MSF: Stigma-free care in a country ranked second in global suicide rates: Eswatini

The unfortunate combination of poverty, weak psychosocial support, poor access to education, limited development, and inadequate medical care creates difficult and complex circumstances that often pass from one generation to the next.

While people struggle to find confidential help for their sexual and reproductive health needs, another hidden issue has grown silently: the psychological burden. With limited access to both free of charge and stigma support services, the gap in mental healthcare continues to widen.

“We currently have over a million people in the population, but only one mental health hospital in the country — the National Psychiatric Referral Hospital based in Manzini. This facility targets people from all four regions, and access can be challenging for most due to the distance they must travel,” says Nomthandazo (“Nomté”), MSF Ppychologist at Sitsandziwe Clinic.

In such conditions, mental health and sexual health issues are deeply interconnected. Socio-economic struggles and social de-prioritization can lead to both mental health problems and unsafe sexual behavior, endangering people’s well-being. Mental health issues can also impact self-esteem and emotional control, leading to risky sexual behaviours.

“Mental health problems can be just as serious as physical diseases such as syphilis or gonorrhea, and sometimes even more difficult to treat. This is why in the MSF clinic, we not only offer diagnosis and treatment by nurses and doctors for infections like gonorrhea and hepatitis, but also by mental health specialists for issues such as stress, anxiety, and depression”, says Dr Florian Prechter, MSF project medical referent.

Not only for women; a safe space for men too

When sexual and reproductive health services are mentioned, they are often seen as being mainly for women. However, this is far from the full picture. Men are also part of the community in dire need of both sexual and mental health support, despite the stereotypes that discourage them from seeking it.

“There are also cultural beliefs, like the idea that men do not cry and are not supposed to be vulnerable. This becomes a barrier for someone who needs to ask for help and support. Low employment rates and economic challenges also contribute to suicide-related behaviors such as thoughts of death and self-harm. People slowly adopt unhealthy ways of dealing with their difficult situations, and in most cases, it becomes extreme,” says Nomté.

Because of this, mental health is often deprioritized at a time when the population is facing multiple vulnerabilities. In Manzini city, the largest industrial city in the country, where universities, factories, and a young and marginalized population live, such services are vital.

“As we try to increase awareness and encourage support, only about 20 per cent of our patients are men. Often, seeking mental health counseling is still seen as a sign of weakness. But to truly be healthy, we all need to take care of our minds just as much as we care for our bodies. Talking to a psychologist is no more a sign of weakness than talking to your doctor. Everyone deserves good mental health,” says Dr Prechter.

A medical mission by choice

MSF has worked in Eswatini for almost 20 years, focusing on unmet needs in communities that struggle with high rates of illnesses like HIV and sexually transmitted infections. Opened in October 2023, the MSF Sitsandziwe Clinic (in English: “We Are Loved”) provides integrated medical and psychological care.

The clinic offers laboratory-based testing and treatment for sexual infectious diseases, HIV testing and linkage to care, as well as PEP (post-exposure prophylaxis) and ART (anti-retroviral treatment). It supports survivors of sexual and gender-based violence, provides family planning and safe abortion care, and conducts cervical cancer screening and prevention. Mental health and counseling services are integrated into every aspect of care, recognising the strong link between emotional well-being and sexual health.

Beyond the clinic walls, MSF teams conduct outreach and awareness activities in the community, working with peer groups, local leaders, and partner organisations. These efforts help to reduce stigma and encourage both men and women to seek care.

“We care for both the body and the mind. Physical health problems can cause mental health issues and the other way around. Many things can affect our mental well-being: a newly diagnosed disease, problems at work or in a relationship, violence, an uncertain future, or simply being overwhelmed by constant bad news,” says Dr Prechter.

“I was sexually abused, now I am mentally distressed”

Despite the high level of stigma that prevents many people from speaking out about their struggles — both physical and mental — Zia (her real name is withheld for privacy), a 21-year-old woman from Eswatini, wanted to share her story:

“I was born in KaHlatsi, and I stayed with my grandmother until the age of seven. Then I had to go stay with my relatives, which was something I was not comfortable with, because at some point, one relative of mine took advantage of me sexually. That made my stay really uncomfortable.

“At some point, I met Maphalala, the MSF psychologist, at Sitsandziwe Clinic after I discovered that I was pregnant. She asked if I would cope with the situation. I told her it would be very difficult, and she said we would have a few mental support sessions. Since then, we have been having those sessions.

“These sessions have been really helpful. It took time for me to be comfortable with life because being pregnant triggered the pain of being sexually abused in the past. The sessions taught me coping mechanisms, especially for sleeping.

“I am someone who likes to stay alone, and I always tell myself that these mental support sessions are going to help me. Up until now, I am still attending them, and I think as time goes on, everything will be okay.

“Right now, I am still not okay. I still have trauma and can’t sleep, but hopefully, as time goes on, I will be okay. And that’s my story.”

Zia is one of 314 people to whom MSF teams have provided mental health consultations up to September 2025, reaching people of all genders seeking support for suicidal thoughts, stress, trauma, anxiety, or emotional distress — not only those linked to sexual and reproductive health concerns, but also broader challenges such as family struggles and overall emotional wellbeing.

“Our clinic is located in Manzini, which is the most populated region in the country. It has a high population concentration, a young and mobile population, and a temporary or migratory setup, including internal economic migrants, students, and cross-border workers.

The area includes diverse socio-economic groups — university students, factory workers (with over 700 factories nearby), and sex workers among others — making it a hotspot where the need for both sexual and mental health care is extremely high,” says Dr Joseph Joe, MSF medical coordinator in Eswatini.

* Source: “WHO Sounds the Alarm on the Rising Number of Suicides in Eswatini,” - WHO Regional Africa website, September 18, 2025.