In recent times, the international community has made great strides in combatting HIV/AIDS, malaria, preventable diseases, and other public health issues. For example, the global focus on immunization has seen full coverage increase from around 5% in the 1970s to 83% today;[i] international funding commitments have witnessed a dramatic scale up of malaria control interventions generating measurable reductions in malaria burden; and in many low and middle income countries, millions of people now have access to antiretroviral therapy (ART).[ii] Though the progress is certainly commendable, it is important to recognize that a multitude of challenges are outstanding, particularly within Africa and the developing world. East and Southern Africa still remain most heavily affected by HIV/AIDS, with 10 countries in the region accounting for 34% of the world’s HIV/AIDS cases;[iii] approximately 20% of the world’s children – mostly in the developing world – are not fully vaccinated during their first year of life;[iv] and the majority of the world’s malaria related deaths continue to occur in Africa, where a child dies every minute from malaria.[v]
Though the lingering health issues have prompted commitments of millions of dollars[vi] and the organization of large campaigns,[vii] one of the most successful efforts has been quietly taking place in Eritrea. Located in the fractious Horn of Africa, Eritrea has proceeded to become one of the few countries to achieve the UN Millennium Development Goal regarding HIV/AIDS, malaria, and other diseases.[viii] Further, its immunization and vaccination coverage rates compare quite favorably with much of the developing world. This paper spotlights Eritrea’s recent success in immunization, vaccination, and malaria prevention – evocative of the country’s general health efforts during its liberation struggle – while also outlining several forthcoming programs that bode well for the future.
To begin, Eritrea’s recent efforts at vaccination, immunization, and malaria control arouse memories of the country’s historical attention to health and healthcare. While the first modern hospital was built during Italian colonial rule,[ix] the national focus on and commitment to health began in earnest in the late 1960s and early 1970s, during the early years of the protracted war of independence. In developing a medically sound health system, the Eritrean People’s Liberation Front (EPLF) prioritized: “…proper nutrition; adequate and safe water supplies; basic sanitation; immunization; the prevention and control of endemic disease; health education and curative services” (Pateman 1990: 222).[x]
Although in 1970 it only possessed a single mobile health unit, the EPLF was soon able to boast: having trained 1600 barefoot doctors and forty-one barefoot midwives (by 1985); 418 village health workers and 150 birth attendants (by 1986); thirty functioning health service stations and twenty-two health centers; forty-one mobile barefoot health units; 320 village health workers; 41 radio technicians; 18 dental assistants; 151 nurses; six regional and one central hospital (Pateman 1990: 22).
Of particular note, the EPLF’s central hospital at Orotta, in Barka, and the pharmacy unit hold legendary, almost mythical auras. The Orotta hospital was often distinguished as the “longest hospital in the world” since it was built into the underground maze of trenches and tunnels,[xi] and it was the scene of thousands of operations performed by EPLF surgeons. Equally impressive, the EPLF’s pharmacy unit was made up of twenty-two members, and “…by the end of 1987 it was producing fourteen types of tablets and capsules – two million per month – and hoping to provide…for sixty percent of the population’s needs” (Pateman 1990: 222) Further, it produced 44 different types of medical supplies, including infusions, intravenous fluids, syrups and ointments.[xii]
Discussing Eritrea’s health system during the pre-independence period, Sabo and Kibirige (1989)[xiii] conclude that Eritrea remained unwaveringly “…committed to developing a needs-based health care system, which functioned efficiently well” and that through a careful, methodical selection of priorities and an allocation system for the distribution of scarce resources, the EPLF provided remarkably effective emergency services, primary care and preventive health services (Sabo and Kibirige 1989). Findlay (1989) also adds that the EPLF’s health care system was “…better than those of many already independent African states.”[xiv]
Though many of these unique health related efforts were key to Eritrea’s momentous liberation and embodied the EPLF’s commitment to the health of the population, at independence the country immediately faced destruction upon a mass scale, “…everything was destroyed [and there were]…no roads, no electricity, no water.., no education…nothing was there”; for all intents and purposes, Eritrea started from well “below zero.”[xv] Health, especially in terms of basic immunizations, vaccinations, and preventable diseases, was in a terrible state.
For example, WHO data for 1993 show that only 32% of Eritrean children had received DTP3 immunization, while measles and polio coverage were 34% and 32% respectively.[xvi] The general period also saw a high malaria prevalence rate: in 1995, there were between 300,000-400,000 malaria patients, and in 1998, approximately 500 people died annually from malaria.[xvii] To put these figures into context, consider Eritrea’s regional neighbors for similar categories (see Figure 1): in terms of DTP3 immunization, 1993 WHO figures show: Djibouti at 41%; Ethiopia at 28%; Somalia at 22%; Sudan at 49%; Kenya at 89%; Uganda at 56%; and Africa at 50%. Regarding measles coverage Djibouti was at 41%; Ethiopia was at 28%; Somalia was at 21%; Sudan was at 51%; Kenya was at 84%; Uganda was at 57%; and Africa’s coverage rate was 52%.[xviii]
Since the early post-independence period, however, Eritrea has remained staunchly committed to improving the health of citizens. Further, much like during the liberation struggle, it has utilized cost-effective, pragmatic approaches, involving broad participation.
In regards to malaria, Eritrea has categorized the infectious disease as an issue of utmost national concern. Significantly, approximately 67% of the population live in endemic areas, with the Gash Barka region bearing greater than 60% of the burden.[xix] Of note, the most common malaria parasites found in the country are Plasmodium vivax and Plasmodium falciparum;[xx] the former leads to severe disease and death, while the latter is the deadliest species of all malaria parasites infecting humans.[xxi]
To control malaria, Eritrea has employed an assortment of strategies, including the promotion of national campaigns and community based-programs. Many programs have focused on providing extensive awareness and information, organizing focus groups, using preventative interventions, and encouraging the use of medical check-ups and medication.[xxii] As well, control strategies have incorporated early treatment, indoor spraying, a focus on drainage and larviciding, mass distribution of insecticide-treated nets (ITNs), and a variety of source reduction efforts.[xxiii]
As a result of the various control measures, nearly 70% of children below age 5 now sleep under ITNs and over 60% of people own at least 2 ITNs. In addition, national malaria incidence and deaths have declined dramatically. Across the 1998-2012 period, Eritrea’s malaria deaths per 1000 people at risk dropped by 90% (see Figure 2), while the annual malaria incidence was reduced by over 85% (see Figure 3).[xxiv] Remarkably, Eritrea’s malaria intervention was recently described as “the biggest breakthrough in malaria mortality prevention in history.”[xxv]
Much like its national malaria intervention, Eritrea’s approach to immunization and vaccination has been practical and cost-effective, ultimately leading to laudable outcomes. According to UNICEF, “immunization remains the single most feasible and cost-effective way of ensuring that all children enjoy their rights to survival and good health.”[xxvi] Notably, for a developing country such as Eritrea, preventative vaccinations and immunizations can prove critical since they help avoid expensive treatments for illness. As well, immunization programs are important since they can boost a country’s general growth, with many analyses illustrating positive economic impacts.[xxvii]
Eritrea’s approach to immunization and vaccination has been based upon an array of cooperative agreements with various international organizations and partners, including the United Nations Development Programme (UNDP), UNICEF, the WHO, and the GAVI Alliance.[xxviii] These partnerships have increased supplies such as vaccines, syringes, and Vitamin A capsules, while strengthening support for the development, production and dissemination of social mobilisation materials, regional plans and logistics.[xxix] Vitally, the Eritrean government has also encouraged the expansion of outreach facilities, organized mass volunteer campaigns, and generally exhibited a high commitment to “achieving financial sustainability and full ownership of vaccine financing.”[xxx]
Ultimately, the result has been that more people – particularly nomadic peoples and children in rural areas – have received important vaccinations and immunizations. As a testament of Eritrea’s immunization and vaccination efforts and effectiveness, consider its DTP3 coverage figures. DTP3 is amongst the most prominent immunization series, and helps to prevent diphtheria, tetanus, and pertussis (whooping cough). Administered in 3 separate doses for infants (at one month, one month and a half, and three months), DTP3 coverage rates provide a useful gauge for how effective a country is in providing immunization for children.[xxxi] According to the WHO, in Eritrea, DTP3 immunization coverage has been at 99% since 2008 (see Figure 4), while average immunization for the years 2000-2012 is 95%. In comparison, average DTP3 immunization figures across the years 2000-2012 for Eritrea’s neighbors are as follows (see Figure 5): Djibouti at 74%; Ethiopia at 46%; Somalia at 37%; Sudan at 78%; Kenya at 81%; Uganda at 67%; and Africa at 64%.[xxxii]
Yet, impressive immunization coverage rates are not restricted to DTP3; notably, Eritrea’s measles and polio coverage figures also merit admiration. In 2012, the country’s measles coverage was 99%, well ahead of its neighbors: Djibouti at 83%; Ethiopia at 66%; Somalia at 46%; Sudan at 85%; Kenya at 93%; Uganda at 82%; and Africa at 73%.[xxxiii] In terms of polio immunization, Eritrea boasted a 99% coverage rate while its neighbors posted the following: Djibouti 81%; Ethiopia 70%; Somalia 47%; Sudan 92%; Kenya 82%; Uganda 82%; and Africa 77%.[xxxiv]
Overall, Eritrea’s rapid, remarkable improvement in immunization, vaccination, and malaria intervention was the result of a capacity to adapt, community buy-in, effective coordination, resourcefulness, mutually respectful partnerships, cost-effective projects, and extremely hard-working volunteers and employees.[xxxv] Nonetheless, the country has sought to build upon past successes and recently it has begun to implement expanded services to better ensure the health of citizens.
Specifically, Eritrea will introduce the Pneumococcal vaccine during the first quarter of 2014 and the Rota Virus vaccine during the fourth quarter of 2014. The Pneumococcal vaccination will help combat diseases such as pneumonia, meningitis and febrile bacteraemia, as well as otitis media, sinusitis and bronchitis.[xxxvi] In regards to the Rota Virus vaccination, it will aid in fighting rotaviruses, which are the most common cause of severe diarrheal disease in young children throughout the world.[xxxvii] Through the imminent introduction of the two vaccinations, as well as the strengthening of other national interventions, Eritrea expects to reduce under-five mortality to a level below 40 per 1,000 live births by 2016.[xxxviii]
In terms of malaria, the country has renewed its commitment “to [completely] eradicate malaria prevalence.”[xxxix] Most recently, in October of 2013, it was announced that Eritrea would officially proceed to a new stage of malaria intervention, entering a pre-elimination phase via a 2-3 year period of consolidation. This would see the establishment of a Presidential Task Force on malaria elimination, and the renewal of nationwide partnerships across the Ministries of Agriculture, Mines, Defence, Education, National Development, Finance, Health, Zonal and Sub-zonal Administration. As part of the new phase, the country has already begun to develop performance management systems at national, zonal and sub-zonal levels. In addition, the pre-elimination phase is expected to feature a strengthening of malaria diagnosis and treatment measures at health facilities, and an expansion of optimal logistical capacities in each zone for targeted malaria elimination interventions.[xl]
Overall, with a sustained commitment to effective immunization, vaccination, and intervention programs, as well as ongoing support from international partners, Eritrea can continue to improve the health and development of its greatest asset – its citizens.[xli]
[x] Pateman, R. 1990. Even The Stones Are Burning. Trenton, NJ: Red Sea Press.
[xiii] Sabo, Lois E. and Joachim S. Kibirige. 1989. “Political violence and Eritrean health care.” Social Science & Medicine 28(7): 677-684.
[xix] Eritrea: Going Beyond Malaria Control. Presentation by Dr. Araia Berhane, Director of Communicable Disease Control Division: Eritrea Ministry of Health. October 22, 2013. Asmara, Eritrea.
Müller, T.R. 2005. “Responding to the HIV/AIDS Epidemic: Lessons from the Case of Eritrea.” Progress in Development Studies. 5(3): 199-212.
[xxiii] Eritrea: Going Beyond Malaria Control. Presentation by Dr. Araia Berhane, Director of Communicable Disease Control Division: Eritrea Ministry of Health. October 22, 2013. Asmara, Eritrea.
[xxiv] Eritrea: Going Beyond Malaria Control. Presentation by Dr. Araia Berhane, Director of Communicable Disease Control Division: Eritrea Ministry of Health. October 22, 2013. Asmara, Eritrea.
[xxxviii] Progress in Health Millennium Development Goals (Health MDGs). Presentation by Dr. Mismay Ghebrehiwet. Ministry of Health. October 22, 2013. Asmara, Eritrea.
[xl] Eritrea: Going Beyond Malaria Control. Presentation by Dr. Araia Berhane, Director of Communicable Disease Control Division: Eritrea Ministry of Health. October 22, 2013. Asmara, Eritrea.