The Ministry of Health (MoH), Health Division at that time, first publicized its National Health Policy (NHP) in November 1991 through Hadas Eritra newspaper. The health policy focused on developing primary health care system and was based on the guiding principle of ensuring social justice. The MoH launched a health policy not more than six months after Eritrea’s liberation and has been developing and refining its policies further since then.
The 1991 health policy was based on the principles of social justice, equal distribution of services and opportunities, self-reliance and active participation of the people – guiding principles of the EPLF during the struggle for independence. After the liberation of Eritrea, these were the basic approaches followed for the delivery of a primary health care system.
Although building healthcare facilities and equipping them with qualified personnel and medical supplies is key to ensuring the provision of quality healthcare service, it is not sufficient. What is also needed is clearly stated policies and strategies whose implementation should be supervised and reviewed after which the policies are then improved.
When the 1991 NHP was reviewed it was found to be not comprehensive. In 1996 the MoH drafted a more detailed NHP that initiated the successes in healthcare that Eritrea has achieved. The policy and policy guidance of primary health care system was reviewed in 1998 based on the feedback and experience obtained from health facilities all over the country.
The 2010 Eritrean National Health Policy (NHP-2010) has served well in guiding the healthcare sector in its five-year strategic and annual operational plans at the sector and program levels. Now, almost ten years later, taking into account the new era of development that we are embarking on, the challenges of health care, including epidemics and pandemics, we face, the demographic changes that are happening as well as other national and international issues, it is high time that the 2010 policy is reviewed to see its progress and determine Eritrea’s next ten-year health policy direction that responds to the country’s national development aspirations. To do this, a newly drafted health policy has been in use since 2019. After it was reviewed extensively, the NHP-2021 has now been completed, awaiting publication.
NHP-2021 will be the third of its kind and will guide Eritrea’s healthcare for the next ten years, until 2031.
It 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 wellbeing of all, through universal access to affordable, quality and essential health services delivered through resilient and responsive health systems. Its mission is ensuring physical, mental and social aspects of health of the people of Eritrea by providing universal health coverage.
Right after independence, one of the priorities of the government of Eritrea was replacing the incapacitated health facilities it inherited and building new ones in areas where there had been none. NHP-2021 stipulates that the building of new health facilities by identifying areas where they are needed and expanding services to reach all citizens will continue.
The health sector’s goal and objectives cannot be met without making substantial progress in Universal Health Coverage (UHC), which is constituted by three policy directions. Hence, achieving UHC lies at the center of the policy priorities. The UHC aims to ensure that the country is able to (a) identify and plan to make available the full range of essential health and related services that the population requires, (b) progressively increase coverage with these essential health and related services by addressing access and quality of care barriers, and (c) progressively reduce the financial barriers that populations are facing when accessing these essential health and related services until there is equity and financial risk protection in the financing of services.
Achieving UHC will, in turn, require strengthening the health system to deliver effective and affordable services to prevent ill health and to provide health promotion, prevention, treatment and rehabilitation services. The strengthening of a Health system requires a coordinated approach involving improved health governance and financing to support the health workforce and access to medicines and other health technologies in order to ensure the delivery of quality services at the community and individual levels. As part of this, health information systems will be vital in informing decision-making and monitoring progress. Investments in these areas should seek to increase responsiveness, efficiency, fairness, quality and resilience based on the principles of health service integration and people-centered care. To strengthen the health sector and help attain its goals and objectives, the policy identified policy priorities in four action areas — inputs and process, outputs, outcomes and impact levels. These four priority action areas are rooted in an integrated approach toward the strengthening of the system and appropriate sequencing of actions for the best possible outcomes.
Health service in Eritrea is given on a three tier system. The primary level constitutes community health services, health stations, health centers and community hospitals. The secondary level includes regional referral hospitals and first contact hospitals while the tertiary level covers national referral hospitals.
Community based health service facilities are administered under the local administrations and local health representatives to serve 500-2000 people by a trained community health representative. The service they provide focuses on healthiness and preventing diseases, and they are mandated to give certain medications in accordance with their level and to oversee prescriptions.
A health station is an elementary health facility that provides basic health service and focuses on enhancing health, giving medication and preventing diseases. It is designed to serve from 5,000 up to 10,000 people. Some of the units that it comprises include delivery unit, OPD rooms, temporary inpatient rooms, pharmacy and laboratory. Based on NHP-2021 the health stations will be upgraded to health centers.
A health center is similar to a health station but with an increased capacity. It is designed to serve 50,000 – 100,000 people.
Based on NHP-2010, a number of health centers have been upgraded to community hospitals. And based on the new NHP-2021, the functioning health centers will be upgraded to community hospitals where they are needed. The remaining will continue to provide service with qualified health professionals as the lowest tier of the health facilities.
A Community hospital is the first contact hospital that oversees, supports and controls health institutions below (health centers and community-based health services) and is the highest health institution within the first tier of health system. It is designed to serve people between 100,000 to 200,000. Some of the services provided in this system include delivery units, operation, radiology, OPD, laboratory, inpatient units and pharmacy.
The second tier of health service includes regional referral hospitals and national referral hospitals. Regional referral hospitals are administered under the auspices of MoH regional branches and provide all kinds of medical services as the highest referral hospitals to the health institutions within their region. They can serve more than 200,000 people.
The tertiary level of health service includes the National Referral Hospitals in Asmara. At this level specialists give medical aid to patients who come from regional referral hospitals for higher medical service. Tertiary level health institutions serve as the highest level of medical institutions, training centers of health professionals and research centers.
Eritrea aims to achieve UHC, and the progress on several fronts is very encouraging. The following indicators demonstrate that Eritrea has been moving towards the attainment of UHC.
Eritrea has also been notably successful in the Expanded Program on Immunization (EPI), achieving virtually universal (98%) immunization coverage. It 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, Eritrea was also given the 2016 UNICEF award in recognition of its outstanding achievement in vaccine management.
Eritrea has made a significant progress in securing mother and child care and in controlling and preventing communicable diseases. The plan is now to improve the quality and coverage of health services by retaining what has been achieved.
In 2019, virtually all women (96%) attended Antenatal Care (ANC) during their most recent pregnancy. This has shown significant improvement from 19% in 1991 to 98% in 2019, which is a 416% increase (five-fold). Moreover, around 71% of mothers gave birth in health facilities with the help of health professionals, a 1083% increase from 1991. A 2015 health and demographic study by the MoH shows that maternal mortality ratio was reduced by 69%. Child mortality rate for children below five years of age was 153 from 1000 in 1991 and was reduced to 40 out of 1000 in 2019, which is a 74% decrease. The mortality rate of children below age one was 94 out of 1000 in 1990, and a 2019 data reveals a 68% decrease. 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.
The prevalence of HIV in the general population was 0.93% in 2010. At this time HIV prevalence (in ages above 15) is estimated at 0.6%. Moreover, in malaria control, Eritrea is working towards pre-elimination phase. From 1999 to 2020, malaria-caused death was reduced by 98%. As a result, HIV and malaria prevalence has not only reduced to the lowest level, but are on the elimination phase.
But this doesn’t mean nothing remains to be done in controlling communicable diseases. Although most of the common communicable diseases have been significantly reduced or eliminated, some hygiene-related diseases continue to pose health risks. By gaining momentum from what has been achieved, the plan is to pay due attention to controlling and preventing communicable diseases. Moreover, the coronavirus pandemic has taught countries that communicable diseases can appear anytime and cannot be ruled out.
On the global level non-communicable diseases have been on the rise and caused 71 percent of deaths last year. Similarly, the trend is evident in Eritrea as the prevalence of non-communicable diseases and injuries are increasing, already posing a challenge to 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 double burden of diseases’. Road traffic injuries are high, mainly affecting the productive and young population, with increasing mortality levels over the years. There is no evidence of reductions in the trend of these diseases. On the contrary, malaria, tuberculosis and HIV-AIDS and pregnancy and delivery related deaths are projected to be retained at the current level or be reduced.
A life course approach is one of the methods the NHP- 2021 will work on to achieve a secure health for all citizens in all ages. This method is aimed at giving treatment starting from pregnancy, during the early childhood, adulthood to aging. The risk of non-communicable diseases increases with aging and other causes and a life course approach reduces this risk.
NHP-2021 aspires to increase not only the number of health facilities but also the quality of service provided. This is measured by the competence of health professionals, capability of health institutions and facilities, quality of medicines and medical instruments, demand and usefulness of health services, health policies, directions, plans and their implementation, capability of controlling and informing systems, administering, researching and studying.
The MoH has been working not only in expanding health service coverage but ensuring a clean and quality health service. It is important to acknowledge that a clean and quality health service is not a specific time target but a continuous process.
The third Sustainable Development Goal (SDG-3) of the UN is aimed at achieving “health and wellbeing for all citizens in all ages.” This has been primarily a mission of the MoH and is included in the NHP-2021. The fundamental aim of this goal is to achieve UHC by strengthening the health system at all levels (health facilities infrastructure, health professional training, medical supply, quality services and information systems).
The MoH will work in cooperation with other stakeholders to achieve the SDG goals directly related to the health and wellbeing of citizens. It will endeavor to respond to the Eritrea’s Vision to become a nation that is economically, politically, socially, culturally and psychologically well developed by building a resilient health care system.