Access to health care has become a luxury to many around the world. Health expenditures continue to increase; in some countries health insurance companies continue to choose their clients based on their health status. Many patients wait in line for hours for a simple check-up with out-of-pocket costs for medical care ruining households. In regards to the health sector the world is further divided between the developed and the least developed worlds. Some countries may have excellent health care services while others are striving to find medicine at affordable price. The world is facing an increase in expenses in health care.
Financing health care and providing access to all remain a developmental challenge for the continent. Financing health is key to promote and achieve the 2030 Sustainable Development Goal (SDG) on Universal Health Coverage. Financing health requires political will to allocate public funding to the health care sector, but financial capacity is often challenged by the lack of proper tax system and widespread informal economies. Challenges around financing health have direct impact on the people. According to the WHO’s Report entitled State of Health Financing in the African Region of January 2013, to overcome issues of health expenditures and lower the out-of-pocket expenses of individuals, several declarations have been signed such as the Abuja Declaration of 2001 on increasing public funding for health, the 2006 Addis Ababa Declaration on Community Health, the 2008 Ouagadougou Declaration on Primary Health Care and health systems in Africa and the 2012 Tunis Declaration on value for money, sustainability and accountability in the health sector.
In Eritrea, access to health care has been top priority since independence. There were 93 health facilities nationwide giving free health services in 1991. Today there are 340. The newly independent nation had the huge task of giving access to health care to its citizens without any discrimination of age, gender, ethnicity or wealth. Free health care was introduced to ensure that everyone has the right to health. Three levels of health care were quickly implemented, primary, secondary and tertiary levels comprising clinics at the primary, health stations/centers and community hospitals at secondary level and regional and national hospitals at tertiary level. Primary and secondary levels are health centers closer to inhabitants within a subzone. People are able to visit those centers for basic health service, vaccinations and prenatal check-ups among others. Mobile clinics, vaccination campaigns in schools, ears and eyes checkups are also given at the primary health care level.
During a panel discussion on local TV last week, three professional from the Ministry of Health – Mr. Berhane Ghebretensae, Director General of Health Services, Dr. Andeberhan Fessehatzion, Acting General Director and Dr. Mismay Ghebrehiwet discussed the achievements, challenges and future prospects of the health care system and health financing in Eritrea.
The health care system in Eritrea has shown progress since 1991. Communicable diseases such as HIV/Aids and malaria are close to zero while polio has been totally eradicated in 2006. According to Mr. Berhane, child mortality was at 72 per 1000 in 1995 and the number went down to 42 in 2012. Similarly, maternal death decreased from 998/100,000 in 1995 to 480/100,000 in 2012 while the national life expectancy grew from 49 to 63 in comparison to the African continent’s average of 59. Dr. Mismay also shared some numbers in terms of health care facilities. In 1991 there were only 16 hospitals compared to 26 today, which is an 81% increase. Central hospitals have increased from 5 to 59 and clinics or health centers from 72 to 300. Many hospitals including the Mendefera and Orota referral Hospitals have been renovated. The improvement in health care coverage nationwide is also remarkable, with an increase of vaccinations of children from 10% in 1991 to 98% today. Pregnant women are now keener to visit health facilities, their number has grown from 19% in 1991 to 93% today. Besides under-5 child mortality decreases from 151 to 41 i.e. a 70% decrease compared to 54% decrease in Sub-Saharan Africa. The achievements of the first 25 years of Eritrea are results of efforts in, firstly, raising awareness about health care, disease prevention and understanding in changing bad habits in terms of nutrition and the importance of visiting health stations. The achievements registered deserve recognition, but, the panelists underscored there is room for improvement.
The image of health care has changed over the years but many patients continue to go directly to referral hospitals or do not go to hospital until reaching an emergency situation. Actually, Dr. Mismay said that most health cases could be treated at the health stations nearest to patients’ home.
Hence, there is room for improvement in changing habits and informing people that going to clinics may be less costly and efficient. Certainly, areas where health care access remains low or is of poor quality push people towards bigger health facilities. Therefore, the strategic framework for 2017-2021 focuses on the Sustainable Development Goal (SDGs) on Universal Health Coverage including improving access to health care in all corners of the country and, particularly, in improving the quality of services by providing further training to health workers and by monitoring activities and responding to the increase in non-communicable diseases including diabetes, cardiovascular related diseases and injuries and continue the fight against communicable diseases.
The strategy is also to “un-congest” hospitals by informing people and by ensuring that health care services are of quality at every health station. “About 90% of people’s health issues can be solved at primary level”, Mr. Berhane said.
Expanding access to health care through the different levels of infrastructure goes hand in hand with the vision of social justice. To ensure equal access to health care services, most health services, including medicines, are given free of charge or at nominal prices. The question is: how much of the medical expenses are covered by the ministry and how much is out-of-pocket expense of patients? On the African continent, more than 40% of health related costs are paid by out-of-pocket despite the Abuja Declaration recommending the African Union member states to allocate “at least 15%” of national budgets to the health sector (WHO 2013). By 2010 only five African countries managed to meet the target while 13 others actually decreased their health related expenditures.
According to the Global Health Expenditure Database of the World Health Organization (WHO), on average a person living in the United States spends 8,362 US Dollars annually whereas in Eritrea the amount is 12 US Dollars. In fact, the Eritrean government carries more than 85% of total health expenditures in comparison to the 9.8% average allocated to the health sector in Africa (WHO 2017).
Salary of health workers, laboratory related costs, vaccinations, radiology, rooms, food, lightning, medical and transport equipment, water and all related costs make the health sector an expensive one. The Government took upon the task of giving nearly free health care services to ensure that no one is left behind. Dr. Andeberhan explained that those who cannot afford to pay their medical fees are exempted by their local administration.
According to the National Health Policy (2010:8), “Eligibility for exemption on poverty is on the basis of the provision of poverty certificate from the local government with the understanding that the local administration that issues the poverty certificate will be responsible for paying for the services provided to the poor”. Emergency services are free of charge for the first 24 hours in all health stations. The nominal fee remains very low at 1 Nakfa for an inpatient per night to register in small clinics and 3 Nakfa for the registration card in health stations. The amount is 15 Nakfa at zonal hospitals and can reach up to 50 Nakfa at Orota Referral Hospital, said Dr. Andeberhan.
Regarding the National Health Policy of 2010, hospitals absorb about 50% of the public budget whilst health centers account for about 25%. According to Dr. Mismay, in referral hospitals, the nominal cost for an inpatient is 9.50 Nakfa including breakfast, lunch and dinner. The cost varies according to the service sought. A four bed-room facility costs a patient 30 Nakfa, a two bed-room 50 Nakfa and a single room 200 Nakfa.
The country responds to the necessity to ensure that all citizens have access to health care especially children and women through subsidies, resulting in the provision of all 11 vaccinations free of charge although international prices continue to increase. Dr. Mismay gave some figures for comparison: “the international expenditure on vaccination was between 3.50 to 5 USD for one child in 1980. The price was registered rose 6 USD in 2000 and 18 in 2010. By 2013 the price went up to 50 USD for one child. However Eritrea continues to provide it for free”.
Health financing is thus an important part of public expenditure and assessing its future is essential. Subsidies and out-of-pocket expenses will need further analysis within the next five-year plan, Mr. Berhane said. Public expenditures continue to increase with the introduction of new technology, the establishment of new departments such as a fertility center in the near future and better gynecological unit among others. The emergence of non-communicable diseases and injuries require higher expenses in treatment and medicine and, more importantly, quality control of service provision at all level of care.
Certainly, out-of-pocket expenses in Eritrea are far lower than the global average. However, external expenses related to health care have to be considered. Transportation, accommodation and food including those accompanying a patient can be a heavy financial burden especially those coming from rural areas to see a specialist for instance. The idea is to enable patients to find all care nationwide without having to go on a long journey to find a referral hospital. Besides, if expenditures continue to increase, the 10% paid by patients will also continue to increase. “If a patient has to make an important surgery and, let’s say, the overall expense is 20,000 Nakfa, the patient will have to pay 10% of it. In other words, 2,000 Nakfa which may be difficult to pay all in one as it may be equivalent to the patient’s two month salary”, said Dr. Mismay. Out-of-pocket expenses are therefore heavy to poorer households who may turn to borrowing to pay the fees. Although the high coverage through subsidies by the Government is commendable compared to other African countries, ensuring the provision of health services would require the establishment of health insurance or national security number as mandatory in the near future and as a pillar for sustainable development.
Eritrea understood early on that the greatest wealth is health for its society to prosper. After more than a quarter of a century since independence, Eritrea’s health sector is posed to implement the next five-year strategic plan by improving its quality of health care service, continuing its mobilisation campaigns against the spread of communicable diseases, providing prevention on non-communicable diseases and injuries, raising awareness of the consequences of bad habits, establishing new technology, extending training, specialization to respond to the need of a growing population and curb the current trend that pushes people to go abroad to seek medical care and ease the out-of-pocket expenses of patients.