principles of community-based rehabilitation propose that persons
with disabilities are able to receive healthcare and rehabilitation services
within their communities.77 The World Health Organisation defines
community based healthcare workers as members of the very same
community who are trained by the department of health in this case,
rehabilitation healthcare professionals to provide basic rehabilitation
techniques. As such, healthcare professionals may conduct community
and home visits, while at the same time train community based healthcare
workers and families on how to conduct basic rehabilitation or how to
implement home programmes in between their visits. Strengthening
community programmes might mitigate some of the challenges related to
geographical and financial accessibility, while at the same time improve
attitudes of community members towards disability and persons with
disabilities. This strategy has been implemented in certain parts of South
Africa in order to address the shortage of healthcare workers. Mulumba et
al78 posit that community participation is not only a human right, but an
essential underlying determinant for realising the right to access health.

75 McConkey et al (n 72).
76 O’Hare, Devakumar & Allen (n 35).
77 Sherry (n 47).
78 M Mulumba et al ‘Perceptions and experiences of access to public healthcare by people
with disabilities and older people in Uganda’ (2014) 13 International Journal of Equity
Health 76.
 Access to healthcare for persons with disabilities in Eswatini 159

7.3 Addressing policy shortcomings

It is imperative to determine and communicate the shortcomings of the

National Disability Policy of Eswatini in systematic research studies, so
that these findings can be considered during the policy evaluation stages.
A policy brief was developed to communicate the fact that the policy
document has not considered the role of geographical access to services,79
as this is significant in whether persons with disabilities access healthcare
or not. The lack of clarity of policy on whether or not the policy was
implemented has also been brought to the attention of policy makers.
Policy makers have been urged to consider fast tracking the passing of the
National Disability Bill of Rights as law. The National Disability Bill of
Rights is an integral part of the implementation of the national disability
policy. By implementing the bill, the state government of Eswatini would
in essence, be committing itself to the realisation of disability rights,
including the basic right to healthcare.

8 Conclusion

The right to healthcare is acknowledged in various international and

regional human rights instruments and laws. Eswatini being a signatory to
most of these human rights instruments, the CRPD in particular, has
committed to the realisation of the right to healthcare. Eswatini’s
commitment to the right to healthcare was discernible through the
development of the National Disability Policy, the National Disability Bill
of Rights and the National Disability Plan of Action. Regardless of the
development of these local instruments, the right to healthcare for persons
with disabilities in Eswatini is yet to be realised as noticeable in the
challenges that persons with disabilities still experience when they attempt
to access healthcare.

Human rights legislation serves no purpose if states do not commit to

implementing these laws. Eswatini needs to recommit to the process of
implementation of the National Disability Policy as there is evidence of
significant gaps in the process, particularly related to human, skills and
financial resources. The passing of the National Disability Bill of Action is
key to the process and should thus be prioritised. Policy implementation
should be done in the context of social determinants of health.

The implementation of disability legislation should be done parallel to

disability conscientisation, starting at community level. Eswatini should
therefore be deliberate in adopting programmes aimed at dismantling
negative stereotypes regarding disabilities within communities.

79 Masuku (n 74).