Findings from the interviews of the surveillance agents and health care providers
Most of the NMCP surveillance agents expressed the need to solve the importation problem because their experience has shown them that travellers do not often use chemoprophylaxis, so the agents were concerned travellers would continue to contract and import malaria, putting the Swazi population at risk. Agents mentioned challenges related to their everyday work. They reported language barrier as a challenge. According to the agents, most of the malaria imported cases in their catchment areas are Mozambicans. Some of them do not speak the local languages common in Swaziland and the agents do not speak Mozambican languages. Additionally, the agents reported limited resources as a hindrance to a successful case investigation. They reported that because most of the imported cases are mobile, working during the day, it is hard for them to find them at one place, and because the agents have limited mobile phone airtime to work with, they cannot call the cases to localize them prior to visiting. Furthermore, poor documentation of information necessary to follow up a case was another challenge. In some cases it was the reporting itself. According to the agents, some health providers just don’t like to report. The failure to report a case in a timely manner can cause a delay in the investigation, and raise some resentment from the agents as some revealed during the interviews:
“You know, people just don’t want to report. I don’t know if it’s a culture of ours. There are some people who cannot recall what they have done. Sometimes they do it perfectly their job. The client goes home having been treated everything goes well. But the problem where have you written what you’ve done? You’d find that there is nothing. You’d find gaps on our reporting tools.”
This issue of reporting was later confirmed by one provider only who complained it is a waste of time and duplicate of effort to report a case at the same time record information for the surveillance agents’ investigation.
Agents believed that the individuals who were importing malaria (mostly Mozambicans, based on their experience) knew each other and knew others with similar travel patterns that could similarly put them at risk of contracting malaria.
“… Even if the cases are Swazis you’d find that they are females and married to Mozambicans. You would find that she goes to visit her husband’s family. That’s how you’d find Swazis. But mostly, in a scale of 10 you’d find that nine are Mozambicans.”
“Definitely, they know each other. Most of our imported cases are Mozambicans who are residing here in Swaziland. They are living here, so they go home month-end or anytime when they feel like going to Mozambique for whatever business they go.”
The health care providers were aware of the activities of the NMCP and support them in diagnosing, treating, and reporting cases of malaria. When asked about the profile of a typical imported malaria case, all the providers had close answers on the similarity of their provenance, their professions, and the frequencies and reasons for their travels. The providers suggested some places and days where and when those individuals could be found.
“Most of them are staying here and they are Mozambicans and they go to Mozambique every month end those are the type of people that we see. They are road constructors we have a number of them, cane cutters, general labourers, hawkers.
“You will find them at the Manzini market where they sell clothes on Wednesday and Thursday. There is an office where they are all controlled. Those women meet regularly at that office. You can go to that office and talk to them during their mass meeting.”
With regard to importation prevention, some of the providers referred to health education through media campaigns, as well as screening at border gates. Some even proposed a law that will require travellers to carry a certificate, like the one documenting yellow fever vaccination, showing that they are malaria free and are taking chemoprophylaxis.
“I think we would need to make a law that requires visitors to have a certificate of being malaria free before coming to Swaziland, just like Yellow Fever Certificate.”