The roots of significant health progress in Eritrea can be traced to the years of the armed struggle against Ethiopia’s rule.
The Eritrean government, officially known as the Eritrean People’s Liberation Front (EPLF) at the time, had recognized the necessity of health for the cultivation of a productive, economically developed and resilient society, which led the front to take responsibility and establish a parallel state system in the already liberated areas. As a matter of fact, the war for independence wasn’t just aiming to liberate the Eritrean people from Ethiopia’s domination but also from “illiteracy, ignorance, disease and backwardness” (Findlay, 1989 in ODI, 2011). Thus, the EPLF developed mobile clinics, fully equipped underground hospitals, a drug manufacturing factory and skilled health workers with an eye towards the future. With advancements in all sectors, Ethiopia’s rule was forced to come to an end in 1991 with only 5 of the 31 heath facilities constructed, accredited to its name (MoH, 2006).
After the sovereignty of the State of Eritrea was ratified by the world, the government expended further efforts in promoting the health of its people by constructing, rehabilitating, equipping, furnishing and staffing the dilapidated health system without losing sight of its main focus: Comprehensive Primary Health Care. Since then the Ministry of Health (MOH) and partners have been making countless endeavours towards the “provision of sustainable quality health care that is effective, efficient, acceptable, affordable and accessible to all citizens” (NHP, 2010). This led to the construction or rehabilitation of a total of 28 hospitals, 13 community hospitals, 53 health centres and 186 health stations (HSSDP II, 2016) nation-wide to attain universal health coverage. The MOH’s mantra of “Health for All” further led to the introduction of the nominal user’s fee scheme which allowed the society to enjoy health care services for free or with nominal charge. This scheme holds anyone with very low economic status eligible for exemption if he/she brings a poverty certificate from the Local Government. Moreover, the MOH connects the three-tier health care delivery system it follows through a free referral network.
In addition to the inheritance of a devastated infrastructure, the country’s skilled man power was not sufficient to meet the scale of the society’s health needs. Thus, the government put its emphasis on human capital investment by establishing unprecedented colleges for the production of new health cadres and pioneering in-service and on-the-job training to strengthen the existing workforce. Consequently, the doctor-population ratio has increased from 1: 37,500 in 1991 to 1: 17,000 in 2016, while nurse to population ratio has increased from 1: 9,500 in 1991 to 1: 3,386 in 2016 (HSSDP II, 2016). In line with the MOH’s principle of equity, Eritrea is one of the few countries in Africa to decentralize health services, allowing no disparities in health personnel allocation between urban and rural settings.
According to the government’s Macro policy, “the overall vision of Eritrea’s future progress is ultimately to tone up the human capital, particularly through strengthening the education and health sectors” (GoE 1994 in ODI, 2011). The key elements of Health and Education together with the government’s principle of self-reliance, enshrined at the core of this policy, proved to be mutually reinforcing and served Eritrea well in registering commendable progress in the health sector.
Eritrea has been one of the few countries to achieve Millennium Development goal 4 by reducing under-five mortality rate by two-thirds between 1990 and 2013 (two years earlier than the due date), that is from 150 to 50 deaths per 1000 live births (MoH, 2014). This figure has further declined to 44 per 1000 live births in 2016 (WHO, 2017). Likewise, infant mortality rate has decreased from 93 per 1,000 live births in 2010 to 33 per 1,000 births in 2016 (WHO, 2017). These declines are owed to the Ministry’s focus on Primary Health Care, which includes cost-effective interventions capable of offering the greatest health impacts. The strategy of basic health care has helped the country eliminate maternal and neonatal tetanus and reduce measles incidence to less than 90% of the 1991 levels (WHO, 2017). Eritrea has also been certified as “Dracunculiasis-free” (guinea-worm disease) and has achieved polio-free status (WHO, 2017). Recently, the country has also been able to maintain over 95 percent coverage for nation-wide immunization programmes, with the help of UNICEF (UNICEF, 2019). Another factor contributing to under-five mortality is malnutrition which the Ministry is tackling by setting up health facility-based and community-based therapeutic feeding centres throughout the country. Through this initiative, supplementary feeding is being provided free of charge to children with mild and acute malnutrition.
Primary Health Care services have also assisted Eritrea in improving maternal health by increasing antenatal coverage from 19 percent to 95 percent and skilled delivery from 6 percent to 59 percent from 1991 to 2015 respectively (HSSDP II, 2016). These factors helped decrease the maternal mortality rate from 998 deaths in1995 (MoH, 2006) to 485 deaths per 100,000 live births in 2016 (HSSDP II, 2016).
Furthermore, communicable diseases like HIV, TB and Malaria have been controlled successfully. According to the World Health Organization’s global health data observatory the prevalence of HIV/ AIDS is showing a declining trend as it has reduced from 1.3% in 2005 to 0.84% in 2015. TB treatment success rate has increased and Eritrea has entered the elimination stage for Malaria. However, non-communicable diseases, especially the incidence of hypertension and diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases and cancer, are on the rise, indicating Eritrea is no exception to this global phenomenon (WHO, 2017). Overall, the health status of the population has improved significantly with the increment of life expectancy from 49 years in 1991 (MoH, 2006) to 64.7 years in 2016 (HSSDP II, 2016).
Eritrea’s progress health care is striking and very surprising to many given the contextual barriers it has faced. The country has been able to show improvements in the health sector prior to its independence, during the 30-year war of liberation, and has even made greater advancements in the post-independence period. It has survived and was capable of maintaining its progress during the national recession brought about by the renewed border conflict with Ethiopia and later on by the UN sanctions. Thus, these remarkable achievements are a tribute to the titanic resilience, willingness, readiness and responsiveness of the government and the people of Eritrea.
In conclusion, although the MOH has been on a very successful journey, it still has a long way to go as neonatal mortality rate, maternal mortality rate, unskilled delivery and a bunch of other indicators are still high and need immediate and effective interventions. Efforts are underway to push these accomplishments to new heights and achieve better standards of living.