BY HABTOM TESFAMICHAEL | SHABAIT
The vision of the Eritrean Government as stated in the Macro-Policy and the Charter of the People’s Front for Democracy and Justice (PFDJ) is to achieve rapid, balanced, home grown and sustainable economic growth with social equity and justice, anchored on the principle of self-reliance. The same vision is further reinforced in the Eritrea National Indicative Development Plan 2014 – 2018.
As reflected in its Macro-Policy, the Charter and the National Development Plan, the Government of the State of Eritrea recognizes that a healthy population is necessary for the establishment of a dynamic, productive and resilient society.
The National Health Policy of Eritrea (NHP) promotes the enjoyment of the highest attainable standard of health for all as one of the fundamental rights of every citizen. The policy prioritizes the health and well being of all, through universal access to affordable quality, essential health services delivered through resilient and responsive health systems.
In September 2015, the UN General Assembly adopted the “2030 Agenda for Sustainable Development” as the successor to the Millennium Development Goals (MDGs). The 2030 Agenda for Sustainable Development represents an unprecedented undertaking of the global community to eradicate poverty and achieve sustainable development worldwide by 2030. Its 17 goals and 169 associated targets represent a commitment to improving, by 2030, the livelihood of people in a sustainable manner. Eritrea has formally ratified these goals so that they will guide the development agenda in the country.
The single health goal SDG-3 relates to direct actions that influence health within the SDGs. However, achieving health and well-being are also closely intertwined with other SDGs: including the 13 targets of SDG 3, nearly 50 of the 169 targets of the 17 SDGs have a direct impact on health and well being. Goal 3, “ensuring healthy lives and promoting well being for all at all ages” has nine targets that cover the unfinished MDGs agenda, newly formulated targets and targets that facilitate implementation. Umbrella target 3.8, “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services, medicines and vaccines for all” underpins the achievement of all the health targets and Goal 3.
In addition to the 2030 Agenda, whose goals and targets link well with Eritrea’s Self-reliance Policy and Development Agenda, Eritrea is also signatory to several other health and health-related global and regional commitments.
The 2010 Eritrean National Health Policy (NHP-2010) has served well in guiding the approach for the health sector in its five-year strategic and annual operational plans at the sector and program levels. Now, almost ten years after the NHP-2010 began to be implemented, the national and global contexts have changed in three major ways, which created the need for reviewing its progress and determine the next health policy direction that shall respond to Eritrea’s national development aspirations.
First, Eritrea is now embarking on a new era of peace and rapid all-round development, following the end of the two decades of war and no-peace-no-war situation with Ethiopia and the era of unjust and unfair sanctions.
Second, the priorities of healthcare are changing. Although maternal and child mortality as well as morbidity and mortality due to communicable diseases such as malaria, HIV-AIDS and tuberculosis have rapidly declined, there has been an increase in the incidences of non-communicable diseases, injuries, mental disorders and some infectious diseases of national and international concern.
The third important change, which is global, has to do with health issues associated with key changes in people’s life styles and work habits, leading to changes in the understanding and management of health. The Sustainable Development Goals (SDGs) have placed health actions at the center of sustainable development, which created the need of aligning national health policies, strategic plans and operational plans with the global reforms.
The Government of Eritrea has made its health policy reviews in 2019 and renewed its 2010 national health policy (NHP-2010) to accelerate actions to improve the health of its population by aligning them with the anticipated rapid national development aspirations, the 2030 Agenda for Sustainable Development and Agenda 2063 (the Africa we want).
The renewed robust National Health Policy is intended to respond to the growing calls for strengthening health systems and renewing Primary Health Care (PHC): universal health coverage, people-centered care, health security, public health and health in all policies. The policy serves to guide and steer the entire health sector and go beyond the boundaries of health systems, addressing the social determinants of health and the interaction between the health sector and other sectors in society.
As Eritrea aims to achieve Universal Health Coverage (UHC), progressive realization on several fronts is very encouraging. The following indicators demonstrate that Eritrea has been moving towards the attainment of UHC.
As revealed in the graph, the number of hospitals in Eritrea increased from 16 in 1991 to 30 while the number of health centers increased from 5 to 54 and the number of health stations (including clinics and MCH centers) increased from 72 to 248. However, this quantitative increase, as big as it is, grossly underestimates the efforts made in the construction of health facilities because many of the new health facilities constructed have replaced the old run down facilities.
Despite the quantitative masking, over all the total number of health facilities increased from 127 in 1991 to 332 in 2018, which is 160 percent (2.6 fold). Since the construction of health facilities began in Eritrea at the time of the Italian Occupation in the 1890’s, the number of health facilities that have been constructed in the past twenty seven years were 2.6 times the number of health facilities that were constructed in the whole century prior to Eritrea’s liberation in 1991.
As a result of the concerted efforts made to expand health services by building health facilities and equipping them with the necessary equipment and skilled health personnel, access to health care within 10 km radius increased from 46 percent in 1991 to 80 percent at present (2019).
Currently, over 60 percent of the population has access to health facilities within a 5 km radius.
There are notable successes in the areas of service provision which include at least one antenatal coverage that stands at 96% and institutional delivery (delivery in a health facility), that stands at 62%. Immunization coverage for Penta and Measles, including Pneumococcal conjugate 3rd dose (PCV3), stands at 98%. Drastic reductions were also seen in harmful practices, including early marriage and female genital mutilation.
In the area of hygiene and sanitation, which was lagging behind, successes are reported with already 695 (26.1%) of the 2,666 rural villages in the country having been declared “Open-Defecation-Free”. Efforts towards declaring Eritrea open-defecation-free are being scaled up, and Eritrea is planning to end open defecation by 2022.
The Expanded Program on Immunization (EPI) has been notably successful in Eritrea, achieving virtually universal (98%) immunization coverage rates. Subsequently, Eritrea was awarded by Global Alliance for Vaccine Initiative (GAVI) on October 17, 2009 in Hanoi, Vietnam, for its high and sustained immunization coverage. In 2016, the Immunization program was also awarded the 2016 UNICEF award in recognition of Eritrea’s outstanding achievement in vaccine management.
Eritrea’s immunization coverage is virtually universal; hence, it is highly equitably accessible to all children and women in the reproductive age group. The country has been polio-free since 2008 and has maintained its maternal and neonatal tetanus (MNT) elimination status validated in 2002. There has been no confirmed measles outbreak among children since 2005.
In 2017, virtually all women (96%) attended Antenatal care visits during their most recent pregnancy. This has shown significant improvement from 48% in 1995 to 70% in 2002 to 90% in 2010, to 93% in 2013 and to 96% in 2017. Moreover, around 60% of the mothers received ANC service four or more times.
A study in 2017 revealed that among mothers of children 0-11 months, 62% gave birth in a health facility. The finding of the 2017 EPI coverage survey was also similar. Health facility delivery in 1991 was very low at 6%, which progressively showed tenfold increase to 62% by 2017.
Trends in both HIV and AIDS cases in Eritrea are favorable, suggesting stabilization at a low prevalence level and reversal of HIV infection in the general population, with a prevalence of less than one percent since before 2010.
The prevalence of HIV in the general population was 0.93% in 2010 and the prevalence among women of 15–19 years was 0.2% and peaks, at 2.9%, for women in their late thirties (EPHS 2010).
The 2017 National Antenatal Sentinel Surveillance (ANC) Survey revealed that, overall, HIV prevalence among pregnant women aged 15-49 attending ANC for their first pregnancy in 2017 was estimated to be 0.65%. Trend analysis of the Antenatal Sentinel Surveillance results revealed that the HIV infection rate among pregnant women in Eritrea has shown steady and significant decline in the last 15 years. The prevalence has significantly declined from 2.4% in 2003 to 0.65% in 2017 at an average annual declining rate of 5.2%.
Prevalence among the youth aged 15-24 can be taken as a good proxy for the level of new HIV infection or level of HIV incidence in a country. The study estimated that the prevalence among this group of youth was 0.11% and this has shown significant and steady decline during the last 14 years where it was 2% in 2003.
Moreover, in malaria control Eritrea is working towards pre-elimination phase.
The people of rural Eritrea have practiced open defecation for hundreds of years. This is probably the result of lack of awareness about safe hygiene, coupled with the vast space around homes and villages. In the late 1800s, the Italian colonial administration required that sanitary facilities be included in new housing projects, particularly in urban areas. There was little enforcement in the rural communities.
Eritrea drew a road-map to end open defecation. The road map presents Eritrea’s strategy to end open defecation by 2022. It was discussed at the first National Sanitation Conference held in Asmara from 11 to 12 December 2018. The meeting was attended by more than 500 participants, including students and community members from villages that were declared open-defecation-free.
These efforts and achievements and many other aspects of Universal Health Coverage resulted in continuous improvements of impact indicators such as under-five mortality, maternal mortality and life expectancy.
From 1991 to 2015, maternal mortality ratio was reduced by 69%; Neonatal mortality rate was reduced by 45% and Under-five mortality rate was reduced by 69%. These remarkable achievements are among the few best in Africa.
As shown in the World Health Statistics Annual Reports (WHO, 2016), during the same period, the average reductions in Africa were 45%, 38% and 54% for maternal, neonatal and under-five mortality respectively. Life expectancy at birth, which is considered as a summative health indicator, increased by 35%, from 48 years in 1990 to 65 years in 2016 (62.9 years for males and 67.1 years for females), while the healthy life expectancy at birth was estimated at 57.4 years in 2016.
Eritrea was among the ten countries in the WHO Africa region that have achieved MDG4 in 2015, by reducing under-five mortality by two-third. If current trends continue, Eritrea is also one of the countries that are expected to achieve under-five mortality SDG Target before 2030.
Eritrea’s achievement in all three health MDGs, namely MDG-4 on the reduction of child mortality, MDG5– on the reduction of maternal mortality, and MDG-6 on the control of communicable diseases, including HIV/ AIDS, malaria and tuberculosis, has been one of the most remarkable achievements in Africa Region.
Although non-communicable diseases were historically viewed as a burden to industrialized nations, they are already altering the health of the globe dramatically. This trend is already evident in Eritrea as the prevalence of non-communicable diseases and injuries is increasing, already posing a challenge on our health service delivery.
There are now emerging issues related to communicable and non-communicable diseases which include cardiovascular diseases, cancer, respiratory diseases, psychiatric conditions, congenital anomalies leading to a ‘double burden of diseases’. There is no evidence of reductions in the trend of these diseases. Road traffic injuries are high, mainly affecting the productive and young population, with increasing mortality levels over the years.
Although the effect of communicable diseases will still remain significant, emerging trends point that non-communicable conditions and injuries will, in the foreseeable future, be the leading contributors to high burden of disease in the country. Another key cross-cutting intervention that shall be focused by the health sector and other stakeholders is the high rates of malnutrition.