HEALTH MILLENN:UM DEVELOPMENT GOALS REPORT ABRIDGED VERS10N

INNO

10NS DRIVINGHEALTH MDGslN ERI丁 REA
SEPttEMBER′ 2014

United Nations

HEALTH MILLENNIUM DEVELOPMENT GOALS I REPORTMESSAGEFROMHE AMINANURHUSSIEN,
MINISttER FOR HEALTHAs articulated in the Health Sector Strategic Plan Development Plan (2013-20161, the overallgoal of the healthsystem in Eritrea is the improvement of health status, generalwellbeing, longevity and economic productivity for
all Eritreans. Over the last few years, the country has achieved remarkable progress on basic health indicators,
including significant reductions in maternal and child mortality ratios and HIV prevalence. Access to healthcare

within a 1O-kilometre radius has increased significantly since Eritrea gained independence in 1991, from 46
per cent to 78 per cent. More than 60 per cent of the population enjoys access to health care facilities within
a 5-kilometre radius, which has generated substantial improvements in access to and utilization of quality andtimely healthcare. Eritrea is now poised to meet the three health-related Millennium Development Goals (MDGs)
by the 2015 deadline.

These achievements are the result of a concerted effort undertaken by the Government, the citizens of Eritrea,
civic and community leaders and development partners. The country's progress is also tied to the high priority
placed on health and education, the population's commitment to development and our innovative multi-sector
approaches to health.

Much work remains to be done, however, especially with regards to non-communicable diseases and new andemerging communicable diseases, which are already among the 10 leading causes of morbidity and mortality inadults. lt is also important to note that the eight MDGs are inter-linked, and sustaining the gains made in health will
require support from and attention to the sectors covered by the other five MDGs. Furthermore, more resources
are needed to improve the general wellbeing of all Eritreans.

As we approach the 2015 deadline and the years ahead, it is our sincere hope that useful lessons can be drawn

from Eritrea's successes in the health sector that can help formulate, shape and implement the post-2015 global
development agenda.
Thank you.

EI

口 H壼

抒

HEALttH MILLENNI∪ M DEVELOPMENtt GOALS I REPORT

1.INttRODUC丁 10N
1.1. Background on the MDGs
All United Nations member states, including Eritrea, adopted the eight mutually reinforcing Millennium Development
Goals (MDGs) in 2000 as a global framework for development monitoring aimed at ensuring a commitment tooverall human security and development.
Although E「 itrea has produced only one natlonal MDG report(ln 2006)since independence ln 1991′ the Governrnent
ofthe State of E「 itrea(GoSE)has lnltiated and implemented several enabllng poHcies and prograrnrnes that havefacllitated integrated development plannlng and multi―

sector prograrnrning.丁 hese sustained policy actions have

had animpact on a number ofthe R/1DGs and their assoclated targets.
This report on E「 itrea′ s progress on the health… related N4DGs′ which was prepared under the overslght of the

Ministry of Health(MoH)′

is a preliminary and partial effort towards a national MDG progress report′

fifteenmonths before the 2015 deadline.lt documents the achievements rnade towardsヽ 4DGs 4′ 5 and 6 to showcase
the po‖ cy and institutionalinnovations d「 lving that progress′
E「and identify cha‖ enges and emerging lessons thatitrea and other countries rnay use to bolster post‑2015 development agendas.丁practices for achieving the R/1DGs that can be further developed orrep‖

he report also highlights 9ood

cated,Particular emphasis is placed on theinnovative strategles that rnay have both accelerated progress towards h/1DGs 4′ 5 and 6 and generated positive

momentun∩ towards the otherfive R/1DGs.
1.2t]、 /1etl桑 oぼ Glo「 y丁his evldence― based progress report was prepared through a comprehensive analysls ofthe achievements′
drivers′ cha‖ enges

and lessons learned.A desk review was conducted′

of sources at national′

sub― national and regionallevels′

thei「with inforrnation drawn f「 orn a variety

includlng Government surveys,Data、 Ⅳas analysed using

both quantltative and qualitative rnethods′ as appropriatei Crltlcal data/inforrnatlon gaps were supplemented using

credlble∪ N sou「 ceS.Addltlonalinputs from the∪ N Country tteam in E「 itrea were also included in the reporti

だ三 二

ロエ

皿

2E COUNttRY BACKGROUND
AND DEVELOPMENtt CONttEX丁2.1.Cttunt「 y backgro∪ nd
E「 itrea

is located in the Horn of Africa region′ where arid and serni― arid c‖ matic conditions prevail.Rainfa‖

ranges from less than 200 rnillimetres per annum in the eastern lowlands to about l′

ln E「 ltrea

000 rn‖ lirnetres per annum lnasma‖ pocket ofthe escarpment.丁 he country is therefore vulnerable to the adverse effects of climate variab‖
recurring droughts and environmental degradatlon′

a‖of、 Ⅳhlchity′hamper development efforts,

党こ星L Count「 y developR̀nettt context
ln the six years fo‖ ovving independence ln 1991′

E「

itrea forrnulated and implemented socioeconornic development

policies and strategies that resulted in marked improvements. However′a border dispute with neighbouring

Ethiopia(1998‑2000)′ which escalated into a fu‖ ―scale、 ⅣaL reversed these gains,丁 he unresolved no― peace― no…

war border stalemate remalns a malorimpediment to the Government's developments efforts′

as a numberof

initiatives and resources are tied to the border stalemate.

ln addition′

E「 itrea′s economy′ which is largely based on subsistence agriculture′

the country′ s sociO― eConornic

conditions′ and the envi「 onment′ have a‖ struggled in the face of persistent drought,Vulnerable cornrnunlties′groups and households(eSpecia‖ y the female… headed)′ are particularly lmpacted by the effects of d「 ought,
More recently′ however′ econon∩ lc prospects have shown signs oflrnprovement′
rnining sector contlnue to grow.Although Eritrea is currently not、

especia‖ y as investments ln theve‖ lntegrated into global value chains′there isthe potentialforlncreased global production and trade for mineral and agrlcultural exports,Reflecting these facto「s′estimated real g「 oss domestic product growth was 7 per centin 2013′ largely d「 lven by grovving investrnent in

the mlning sector,ln the mediurn terrn′

E「 itrea anticlpates additional prospects in oil production′

tourism。 lrnprovements are also underway in the educatlon and health sectors′

fisheries andthanks to increased investment̀

Significant cha‖ enges remain′ however′ especia‖ y in regards to creating an enabling business environment,∪NITED

NAT10NSHEALttH MILLENNI∪ M DEVELOPMENtt GOALS I REPORTS

3US OF HEALTH― RELATEDMILLENNIUM DEVELOPMENtt GOALS
3.1. Goal 4. Reduce Child Mortality
MDG 4 calls for the reduction of the under-five mortality rate by two-thirds between 1990 and 2015. The global
annual rate of reduction has steadily accelerated since the 1990-1995 period, more than tripling lrom 1.2 per centto 4.0 per cent in the 2005-2013 period. Despite these gains, child survival remains an urgent global concern.
Eritrea has witnessed an unprecedented reduction in infant mortality rates per 1,000 live births, from 92 in 1990, to

58 in 2000, to 37 in 2012 WHO, 2014). As illustrated in figure 1, during the same period, the under-five mortality
rate per 1,000 live births was reduced from 150 in 1990, to 89 in 2000, to 50 in 2013 (UNICEF, 2014). Eritrea has

therefore achieved MDG 4 as of 2013.

Figure 1: Progress in Reducing Under-S Mortality Rate by Year 2015
200
150
100
50

1990

Source:∪ N IGME 2014 Report

2000

2013

︸
孤
口■
ロ
丁he lntegrated Management of Childhood lllness{IMCI)programme was formally launched in 2000′
by 2010′

guidellnes.Although there are no current statistics′
lr∩

and

facllities had at least one health worker trained to rnanage childhood i‖ nesses in line with lh/1CIa‖provements ln the use of antiblotics′

a recent evaluatlon of lR/1Cl implementation conflrrned

the quality of care and the level of knovvledge and sk‖

as vve‖ as a reduced case fatality rate.丁

ls of health staff′

o complementthe lR/1Cl prograrnrne′ E「 itrea lntroduced Cornrnunity―

IMCI(C― IMCI)in 2005.
As revealed ln figure 2′

irnrnunization coverage for the third dose of the diphtheria′ tetanus toxoids and pertussis(DP丁 )vaccine(and since 1998 wlth the thlrd dose ofthe hepatitis B vaccine)increased from 10 per centin 1991

to 98 per centin 2013.

Figure 2:lmmunization Coverage(DP丁 3)F1991‑2013
８
９

８
９

100
３
８

90
80

70 ‐
９
４

60
50
40
30
20

1。

︒
．
２

As a result of its strong routlne irnrnunization prograrnrne′

E「 ltreaヽ

1991

３

９
︒
︒
２

２
︒
︒
２

５
９
９
・

1■

Source:EPHS 2010&MOH EPlsurvey

Ⅳas certlfled as a pollo― free country by theWorld Health(Э rganization(1/VHC))ln 2008.E「 itrea has rnaintained its pollo― free status′ desplte its proxlrnity tocountries、 Ⅳhere pollo has not yet been contalned.Since 2004′

neonatal tetanus has been virtua‖ y elirnlnated′

as cert雨 ed by WHO in 2007,Measles also no longer pose a maOr threat to children wtth virtualv all Chlldren
taking their doses according to schedule,ln recognition of Erltrea′s strong irnrnunlzatlon prograrnrne′ the Global

AIliance for Vaccine lnitiatlve awarded the country for high and sustained lrnrnunization coverage on(Эctober 17′

2009 in Hanoi′ ∨ietnam。

3.2民

Goa1 5il「lprove Vlaternal Health

The M[)G‑5 target ls to reduce rnaternal rnortality by three quarters between 1990 and 2015,As i‖
figure 3′ the rnaternal rnortality ratlo for Eritrea per 1 00′

2000′ to 380in 2013(VVHO′ 2014).Eritrea has already exceeded its R/1DG‑5 target of 425 per 100′

∪NITED

NAT10NS

ustrated ln

000 1ive births dec‖ ned frorn l′ 700 in 1990′ to 670 in
000 1ive birthsi

HEALttH MILLENNIUM DEVELOPMENtt GOALS I REPORT

了

欅

1

義

臨

Fi9ure 3:Maternal h/1ortality Ratio(MDG‑5)
2000.
1500
1000
500
0

2013

2000

1990
Source:1/Vorld Health Statistics,2014

As shown in figure 4,antenatal coverage (measured as at least one visit during pregnancy) increased from 19 percent in 1991 to 93 per cent in 2013. As illustrated in figure 5, delivery by a skilled birth attendant increased during
the same period, from 6 per cent to 55 per cent.

Figure 4: Antenatal Care Attendance, 1991 -2013
100 .:

93
80
０
６
０
４

００﹄ＯＬ

20

1991
Source:EPHS 2010′

a∩

1995

2002

d LQAS Study{MOH(a),2013

2006

2010

2013

Iロ
口■皿

Flgure 5: Per cent of deliveries attended by health workers, 1991

- 2013

60
50 1
40 1

菫301
20 1
10 1

6

1991
Source:EPHS 2010′

1995

2002

2010

2013

and LQAS Study(MOH{a),2013

Ninety― slx per cent of mothers get atleast one post― natal care vlsit(MOH′ 2013(a))。 Access to emergency obstetriccare services increased by rnore than 300 per cent bet、 Ⅳeen 1995 and 2013′ frorn 21 per cent to 88 per centi

丁he R/1inistry of Health uses a′ 6‑6‑6′ prograrnrne to improve post― natal care coverage′ which means a six hour′ー
slx day and six week fo‖ oⅥノ
Up rnonltoring process.

3,3.Goa1 6:Co師 lbat HIV/AIDS′ 陣lalaria and Other Diseases
Steady progress has been rnade towards expandlng both prevention and treatrnent services in Eritrea′s national

response to HIV and ttuberculosls.丁 he 2010 National AIDS and Tuberculosis Control Dlvision report showsthat HIV and syph‖ is prevalence were l.31 per cent and O.58 per cent′ respectively′ whlch is remarkably lower
than the prevalence rates noted in previous surveys.丁 here is also evidence of dec‖ ning HIヽ /prevalence among
pregnantヽ Ⅳomen(attending antenatal care services)′ vvith extrapolated national adult prevalence rate fa‖ ing from
2.41 percentin 2003 to 2.38 per centin 2005 and furtherto l.33 percentin 2007,As shownin table l′E「ltrean Population 8t Health Survey(EPHS)dOcumented HI∨

prevalence at O.93 per cent′than two tirnes as llkely to be infected with HIV as rnen.Furtherrnore′

ロ「
ロロ
口甲「ロ
T賄

llllllllllllllll口

11111ll膠

,:口

,::,

:ロ

'ロ

∪NITED

NAT10NS￨17

the 2010

with women rnore

data derived f「 orn blood donors and cllents

HEALttH MILLENNI∪ M DEVELOPMENtt GOALS I REPORTof voluntary counselling and testing and prevention of mother-to-child transmission services continually showsa reduction in HIV and syphilis positivity rates. ln addition to generating progress towards MDG 6, controlling
HIV/AIDS, tuberculosis and malaria will have far-reaching impacts on reducing poverty and child mortality andimproving maternal health, and s therefore key to achieving the other health-related MDGs.

Table 1' HIV prevalence by age and sex, EPHS 2010Men

15‐ 190.15

O=00

20‐ 24

0323

0300

0.16

25‐ 29

1。

49

0.26

1.21

30‐ 34

1.72

0.82

1.5

35‐ 39

2.89

1.61

2.55

40口 44

1.32

1.52

1.38

45‐ 49

0.91

0.89

0.9

丁otal

1115

0.5

0。

９
０

Women

０．

︲
ａ
ｔ

■

Age

93

Source:巨 PHS 2010

Asi‖ ustrated in flgure 6′ Sentinel Sites Surve‖ lance reports reveal a steady decline in the HIヽ /prevalence among

young pregnant、 Ⅳomen aged 15‑24.Declining prevalence in this age group can be considered a rough proxy for
declining prevalence overa‖.

F19ure 6:HIV Prevalence(%)tre∩ d′ ANC SSS 2003‑2011
3 .
2′

41
2′

2′

38

‑15‑24‑15‑49

1

５

００﹄ＯＬ

１
0′

0′

79

5
0′

28

0

2005
Source: ANC SS Survey, Eritrea

2007

2009

2011

ＥＥ
VVlth decreasing trends ln HIV incidence and lncreasing use of antiretroviral therapy′

HIV― related deaths are

decreasing and are expected to continue decreasing.Data on the annual number of AIDS cases and AIIDS deathsand HIV prevalence among pregnant women′

blood donors and voluntary counselling and testing cllents suggest

a reversal and stabilization of HIV infection rates within the general population′

3.S,1̀Malaritt control
E「itrea faced serlous malarla epidernics fo‖ owlng an unusua‖ y heavy ralnfa‖ in 1998 and the 1997 EI Nino.lt has

been estimated that approxirnately 7 to 12 working days are lost on average per episode of rnalaria′ 、Ⅳhich hasan enorrnous impact on the productive labour force. By 2006′

rnalarla morbidity had decreased by 74 per cent′mortality by 85 per cent and case fatallty by 78 per centitthe number of cases per 100,000 plunged by 92 percent

between 1998 and 2006{Wo‖ d BanЮ .By 2008 malatta accounted foriUSt l per cent of all deaths among children
under ive′ represenjng a maOr success story wtthin sub―Saharan Afttcao Malatta morbidtty has decllned by morethan 85 per cent and rnortallty due to rnalarla by 90 per cento According the World Health Statistics the incidence ofmalaria in 2012 was l′ 282 per100′ 000(ヽ ⅣHO′ 2014)′ moving the country towards malaria pre― elimination status.

丁he Government does note′「 isし e7:A:￢
1夢

however′ that the incidence of rnalaria cases has「 isen over the last three years.

。

11ヒ

Jal丁「
elRd of)顆 alario lncide「 ]ce轡 o「 1900 Pop∪ lation et hisk,1998‑重 01盆60

10199819992000200120022003200420052006200720082009201020112012
Source:Based on Health Facllltly Reports,1998‑2012

3、!riity… lDased 11lanage「 tent of nttalaria
3)2,Com「 ηヒA total of 4′ 067 Comrnunity Health Agents(CHAs}have been tralned since 1999 to focus on diagnosis andapproprlate treatment of fever cases、 Ⅳithln the communityi coordination of envlronmental activities;and provisionof health educatlon on bed net user environmental management′
an estimated 51.7 per cent of a‖and early treatrnent。

ln 1998′ the CHAs treatedcases of rnalarla in E「 ltrea,丁 he 2012 Malaria lndicator Survey showed that 24.2

per cent of respondents had seen or heard rnessages related to rnalaria frorn CHAs.丁 he training and deploymentof CHAs has been an innovatlve and effective strategy to control rnalarla both in the short and long terrns,∪NITED

NAT10NSHEALttH MILLENNI∪ M DEVELOPMENtt GOALS I REPORT

丁here ls an ongoing retralning of CHAs on home rnanagement of malarla′envi「 onmental control′use ofinsecticide

treated bed nets′ and early health seeklng.Between l′ 800 and 2′ 000 CHAs have been covered so far.

3.3.3,丁Llbercdosls co∩ trol
As shown in table 2′ the incidence of tuberculosis per 1 00′ 000 has decreased by 60 per cent′frorn 243 in 1990

to 97 in 2011.During the same period′ tuberculosis prevalence per 1 00′ 000 decreased by 68 per cent′ frorn 478
to 151.Mortality due to tuberculosis decreased by 61 per cent′fron∩

12 per100,0001n1990 to 4.7 per100′ 000

in 2011.According to the World Health Statistics′ tuberculosis prevalence per 1 00′ 000 decreased frorn 192 in

2000 to 152 1n 2012(VVHO′ 2014).

丁念ble ttB P「 o9「 ess in combating ttJboFculosisF 1 9SO…
Estimates per 100,000 population

lndicators

2011
Per cent reduction
1990‐ 2011

1990

2011

lncidence

243

97

60

Prevalence

478

151

68

Mortality due to TB

12

4.7

61

incidence of TB Is iess than the giobal average of125ノ 100′ 000 population&Africa average of 243/100,000.
Source:Health Bulletln′

MOH(b)

3,3.4=Life expectancy trends
Life expectancy trends are usua‖ y taken as a surnrnary lndicator of rnany other health indicatorsi As shown intable 3′ life expectancy at birth increased slgnificantly f「orn 48 years ln 1990 to 63 years in 2012.丁 hls is partly

due to reductions in infant and ch‖ d rnortality′ as we‖ as the reductlon in adult rnortality due to rnalaria and othercommunicable diseases,
Table 3i Eritrea′
Life expectancv lvears}

life

expecta∩ cy
Male

Both sexes

1990

2012

Female1990

2012Life expectancv at birth

46

61Life expectancy at age 60

11

13

Source: World Health statistics Report, 2014

1990

2012

●Ｅ

4EINNO

10NS D「 RIVING PROGRESS丁ON＼RDSttHE HEALTH MDGS
4.1. Cross-cutting innovative strategies driving progress
towards health MDGs

The Government places a high priority on health and is committed to achieving and sustaining the progress madetowards achieving its health-related goals. The Government particularly appreciates and continuously emphasizes

the decisive role of all Eritreans in development and self-reliance programmes at all levels. The innovative bestpractices used early on to achieve strong progress in health were initiated by the Eritrean People's Liberation
Front (EPLF) prior to independence and have been consolidated since independence. Chief among these is the
adoption of the Primary Health Care (PHC) approach as a principal strategy.
The Eritrean development process has been an inter-sectoral collaboration. Under the School, Health and Nutrition
Project, the health and education sectors coordinate closely to address the specific needs of children and youth

from kindergarten to secondary school.t The Government realised that schools were the only institutions that
could reach even the most remote areas and so began using schools to implement health interventions bytraining teachers to be allies for health workers. Tasks include regularly monitoring and screening students forbasic health problems, and providing lectures on topics in health education such as nutrition, hygiene, HIV and
AIDS prevention and life skills.

4.2. Efforts towards universal health coverageln the Eritrean health care planning and delivery process, the drive for equity calls for universal coverage, withcare provided according to need. ln principle, no one should be left out, no matter how poor or how remote theyare. lf all cannot be served, those most in need should have priority. Here lies the "all" in the health for all mantra.
Here also is the basis for planning services for defined populations, and for determining differential needs in alladministrative locations.
I World Bank (2008) 'One Childhood.' Documentary Film

UNI丁 ED NAT10NS

on School Health and Early Child Development in Eritrea. Asmara: World Bank.

HEALttH MILLENNI∪ M DEVELOPMENtt GOALS

4.3. lntegrated health service provision in Eritrea
The 2010 Overseas Development lnstitute study of Eritrea's progress towards the health-related MDGs concluded

that the success of the Eritrean experience was particularly due to the cost-effective inter-sectoral interventions
and the Government's long-term approach to tackling the country's health issues.2
The Government runs a coordinated and stratified three-tier health care delivery system that has also provencapable of meeting the needs of communities at all levels. The diagram below attempts to depict how this healthcare delivery system works.

(i) Primary level of service consists of community-based health services with coverage of an estimated2,000 to 3,000 people. This level provides the basic health care package (BHCP) services by empoweringcommunities and mobilizing and maximizing resources. The key delivery agent is the community healthworker led by the Village Health Committee;(li)Health Stations offerfac‖
5′(ill)丁ity―

based primary health care services to a catchment population of approxirnately

000… 10′ 000;he Cornrnunity Hospltalis the referralfac‖

servlng a

ity forthe primary health care level of service delivery′

cornrnunity of approxirnately 50′ 000… 100′ 000 peoplei Cornrnunity hospltals provlde a‖services avallable atlowerlevel fac‖ itles′ and also deliver obstetric and general su「 9ical services wlth the alrn of providing vitallife― savingsu「 gical夕 medical and otherinterventions.

eLolnsivc seFvico dclive「 y434.Stratogy of com轡 訂
丁he MoH increasingly emphasizes promotlng and preventive services in addition to curative services,Examples
include the improvementln the percentage ofirnrnunized children′

frorn about 10 per centln 1991′

to rnore than95 per cent today;the reversal and stab‖ izatio∩ of HI∨ infection in the general population at less than one percent prevalencei the ellrnination of po‖ o and neonataltetanusi and the control of rneasles and rnalaria,
2 PrOgress in health l∩Erltrea:Cost― effective i∩ tersectoralinterventions a∩ d along¨ term perspective′

p6.

I REPORT

口Ｈ

I

4E4.1,Col琥 舶∪nity i∩ volvement
E「

itrean communitles have a long― standlng culture of being actively involved ln a‖the country′ s polltical′ soclal and econornlc issues is one of key d「MDGs.Studies have shown that one of the key success stories of E「to mobilize and motivate cornrnunlties to participate in the design′lssuesi tthelr investment inivers of the rnade towards the health―itrea′

relateds development process is its ability

development and utilization of prograrnrnes′

including those related to health..

4.4.2″

lntersectorial approaches

丁he success ofinter― sectoral co‖ aboration in E「 itrea is demonstrated by approaches such as education forliteracy′
income supplementation′marketing of products′

clean water and sanitation′ irnproved housing′ ecological sustainabllity′ rnore effective

building of roads or、 Ⅳaterways′ enhanced roles for women as part of the development

agenda across sectors,A‖ of these approaches have had positlve and substantialirnpacts on the health― relatedMDGs,Experience has shown that cornrnunities often responded more eagerly to broadeL loca‖ sed and breadand butter approaches to development′

as opposed to fragmented sector― specific approaches,

4.4、 3.Political co「 vη itmeint 81η

ぼleaCershlロ丁he Government emphasizes the importance of cornrnunities developing self― rellance and inter― sectoral approaches
to health′ as、 Ⅳe‖ as the affordab‖ ity and sustalnability of a‖interventions and prograrnrnes,The National Health

POncy and the Health Sector Strategic Development Plan(2011‑2015)were forrnulated with a clear understandlng
of the principles and imperatives of the above―
also set to extend services and support this、

discussed strateglesi C)「 ganizational structures and capacitles areⅣe‖ acculturated development process and agenda ln Erltrea,﹂Ｅ Ｌ Ｆ∪NITttD

NAT10NSHEALTH MILLENNIUM DEVELOPMENT GOALS I REPORT

5.CHALLENGES ttO SUSTAIN AND
IMPROVE ttHE HEALTH― RELATEDMDGSIN ERI丁 REA
5.'1. Need for more money for healthNo country, no matter how rich, has been able to ensure that everyone has immediate access to every technology

and intervention that may improve their health or prolong their lives. Universal coverage should articulate who
is covered for what, what services are covered, and how much of the cost is covered. Health financing is much
more than a matter of raising money. lt is also a matter of who is asked to pay, when they pay, and how the money
raised is spent. This is one area in which Eritrea would benefit from learning about the experiences of others.

5.2. Need for more health for the money
Raising sufficient money for health is crucial, but just having the money will not ensure universal coverage. Nor willremoving financial barriers to access through prepayments and pooling. The critical question and abiding challenge

is how can Eritrea get the 'best bang for the limited dollar'? Efforts are currently being made to continuously
improve the quality of health care services and to institutionalize systematic approaches to measuring and ensuring

optimal levels of quality in health service provision.

5.3. Maternal and child health
As previously mentioned, while more than 90 per cent of pregnant women attend antenatal care (ANC), only
about half are delivered by skilled professional attendants. ln addition, while there has been drastic reduction in
the maternal mortality ratio since 1990 (77 per cent), it is still high at 380 per 100,000 live births. There remains

the even more pressing need to reduce neonatal mortality, which currently accounts for close to half of infantmortality. Tuberculosis control is also a remaining challenge that requires the expansion of existing interventions

with special emphasis on the DOTS Strategy in order to improve overall coverage.

口■Despite commendable achievements in the control and prevention of malaria, the threat of resurgence due toclimatic changes, cross border transmission and the national strategy on irrigation expansion for food security,
remains a realthreat in the foreseeable future. The remarkable progress in this area should not lead to complacency.

5.4. Non-communicable diseases (NCDs)
NCDs are becoming a menace in Eritrea. Epidemiologists estimate that by the year 2020, chronic diseases willaccount for "seven out of ten deaths in low-income regions of the world compared with less than half today". This

trend is already evident in Eritrea as the prevalence of non-communicable diseases and injuries is increasing. The
increasing trend of non-communicable diseases combined with the prevailing disease burden of communicablediseases pose a double disease burden challenge.

5.5. Human resources for health
The rapid expansion of the health infrastructure since independence to cater to national health needs led to a highdemand for health personnel. The adoption of primary health care as a policy priority was effectively implemented

with the necessary re-orientation of health workers, including re-training of staff to standardize the skills of thedifferent categories of health cadres that existed. Newer reform initiatives such as decentralization to the zobas
have also introduced new health resource requirements and further challenges for the sector. With the increaseof non-communicable diseases combined with the burden of communicable diseases, the sector is faced withthe challenge of providing specialised services that require a higher level of skilled staff. ln essence, the current
issue is not only numbers but also competency and the right mix of the health professionals that are able torespond to current, emerging or re-emerging health conditions in Eritrea.

5.6. Health care flnanclng
Considering the desire to improve the quality of care in health facilities for a growing population with an increasing

burden of non-communicable diseases, there is need to transform the financing framework that has been in
existence since independence. The aim should be to reduce, the economic risks to individuals and households
and concurrently generating additional resources to support the achievement of the sectors' strategic objectives.

∪NITED

NAT10NSHEALttH MILLENNI∪ M DEVELOPMENtt GOALS I REPORT

6.LttSSONS LEARNED AND
IMPLICAT10NS FOR ttHE POST‑2015

DEVELOPMENtt AGENDA
Stl.9∪ ギinler'v of losso1ls iθ arfeC
VVith less than 500 days toヽ 4DG dead‖ ne′ rnany countries have started to note lessons that ca∩ assist in theforrnulation and rnanagement ofits successorframework.丁 helessons drawn from the巨 「ltrea′ s successesln thehealth sector which could help forrnulate′ shape andimplementthe post‑2015 global development agenda includei.

1)A strong Government′ with the ab‖ ity to motivate and mobilise people behind a clear goalis key to progress.
The EPLF has rnanaged to generate a unique sense of cornrnunlty among a diverse group of ethnicities andreng10ns.
2)Cornrnunity partlcipatlon and lnvolvement in health service de‖staff and b「 ings′ services closer to the community.丁very both helps′a‖eviate shortages of skilled

his has also had an importantimpact on awareness at

the community level and′ as such′ has removed barriers to the dissernination of health lnforrnatlon.
3)lnvestmentin human capltalas a key dttver of development.丁long… terrn investments in health and education′

he Governmentforesaw future needs and madealthough this has as yet not sternrned widespread poverty.

4)Government ownership of development proleCtS and programmes is important to ensure sustainabllity andcommitmentto goals′ as well as to avold unpredictable shttts in donor priorities and/orfinancial commltments.
5)EffectⅣ e coordination among sectors avoids duplication of efforts and allows for cost中

effeclve prolects.ln

the Eritrean health sectot what rnight have constltuted rivalry between ministries has been transforrned into
opportunities to scale up services more efflciently,
6)ノ ヘStrOng

understanding and down― to… earth assessment of the resources avallable to foster developmentencourages both rea‖ stic actlons and common― sense policies.

ロエ
Ｉロ
6.2. Posl-2015 development agenda
The establishment of a post-2015 development agenda will need to capitalise on the strengths of the MDGs, while
also ensuring that the gaps are addressed and that the new development context is considered. The world haschanged considerably since the year 2000, as have individual countries and populations. The fourteen years since
the start of the millennium have seen new crises affecting development, such as the global financial and economiccrisis and an acute food crisis, especially in sub-Saharan Africa. The impact of climate change is also affecting ourplanet to a much greater extent. The global discussion on these issues has already begun and Eritrea should notmiss the opportunity to contribute to those global discussions and help to shape the post-2015 development agenda.

6.3 Shaping the national discussion on the post-2015 agenda
There are increasing calls to go beyond the MDGs and address challenges that are now becoming critical for ourcommon global wellbeing.3 Many of these elements and principles were addressed in the Millennium Declaration
but did not into the MDGs. Four issues stand out: inclusive growth and decent jobs; governance and accountability;
peace and security;and environmental sustainability. Participants in the majority of post 2015 consultations also
clearly shown how important certain values are, such as equality. People are demanding not only education, food andhealth, but also justice, participation and dignity for everyone. There is no lasting progress if people are left behind.

6.4 Where do we go from here and how?
Greater commitment, stronger action, enhanced resources and better partnerships are required to deliver the'world we want'. The post-2015 agenda requires the mobilization and equitable sharing of resources, especiallyfor countries that require them the most, in order to complete the unmet MDGs, while focusing on the next
agenda. Eritrea is ready to be part of that global dialogue and planning.

3 The MDGs

were drawn from the Millennium Declaration as well as the UN conferences of the preceding decade, but with limited popular engagement.
Some groups have criticized the MDGs for capturing a reduced and simplistic vision of development: one that ignores the linkages between issues as wellas the root causes of poverty, inequality and discrimination.

22∪NITED

NAT10NS■■ ■HEALttH MILLENNI∪ M DEVELOPMEN丁丁HE SGOALS I REPORTUS AT A GLANC圧

GOAL4:REDUCE CHiLD MORTALITY
Target 4A:Reduce by two‐ thirds′ between

1993‐ 95

2001‐ 03

2010

2013

Indicator l:∪ nder fl∨ e rnortallty rate

136

93

Male
Femalelndicator 2: lnfant mortality rate (per 1,000)

Target2015

1990 and 2015′ the under‐ five rnortality rate

63
75

49.5

50

61

72

48

42

Male

50

Female3764.2

lndicator 3: Proportion of one-year old children
immunized against measles
Male

91.4

20

99

98

2013

Target91.6
91.3

Fema leGOAL5:IMPROVE MATERNAL HEAETH
Target 5A: Reduce by three-quarters, between
1990 and 2015, the maternal mortality ratio

lndicator 1: Maternal mortality ratio

1993‐ 95

2001‐ 03

2010

2015

985

581

486

209

220

20.6

28.3

34.1

55

69.6

(per 100,000 live births)

lndicator 2: Proportion of births attended
by skilled health personnel
Male

34.4

Fema le33.8

Target 58: Achieve, by 2015, universal accessto reproductive healthlndicator 1: Contraceptive prevalence rate

8

8/5,8

100

10.6

(currently married or all women)
Male

16.3

Female8.4

lndicator 2: Adolescent birth rate

23

14

lndicator 3: Antenatal care coverage

48

70.4

27

27

89

‑

0

93

100

(at least 1 and 4 visits)

Indicator 4: Unmet need for family planning

23

EI口 盟讀 口 H皿G0A[ 6: COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES
Target 6A: Have halted by 2015 and begun to reverse 1993-95 2001-03 2010
the spread of the HIV/AIDS

lndicator 1: HIV prevalence among population aged 15-24

-

2.4

-

2
96

2013

Target
2015

0.93

0

years

lndicator 2: Condom use at last high-risk sex (7o) (Male)

Indicator3: Proportion of population aged 15-24years

I
27.9
91

100
100

with comprehensive correct knowledge of HIV/AIDS (7o)

Male

33.8

Female24.7

lndicator 4: Ratio of school attendance of orphans to

95.3

100

school attendance of non-orphans aged 10-14 years

Male

104.1

Female89.5

Target 68: Achieve by 2010 universal access totreatment for HIV/AIDS for all those who need it

lndicator 1: Proportion of population with advanced
AIDS infection with access to antiretroviral drugs

HIV/

100

Target 6C: Have halted by 2015 and begun to reverse
the incidence of malaria and other major disease

lndicator 1: lncidence and death rates associated with

-

36

12

-

0

-

4

27

.9

-

100

-

100

malaria (per 1,000)

lndicator 2: Proportion of children under 5 sleeping under
insecticide-treated bed-nets

Male

28,4

Female27.4

lndicator 3: Proportion of children under 5 with fever who

4

1.5

are treated with appropriate anti-malarial drugs

Male
Female1.8
1.2

lndicator 4: lndicator 4: lncidence, prevalence and death
rates associated with tuberculosis (estlmates per 100,000)
lncidence ofPrevalence of

TB
TB

lndicator 5: Proportion of tuberculosis cases detected
cured under directly observed treatment short course

1990
243
478

and

Source: Eritrea Population and Health Survey {EPHS) (2010); Eritrea DHS (1995;2002)24

uNITED NAT10NS

2011

85

91

0

151

100

HEALttH MILLENNI∪ M DEVELOPMENtt GOALS I REPORTREFERENCES
P「 imary

Blblio9「 aphyl.MOH(a)′ Cornrnunicable Dlseases Control Dlvislon′ Lot OualityAssurance Sarnpling Survey Reportfor HIV/
AIDS′ S丁￨′丁B.2013′ Asmara E「 itrea

23 MOH(b)′ Health Bulletin(丁 igrigna).2013′ Asmara E「 ltrea

3.MOH′ Health Sector Strategic Developrnent Plan′ 2012‑2016(HSSDP 2012‑2016)′ 2012′ Asrnara Eritrea.
4.MOH′ Health Bulletln.2011′ Asmara E「 itrea
5.MOH′ Natlonal Health Policy.2010′ Asmara E「 itrea.
6.R/1(Э H′ 2013 National EPI Coverage Survey′

Asmara E「 itrea.

7,MOH′ P「 ogress in Health MIIlenniurn Developrnent Goals′ 2013 Asmara E「 ltrea
8.NSEO(National Statistics and Evaluation Offlce′Oslo′

E「 itrea)and

Fafo― lnstitute for Applied lnternational Studies

Norway,E「 itrea Population and Health Survey 2010.2013′

Asmara E「 ltrea.

9.∪ srnan Abdulmumini et al′ Prevalence of Non― Cornrnunicable Disease Risk Factors ln E「 itrea′ ′Ethnicity&
Spring 2006

Disease′ Volume 16′

10.Report of an external review of the National Tuberculosis Control Prograrnrne 2012′ Departrnent of HealthServices National HIV/AIDS&丁 uberculosis Control Divislon(NATCoD′

Asrnara E「 ltrea

ll.Rornina Rodriguez Pose and Fiona Samuels:(Э verseas Development lnstltutei(2010)Progress in health inE「 itrea:Cost― effective inter―

sectoralinterventlons and a long― terrn perspective

12.MND′ Millenniurn Developrnent Goals Report′ 2006′ Asmara E「 itrea
13,Nttd中丁
errn Review of the Sexual and Reproductive￢ ￢ Health Strategic Plan 2011‑2015 for巨「itrea′」une′2013′ Asmara巨「itrea

14.NSEO(National Statistics and ttvaluation Office′ E「 itrea)and ORC h/1arco.1996.E「 itrea Dernographic andhealth survey 1995。

Calverton′ Maryland′∪SA;National Statlstlcs and Evaluation Office and(DRC,darco

15,∪ NICEF′ VVHO′ World Bank′ ∪nited Nations′ Levels and ttrends ln Child R/1ortallty′ Report 2013′ 巨stimates
Developed by the lnter― agency Group′ for Ch‖ d,uo「 tality Estimation.∪ NICEF′ 2014.
16。

WHO/ICO lnforrnation Centre on HPV and Cervical Cancer:Eritrea;Hurnan Paplllornavl「us and Related

Cancers′ Fact Sheet 2009(」 an 29′ 2010)

17.VVHO′ World Health Statistics Report′
18。

African Economic Outlook′E「 itrea

2014

2014

Secondary BibliogralDhy
19.R/1(DH:Natlonal health Policyl March 201 0

20,M(DH:Health Sector Strategic Development Plan 2010… 2014
21,R/10H:Surnrnary of Health Sector Development Plani 2012‑2016
22.R/10Hi Sexual and Reproductive Health Strateglc Plan 2011‑2015
23,MOH:Road R/1ap for rnaternal and Newborn Health 2012…

2016

24.MOH/HMISi Annual Health Servlce Report of Year 2011(May 2012)
25,R/10H:Eme「 gency Obstetric and Newborn Care Curriculumi 2nd Edition′

2011

26.MOH:PMTC丁 lmplementation guidellnes(」 an 2012)
27,MOH:Natlonal Guidelines for HIV Counseling and ttesting(Nov 2005)
28,R/10H:Post ttxposure Prophylaxls Guideline
29,R/10Hi natlonal Health lnforrnation Systems Pollcy and Policy Guidelines′

June 2011

R/10H:丁 ralning Package for S丁 l and Syndrornic Approach to R/1anaglng S丁 I Cases

25鞣口 H剛Credits
Production: Julie Pudlowski Consulting
Photography: @ UN/ Ladavicius