who CoUNTRY CooPERATIoN STRATEGY 2014-2016 ERITREA

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who CoUNTRY CooPERATIoN STRATEGY

2014-2016

ERITREA

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AFRoLibrary Cataloguing-in-Publication Data who Country Cooperation Strategy 2014-2016: Eritrea 1. health planning

2. health plan Implementation 3. health Priorities

4. International cooperation

I. world health organization. Regional office for Africa ISBN: 978 929 023 275 9 (NLM Classification: wA 540 hE8)

Copies of this publication may be obtained from the Library, who Regional office for Africa, P.o. Box 6, Brazzaville, Republic of Congo (Tel: +47 241 39100; Fax: +47 241 39507;

E-mail: afrobooks@afro.who.int). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should be sent to the same address.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the world health organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the world health organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the world health organization to verify the information contained in this publication. however, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the world health organization or its Regional office for Africa be liable for damages arising from its use.

Designed and Printed in the who Regional office for Africa,

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MAP oF ERITREA

Gash Barka Anseba

NRS

SRS Debub

Maekel

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ABBREVIATIoNS

AfDB African Development Bank

AN Anseba Region

ANC Antenatal Clinic

ASRH Adolescent, Sexual and Reproductive Health BEMOC Basic Emergency Obstetric Care

CCM Country Coordination Mechanism CCS Country Cooperation Strategy CDS Communicable Diseases Surveillance CEMOC Comprehensive Emergency Obstetric Care

DaO Delivering as One

DGC Designated Government Convener DPAH Diet, Physical Activity and Health EDHS Eritrean Demographic and Health Survey

ENC Emergency Neonatal Care

ENT Ear, Nose and Throat

EPHS Eritrean Population Health Survey EPI Expanded Programme on Immunization FAO Food and Agriculture Organization FBOs Faith-Based Organizations FGM Female Genital Mutilation

FP Family Planning

FSS Food Security Strategy

GAR Global Alert and Response

GAVI Global Alliance for Vaccines and Immunization

GB Gash Barka Region

GDP Gross Domestic Product

GFATM The Global Fund to Fight AIDS, Tuberculosis and Malaria

GPI Gender Parity Index

GPW General Programme of Work

GSOE Government of the State of Eritrea GVAP Global Vaccine Action Plan

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HIV/AIDS Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome

HMIS Health Management Information System

HOAs Heads Of Agencies

HRH Human resources for Health HSS Health System Strengthening

HSSDP Health Sector Strategic Development Plan HSSP Health Sector Strategic Plan

IASC Interagency Standing Committee

IDSR Integrated Diseases Surveillance and Response IHR International Health Regulation

IMNCI Integrated Management of Neonatal and Childhood Illnesses

IST Intercountry Support Team

ITN Insecticide-treated Net LLIN Long-lasting Insecticidal Net

LMIS Logistic Management Information System M&E Monitoring and Evaluation

MDGs Millennium Development Goals

MDR Multidrug Resistant TB

MND Ministry Of National Development MNH Maternal and Neonatal Health

MOH Ministry of Health

MOSS Minimum Operating Security Standard NATCOD National AIDS and TB Control Department

NCDs Noncommunicable Diseases

NDP National Development Plan

NER Net Enrolment Rate

NGOs Nongovernmental Organizations

NHPSP National Health Policies, Strategies and Plans NMP National Medicines Policy

NPJA National Plan for Joint Action NPOs National Professional Officers

NRS Northern Red Sea Region

NTDs Neglected Tropical Diseases

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NUEW National Union of Eritrean Women

NUEYS National Union of Eritrean Youth & Students

OPD Outpatient Department

PAC Programme Area Coordinator

PHC Primary Health care

PMTCT Preventing Mother-to-Child Transmission PRSP Interim Poverty Reduction Strategy Paper RBM Results-Based Management/Roll Back Malaria

RC Regional Committee

RDT Rapid Diagnostic Tests

REC Reaching Every Child

SANA Situational Analysis and Needs Assessment SPCF Strategic Partnership & Cooperation Framework SRH Sexual and Reproductive Health

SRS Southern Red Sea Region STIs Sexually Transmitted Infections

TB Tuberculosis

TFR Total Fertility Rate

U5 Under five years

UHC Universal Health Coverage

UN United Nations

UNCT United Nations Country Team

UNDAF United Nations Development Assistance Framework UNDP United Nations Development Programme

UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UNRC United Nations Resident Coordinator VCT Voluntary Counselling and Testing

VIP Ventilated Improved Pit/Violence & Injury Prevention

WCO WHO Country Office

WHO World Health Organization

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PREFACE

The WHO Third Generation Country Cooperation Strategy (CCS) crystallizes the major reform agenda adopted by the World Health Assembly with a view to strengthening WHO capacity and making its deliverables more responsive to country needs. It reflects the WHO Twelfth General Programme of Work at country level, aims at achieving greater relevance of WHO’s technical cooperation with Member States and focuses on identification of priorities and efficiency measures in the implementation of WHO Programme Budget.

It takes into consideration the role of different partners including non-State actors in providing support to governments and communities.

The third Generation CCS draws on lessons from the implementation of the first and second generation CCS, the country focus strategy (policies, plans strategies and priorities), and the United Nations Development Assistance Framework. The CCSs are also in line with the new global health context and the move towards Universal Health Coverage, integrating the principles of alignment, harmonization, effectiveness, as formulated in the Rome (2003), Paris (2005), Accra (2008), and Busan (2011) declarations on Aid Effectiveness.

Also taken into account are the principles underlying the “Harmonization for Health in Africa” (HHA) and “International Health Partnership Plus” (IHP+) initiatives, reflecting the policy of decentralization and enhancing the decision- making capacity of governments to improve the quality of public health programmes and interventions.

The document has been developed in a consultative manner with key health stakeholders in the country and highlights the expectations of the work of the WHO Secretariat. In line with the renewed country focus strategy, the CCS is to be used to communicate WHO’s involvement in the country; formulate the WHO country workplan; advocate for and mobilize resources and coordinate with partners; and shape the health dimension of the UNDAF and other health partnership platforms in the country.

I commend the efficient and effective leadership role played by the Government in the conduct of this important exercise of developing the WHO Country Cooperation Strategy. I also request the entire WHO staff, particularly

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the WHO Country Representative to double their efforts to ensure effective implementation of the programmatic orientations of this document for improved health outcomes in order to contribute to health and development in Africa.

Dr Luis Gomes Sambo Regional Director

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EXECUTIVE SUMMARY

Eritrea has recorded significant achievements in disease control and made substantial progress towards the attainment of health MDGs through the implementation of proven interventions. Overall, the health status of the population has also improved significantly. The National Health Policy and Health Sector Strategic Plan took stock of the achievements and the key challenges to be addressed including low percentage of pregnant women who have access to skilled birth attendance; high neonatal mortality; rapid expansion of health infrastructure; the need to prevent, control/manage the double burden of communicable and Non-communicable diseases;

progressive technological advancement in health; and the high demand for appropriately skilled health personnel.

Eritrea has succeeded in reducing its child mortality significantly and is currently on record as being on track with regard to attainment of MDGs 4, 5 and 6. Its infant mortality rate decreased from 72 deaths per 1000 live births in 1995 to 48 deaths in 2002 and 42 deaths in 2010, which is lower than sub-Saharan Africa’s average of 105 deaths. Under-five mortality rate dropped from 136 deaths per 1000 live births in 1995 to 93 deaths in 2002 and 63 deaths in 2010 compared with sub-Saharan Africa’s average of 151 deaths. Maternal mortality ratio has declined from 998 per 100 000 live births in 1995 to 486 per 100 000 live births in 2010. Challenges however exist in the reduction of neonatal mortality. The outcomes of EDHS 1995 and 2002, and EPHS+ 2010 show that maternal mortality virtually stabilized at 25, 24 and 23 per 1000 livebirths respectively.

The eight major vaccine-preventable diseases (poliomyelitis, measles, diphtheria, tetanus, hepatitis B, TB, Haemophilus influenzae type b and whooping cough) no longer pose any major public health challenge in Eritrea.

The country has eliminated maternal and neonatal tetanus and reduced measles incidence to less than 90% of the 1991 levels. The country has been certified as “Dracunculiasis-free” (guinea-worm disease) and has achieved polio-free status with the last polio case reported in 2006. The prevalence of HIV/AIDS is showing a declining trend from year to year. The prevalence of HIV infection in the general population is sustained at less than 1%. The country is

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moving towards pre-elimination of malaria. In addition to the need to sustain these gains, areas with limited success such as control of tuberculosis and neglected tropical diseases need to be addressed. The emerging epidemic and pandemic threats including dengue fever also require special attention.

Non-communicable diseases (NCDs), especially diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases and cancer, are on the rise.

A recent survey (2010) shows a prevalence of 14.1% for hypertension and 4.7% for elevated blood sugar levels in the general population. The 24–75 year population that smokes daily is 7.2%, while 39.6% drink alcohol. Malnutrition remains one of the major public health problems in the country.

There has been significant progress in addressing Sexual and Reproductive Health issues. Some gaps however exist in this area including a progressive increase in ANC dropout rates; a persistent high unmet need for family planning; and inadequate competencies for SRH/MNH including for ASRH, FP, ENC. Sepsis is emerging as a major cause of maternal mortality and should be addressed. Additionally, strategies aimed at improving skilled birth attendance should be further strengthened in order to attain the targets of MDG 5b.

There have been efforts to improve the health system in order to deliver services to the population in an equitable manner focusing on Primary Health Care (PHC). The key health system challenges include the need for improving management of human resources for health including skill mix and retention;

addressing the fragmentation of health information; developing appropriate health financing policy and strategies; and improving access to and rational use of safe medicines and technologies. Gaps and challenges in service delivery include the capacity to provide comprehensive and quality health care; the fact that the referral system is not being followed by the majority of those who attend health facilities; and limited availability of transportation and communication.

Eritrea is vulnerable to natural disasters including earthquakes and volcanic eruptions. The country is also vulnerable to climate change variability with attendant droughts and floods. These pose a challenge to health and health service delivery including an increase in communicable diseases as well as preparedness of the health sector to provide adequate response in line with the regional strategies on disaster risk management, and health and environment.

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dialogues is to sustain the achievements, improve on them, and address the existing and emerging challenges.

This Third Generation Country Cooperation Strategy builds on the achievements, lessons learnt and challenges from the Second Generation CCS in order for WHO to support the Government of Eritrea to achieve its priorities as highlighted in the health sector strategic plan. The CCS is informed by Eritrea’s health and development challenges as well as the key focus and principles of the country’s health sector policy and strategic plan including universal access; intersectoral approach/action for health; and decentralization. It takes into account the joint commitment of the health partners to support the Government of Eritrea to achieve its health objectives including the attainment of health MDGs in a coordinated and complementary manner.

The following strategic priorities provide a framework for collaboration between WHO and the Government of Eritrea for the period 2014–2016:

(a) contribute to the achievement of the health-related MDGs through the implementation of high impact interventions; and support the preparation of the health sector to address future health challenges through the post-2015 development agenda;

(b) support the surveillance, control, elimination and eradication of priority communicable diseases including neglected and emerging communicable diseases;

(c) support the surveillance and control of emerging threats of noncommunicable diseases;

(d) support the strengthening of the health system including addressing the social, economic and environmental determinants of health with a view to achieving universal health coverage.

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SECTIoN 1:

1. INTRODUCTION

This document is the Third Generation Country Cooperation Strategy (CCS) produced after implementing the First and Second generation CCSs. The document is a product of a process of consultation with the Government and UN partners, leading to an agreement on WHO support to the priority strategic areas. The development of this CCS commenced with defining a roadmap and setting up a task force comprising all the technical staff of the WCO and the two Directors-General of the Ministry of Health. The priority areas of support were identified following a review and analysis of the achievements and weaknesses of the WHO Cooperation Strategy 2009–2013, and the national priorities set in the National Health Sector Development Strategic Plan mutually agreed between the Ministry of Health and WHO. The draft CCS was discussed extensively with the Minister of Health, the Directors-General and Directors of the Ministry of Health as well as UN partner agencies including UNICEF, UNAIDS, FAO, UNDP and UNFPA before its finalization.

The implementation of the Second Generation CCS was thoroughly reviewed and the unfinished agenda was proposed to be addressed in the context of the Third Generation CSS. This formed the foundation of the new CCS to which a new agenda was added. This new agenda was informed mainly by the Health Sector Strategic Plan (HSSP), the 12th General Programme of Work (GPW) and the Strategic Directions for WHO Action in the African Region 2010–2015.

Eritrea is not a UN Delivering-as- One (DaO) country and does not have a UN Development Assistance Framework (UNDAF). The UN and the Government have, however, developed a four-year partnership agreement for the period 2013–2016 called UN Strategic Partnership and Cooperation Framework with the Government of Eritrea (SPCF). One of the eight outcomes of the SPCF, namely Health and Nutrition, for which WHO and MOH are co-conveners, was also taken into consideration in the development of the new CCS.

The country does not have a National Development Plan (NDP). Therefore, the Government’s guidelines direct that cooperation with all development partners be based on sector-specific strategies pending the drawing up of

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the NDP. Thus, the areas of cooperation for this CCS have all been selected on the basis of priorities in the Health Sector Strategic Plan (HSSP) for the period 2012–2016, namely communicable diseases and noncommunicable diseases control; health systems strengthening; maternal and child health.

Also considered in the CCS were the principles of the HSSP including promoting equity in the provision of health service; ownership and participation;

partnership and intersectoral collaboration; empowerment of individuals in households to prevent illness and maintain healthy lifestyles; efficiency through rationalization of health inputs; and government stewardship. Furthermore the CCS is based on the principles of universal access; intersectoral approach/

action for health; and decentralization.

The national priorities enumerated above are put in the context of WHO’s mandate, its comparative advantage and its six core functions. The CCS priorities are therefore matched against the priorities of the 12th General Programme of Work (GPW) 2014–2019, namely advancing universal health coverage (UHC); health-related MDGs; addressing the challenge of NCDs and mental health, violence and injuries, and disabilities; implementing the provisions of the International Health Regulations (IHR); increasing access to essential, high-quality and affordable medical products; and addressing the social, economic and environmental determinants of health. The CCS likewise incorporates the values and principles of the 12th GPW as enshrined in the WHO Constitution including equity and social justice, as well as approaches such as promoting evidence as the basis of policy.

In addition, this CCS takes into account the Strategic Directions for WHO Action in the African Region 2010–2015 namely: leadership, partnerships and harmonization with countries; health systems strengthening using the PHC approach; health of mothers and children first; accelerated actions on HIV/AIDS, malaria and tuberculosis; intensified prevention and control of communicable diseases and noncommunicable diseases; and accelerated response to health determinants. These priorities have been endorsed by ministers of health of the WHO African Region through major declarations especially the Ouagadougou Declaration on Primary Health Care, (Ouagadougou, 2008), the Algiers Declaration on Research for Health (Algiers, 2008) and the Libreville Declaration on Health and Environment (Libreville, 2008); as well as through resolutions on noncommunicable diseases, disaster risk management, polio eradication, IHR, among others. The UN political declaration on NCDs and the Rio Declaration on social determinants of health were also considered in preparing this CCS.

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Implementation of this CCS will start from the commencement of the WHO 12^th General Programme of Work in 2014. The duration has been reduced to three years in order to align it with the HSSP covering the period 2012-2016 and the Government of Eritrea/UN Strategic Partnership Cooperation Framework (SPCF) covering the period 2013–2016. The WCO programme budgets 2014- 2015 and 2016-2017 will be informed by the priorities set forth in this CCS.

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SECTIoN 2:

2. Health and development challenges,

attributes of the national health policy, strategy or plan and other responses

2.1 Macroeconomic, political and social context

Eritrea is located in the Horn of Africa and lies to the north of the Equator between Latitudes 12⁰22 N and 18⁰ 02’ N, and Longitudes 56⁰26’’21’ E and 43⁰13’E. It covers an area of 124 400 square kilometers. To the east, the country is bordered by the Red Sea, extending about 1212 kilometers from the Ras Kaisar Mountain in the north to Dar Elwa in the southeast where it borders Djibouti. It shares borders with Sudan to the west and with Ethiopia to the south.

Administratively, the country is divided into six Zobas (Regions): Anseba, Maekel, Debub, Northern Red Sea, Southern Red Sea and Gash Barka. Its estimated population in 2012 was 3.95 million (HMIS 2012). The population is essentially rural with about 75% of the people living in the countryside.

Eritrea is a multiethnic society with nine ethnic groups speaking nine different languages and professing two major religions, namely Christianity and Islam.

In 1994, Eritrea formulated and implemented socioeconomic development policies and strategies that concentrated not only on rebuilding and rehabilitating war-damaged and destroyed economic and social infrastructure but also on formulating numerous national economic and social development plans. The macroeconomic policy of the Government identifies human capital formation through education and health as the main strategy for long-term national development.

More recently, there have been signs of good economic prospects as investments in the mining sector continue to grow. GDP grew by 8.2%, up from 2.2% in 2010, but falling mineral prices are expected to result in a more moderate economic growth of 6.3% in 2012 (AfDB economic outlook, 2012).

Eritrea’s development aspiration is to achieve rapid, balanced, home-grown and sustainable economic growth with social equity and justice, anchored on the principle of self-reliance. Moreover, the Government places emphasis on

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community and individual rights as well as social justice, such as the right of access to education, health and food and equitable access to services regardless of locality.

The Ministry of Health takes the lead in health matters. However other sectors including Agriculture, Environment, Water resources and Education play key roles in health especially in multisectoral action for disease control and social mobilization and in addressing social determinants. Relevant stakeholders also play their own role including the international organizations mainly the UN and the GFATM, civil society organizations, faith-based organizations and communities.

Substantial progress has been made in the health sector. Eritrea has succeeded in reducing its child mortality and is currently on record as being on track with regard to the attainment of MDGs 4, 5 and 6. EDHS 1995 and 2002, and EPHS+ 2010 shows that neonatal mortality virtually stabilized at 25, 24 and 23 per 1000 live births respectively. Life expectancy has progressively increased from 49 in 1990 to 60 in 2000 and 63 by 2007, i.e. higher than the sub-Saharan African average of 51, 50, and 51 during the same years (WHO, 2009). The trends of some MDG indicators are highlighted below:

(a) infant mortality rate decreased from 72 deaths per 1000 livebirths in 1995 to 48 deaths in 2002 and 42 deaths in 2010, which is lower than sub-Saharan Africa’s average of 105 (EDHS 1995 and 2002, and EPHS+ in 2010);

(b) under-five mortality rate dropped from 136 deaths per 1000 livebirths in 1995 to 93 deaths in 2002 and 63 deaths in 2010 compared with the sub-Saharan African average of 151 (EDHS 1995, 2002 and EPHS+ in 2010);

(c) total fertility rate (TFR) decreased from 6.1 in 1995 to 4.8 in 2002 and 2010, which is below the sub-Saharan African average of 5.4 (EDHS 1995, 2002 and EPHS+ in 2010);

(d) maternal mortality ratio declined from 998 per 100 000 livebirths in 1995 to 486 in 2010 (EDHS 1995, 2002 and EPHS+ in 2010);

(e) proxy HIV incidence in the 15–24 years age group decreased from 2.1% in 2003 to 0.28% in 2011 (ANC sentinel surveillance, 2003/2011 NATCoD);

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(f) malaria morbidity and mortality were reduced by 74% and 83%

respectively in 2012 compared with the year 2000 levels (Malaria indicator survey, 2000 and 2012).

(g) estimated TB incidence decreased from 243 per 100 000 population in 1990 to 97 per 100 000 population in 2011 (MOH annual TB programme reports, 1990 and 2011).

As is the case in other developing countries the burden on the country’s health system is attributed to infectious diseases, malnutrition and maternal health problems. In addition, the rise in noncommunicable diseases is making the system face a double burden that will affect its strategic direction in the next decade.

2.2 Other major determinants of health

There has been a remarkable improvement in school attendance by both males and females at middle and secondary school levels since 2002 EDHS.

The middle school Net Enrolment Rate (NER) increased from 21.1 per cent in the EDHS 2002 to 40.0 percent in the EPHS 2010 while the secondary school attendance ratio increased from 23.5 per cent to 30.5 per cent. However, the primary school NER declined from 61.2 per cent in 2002 to 56.2 per cent in 2010. The gender gap in school attendance has also been narrowed during the last eight years especially at primary school level. The Gender Parity Index (GPI) was 0.89, 0.77 and 0.71 for primary, middle, and secondary school levels, respectively, in 2002 EDHS, compared with 0.96, 0.88 and 0.77 in EPHS 2010. The substantial decrease in primary school GAR from 100.5 per cent in 2002 to 84.5 per cent in 2010 would imply that families are sending their children to school at the appropriate age.

According to the EPHS 2010, the percentage of the population with sustainable access to an improved water source is 57.9%. This means that nearly six in ten households in Eritrea have access to an improved source of drinking water. Improved source of drinking water includes pipe-borne water supply to residences, yards, plots; public/private tap water; protected dug well (inside residences, yards, plots); bottled water; and rain water. Similarly, the percentage of the population with access to improved sanitation averages out to 11.35 % (25.8% urban and 3.5 % rural). Improved sanitation includes flush/

pour flush to piped sewer system; flush/pour flush to septic tank; flush/pour flush to a pit latrine; ventilated improved pit (VIP).

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The country is vulnerable to droughts, floods, increased variability in rainfall patterns and/or decreasing precipitation, soil erosion, desertification and land degradation. Different policies, strategies and legal instruments regarding the protection, conservation and proper management of biodiversity have been put in place as part of the Government’s efforts to address these challenges and meet its obligations under different conventions such as the Conventions on Biological Diversity; the Convention to Combat Desertification; the UN Convention on Climate Change; and the Montreal Protocol. The WHO Framework for Public Health Adaptation to Climate Change, aimed at providing a comprehensive, evidence–based and coordinated response to the negative effects of climate change, is being adapted by relevant government departments. This is expected to foster strategic alliance between health programmes and environment programmes.

Food insecurity in Africa threatens the lives of millions of vulnerable people especially displaced people and people living with HIV/AIDS. Cognizant of this regional threat, the Government of Eritrea has made food security one of the main pillars of national development strategies. Furthermore, taking into account the WHO Regional Committee Resolution AFR/RC57/R4 on Food Safety, as well as other initiatives and resolutions, modest efforts have been made to strengthen the capacities for food safety and nutrition and to participate in the Codex Alimentarius Commission. A national task force on Codex Alimentarius exists.

The vast majority of the population rely on agriculture as the main source of livelihood. There is an ongoing effort to improve water conservation and non- rain-fed farming through irrigation schemes and construction of dams. The health sector needs to address the health impact of these developments as well as the short-and-long-term impacts of mining activities. Up to 29% of the population in one of the six regions of the country are nomadic, moving from place to place according to changes in the climate. This has implications for both disease transmission and access to health services. Strategies targeting this group are therefore vital to attaining health targets.

The determinants of and response to women’s health must take into account all the relevant factors including the economic, social and cultural factors that affect their status as well as gender relations between women and men. Efforts are underway for a new paradigm shift. This shift in perspective will bring into focus the gender dimension in women’s health. The Government is promoting the participation of women in development through the promulgation of relevant

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policies and the engagement of the National Union of Eritrean Women. The active engagement of women’s groups would foster gender approaches to women’s health. The recommendations contained in the report of the Commission on Women’s Health in the African Region are useful in this regard.

Health-related risk factors have been documented through the STEPS survey on NCDs risk factors and the SANA for environmental risk factors. Strategic plans are being developed in line with the results of studies on primary intervention. The strategic approach is to involve other sectors of the economy through active engagement. WHO is mobilizing the UN Country Team to support the Ministry of Health in this endeavour.

2.3 Health of the population

Health Services: Since independence, the Ministry of Health has made significant progress in enhancing access to health services through the restoration of health facilities damaged during the war; the provision of adequate supplies of medicines and equipment; the expansion of available health services to communities where they are lacking; the construction of new facilities; and the training of qualified personnel. The Health Sector Development Strategy emphasizes the provision of basic health services at the local level to reach out to more people through the Primary Health Care (PHC) approach and to strengthen preventive public health activities including the prevention and control of both communicable and noncommunicable diseases. However, some gaps and challenges remain especially in improving the quality of health care, establishing a well-functioning referral system, and improving health-seeking behaviour.

Health-seeking behaviour: The health-seeking behaviour of the population shows preference for certain services compared with others. Immunization and protection against malaria are well accepted as evidenced by the proportion of fully-immunized children, estimated at 95% (EPI Coverage Survey 2013), while 60.1% of women aged 15–49 years and 67.4% of children under the age of five years sleep under ITN (Malaria Indicator Survey, 2012). On the other hand, antenatal services, family planning and skilled delivery services are not well utilized. According to HMIS 2012, the antenatal consultation drop-out rate was over 60%, skilled birth attendance was 32% and couple-year protection rate was 2.1%.

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Disease burden: An estimated 27% of infant deaths are related to neonatal problems. Congenital malformations are also among the top ten leading causes of infant deaths. In 2012, diarrhoea; acute respiratory infections mainly pneumonia; skin, eye and ear infections; malnutrition; fever of unknown origin;

injury of all types; and soft tissue injury were among the top ten leading causes of outpatient and inpatient morbidity among children under five years of age.

Among the older age group (above five years), HIVAIDS, pneumonia and TB account for about 23% of mortality. At the same time, noncommunicable diseases, namely injuries of all types, heart diseases, diabetes, anaemia of all types and hypertension-related diseases account for 29% of deaths reported in health facilities in this age group. The situation of the disease burden as reported in 2012 is similar in pattern compared with 2010 and 2011 (HMIS 2012).

The eight major vaccine-preventable diseases (poliomyelitis, measles, diphtheria, tetanus, Hepatitis B, TB, Haemophilus influenzae type B and whooping cough) no longer pose any major public health problem in Eritrea.

The country has eliminated maternal and neonatal tetanus and reduced the incidence of measles to less than 90% of the 1991 levels. The country has been certified as “dracunculiasis-free” (guinea-worm disease) and is also polio-free.

The prevalence of chronic Neglected Tropical Diseases (NTDs) such as schistosomiasis, leishmaniasis, soil-transmitted helminthiasis, lymphatic filariasis and re-emerging diseases like brucellosis and dengue fever are not well-documented. According to the data available from a 2006 survey, the prevalence of active trachoma among children aged 1–9 years ranged from 2.4% in Gash-Barka to 14.9% in Debub Region, whereas the prevalence of trachomatous trichiasis in adults above 15 years of age ranged from 1.1% in Northern Red Sea to 2.2% in Debub.

The prevalence of HIV/AIDS has been declining from year to year. The prevalence of HIV infection in the general population is sustained at less than 1%. There is a particular need to accelerate progress towards zero new infections, zero AIDS-related deaths and zero discrimination against people living with HIV/ AIDS. This will mean focusing on zero mother-to- child transmission, strengthening prevention of mother-to-child transmission (PMTCT), promoting the development of cheaper diagnostics, and putting new guidelines into practice.

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For the year 2011, the estimated incidence of tuberculosis was 97 per 100 000 population, TB prevalence was 151 per 100 000 population and TB mortality (excluding HIV) was 4.7 per 100 000 population. The MDR-TB rate is estimated at 1.8% among new cases and 19% among previously treated cases (WHO Global TB Report 2012). The overall HIV prevalence among TB patients in 2011 is estimated at 17.9% and this represents a decrease by 47.8% from the 34.3% obtained in a similar survey in 2006 (2011 HIV surveillance study on tuberculosis, MoH). The National TB Control Programme is currently implementing the second five-year strategic plan 2010–2014. The programme has achieved a treatment success rate of more than 85% for several years.

However, case detection, particularly of drug-resistant TB, has remained a major challenge.

Malaria morbidity and mortality have dramatically dropped since 1999, both in young children and in the general population. The overall malaria morbidity (in both children and adults) has reduced by 74% between 2000 and 2012, while the overall mortality due to malaria has decreased by 83% over the same period. The 2012 Malaria Indicator and Prevalence Survey showed a low parasite prevalence of 1.4 % by RDT and 1.1% by microscopy indicating that the country is progressing towards pre-elimination of malaria.

According to the HMIS report 2012, anaemia and malnutrition are two of the leading causes of morbidity and mortality in both adults and children under five years of age. In 2012, malnutrition ranked as the 12th leading cause of outpatient morbidity, the third cause of inpatient morbidity and the leading cause of mortality in children under five years. It remains one of the major public health problems in the country.

Noncommunicable diseases (NCDs) especially diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases and cancer, are on the rise.

A recent survey (2010) shows a prevalence of 14.1% for hypertension and 4.7% for elevated blood sugar levels in the general population. An estimated 7.2% of the population smoke daily while 39.6% drink alcohol. The prevalence of low fruit consumption in the population was about 85%, low vegetable consumption was 50%, 3% of the population are obese (> 30Kg/m2) and around 10% are physically inactive. In 2010, a total of 6077 cases of mental disorder were reported in hospitals and health centres out of which 32% were due to neurosomatic disorders, 17.1% were schizophrenia cases, while 16.2%

were mood disorder cases.

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Sexual and reproductive health, child health, adolescent health: The Mid-term Review of the Sexual and Reproductive Health Strategic Plan 2011–2015 noted that with support from partners the Ministry of Health has made significant progress in implementing the SRH Strategic Plan. The BEMOC and CEMOC are available in 80% of health facilities and 90% of hospitals respectively. The proportion of pregnant women attending one ANC visit is 90%. There are no stock out of essential drugs and commodities. There are several initiatives in place to improve access to emergency obstetric care services (maternity waiting homes, special newborn care units, etc.). The incidence of FGM has significantly declined. There is accelerated development of human resources in pre-service and in-service training. However, a progressive increase in ANC dropout rates has been noted and may require further investigation. There is a persistently high unmet need for FP, several key SRH/MNH competencies are inadequate (PAC, ASRH, FP, ENC etc.) and sepsis is emerging as a major cause of maternal mortality and deserves increased attention. Additionally the focus on critical indicators being tracked under MDG 5b is limited, thereby hindering progress towards attainment of the targets of MDG 5 b.

Health and Environment: Eritrea is vulnerable to climate change and variability with its attendant droughts, floods, and rainfall — all of which could reverse the development gains of the country. This has an impact on the health of vulnerable groups especially the nomadic community that relies on pastoralism as a means of survival. This group has to access health services including immunization and antenatal care through special outreach services as they move from place to place in search of water and pasture for their animals.

In addition, the country is vulnerable to volcanic eruption and earthquake due to its location in the Rift Valley. Therefore disaster risk management is critical to minimize the impact and build resilience of systems and individuals.

2.4 National response to overcoming health challenges

One of the guiding principles of the national health policy is to promote equity in the provision of health services. This refers to equitable distribution of the costs and benefits of health services to all people regardless of their location, ethnicity, gender, age as well as their social, economic, cultural and political status. The principle aims at ensuring universal access to available resources and services in order to ensure coverage of the most important health needs of the population, with care provided according to need. The policy underlines

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that in principle no one should be left out, no matter how poor or how remote they are. However, all people cannot be reached at the same time; hence those in greatest need receive priority. Among those whose needs are greatest are those who have limited physical, financial or cultural access to the service and those who are most vulnerable like mothers and children. This need-based priority setting is the basis for planning the delivery of health services in the country. In line with this principle, health services are provided at nominal cost affordable by the majority of the population. Health facilities are constructed within the 5 kms radius throughout the country with ambulances stationed in the remotest health facilities to support referral of patients who need it.

In addition, regular rounds of integrated sustainable outreach services (EPI, ANC, FP, growth monitoring, and health promotion) are conducted in hard-to- reach areas and among the nomadic population.

National development process and policies

The overarching national development strategy is yet to be finalized.

However, sector strategies and policies for Health, Education, Agriculture and Environment are in place. In order to improve the economy and reduce poverty, the Government of Eritrea has formulated two strategies: The Interim Poverty Reduction Strategy Paper — I-PRSP (GOE, 2004) and the Food Security Strategy — FSS (GOE, 2004). The long-term objective of the PRSP is to attain rapid and widely-shared economic growth with macroeconomic stability and steady and sustainable reduction in poverty. The Government remains highly committed to the achievement of the MDGs and, at present, commendable progress has been recorded towards the achievement of these goals especially MDGs 4, 5 and 6.

The Government of Eritrea has made efforts to mainstream disaster risk reduction at the sectoral level, under key ministries such as Health, Agriculture, Labour and Human Welfare. However, these sectoral initiatives require synergy for maximum impact. This therefore calls for a coordinated multisectoral response mechanism.

National health policies, strategies and plans

The National Health Policy takes stock of the achievements post-independence and recognizes the key challenges to be addressed. These include low percentage of pregnant women who access skilled birth attendance; high

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neonatal mortality; the most-at-risk population groups still exposed to HIV; TB prevalence and incidence that is still a challenge; the threat of resurgence of malaria due to climate change and cross-border transmission; emergence and/

or re-emergence of vector-borne diseases; prevalence of noncommunicable diseases and injuries that are on the increase; the rapid expansion of health infrastructure with the need to prevent, control and manage the double burden of communicable and noncommunicable diseases; progressive technological advancement in health; and the high demand for appropriately skilled health personnel. In order to respond to these challenges the health sector strives to attain strategic policy goals. The Health Sector Strategic and Development Plan 2012–2016 is developed on the basis of the National Health Policy and broad health situation analysis. The National Health Sector Strategic Plan development was led by the Ministry of Health. The strategic plan is in the process of being implemented with the support of relevant partners through programme-specific annual operational plans. Mid-term review of the strategic plan is envisaged by mid-2014.

2.5 Health systems and services and the response of other sectors

A health system, like any other system, is a set of inter-connected parts that must function together to be effective. Changes in one area have repercussions elsewhere. Improvements in one area cannot be achieved without contributions from the others. Interaction between building blocks is essential for achieving better health outcomes.

Leadership and governance (stewardship)

The Ministry of Health provides leadership in the health sector through the development and provision of policies, strategies, guidelines and support to the facilities and governance structures of regions. Guided by the national health policy and strategic plan, the MOH exercises leadership and directs partners’ support towards achieving results.

The UN agencies constitute the major partners in the country. The Government and the UN have developed a four-year Strategic Partnership Cooperation Framework (2013–2016) that has eight key outcome areas. Health, Nutrition and HIV/AIDS are among the key outcome areas of the framework and the Ministry of Health and WHO are the partners coordinating this outcome.

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Association, Youth Association, the Association of People Living with HIV/

AIDS and professional associations mainly in planning and implementation of programmes. GFATM and GAVI are major sources of funding of health programmes including health system strengthening.

Health services delivery

The health delivery system in Eritrea is organized in three-tier system namely primary, secondary and tertiary levels. The main thrust of the health policy framework is to strengthen community-based health services; gradually restructure facility-based health services in order to make them more responsive to the people closest to their homes especially in the rural areas. This is done mainly by upgrading health centres to community hospitals or downgrading them to health stations, which will require that the scope of work of health stations be enlarged to improve their service. In this regard, the strategy being used involves strengthening the decentralized health governance structures;

improving the efficiency and quality of care provided by hospitals; restructuring the existing health financing framework into an acceptable and appropriate financing structure that minimizes catastrophic health care expenditure and impoverishment of care-seeking individuals; and strengthening health sector coordination at all levels to enhance the participation of all players. Efforts and time have been put into this endeavour in order to translate all these into action. There is a new focus to formulate strategies to develop the referral system with the provision of appropriate care at every level. There is likewise a new focus on improving the quality of care at all levels and the Ministry of Health would require support in this area.

Health workforce

In response to the health challenges encountered, the health sector has adopted the policies and strategies for human resource planning, development and training, continuing education and management of human resources for health in Eritrea. Efforts were made to capture data on human resources for health at regional and national levels, but this requires consistent follow- up and sustainability to inform the decision-making process and update the current health workforce strategic plan. The Ministry of Health in association with the institutions of the Higher Board of Education, i.e. the College of Health Sciences, the Orotta Medical School and the Postgraduate Programme, is producing middle level health cadres, medical doctors and specialists in various professional disciplines. The Ministry of Health trains and produces

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associate nurses from its training schools located in the regions. However, gaps and challenges remain and should be addressed. These include developing staffing norms for different levels of service delivery points, strengthening the health workforce management system and investing in the development of human resources for health including career path and retention mechanisms to improve coverage and quality of service. The establishment and management of the human resource for health observatory is another challenge.

Health information management

The Ministry of Health has a strong HMIS that serves as the main source of data and information. However programme-specific data sources from the IDSR, LMIS, malaria, HIV/AIDS and others exist. As part of reorganizing the information system to address the issue of fragmentation of health information, the Ministry of Health has set up an HIS Division within the Office of the Minister.

Emphasis is being focused on the quality of collection, storage, analysis and dissemination of health information at all levels. Building on past experience and assessment of the HMIS system, efforts are underway to progressively integrate all Basic Health Care Package information and create an integrated and automated information hub or repository at national and regional levels.

Efforts are also being made to ensure community involvement in the process of data generation through expansion of community-based surveillance.

However, the use of processed data in decision making at the community level needs to improve as part of the health system at grass-roots level.

Medicines and technology

The National Medicines Policy (NMP) is the framework for coordination of activities in the pharmaceutical subsector. Strategic direction to improve the availability, access and rational use of medicines and medical supplies is articulated in the policy document and is being operationalized. The focus is to strengthen the regulatory mechanism to maintain the standards of manufactured, imported, exported, marketed and locally-utilised medicines and medical supplies. This is done through medicines registration; licensing of pharmaceutical premises and pharmacy practitioners, inspection and control;

development of quality control capability to ensure the efficacy and safety of medical supplies; use of national list of essential medicines as a guideline;

promoting rational use of medicines by prescribers, dispensers, patients and the community through the provision of necessary measures including

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training, education and information; promoting and supporting local production of essential medicines and medical supplies; investing in the manufacture, importation and distribution of medicines and medical supplies; strengthening the logistics management system for all supplies including laboratory and other diagnostic services.

Gaps exist in medicines registration, development of quality control capability, use of national list of essential medicines as a guideline, promoting rational use of medicines, supporting local production of essential medicines, and strengthening the logistics management system. Gaps also exist in the identification and documentation of traditional medicines, the practices in use in their promotion and their safety and efficacy. The Ministry of Health would therefore need to develop a legal framework, policy and code of ethics and practice to guide traditional medicine practice.

Health financing

The total cost of the Health Sector Strategic Plan 2012–2016 is estimated at US$ 418 404 847.00 mostly to be funded by the Government, which is the main source of financing of health services in the country. The Government is responsible for building and maintaining health infrastructure; training, recruitment and remuneration of health personnel; and procurement and distribution of essential medicines. The central Government allocates resources for health as a lump sum during the annual budgeting cycle.

Provision of health care to the population is generally free with a nominal fee charged for registration.

The UN agencies, GFATM, GAVI and a few bilateral organizations contribute to health care financing in the country mostly through specific programmes for disease control and maternal/child health, among others. These partners contribute mainly through direct financial payment into a central account of the Ministry of Health or through the provision of supplies and technical support. As a matter of government policy, there are no private health facilities operating in the country. However, there is a system of private practice within government health facilities by way of partnership between the Government and health workers. Health insurance scheme is yet to be developed in the country. The development of a health care financing policy and a clear strategy for health system financing remains a gap to be addressed.

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Responses from other sectors

Other sectors and civil society are being engaged during the implementation of the health policy, strategy and plans with a view to addressing the health determinants. The Ministry of Health is working closely with the Ministry of Environment, Land and Water for the implementation of the Libreville Declaration. In view of this, the Situation Analysis and Needs Assessment (SANA) has been jointly completed with inputs from other sectors including Ministry of Agriculture, Ministry of Public Works, Ministry of Marine and others.

The regional Plan of Action to address the health impact of climate change has been adapted by the Ministry of Health and Ministry of Environment.

2.6 National contribution to the global health agenda

Over the last decade, health has assumed an increasingly prominent dimension politically as evidenced by the emergence of a number of international agreements and initiatives. Eritrea has developed a “National Health Strategy” addressing global issues in addition to national health issues.

The areas of engagement of Eritrea include combating health threats of international concern; health as a key to poverty reduction; maternal and child health; communicable diseases control; and access to essential medicines.

The Millennium Development Goals (MDGs) include some of the most serious challenges to the health of the population and one decade after their adoption, substantial progress has been made in Eritrea in reducing child and maternal mortality, improving nutrition and reducing morbidity and mortality due to HIV infection, tuberculosis and malaria.

Legal instruments negotiated by WHO Member States such as the International Health Regulations (2005) and the Framework Convention on Tobacco Control have helped to protect the people from new or emerging public health threats of international concern. Although Eritrea has yet to ratify the Framework Convention on Tobacco Control, it is a state party to the International Health Regulation (IHR 2005).

Eritrea relies on global initiatives and international support (Global Fund, GAVI, UN, etc.) for progress in MDG attainment through projects for improving health outcomes and system improvements at local and national levels. Therefore, the dialogue between country stakeholders is often framed as a need to mobilize resources to contribute to global health goals. On a positive note, the process

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of Aid Harmonization and Alignment, through implementation of the Paris Declaration, has helped to frame the issues and ensured a more structured approach of the Government and development partners to identifying the solutions for addressing the current challenges. In addition, the country is contributing to the global debate on research and development financing and coordination for medicines and technologies.

The WHO Country Office is playing its role in the WHO reform debate in supporting global health negotiations. Under the UN Country Team, there have been some successes. In Eritrea, the WHO, through SPCF, will be working with sectors that have an impact on health. In addition, there are ongoing discussions with other UN agencies including UNDP and FAO to develop joint programmes on the control of NCDs.

2.7 Similarities with other countries

Most of the countries in the African Region still face a high burden of communicable diseases like malaria, HIV/AIDS and vaccine-preventable diseases, an area in which Eritrea has made substantial progress. The experiences from implementing strategies that led to the reduction of the burden of these diseases would be shared with other countries in the Region.

Other African countries facing a rising burden of noncommunicable diseases and their risk factors, initially considered to be a problem of the affluent developed countries, include Ethiopia, Cameroon, Malawi and Mozambique.

(Jacob Mufunda et al.: Emerging Noncommunicable Diseases Epidemic in Africa: Preventive Measures from the WHO Regional Office for Africa. Ethnicity

& Disease, Volume 16, Spring 2006).

The health system challenges are similar for most countries in the Region.

These include making the case for more effective investment in health systems in a competitive funding environment; creating better functional links between programmes with mandates defined in terms of specific health outcomes and those with health systems as their core business; building the capacity to respond to current issues and identify future challenges; and ensuring that resources are used as effectively as possible (WHO’s framework for action, 2007).

Eritrea is located in the Horn of Africa where pastoralists and nomads account for 16% of the population (reference: UNSO/UNICEF, 1992 cited Tekeste et al, 1997). A mapping of the migratory routes of the nomads in two regions of

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Eritrea estimated the proportion of nomads to be 14% in NRS and 29% in SRS Regions respectively (WHO Eritrea: Mapping of the Migratory Routes of the nomads in Northern and Southern Red Sea Zobas of Eritrea. Asmara, May 2007). This nomadic population move from place to place in search of food and water for their animals sometimes even across borders. In the process, access to health services is broken, while at the same time increasing the risk of trans-border transmission of disease. Thus there is the need for an innovative health service delivery model for these groups as well as increased trans- border collaboration. Through its networks, WHO will help local stakeholders to engage in subregional, regional, South-South and triangular partnerships.

2.8 Summary

Eritrea has made significant achievements in disease control and substantial progress towards the attainment of MDGs through the implementation of proven interventions. The health status has also improved significantly. The major challenges include the rising trends of noncommunicable diseases and strengthening of the health system. The emerging communicable diseases also pose a threat to the health gains of the country. The major focus of the Government and its partners is to sustain the achievements, improve on them and address the existing and emerging challenges.

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Table1:Key health sector achievements, opportunities and challenges Key health achievements, opportunities and challenges

Achievements and opportunities

· Impressive improvement in health status (MDGs 4,5,6). Country is on track to achieve these MDGs.

· Country has been certified as freed of dracunculiasis (guinea-worm disease).

· The country has been polio-free for over five years.

· Vaccine-preventable diseases including neonatal tetanus, measles and pertussis have ceased to be a major public health concern.

· Malaria morbidity and mortality have dropped dramatically since 1999, both in young children and in the general population. The country is therefore moving towards malaria pre-elimination.

· Eritrea has managed to sustain a strong surveillance system using the Integrated Disease Surveillance and Response approach, which has managed to detect timely and respond adequately to all outbreaks.

Challenges

· Noncommunicable Diseases (NCDs) especially diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases and cancer, are on the rise. Yet the country has not ratified the Framework Convention on Tobacco Control.

· Addressing the emerging communicable diseases such as dengue in parts of the country as well as global pandemic threats is posing a challenge.

· Acute respiratory infections, diarrhoea and malnutrition remain as public health problems that need to be addressed.

· There are health system challenges including sustainable health financing and the analysis and use of health information. Human resources management including retention remains a challenge to improve coverage and quality of service.

· The referral system remains a challenge due to inadequate transportation and communication facilities as well as lack of adherence to referral directives by the majority of those who attend health facilities.

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SECTIoN 3:

3. Development Cooperation and Partnerships

3.1. The aid environment in the country

Only a few development partners, mainly agencies of the UN system, European Union, GFATM, GAVI and JICA provide direct or indirect development assistance to support health development. In the last United Nations Development Assistance Framework (UNDAF) covering the period 2007–2011, the bulk of the support was for health. The commitment of the Government and people of Eritrea towards long-term goals and accountability in the use of partners’ funding related to specific programmes or agreements underpin the drive for further support. The UNDAF mid-term review of 2010 confirmed that significant achievements were recorded in basic social services (including health), capacity building within the civil service, emergency and recovery, and wind energy piloting. In 2012, a Strategic Partnership Cooperation Framework (SPCF) was prepared. In the SPCF the main development partners are the multilateral agencies of the UN system and national nongovernmental organizations that are to provide continuous support to the Government. The SPCF, which continues to put emphasis on health, was developed through a consultative process by the Government of Eritrea and the United Nations system to enhance the well-being of the people of Eritrea particularly the most vulnerable. Resource documents and extensive consultations with implementing partners informed the five interlinked priority areas identified for UN support namely: (a) basic social services (including health); (b) national capacity development; (c) food security and sustainable livelihoods; (d) environmental sustainability; (e) gender equity and advancement of women from which eight (8) outcomes are articulated.

3.2. Stakeholder analysis

In line with the Government’s policy of self-reliance, the number of development partners in the country is limited. Currently, the main development partners are the multilateral agencies of the UN system, GFATM, EU and JICA that

who CoUNTRY CooPERATIoN STRATEGY 2014-2016 ERITREA