For many young people in Eswatini, health challenges begin with poverty, unemployment, stigma, misinformation and limited opportunities that continue to shape decisions around mental health, HIV prevention and sexual and reproductive health.These issues took centre stage at the MTN Bushfire Bring Your Fire Live Dialogues 2026, where a panel comprising representatives from UNFPA, AIDS Healthcare Foundation (AHF), Helping Hand Foundation and the Luke Commission gathered at House on Fire under the theme: “Beyond Access: Rethinking Health Equity in Eswatini.”The conversation comes at a critical moment for Eswatini. Despite progress in health outcomes, adolescent pregnancy remains a challenge, particularly in rural communities where girls are twice as likely to give birth before the age of 18 compared to those in urban settings (14% versus 6%), according to the 2021–2022 Multiple Indicator Cluster Survey (MICS). Young people, especially adolescent girls and young women, continue to face heightened vulnerability to HIV, while increasing concerns around depression, substance abuse and suicide are placing mental health higher on the national agenda. These interconnected challenges reinforce a reality echoed throughout the dialogue: health outcomes cannot be separated from poverty, inequality and access to opportunities. Representing UNFPA, Gender and Youth Program Analyst, Ms. Zenanile Dlamini argued that health inequities cannot be addressed without confronting the broader socioeconomic realities that influence wellbeing.“We cannot speak about health equity without addressing economic justice. We cannot speak about health outside of education, social protection, gender equality and economic empowerment,” she said.Her remarks echoed a recurring theme throughout the dialogue: health outcomes are inseparable from development outcomes.When discussing barriers to sexual and reproductive health services, Ms. Dlamini highlighted stigma and misinformation as persistent obstacles preventing young people from accessing care.“Young people still express that they feel stigma when they go to access Sexual and Reproductive Health and Rights (SRHR) services. There’s still misinformation around SRHR, and many continue to get information from friends or social media,” she said.UNFPA also emphasised opportunities to strengthen digital and youth-centred approaches, including the Tune Me platform, developed with the Eswatini National Youth Council to improve access to SRHR information among young people.Yet for young participants attending the dialogue, awareness alone was not enough.“We understand the mental aspect, now we need actual help. It’s coming down to poverty. It’s coming down to the economic crisis,” one student challenged, calling for practical solutions to address financial hardship and mental wellbeing.Another student, Siniketiwe Simelane raised concerns about burnout among university students:“We are students, we are burnt out. Rest is productive too. I can’t do anything if I’m burnt out.”Such concerns reflect broader trends. Recent evidence suggests 15% of adolescents in Eswatini have attempted suicide, linked to anxiety, depression and social pressures. Between 2022 and 2024, 486 suicides were recorded nationally, signalling a growing mental health crisis.Responding to these concerns, Dr Wanda Shaw from the Luke Commission stressed that mental health cannot be separated from unemployment and hopelessness.“If you don’t have a structured purpose and you have lack of hope, it has been associated with depression, anxiety and other mental health issues,” he said.Meanwhile, AHF Prevention Programme and Advocacy Manager Tulani Mthethwa warned that poverty continues to drive HIV vulnerability among young people through transactional relationships and unequal power dynamics.For UNFPA, the dialogue reinforced an urgent lesson: young people are not only asking for access to services, they are demanding systems that understand their realities, respond to their needs and invest in their futures. 

A deep, expanding donga cuts across the landscape at Simoyini community, kaPhunga, in Eswatini’s Shiselweni Region. With every rainy season, its steep, crumbling edges have threatened livestock, endangered children, and crept steadily closer to a nearby road.Beyond these immediate risks, the donga reflects deeper environmental pressures affecting fragile watershed systems in the area. Increasingly intense rainfall, combined with degraded vegetation cover and unstable soils, has accelerated erosion, reduced the land’s ability to retain water, and weakened the resilience of surrounding ecosystems and infrastructure.Over time, this degradation has contributed to the loss of fertile topsoil, declining land productivity, and growing pressure on already limited water resources.Community-led Ecosystem Restoration in ActionOrganised restoration efforts are now underway to stabilise the donga and protect surrounding ecosystems and infrastructure.“We are working to close the donga using gabions and will plant trees to stabilise the soil and prevent further erosion,” explains Sive Nkambule, chairperson of the Simoyini Wetland Development Committee.Gabions, wire mesh structures filled with stones, play a critical role in this process. They help slow water runoff, reduce soil erosion, and stabilise degraded land, supporting the recovery of surrounding ecosystems while protecting infrastructure from further damage.The intervention at Simoyini is supported through the Global Environment Facility Small Grants Programme (GEF-SGP), implemented by the United Nations Development Programme (UNDP) through the United Nations Office for Project Services (UNOPS), with technical support from the Africa Cooperative Action Trust (ACAT).More than a funding mechanism, SGP provides catalytic climate finance that enables communities to implement practical, locally driven solutions to environmental challenges.  Restoring Wetlands and Strengthening Water SystemsWhile land degradation was highly visible, water insecurity was an equally pressing challenge. Despite the presence of two wetlands, access to safe and reliable water remained limited.Wetlands in the area serve as critical ecological infrastructure. They regulate water flow, support groundwater recharge, reduce erosion, and help buffer communities against drought and extreme rainfall. However, the Maculusini wetland had become degraded due to overuse and lack of protection, reducing its ability to perform these functions effectively.The impact extended beyond households. At Matjana Primary School, which serves more than 200 learners, unreliable water access disrupted daily operations.“Every day, learners walked nearly two kilometres to collect water from a rudimentary collection point within the wetland,” says Bonisile Matsebula, a member of the school committee. “The water was used for cooking meals, watering gardens, and meeting the school’s basic needs.”Limited access to safe water placed additional pressure on the school, affecting sanitation, food preparation, and learning time.For households – particularly women and girls – water collection consumed significant time and energy, reducing opportunities for schooling, productive activities, and income generation.Partnerships Enabling Local Climate AdaptationThrough coordinated partnerships, the community has begun to address these challenges. With support from ACAT, Simoyini accessed USD 45,381 (over SZL700 000) in GEF-SGP funding to implement ecosystem restoration and water system improvements.The project demonstrates how climate adaptation can be operationalised through collaboration between communities, grassroots organisations, government institutions, and global environmental financing mechanisms.Residents worked collectively to rehabilitate and protect wetlands, install solar-powered water systems, and restore degraded land. At Maculusini wetland, spring protection measures and a solar-powered pump now supply water to two 5,000-litre tanks at Matjana Primary School, providing reliable water to more than 200 learners and 12 teachers.“Having water at the school is a game changer. Learners can now stay in class and study without interruptions,” Bonisile Matsebula, a member of the school committee, explains.Reliable water access has improved sanitation, reduced disruptions to learning, and strengthened the school’s overall functioning. A secondary water system now serves nearby households. With filtration systems, restored pipelines, and reinforced storage infrastructure, safe water is supplied to 29 households, benefiting over 170 people. Emerging Livelihood Opportunities and Ecosystem RecoveryAt Mgambeni sub-community, restoration efforts have focused on protecting and rehabilitating a second wetland. Fencing has reduced pressure on the ecosystem, and early signs of recovery are visible.Indigenous grasses, including Lukhwane, are beginning to return – an indicator of improving ecological conditions. This recovery is also creating emerging livelihood opportunities. Women are starting to harvest the grass to produce mats and handicrafts, linking ecosystem restoration to income generation while promoting sustainable resource use.While still at an early stage, these activities highlight the potential for restoration to support local livelihoods over time.Strengthening Local Capacity and StewardshipBeyond physical infrastructure, the initiative has strengthened local capacity for environmental management and climate adaptation.With technical support from ACAT, community members have participated in restoration planning, wetland protection, and water system management. This has helped build practical knowledge, local organisation, and a stronger sense of ownership over natural resources.Local structures, including community committees, are playing a growing role in maintaining infrastructure and protecting restored ecosystems – an essential factor for long-term sustainability.Progress, Challenges, and the Path ForwardIn total, more than 370 people at Simoyini are benefiting from improved water access and ongoing ecosystem restoration efforts. Degradation pressures are being reduced, water systems are becoming more reliable, and key environmental assets are gradually recovering.However, restoration remains an ongoing process. Challenges such as heavy rains, equipment breakdowns, and incomplete rehabilitation of the donga highlight the complexity of ecosystem recovery.The donga, covering approximately 0.65 hectares, has begun to stabilise, with gabions slowing erosion and additional materials secured for further work. Continued effort will be required to fully restore the area and protect surrounding land and infrastructure.A Model for Community-based Climate ActionThe experience at Simoyini demonstrates that climate adaptation is not only a policy priority but a practical, local process. Through relatively small-scale financing, strong community participation, and support from grassroots organisations, it is possible to restore ecosystems, strengthen water security, and build resilience to climate variability.Importantly, the initiative is also building the capacity of the community to manage environmental challenges over the long term – reinforcing local stewardship and reducing dependence on external support. Rather than a completed transformation, Simoyini represents a growing example of how community-led ecosystem restoration, supported by catalytic financing and institutional partnerships, can contribute to sustainable and resilient rural development.  

In a major move to increase access to care for severe noncommunicable diseases such as type 1 diabetes, sickle‑cell disease, and rheumatic and congenital heart diseases, Eswatini is preparing to implement the World Health Organization (WHO)’s PEN‑Plus model.The PEN‑Plus model decentralizes the management and treatment for severe noncommunicable diseases, expanding access to care and improving health and well‑being in the African Region. Currently, more than 18 000 people are receiving treatment for severe noncommunicable diseases across 20 implementing countries.In Eswatini, severe noncommunicable diseases disproportionately affect children and young adults and often require advanced diagnostics, specialized treatment, and long‑term care, services typically available only at regional or specialized facilities.The country is also witnessing a growing burden of noncommunicable diseases, The 2024 STEPS survey, - an internationally standardized tool for determining the burden of NCDs risk factors - showed low control rates for hypertension and diabetes. While almost 41% of people with diabetes were on treatment, nearly half (48%) were not adequately controlled. Further assessments show that although many health centres have basic infrastructure, including laboratories, x‑ray units, and pharmacy services, gaps remain in essential laboratory equipment, reagents, medicines, medical supplies, and ultrasound machines.The first international conference on PEN‑Plus in Africa, organized by the WHO African Region in partnership with the NCDI Poverty Network and with support from The Leona M. and Harry B. Helmsley Charitable Trust, held in Tanzania in 2024, showcased Malawi’s successes with PEN‑Plus, generating significant interest among Eswatini’s health authorities. As one of the earliest adopters, Malawi has made substantial progress in implementing the model in 46% of district hospitals, providing specialized care to more than 300 patients living with severe noncommunicable diseases across six secondary-level health facilities.Inspired by the Malawian example, the Government of Eswatini aims to decentralize severe noncommunicable disease services to ensure that patients can receive comprehensive, timely care close to their homes. Under the PEN‑Plus model, general practitioners at first‑level health centres will be trained and equipped to manage severe noncommunicable diseases. PEN‑Plus extends the WHO Package of Essential Noncommunicable Disease Interventions (PEN) by delivering specialized services at first‑level referral facilities such as district hospitals.To operationalize PEN‑Plus implementation in Eswatini, the Ministry of Health has selected two pilot health centres - Mkhuzweni in the North and Sithobela in the South. These rural sites are far from specialist hospitals and were chosen to improve continuity of care for people in hard‑to‑reach areas. PEN‑Plus is expected to close critical gaps in early diagnosis, continuity of care, and timely management of complications. Rollout is scheduled to start in June 2026.“Too many patients are traveling long distances for simple check‑ups or medication refills. This overwhelms specialist hospitals and delays care for those who truly need it. With PEN‑Plus, we will bring treatment closer to communities so people can get the care they need in a timely way - without unnecessary referrals, risk of medical complications or premature deaths,” said Ntombi Ginindza, Noncommunicable Diseases Programme Manager at the Ministry of Health in Eswatini.Preliminary findings from the needs assessment report highlights country readiness such as human resource, substantial chronic disease caseloads, existence of referral pathways and a national electronic data system upon which PEN‑Plus will strategically build on and further strengthen.“PEN‑Plus will mark a transformative shift in how severe NCDs are managed. The implementation of this framework will strengthen the country’s health system and save lives,” said Dr Susan Tembo, WHO Representative in Eswatini.

“There are various reasons for medication failure,” says Majaha Mtshali, tuberculosis (TB) focal person and staff nurse at Piggs Peak hospital in northwestern Eswatini. “When people do not take their medication correctly, whether by missing doses, taking it at the wrong times, receiving the wrong treatment, or stopping treatment early, there can be serious consequences.”These serious consequences include drug resistance where the first-line treatment regimen no longer works. Multidrug-resistant TB (MDR-TB), a form of TB caused by bacteria resistant to at least two of the most powerful first-line TB medicines, is more complex and more expensive to treat. Just like drug-sensitive TB, it can also be easily transmitted through the air when a person with TB coughs, sneezes, sings or simply talks, especially in crowded or poorly ventilated settings.This is what happened to 40-year-old Babazile Ngwenya from Manzini, Eswatini’s second largest city. When she first contracted TB in 2012, she took the first-line regimen but stopped after two months. She later developed MDR-TB, likely because of incomplete treatment, and was admitted into hospital for seven months to ensure adherence. However, this did not work. She remembers feeling “overwhelmed”.“The drugs were too many, that’s why I was defaulting,” she says.At this time, people with MDR-TB had to take treatment for up to 18 months, using a complex combination of daily oral and injectable medicines.In 2022, World Health Organization (WHO) recommended a shorter six-month, all-oral regimen known as BPaL(M), making treatment simpler and easier for patients to complete. Eswatini adopted this new regimen in 2023.  It is now standard treatment for patients diagnosed with MDR-TB.“The shorter all-oral treatment regimen are preferable because they eliminate the need for painful daily injections, which can extend the treatment duration to up to 18 months, depending on the patient's response,” says Mtshali.When Ngwenya experienced persistent coughing, dizziness and shortness of breath in 2024 it was no surprise that she was diagnosed again with MDR-TB. “It was hard for me to admit I had TB again,” she says. She was admitted into hospital for three months because she also had anaemia and was administered the six-month BPaL(M) regimen. This time, she adhered to this easier treatment regimen and was cured.Eswatini is one of the 30 high-burden TB countries globally. According to WHO estimates, Eswatini had a TB incidence of 319 per 100 000 population, including an estimated MDR-TB incidence of 13 per 100 000 population in 2024. “TB continues to be a major public health threat in the Kingdom of Eswatini. The situation is exacerbated by the HIV epidemic and rising rates of drug-resistant forms of TB, which are difficult to treat,” says Mduduzi Matsebula, Eswatini’s Minister of Health.People diagnosed with MDR-TB are admitted to health facilities if they are very ill at the time of diagnosis or if their home environments do not allow adequate infection prevention and control. Discharge occurs once patients are stable and capable of continuing treatment at home.“Adherence to treatment begins with proper counselling,” says Mtshali. “At the initiation of treatment, a patient is educated on TB disease and the importance of adherence. For MDR-TB patients, having a treatment supporter is essential.”A range of supportive measures help the patient to adhere to treatment. Patients and their treatment supporters receive a monthly transport stipend. Monthly food packages are also given to the patient which cover 4‒6 household members. The patient’s treatment supporter, usually a family member, is provided with a card that they mark each observed dose. If the patient misses an appointment, the health facility will make a follow up by calling them. If necessary, they will also send a dedicated treatment adherence supporter on a motorbike to the patient’s home to follow up.For Ngwenya, her support system was her family and her colleagues. “I thank my mom for being there for me, showing me love and care when I was in the hospital. If it were not for her, I would not be here,” she says.In Eswatini, 86% of people diagnosed with MDR-TB in 2022 were treated successfully and the number of TB deaths has declined by 60% between 2015 and 2024. However, as of 2024, an estimated 54% of people with MDR-TB were either not diagnosed or initiated on appropriate treatment. Addressing these challenges requires targeted screening and a high-level of community involvement, as well as improving referral systems and data management.WHO continues to support the Eswatini’s National TB Control Programme. In 2024, the WHO helped develop the new TB national strategic plan 2024‒2028 and the rollout of digital X-rays systems with computer aided diagnostics to strengthen TB case finding. In addition, WHO provides ongoing technical support to improve the quality of TB services and strengthen programme management.“WHO will continue to play a central role in supporting the country to accelerate the TB response, guided by the latest WHO TB guidelines,” says Dr Susan Tembo WHO Representative in Eswatini. “Strong collaboration with affected communities and civil society remains critical to ensuring equitable access to care.”Ngwenya is back at her job as a sales assistant at a boutique in Manzini, one that she was forced to quit after falling ill. She is well and upbeat. “TB can be treated and cured as long as you go get checked and helped when you experience symptoms,” she points out.