Report No. 28267-ER Eritrea Health Sector Note June 30, 2003 Human Development Sector Africa Region Document of the World Bank ... 111 CONTENTS Page ACKNOWLEDGEMENTS vi EXECUTIVE SUMMARY vii INTRODUCTION 1 Backgound Socio-Economic Situation Economic Growth and Structure o f the Economy Government Sector and Public Debt DEMOGRAPHICAND EPIDEMIOLOGICAL SITUATION 5 Demographic Trends 5 Burdeno f Disease and Causes o f Death 10 Child Health 11 Women's Reproductive Health 16 HealthConditions o f Eritrea's Nomadic Communities 18 Changing EpidemiologicalProfile 18 Eritrea and the Millenium Development Goals 19 ERITREA'SHEALTHSYSTEM 21 Policy and Governance Context 21 Planning and Budgeting 22 Decentralization 23 Health System Structure, Coverage, and Capacity 23 Public Health 23 Health Care Delivery System 23 Infrastructure 24 Expansion o f Health Facilities 25 Access to Health Facilities 26 Hospital Beds 26 HumanResources 28 Training o f Health Professionals 30 Pharmaceuticals 31 Procurement and Distribution 31 Private Sector Role 31 Financing 31 Current Status and Action Plan 32 Laboratory Services 33 iv Health Sector Financing 34 Financing Sources 34 Trends in Public Health Capital and Recurrent Expenditures 34 Household Health Care Utilizationand Expenditures 37 Health Care Utilization 37 Health Care Expendituresand MethodsofPayment 38 4 PERFORMANCEOF THE HEALTHSYSTEM 39 Strengths 39 Health Programs 39 Health Systems 39 Challenges 40 Public Health 40 Physical Access 40 Human Resources and Infrastructure 40 Environmental Management 41 Financing 41 Private Sector Role 41 Health Sector Management 42 Pharmaceuticals 42 Laboratory Services 42 The Health ManagementInformationSystem 42 Special Situations 43 5 RECOMMENDEDNEXTSTEPS 44 Short-term Priorities 44 Medium-term Priorities 46 Long-term Priorities 46 ANNEX 1. Ministry OfHealth-OrganizationAnd Process For Establishing 47 A Health Policy and Strategic Development Plan ANNEX 2. Trends InMacroeconomic Indicators - 1993-2000 48 ANNEX 3. Ministry Of Health-Organizational Structure 49 ANNEX 4. Geographic DistributionOfHealth Facilities inEritrea InYear 2000 61 ANNEX 5. Health Care Financing 62 ANNEX 6. International ComparisonTables 73 ANNEX 7. Eritrea-MilleniumDevelopment Goals Progress Status 77 ANNEX 8. Bibliography 78 ANNEX 9. Eritrea-Health Sector Performance-Outline of Study Report 81 V TABLES DEMOGRAPHIC AND EPIDEMIOLOGICAL SITUATION Table 2.1: DemographicIndicators Estimated,2000-2020 6 Table 2.2: Immunization Coverageand Incidenceof Immunizable Diseases 15 Table 2.3: MDGs Indicators 19 ERITREA'S HEALTH SYSTEM Table 3.1: Growthof Health Infrastructure, 1990-2000 25 Table 3.2: Distributionof Health Facilities by Type ofZone, 2000 26 Table 3.3: Number of Beds and BedOccupancy Rate by Zones, 2000 27 Table 3.4: Growth of Human Resources inthe MOH, 1991-2000 28 Table 3.5: Distributionand Category of Available Health Personnel Per Zone 30 FIGURES DEMOGRAPHIC AND EPIDEMIOLOGICAL SITUATION Figure 2.1: Population Pyramid for 2000 and 2020 (inthousands) 5 Figure 2.2: Population Pyramid for 2000 and 2020 (inpercent) 5 Figure 2.3: Global Trends inLife Expectancy at Birth 7 Figure 2.4: Selected Countries, Percentage Change inLife Expectancy at Birth 8 Figure 2.5: Selected Countries, Life Expectancy at Birth(Gender Differentials) 8 Figure 2.6: Selected Countries, Age DependencyRation (inpercentage) 9 Figure 2.7: Selected Countries, Percentage PopulationUsingModern Contraceptives 9 Figure 2.8: Percentage Share of Burden of Disease, 1994 10 Figure 2.9: Global Trends inInfant Mortality 12 Figure 2.10: Selected Countries, Prevalence of Stunting and Underweight in 13 PreschoolChildren Figure 2.11: GlobalTrends inUnder-5 Mortality 14 Figure 2.12: Immunization Coveragefor Children Under-5 (inpercent), 1995-1999 15 Figure 2.13: Selected Countries, Percentage of PregnantWomen Receiving 16 Receiving Antenatal Care, 1995 Figure 2.14: Selected Countries, BirthsAttended by Skilled Health Personnel 17 Figure 2.15: GlobalTrends inMaternal Mortality 18 ERITREA'S HEALTH SYSTEM Figure 3.1: MOH Health Facilities, 1990-2000 25 Figure 3.2: Global Trends in Bed Capacity per 1,000 Population 27 Figure 3.3: MOH Human Resources, 1991-2000 28 Figure 3.4: Global Trends ofPhysiciansper 1,000 Population 29 Figure 3.5: Global Trends inPublic Sector Health Expenditures(as % of GDP) 35 Figure 3.6: Global Trends inPublic Sector Per Capita HealthExpenditures 35 Figure 3.7: Sources of Treatmentfor the Ill,1997 37 vi ACKNOWLEDGMENTS This report was preparedby Eva Jarawan, Lead Health Specialist, and Christine Pena, Senior HD Economist, (AFTH3), with the assistance of Karima Saleh (Consultant), Jean Rutabanzibwa-Ngaiza(Consultant), and Gabrielle Rooz (Consultant). It is based on a review of several documents provided by the Eritrea Ministry of Health, international and national consultants, and partners inthe country. Maureen Lewis (HDNVP) and Salim Habayeb were the peer reviewers. Makhtar Diop, Country Director (AFSCO), Oey Astra Meesook, Sector Director (AFTHD), Mathew Verghis, Senior Economist (ECSPE), and Shiyan Chao, Senior Health Economist (AFTH1) provided comments on an earlier draft. We would like to express our appreciation to H.E. Minister Meky, Minister of Health, officials of the Ministryof Health, zoba health teams, and external partners for their participation to the report, and a special thanks to Dr. Nadia-Al-Alawi for her quick response to our many requests for information. We would like to acknowledge the excellent support provided by Ms. Nathalie J. Lopez-Diouf, ProgramAssistant (AFTH3) inthe processingof the report. The views expressedin this paper are those o fthe authors and do not necessarilyreflect those of the World Bank or officials ofthe Government of Eritrea. vii EXECUTIVE SUMMARY InMarch 2001, the MinistryofHealth ofthe Government o fEritrea launched a process to prepare a long-term Health Sector Policy and Strategic Plan ((HSPSP) with a focus on assuring equitable, quality and sustainable health care. The Ministry o f Health has outlined an open participatory three-step process for developing the HSPSP, with active participation from all partners involved in the health sector. This Health Sector Note is the result of the first phase and serves as the preliminary basis for further rounds o f discussions and analyses among stakeholders to arrive at a strategic vision for the national health sector. This Note is a desk review based on available documents from various sources and of varying quality and, as such, data comparisons should be viewed with caution. SOCIO-ECONOMIC SITUATION Of a total population o f 4.1 million (2002), 62 percent are estimated to live in rural areas, a decrease from 82 percent in 1995, and 38 percent' in urban areas, an increase from 27 percent for the same period (EDHS 2002). Approximately 30 percent o f the total population is comprised o f semi-nomadic, agro-pastoralists, Eritrearemains one o f the poorest countries in the world, with a Gross National Product per capita o f US$200 (1998). Approximately 60-70 percent of the population are classified as living in poverty (1993-98), and unemployment rate inthe non-farming sector is estimated at 15- 20 percent. With respect to current employment status, 69 percent of men and 16 percent of women aged 15 years and above were employed in 2002 (EDHS 2002). An overwhelming majority (93 percent) of men in the workforce are in the 30-34 age group. Current employment peaks at age 25-29 for women (26 percent). There are no urban-rural differences by employment status for men, although employment rate among men is likely to be lower in the capital city o f Asmara than in other areas. By contrast, women are three times as likely to be employed in urban than in rural areas. The border conflict with Ethiopia, which started in 1998 and ended in 2000, has had an profound adverse effect on the economy--with the agriculture sector most affected, and the welfare o f the population. Gross Domestic Product growth declined from about 8 percent in 1977 to less than 1 percent in 1999'. GDP is estimated to have declined by 9 percent in 2000 because of an estimated 75 percent decline in crop production combined with the destruction and loss o f physical capital. An estimated 300,000 to one million people have been displaced during the conflict, representing 10-20 percent o f the population, who now live under difficult conditions with inadequate shelter, sanitation, food and basic services. Approximately 90 percent of displaced ' Theincrease is primarily due to redefining some areas classifiedas rural in 1995. IMF. Eritrea StufSReport, January2001. viii households are headed by women. It is estimated that nearly 1.6 million people will requirefood and other humanitarian aid for another 12-18 months. Lack o f sustained economic growth does not hold much promise for a reduction in poverty in the short to medium term. This will constrain growth in personal income and government revenue, and in turn growth in domestic resources for investment in, and recurrent cost support to, the health sector. Financial contribution from the population in subsistence agriculture for their utilization o f health care services is likely to be minimal, if any. Increase inhuman capital, through literacy and other forms o f education, will have to be matched by an increase inemployment. THE HEALTHSECTOR Strengths Since independence in 1991, the Government has made great strides in improving the living conditions o f the population through expansion and rehabilitation o f basic social infrastructure, such as health stations and schools. By 1999, 70 percent o f the population were reported to have access to primary health care services (defined as 10-km distance to a health facility). In addition, most of the important public health programs, such as child health, expanded program on immunization, reproductive health program, nutrition, environmental health, information, education and communication, and community health services, are either beingdeveloped or under implementation. The Government has made prevention and controlof HIV/AIDS a national priority. M O H is working with other ministries, government institutions, NGOs, and external partners to curb the spread o f HIV/AIDS, primarily through behavioral change. M O H has initiated a new quality assurance program that includes technical efficiency and consumer satisfaction as two methods o f assessingquality. Increase in total M O H staff, such as physicians, nurses, health assistants, and sanitarians has been substantial, There are national schools for nurses and paramedics, although all physicians are educated outside Eritrea. Several key activities relatedto pharmaceuticals are inthe pipeline, including: a survey o f traditional medicine practices; construction o f three standard zonal drug warehouses; publication o f the third edition o f the Eritrean National List o f Drugs and National Formulary; strengthening o f drug quality control and introduction o f new drugtests; inspection guidelines for drug manufacturing plants; disposal guidelines for expired and obsolete items; and improvement o f logistics and the Health Management Information System. Challenges Despite the many positive developments outlined above, a number o f challenges remain. Primary among them is the highburdeno f disease. About 71 percent o f Eritrea's burden of disease is due to communicable and preventable diseases. Peri-natal and maternal health- related problems, as well as diarrhea and acute respiratory infection account for 50 percent o f burdeno f diseaseshare. ix PublicHealth Malaria is a major public health concern affecting 75 percent of the population. Yet, only 34 percent of Eritrea's households reporthaving mosquito nets. Ownership of mosquito nets i s higher in rural (37 percent) than in urbanareas (29 percent). HIV/AIDS has emerged as the leadingcause of adult in-patient mortality and prevalence. Adult sero-prevalencerate is estimatedto be 2.8%3. Tuberculosis was the second cause of in-patient case fatality inthe age group of five years and above in 1998. Treatment is still not reachingadequate numbersofthe infected, especially invulnerable populations. Although both the Infant Mortality Rate and under-5 mortality are below average for sub-Saharan Africa in 2002 (48 and 93 per 1,000 live births, respectively), there still remain tremendouschallengesto bring down high malnutrition rates, Duringthe same period, 40 percent of children under-5 were underweight, with 12 percent classified as severely underweight, 38 percent are stunted, with 16percent suffering from severe stunting. Wasting affects 13 percent of children of the same age group, and an alarming 50 percent of them are anemic. Lastly, close to 74 percent of children with diarrhea disease are under three years of age (EDHS2002). Less than 50 percent of breastfeedingchildren between7-9 months receive complementaryfoods. The above child health statistics suggest that efforts should focus on: (i)education on weaning diets; (ii)nutrition for children under-2 and pregnant women; (iii)providing child caretakers with health education on re-hydration; (iv) improving sanitation; and in the long-term, (v) increasing girls' education because of the positive influence of mothers' education on child health. There has been a significant improvement in coverage of expanded program on immunization, with an estimated 76 percent of children aged 12-23 months fully immunized in 2002 (who have received up to measles vaccine). Only five percent remain unvaccinated, compared to 38 percent in 1995. However, targeted efforts are needed to ensure that immunization services reach all age groups of children, particularly in the poor and nomadic groups, and that children receive all the required vaccine doses4. More emphasis needs to be placed on the Growth Monitoring, Oral Re-hydration, Breastfeeding, and Immunization concept of primary healthcare. Women ReproductiveHealth Several risk factors contribute to Eritrea's high maternal mortality ratio (1,000 reported deaths per 100,000 live births) and morbidity. These risk factors include: Low age at first birth (21 years). Absent or inadequate prenatal care. Although the number of women receiving antenatal care from a health care professional increased from 49 percent in 1995 to 70 percent in 2002, women in urban areas tend to receive care from trained health staff by a greater proportion (91 percent) than those inruralareas (59 percent). UNAIDS 2001. There are highdrop-outrates for second andespecially third dosesof DPT and Polio. X Low immunization coverage: only 28 percent of pregnant and women of child-bearing age received full immunization of at least two doses of Tetanus Toxoid in2000). Inadequate obstetric care: only 28 percent of deliveries are attended by skilled personnel, comparedto 86 percent inSudan, 61 percent inEgypt, and 38 percent inUganda. Low maternal nutritional status. Complications from the (traditional) practiceof female genital cutting or circumcision, Education plays a large role in enablingwomen to access obstetric services. An estimated88 percent of women with some secondary education were assisted by trained health personnel in 2002, compared to 36 percent with a primary education, and only 12 percent with no education. With a population growth rate projected at less than three percent per annum, an estimated Total Fertility Rate of 4.8 (2002), and very low use of modern contraceptivemethods-- only seven percent of married women use contraceptive methods, Eritrea's population growth is expected to increase by 24 percent by 2010. This expected increase will put considerable pressure on health care services. The major health burden will be from children and women of child-bearing age, as this sub-groupwill remain at 60 percent ofthe total population. In order to maintain continued improvements in maternal(and infant and child) health, focus should be placed on appropriate health care programs for women, with particular attention to the disadvantaged and vulnerable groups, such as the nomadic communities. Further assessment of this sub-group is needed to ascertain the extent of health inequity, especially among women and children. Poor access to improved water and sanitation, particularly inrural areas, is an issue. In 2000, only 42 percent of rural dwellers and 63 percent in urban areas had access to safe water supplies, About one percent o fthe rural population had access to some form of sanitary facility, such as a pit latrine, compared to 66 percent in urban areas. The Ministry of Health seeks to increase sanitation coverage from one percent to 30 percent by year 2005. To achieve this objective, the Ministry of Health will need to work closely with the relevant sectors in the rural areas. The current state of waste management systems is inadequate. At present, household and health care waste, both solid and liquid, are collected and disposed by the municipality in urban and semi-urban areas on the country. There seems to be no segregation at the generation and disposal sites of any type of medical waste. Household and health care solid waste are disposedon the same sites with inadequate waste site protection. HumanResourcesand Infrastructure The number of local doctors is insufficient. About 45 percent o fphysicians employedby the Ministry of Health in 1999 were expatriates. Skills mix among health staff needs to be improved, in particular the high ratio of administrative to medical staff, low ratio of medical specialists, and shortage of staff with appropriate training in management. xi Low salaries, lack o f incentives and motivation for staff, as well as poor infrastructure and accommodation inrural areas, exacerbate the human resourcesproblem. The increase in number o f hospitals, without sufficient attention to capacity and availability o f human resources, requires immediate consideration. It is critical that future expansion o f health infrastructure be guided by Eritrea's new Human Resources Development Policy. The Ministry o f Health has embarked on a hospital reform program to respond to the above issues. Assessments are also ongoing to contribute to the health facility rightsizing plan. Public Health Expenditures Public sector spending on health accounts is estimated at about 65 percent of all health spending for 1999, donor contribution at 27 percent, and household contribution at 8 percent (excluding the private sector). Donor dependency is high: 53 percent o f the 1999 drugbudget was financed by external assistance, compared to 47 percent o f Government share, The long-term effect o f this high external dependency sustained drug supply needsto be assessed. The Ministry o f Health is embarking on new initiatives to improve revenue collection at health facilities. However, these new initiatives, and the corresponding changes, need to be closely monitored and evaluated to ensure not only a smooth transition and sustainability o f the new system, but also to gauge their impact on the consumers, particularly the poor and vulnerable groups. Private Sector Role Little is known about private delivery o f health care services, except that most private clinics are located in urban areas, and that the private sector is primarily involved in the procurement and distribution of drugs. In 2000, there were 259 retail drug outlets. Fewer than 20 percent o f medical care seekers use private facilities as a source of care. Given the shortage o f human resources in the health sector and low level o f public sector salaries, public medical personnel, for the most part physicians, also work in the private sector as a way to supplement their income. Coordination between the two sectors is necessary, however, to avoid the emergence o f a two-tier health system, with the public sector providing the poor with mediocre quality services because o f insufficient resources, and the private sector responding to the needs of the better-off segment of the population. The Ministry o f Health is conscious o f that risk and has embarked on a serious program to improve health care quality. Health Sector Management The local and regional health administration capacity needs to be reinforced to enhance effectiveness o f the decentralization o f financial and managerial functions. Pharmaceuticals At present, all drug and medical supplies are imported, although some local production is expected to start shortly, mainly for packaging. xii Drug storage, space and distribution procedures, management systems, as well as transport for drug disbursement need to be improved. Laboratory Services Laboratory services need to be reinforced to support the Ministry's on-going efforts to improve and expand national health care services. Health ManagementInformation System While there is relatively good data collection and analysis, feedback to service providers and program implementers is limited. Critical data for decision-making, in the form o f national health accounts and unit cost information for facilities, are missing and/or inadequate. Information on private sector involvement is lacking. Further data collection and analysis are needed, for example population-based, to improve the policy-making process. Special Situations Two population groups requirespecial attention: the large number o f the population affected by the border conflict with Ethiopia and those living innomadic communities. RECOMMENDED NEXT STEPS Eritrea faces a number o f challenges in the health sector to achieve many o f the MillenniumDevelopment Goals. Given its commitment to eliminate poverty, the Government is willing to take appropriate actions to achieve the desired impact on the health status and general well-being o f the population. To this end, adequate resources need to be mobilized and made available to health care services, as well as to other related sectors, such as water and sanitation. However, given competing demands on the country's limited resources, actions in all sectors need to be prioritized. In the health and health-related sectors, the following actions are recommended: Short-Term Priorities Establish baseline informationfor many o f the MDGs, together with realistic targets, towards which Government efforts may be directed. Evaluate the performance and cost-effectiveness o f specific health programs to better assess the health care needs of, and interventions for, target populations, especially the vulnerable groups. Estimate the National Health Accounts (NHA) to better assess the health sector's sources and uses o f hnds. Evaluate alternative sources of revenues, includinguser charges, as well as public and private insurance options to sustain the current health care system. Given the extent o f poverty inthe country, user fees might not be an optimal option. Prioritization o f strategies and interventions, including minimizing the system's inefficiencies, could maximize use o f limitedavailable resources. Undertake a needs-based master plan of health care facilities and equipment to include the private sector. ... XI11 Explore ways to expand private sector involvement inthe delivery of healthcare services. Develop a staff training and development plan for the Health Management Information System to strengthen the flow of information, identify program needs, and establish a monitoring, supervisionand evaluationsystem. Health worker skills and training needs should be assessed, including training in proper epidemiological surveillance and reporting, as suggested by the high proportion of undiagnosed illnesses (27 percent) at public health facilities in 1999. National environmental policies and regulationsneedto incorporatea strategy for health care waste management. This strategy needs to be accompanied by a health care waste management plan that includes budget requirements, authorities in charge, identification of capacity needs, and a monitoring plan, In addition, partnerships between the public and private sectors as well as civil society are needed. Medium-TermPriorities Undertake unit costing studies at select public hospitals and ambulatory care facilities to evaluate the public system's technical efficiency. Provide the framework for a comprehensive and coherent development of the health sector, with the respectiverole of the public sector, private providers and NGOs clearly defined. Explore the potential for hospital privatization. Long-Term Priorities Develop financing options for universal coverage, such as a national health insurance, or a combination of public-private insurance mechanisms. Develop and implement modern incentive-basedprovider payment mechanisms. Promote private sector integration and develop a rational policy towards private sector development. At the facility level, improve case management quality, focusing on hospital hygiene, improving provider-patient relations, and integrating innovations in Information, Communications, and Technology (ICT) into service delivery. Increase financial and management autonomy of public health facilities, 1 1 INTRODUCTION BACKGROUND InMarch 2001, the Ministryof Health (MOH) ofthe Government of Eritrea launched a process to prepare a long-term health sector policy and strategic plan ((HSPSP), with a focus on assuring equitable, quality, and sustainable health care. MOH outlined an open participatory three-step process for developing the HPSP, with active participation from all partners in the health sector. A diagram o fthe three-step process, action planand timetable is attached in Annex 1. Step 1 is the preparation o f a health sector review carried out by the World Bank, based on existing documentation provided by the Government and other sources, notably the World Health Organization (WHO), the UnitedNations Children's Fund (UNICEF), the United States Agency for International Development (USAID), Demographic Health Surveys. Step 2 consists of conducting an in-depth health sector analysis along five sub-sector working groups: PHC, hospital reform, pharmaceuticals, human resource development, health financing, leading to the preparationo f a rationale for investments inthe future development o f the health sector instep 3. This paper, the Health SectorNote, is the resulto f Step 1o fthe process outlined above. It serves as the preliminary basis for further rounds of discussions and analyses among stakeholders to arrive at a strategic vision for the Eritrea Health Sector. The Note incorporates comments received from MOH central agencies, Zoba (regional) health teams, external partners working inEritrea, and the World Bank Eritrea Country Team. Any attempt to arrive at a strategic vision o f Eritrea's health sector requires first a common understanding o f the current performance o f the health system in terms o f how well that system: (i)enhances the health status o f the Eritrean population; (ii)protects the population financially against catastrophic illness costs; (iii)provides equitable access to high-quality health care services; (iv) performs efficiently at both the macro and micro levels; and (v) is financially sustainable, given the country's projected low economic growth and high demographic trends. To this end, it is necessaryto analyze the health system from different angles: A description o f the present demographic and epidemiological situation, expected changes expected over the next 20 years, and the resulting effects on the underlying needs and demands o f the population. An analysis o f the current socio-economic conditions. An assessmento fthe current healthsystem performance, includingthe policy context. An identification of areas o fthe health sector where further analysis is needed. This paper is divided into five chapters. Chapter I1describes the current and projected demographic and epidemiological conditions in Eritrea in terms of population, age and sex structure, fertility, mortality, morbidity, dependency ratios, and population growth rates. Chapter -describesthecountry'shealthsystem,itsorganization,infrastructureandhumanresources, I11 2 and compares Eritrea's health outcomes, inputs, and expenditures with other countries. The chapter concludes with an analysis of the strengths and challenges of Eritrea's health sector. Chapter IV suggests some further analyseshtudies for Phase 2 in the development of the comprehensive health sector strategy. Chapter V presents the recommendationson priority "next steps" inthe short, medium and long term. It is important to note that this is a desk review based on available documents from various sources and of varying quality. For example, the current HealthManagement Information System (HMIS) became operationalonly in 1998, and comparisonof data prior to 1998 with data from the current system should be viewed with caution. In addition, the H M I S is based on facility-level data, while other sources of information, such as the 2000 EPI Coverage Report, is community-based, leading to differences in sampling procedures and denominators. A Demographic HealthSurvey (EDHS) was conducted in Eritrea in 2002 as a follow-up to the first EDHS of 1995, and some of the preliminary results have been incorporated into this report5. Lastly, the Eritrea Household Health Status, Expenditure, and Utilization Survey (EHHSUES) was completed only recently, a delay caused by the country's two-year border conflict with Ethiopia, which started in 1998 and ended in 2000. Only two out six zones were surveyed in 1997. Its results will be incorporatedinPhase 2 ofthe HSPSP. SOCIO-ECONOMIC SITUATION Despite being a relatively small country of about 124 thousand square kilometers, Eritreahas varying geographic and climatic zones, and its population of 4.1 million includes nine heterogeneous, ethno-cultural groups, each with its own language. Christianity and Islam are the two dominant religions, each claiming about 50 percent of the population as followers. The country is divided into three main physio-graphic regions, which have an influence on physical access to a variety of services: central highlands, western lowlands and eastern lowlands. It has six regions (zobas) and 58 sub-regions (sub-zobas). In 2002, about 62 percent of the population resided in the rural areas. Approximately 30 percent of the entire population is comprised of semi-nomadic, agro-pastoralists. Eritrea is a relatively young country. Since independence in 1991,the Government has made great strides in supporting the development and improvement of the living conditions of the population, even inthe face of a devastated social infrastructure and impoverishedpopulation, the result of the protractedwar for independence. Basic social infrastructure, such as health stations and schools, were rehabilitated and expanded, leading to a concomitant increase in school participation rates and access to, and utilization rates of, health services. However, the escalation in May 2000 of the border conflict with Ethiopia and the recurring drought have had a negative impact on the country's earlier economic achievements, with the agriculture sector the most affected of all sectors. Gross Domestic Product growth declined from about 8 percent in 1997 to less than 1 percent in 19996,only ayear after the start of the conflict. GDP is estimated to have declined by 9 percent in2000 because of a decline incrop production, estimatedat 75 percent, andthe destruction and loss of physical capital. The country's border conflict with Ethiopia also had a devastating effect on the population, with lasting consequences to this day. An estimated300,000 to a million people' (or According to the EDHS PreliminaryReport(September2002), final resultsare not expectedto differ significantly. 'IMF.Eritrea StaffReport, January 2001. Estimatesvary dependingon the source. 3 10-20 percent of the population) were displaced from their homes, and although many of them have returned since the end of the conflict, they suffer from inadequate shelter, sanitation, food and basic services. Although widespread famine and disease outbreaks did not occur, partly owing to Governmentefforts to provide food and other assistance, the situation could deteriorate. It is estimatedthat 1.6 million peoplewill require food and other humanitarianaid for another 12- 18 months*. A direct result of the prolonged conflict and consequent dislocation of the population has been an increase in the number of households headed by women. Forty-seven (47) percent of households are now estimatedto be headedby women, compared to 31 percent in 1995 (EDHS), and 53 percent are headed by men. Of the displaced households, 90 percent are headed by women because of the conscription of all men, aged 18-40, during the border conflict. The number of households headed by women is greater in urban (53 percent) than in rural areas (43%). Interms ofhuman capital,45 percentofEritreans aged 6 and above are uneducated, with the majority being women (52 percent). The EDHS 2002 data indicate that of those in school, female participation decreases, the higher the level o f education because of early marriages and withdrawal from school to assist with household chores, for example. The primary gross enrollment rate in 1999 was 57 percent, an increase from 52 percent in 1998 (48 for women and 59 for men). Secondary gross enrollment rate was 21 percent. However, net enrollment rates are significantly lower: 38 percent and 14 percentfor primary and secondary levels, respectively. Literacy among the adult population (15 years and above) was 48 percent in 1999 (60 percent for men and 34 percent for women). Among the youth (15-24 years), literacy rate was close to 70 percent. ECONOMIC GROWTH AND STRUCTURE OF THE ECONOMY Eritrea remains one of the poorest countries inthe world. Its Gross National Product per capita is US$200 (1998) and its GNP PPP per capita is US$984 (2000). Its nominal GDP per capita is only about US$l73 (estimates range from US$160-US$190). Agriculture accountedfor only 19.2 percent of GDP in 1999, while the industrial sector and services sector accounted for 28.4 percent and 51.5 percent, respectively. In real terms, average per capita income in 1999 was about the same as in 1995'. Approximately 60-70 percent ofthe populationare classified as living inpoverty (1993-98). Excluding people working in the traditional farming sector, current unemployment rate is estimatedto be 15-20percent. In2002, only 15 percent of women aged 15 years and above were employed, compared to 69 percent of men. Employment peaks at ages 30-34 for men(93 percent are employed) and 25-29 for women (26 percent). There are no urban-rural differences for employment among men, but women inurban areas are three times as likely to be employed than in rural areas. With respect to child labor (ages 10-14), the majority of this age group attends school (70 percent for girls and 78 percent for boys), with only about five percent working (four percent boys and one percent girls). This contrasts sharply with 39 percent in the labor force in 1997. IMF.Eritrea StafReport, January 2001. Donaldson, Daryl. Technical Report on Economic and Financial Analysis, September 2000. Lagerstedt,Adam. Trip Report on Health Sector Vision and Health Policy Review, 24 August, 2000. 4 GOVERNMENT SECTORAND PUBLIC DEBT The border conflict with Ethiopia has also exerted severe pressure on public finances. Government expenditures increased over 100 percent in real terms between 1993 and 1999. Capital expenditures ranged from 30 to 40 percent of total government expenditures" during the same period. However, public revenues did not keep pace with public expenditures. Total revenue as a percentage of GDP steadily declined, from 43.3 percent in 1997 to 34.4 percent in 2000. Tax revenues followed the same pattern, decreasing from 20.4 percent in 1997 to 17.6 percent in20001'. Personal incometax comprised 13 percent of total tax revenues in 1999 and 19 percent in2000. Its share of GDP was 2.4 percent in 1999 and 3.4 percent in200012. The fiscal deficit (including grants) increased from 6 percent of GDP in 1997 to 59 percent in 1999,to decline to 36 percent in2000. To cover the fiscal deficit, the Government has been borrowing from external sources, mainly from development loans. Because of the highly concessionalterms of the external debt, debt service as a percent of export was estimated at only 9 percent in 1999. However, external resources were insufficient to cover the widening deficit, and domestic bank financing expanded rapidly. As a result, both domestic and external government debt increased sharply, from a combined 45 percent of GDP by the end of 1997 to an estimated 178 percent by the end of 2000. Current concern about the total level of public debt may be warranted, as debt servicerelative to export has increasedto 27 percent in2000. The above profile ofthe economy and public finance suggests the following: Lack of sustained economic growth does not hold much promise for a reduction inpoverty in Eritrea in the short to medium termI3, constraining growth of personal income and government revenue, and in turn, growth of domestic resources for investment in, and recurrent cost support to, the healthsector. Financial contribution from the population insubsistence agriculture for their consumption of health services is likely to be minimal, if any. While recent improvement in agricultural output since the end of the conflict with Ethiopia suggests that government measures to improve agricultural output may increase income, issues such as land reform and its impact on the poor must also be taken into consideration. Increasein humancapital through literacy and other forms of education will have to be matchedby an increase inemployment. The Government will need to maintain a careful balance between the country's pressing development needs and the burden of excessive debt servicing. This balance will affect the pace of development ofthe healthsector. loInsufficientinformation was collectedregardingthe overall levels, capital andrecurrent cost support from external sources to determine ifresources from the Government and donors are under-financing public recurrentexpenditures in general. "IMF.EritreaStufSReport.January2001. ibid. l3Natural resourcesexploitation may contributeto more rapideconomic growth. 5 2 DEMOGRAPHICAND EPIDEMIOLOGICALSITUATION DEMOGRAPHICTRENDS Eritrea's population was estimated at 4,l million in 2000 (Table 2.1), with a projected annual growth rate of 2.83 percent. Population growth is expected to continue in the next 20 years due to its relatively high fertility rates. Total Fertility Rate (TFR) is estimated at 4.8 (EDHS 2002), although TFR remains higher in rural (5.7) than in urban (3.5) areas. By 2020, Eritrea's population is expected to increase by about 50 percent. Between 2015 and 2020, population growth rate is expected to decline to 1.9 percent, with a population growth of 6.2 million (Figure 2.1). Population under 15 years o f age is expected to decline, from 43 percent of total population in 2000 to about 38 percent by 2020, although in absoluteterms, this sub-group will increase from 1.9 to 2.3 million. The largest percentage increase will be seen amongthe adult population (15-60 years of age), from 50 percent in2000 to 58 percent in2020 (Figure 2.2). Figure 2.1 PopulationPyramid for 2000 and 2020 (in `000) Female -500 -400 -300 -200 -100 0 100 200 300 400 500 Figure 2.2 Eritrea, PopulationPyramid for 2000 and 2020 (Percent) -20% -15% -10% -5% 0% 5% 10% 15% 20% Source: WorldDevelopment Indicators 2001, World Bank, Washington, D.C. 6 Table 2.1 Demographic Indicators Estimated, 2000-2020 Estimated Projected DemographicIndicators 2000* 2005 2010 2015 2020 PoDulation (millions) 4.10 4.60 5.10 5.60 6.20 Population change since 2000 (%) 12 24 37 51 Population by Age Groups No. of Children under-5 0.7 0.7 0.8 0.8 0.8 % of Total Population 18 16 15 14 13 No. of Youth under-15 1.9 2.1 2.2 2.3 2.3 % of TotalPopulation 45 45 43 40 38 No. of Women of Childbearing Age (15-49) 0.9 1.1 1.2 1.4 1.6 % of TotalPopulation 21.3 23 24 25 26 No. ofLabor ForceParticipation (15-60) 2.1 2.3 2.7 3.1 3.6 % of Total Population 50 51 53 55 58 No. of Elderly above-60 0.2 0.2 0.3 0.3 0.3 % of TotalPopulation 5 5 5 5 5 Dependency Ratio (Yo) Total (under 15 and over 60) 100 91 91 81 74 Youth only (under 15) 90 88 81 72 65 Elderly only (over 60) 10 10 9 9 9 Elderly as YOof total dependents 10 10 10 11 12 *According to MOH, the Ministry of Local Government has conducted a survey that estimates the 2000 population of Eritrea as 2.83 million. The methodology of that study is currently being reviewed in light of the 1995 EDHS estimate of 3.5 million and taking into account the population displacement during the conflict with Ethiopia. MOH is also using a population growth rate of 3% in its estimates. These differences will be considered in Phase 2 of the HSPDP. DemographicIndicators 2000-05 2005-10 2010-15 2015-20 2020-25 PopulationGrowth Rate (%) 2.3 2.1 2.0 1.9 1.6 Life Expectancy at Birth (years) 50 51 54 57 58 Life Expectancy at 15 years (years) 42 42 44 47 48 Crude BirthRate 37.0 34.1 31.6 28.9 25.8 Crude DeathRate 14.0 13.1 11.5 9.9 9.5 Total Fertility Rate 5.2 4.7 4.1 3.5 2.9 Infant Mortality Rate per 1,000 live Births 61 57 52 47 43 Under-5 Mortality Rateper 1,000 live Births 94 87 78 68 63 Maternal Mortality Ratio per 100,000 live 998 Births 1,131 (estimated)' Source: WorldDevelopmentIndicators 2001, World Bank, Washington, D.C., 2001. 1/ Hill,Kenneth, C. Abou Zahr, andT. Wardlaw. "Estimates of Maternal Mortality for 1995". In Bulletin of the WorldHealth Organization,2001, World HealthOrganization, Geneva. By 2010, Eritrea's population is expected to have increased by 24 percent. The major health burden will be from children and women of child-bearing age, as this sub-group will remain at 63 percent of the total population. Thus, over the next 20 years, the country will be confronted by the dual burden of communicable diseases as well as non-communicable diseases and injuries. 7 The following is a summary of the demographic and epidemiological trends that will shape Eritrea's healthsystemover the next two decades. With sustained Government's focus on health and population programs, a significant decline infertility couldbe achieved. However, even with the continueddecline intotalfertility from 6.7 births per woman in 1990 to 4.8 in 2002, Eritrea will not reachreplacement level fertility within the next twenty years, and population growth trend is expected to continue. Life expectancy remains low, although it is above that of sub-Saharan Africa's average by about two years (Figure 2.3). Life expectancy increased slightly from 48.8 years in 1990 to 50.4 years in 2000 (49 years for men and 52 years for women in 1998). By 2020, life expectancy in Eritrea is projected to increase to 58 years overall. Figure 2.4 illustrates Eritrea's position vis-&vis its neighboring countries with respect to life expectancy. While most other countries show a decline in life expectancy due to the rising toll in deaths related to HIV/AIDS, life expectancy at birth in Eritreais expectedto show positive growth. Figure 2.5 shows that in 1990 Eritrea had one of the highest gender differentials in life expectancy at birth compared to its neighboring countries. This gender differential has slightly declined over the past decade. Figure 2.3 Global Trends in Life Expectancy at Birth loo 1 7 0 - 5 2 .L 60 - y =31.883~'0927 h 50- $Y% + R2= 0 5421 40- 3 0 - 20, Tanzania Uganda Kenya 10 - Source: WorldDevelopment Indicators, 2001, World Bank, Washington, D.C. 8 Figure 2.4 Selected Countries, PercentageChange in Life Expectancy at Birth 1990-1999 Kenya Tanzania 0Uganda Ethiopia 0Djibouti Eritrea 0EUPt 0Yemen Sudan Somalia 7 -20 0% .I5 0% -100% -5.0% 0 0% 5 0% 100% I5 0% 20 0% Percentage Change Source: WorldDevelopment Indicators,World Bank, Washington, D.C., 2001 Note: A negative sign indicates a reductionin life expectancy at birthbetween 1990 and 1999. Figure 2.5 Selected Countries, Life Expectancy at Birth (Gender Differentials in Years) 1990-1999 Uganda 0 7 Somalia Sudan &PI TanzanIa 0 1990 Ethiopia D ibouri hen)a 0 0 5 1 1 5 2 2 5 3 3 5 4 Differentials(female male) in Years - Total age-dependency ratio remains high and has continued to rise during the past decade (Figure 2.6). In2002, almost halfo fthe population (EDHS 2002) was either under 15 years o f age (43 percent) or above 65 (6 percent), resultingin a total dependency ratio o f almost 100 percent, and an aged dependency ratio of 10 percent. The reduction in the total dependency ratio is expected to remain slow for the next twenty years, reaching 74 percent by 2020. 9 Figure 2.6 Selected Countries, Age Dependency Ratio in Percentage, 1990-1999 1 -Kenya +Yemen &Uganda Y Somalia *Tanzania -Ethiopia *Enuea -Sudan - Djibouti -Eaet 0.54 1990 1999 Source: WorldDevelopment Indicators, World Bank, Washington, D.C., 2001 Overall contraceptive use remains low in 2002, with no increase from the 8-percent level of 1995. However, the contraceptive prevalencerate (CPR) for modern methods has increased slightly, from only 4 percent in 199914to 7 percent in 200215.As Figure 2.7 shows, CPR in Eritrea was one of the worst vis-a-vis its neighboring countries between 1987-1996. Recent DHSdataindicatethat a greater numberof married women living inurbanareas(17 percent), especially inthe capital city of Asmara (23 percent), are more than four times as likely to use family planning methods than rural women (4 percent). Use of contraceptives is positively correlatedwith education. For example, 22 percent of women with a secondary educationor higher report using contraceptives, comparedto 11 percent with a primary school education, and only 4 percentwith no education. Figure 2.7 Selected Countries, Percentage Population Using Modern Contraceptives 1987-1996 Kenya 28 Yemen 10 Uganda 8 Sudan Enuea Ethiopia 0 5 I O I 5 20 25 30 35 40 45 5 0 Percent Source: LJNFPA. TheState ofworld Population 2000, (online) UNICEF Website, 2000. l4 The 1995 EDHS reports CPR-currently married women who are using any methodof family planning-at 8 percent, and for modernmethodat 4 percent. This represents an increase from 50% of contraceptive users to 65%. 10 BURDEN OF DISEASE AND CAUSES OF DEATH Eritrea still faces a high burden of disease (BOD)from communicable and preventable diseases. Around seventy-one (71) percent of BOD is due to communicable diseases (Figure 2.8). Peri-natal and maternal health-related problems, as well as Diarrhea and Acute Respiratory Infection (AM), constitute 50 percent of the BOD share. Most of these diseases are preventable. The high incidence of communicable diseases emphasizes the need for Eritrea to focus on preventive health programs and the provision of appropriate health care services to address communicable diseases and nutritionconditions. Highlights ofthe situation are provided below: Figure 2.8 PercentageShare of Burden of Disease, 1994 ImmunizableDiseases TB 15% 7% Source: Sebhatu, M., et. al., "Burden o f Disease Study, Eritrea Summary Report". In Proceedings of the East Africa Burden of Disease, Cosr-Effectivenessof Health Care Interventions and Health Policy. pp. 33-42. RegionalWorkshop, August 17-19, 1994. Asmara. In the above-5 population group, the top five causes of in-patient mortality in 2000 were consequences of Malaria, HIV/AIDS, TB, AM, and Hypertension. According to facility-based reports, in 1998, TB was the second and HIV/AIDS the fifth causes of in-patient case fatality in this age group at the national level. In 1999, injust one year, HIV/AIDS emerged as the first major cause o f in-patient case fatality far the same age group, to fall to second place in200016; Directly Observed Treatment Standards (DOTS) is estimated to cover 50-60 percent of the population. About 50 percent of diagnosedpatients are smear-positive cases, most likely due to lack of diagnostic services. This should be at least 60 percent, The cure rate is reportedly above 60 percent (70-80 percent in Asmara), and lower in the rest of the DOTS areas. This cure rate is below standard and requires a detailed evaluation to determine the major problemsand possibleremedial actions. l6 MOHEEMISH. Annual HeolthSeryireArtivity Report (January-December 1999), June 2000. MOHISEMISH. Annual Health ServiceActivity Report (Januay-December 2000) cited in Eritrea Health Profile, May 2001. 11 For adults aged 15-49, HIV-1 seroprevalence was 2.9 percent in 1999, with 49,000 adult cases of HIV infe~tion'~.The number of reported AIDS cases increased between 1996 and 1998, from 896 annual cases reportedin 1996to 1,610 cases in 1998. Malaria is a major public health issue affecting about 75 percent of the population. Sixty seven percent of the population is at risk, especially children under5 and pregnant women, Use of mosquito nets for prevention is low, as only 34 percent of households own mosquito nets. More households inrural (37%) than inurbanareas (29%) own mosquito nets. Eritrea has a high coverage of iodized salt intake, with over 71 percent of households consuming iodized salts in 2002. Rural households were less likely to use iodized salts than urban households for reasons related to cost, poor distribution networks in areas with poor access to main roads, and local salt production. The high proportion of undiagnosed cases (27 percent) found in Government data for 1999 suggests the need to review health worker skills and training needs, including proper epidemiological surveillance and reporting. CHILD HEALTH Eritrea's child health care indicators show poor health conditions among children. Diarrhoeal diseases are still a major cause o f morbidity (and sometimes mortality) among the under-5. Yet, less than half who fall sick are taken to a health facility or are seen by a health professional. Malnutrition among children remains high, and as many as 50 percent of children are anemic. Special programs need to be introducedto combat poor child nutrition, and current program management needs to be strengthened to improve coverage efficiency and place more emphasis on the GOBI concept of PHC. With respect to immunization, EPI coverage has been extended, resulting in a substantial increase infull immunization for children aged 12-23 months, from 41 percent in 1995 to 76 percent in2002 : a The Infant Mortality Rate (IMR) declined from 81 in 1990 to 61 in 2000 to 48 in 2002 (EDHS) and is below sub-Saharan African average (Figure 2.9). The under-5 or Child Mortality Rate (CMR) declined from 140 deaths per 1,000 live births in 1992 to 94 deaths per 1,000 live births in 2000 to 93 deaths per 1,000 live births in2002. Although decline in IMR in Eritrea shows steady progress, Government efforts to reduce infant mortality have been adversely affected by the conflict and the resultant population displacement. The disparities between rural and urban areas are reflected inthe pronounced differences in IMR and rates for under-5 mortality. In 2002, the IMR was 48 for urban and 62 for rural areas. Under-5 mortality for urban areas stood at 86, while inrural areas the rate was 117. Under-5 mortality rates of over 100 were reported for four of the six zobas: Debubawi Keih Bahr (186), Semenawi Keih Bahr (154), Gash-Barka (123) and Debub (111). "UNAIDSIWHO. EpidemiologicalFactSheetfor EritreaonHIVIAIDSandSexuallyTransmittedInfections,2000 @date, (online) UNAIDS Website, 2001, 12 Figure 2.9 Global Trends in Infant Mortality 1 y = 2 1 4 6 . 5 ~ ` ~ ~ ~ ' 160 ~ Tanzania U2= 0.7676 140 100 I 2 O ~ 6o i Eritrea 40 20 ~ O L 10 100 1,000 10,000 100,000 per capita GDP, US$ Source: WorldDevelopmentIndicators,World Bank, Washington, D.C.,2001 Under-5 child malnutritionis high, and there has been little change inthe overallrates since the EDHS 1995. Thirty-eight (38) percent of children in this age group are stunted, and 16 percent are severely stunted(low heightfor age), Wasting (low weight for height) affects 13 percent , slightly down from 15 percent in 1995 (EDHS 1995). In 2002, 40 percent of Eritrean children were under-weight, comparedto 44 percent in 1995-9618. Eritreais one o f the few countries where the proportionof under-weight children is higher than the proportion of stunted children(Figure 2.10). The prevalence of under-weight is usually high in the 6-24-month age group and is a reflectionof low birth weight, poor nutrition in the early years, and low female literacy. The latest EDHS data confirms the pivotal role of girls' and women's education in improving child health. For example, stuntingincreases from 20 percent of children whose mothers are highly educated to 35 of children whose mothers have had primary level education, to 44 percent for children of uneducated mothers. These data emphasize the need not only for education on weaning diets and nutrition for children under-two and pregnant women, but also for increased access to education for women and girls. The EDHS 2002 found that less than 50 percent of breastfed children between 7-9 months received supplemental feeding other than breast milk. Sixty-seven (67) percent o f children under-four months are exclusivelybreastfed, which is similarto the DHS 1995 findingig . '* WorldHealth Organization. Global Database on Child Growth and Malnutrition, 2000, (online) WHO Website. l9The PHC division, MOHreportedan increase to 98% exclusively breastfedchildren in2000. 13 Figure2.10 SelectedCountries, Prevalenceof Stunting and Underweight in PreschoolChildren EUPt Djibouti Kenya Sudan Uganda Eritrea Tanzania Yemen Ethiopia 0 10 20 30 40 50 60 70 Percent Source: World Health Organization. Global Database on Child Growth and Malnutrition, 2000. (online) WHO Website. Note: Underweight is measured as children more than two standard deviations below the reference. median for weight-for-age; Stunting is measuredas children more than two standarddeviationsbelow the reference median for height-for-age(Carlsonand Wardlaw, 1990). Fifty percent of children under-5 suffer from anemia(associated with iron deficient diets and also malaria), comparedto the regional average of 32 percent. Anemia is preventable, and Eritrea will needto focus on improvingnutrition awarenessand supplementalfeeding programs. Diarrhea prevalence for children under-3 was 24 percent in 1995. One in four children in this age group were reported to have diarrhea in the two weeks preceding the EDHS 1995, and about 66 percent of them received oral re-hydration therapy ORT (EDHS 1995). Although preliminary results from the EDHS 2002 discuss findings for the under-5 group (those reported to have had diarrhea in the two-week period before the survey), the data suggest a slight increase inthe use of ORT by mothers (68%). Efforts needto be focused not only on providing health education on re-hydration, but also on actions to improve environmentalhealth and hygiene, particularly inthe rural areas and urban slums. Nineteen (19) percent of children under-5 were reported with respiratory illness in the two weeks precedingthe EDHS 2002, and 44 percent receivedsome modernhealth care. 14 Figure 2.11 Global Trends in Under-5 Mortality y = 300 250 i + Tanzania * I R2= 0.7655 .-0 3 -r" 200 - '8 Kenya 150 - 'i: 100 - 5 U Eritrea 50 - 0 7- 1 10 100 1,000 10,000 100,000 per capita GDP,US% Source: World Development Indicators, World Bank, Washington, D.C., 2001 The top five causes of impatient mortality reported in public hospitals and health centers in 2000 included acute respiratory infection (AM); dehydration due to diarrhea, anemia and malnutrition; septicemia; and malaria. With respect to morbidity patterns for under-5 children observed at public health facilities in 2000, cases of ART comprised 40 percent of out-patient department visits, followed by diarrhea with 23.4% of cases. Others were eye and ear infections (7 percent), scabies and other skin infections (5.4 percent), malaria (4.3 percent), and anemia and malnutrition (2 percent). According to routine reports from health facilities, immunization coverage for children under-1 improved from 1995-1999 (Table 2.2 and Figure 2.12), but declined to 43 percent in 2002, probably a result of the conflict. About 55 percent of children inthis age group were fully immunized (received up to measles vaccine) in 199920. However, in 2002 (EDHS), the proportion of children fully immunized (12-23 months) was 76 percent, which is slightly lower than the 2000 EPI coverage survey showing a higher immunization rate of 79.4 percent. Differences in findings may be due to use of different denominators. Further analysis is neededto reconcile these differences. The incidence of immunizable diseases has been erratic. For example, 21 tetanus cases were reportedin 1999, compared to an average of two cases between 1995 and 1998. Overall, the five-year trend shows a decline inmost immunizable diseases amongchildren under-1. Health facility reports show no case of Diphtheria since 1995 and no case of Polio since 1998. *'World HealthOrganization, Department o fVaccines and Biological. WHO VaccinePreventable Diseases: Monitoring System, 2000 Global Summary, (online) WHO Website. 15 Thirteen (13) percent of newborns were low birth weight in 2000 (hospital data from PHC Division, 2000). At least 20 percent of BODamong children under-5 is attributable to conditions directly associated with poor maternalhealth, nutrition, and the quality of obstetric and newborn care. Table 2.2 Immunization Coverage and Incidence of Immunizable Diseases (1995-2000) Immunization Coverage and Incidence of Immunizable 1995 1996 1997 1998 1999' 2O0Ob 2000' 2002* Diseuses Immunization Coverage (YO) BCG 44 52 67 71 64 61 90.1 91 Polio 3 / DPT 3 35 46 60 60 56 52 85.5 83 Measles 29 38 53 52 55 50 81 84 Tetanus Toxoid (TT2+) 13 23 32 34 28 26.8 66 51** Immunizable Disease Incidence (number of cases) Polio 10 0 41 N A Diphtheria 0 0 NA Tetanus -Total 1 0 0 3 21 NA Tetanus -Neonatal 1 2 1 4 1 NA Pertussis 125 45 119 132 NA Measles 185 1783 777 316 320 NA Source: World Health Organization, Department of Vaccines and Biological. WHO Vaccine Preventable Diseuses: a Monitoring System,2000 Global Summary, (online) WHO Website. MOH, Eritrea-2000 HMISreport. ***2002 EPI Coverage Survey 2000, citedinMOH, Eritrea Health ProjZe 2000, May 2001. EDHS-Preliminary Report. Results are for women reportingat least one dosehhot oftetanus toxoid. Figure 2.12 Immunization Coverage for Children under-1, in Percent (1995-1999) 80 - 70 - 60 - 50 - 40 - Y i 30 - 20 - 10 - 0 4 I 1995 1996 1997 1998 1999 Source: World HealthOrganization, Department o f Vaccines and Biological. WHO Vaccine Preventable Diseases: Monitoring System, 2000 Global Summary, (online) WHO Website. 16 WOMEN'S REPRODUCTIVEHEALTH Eritrea has several of the risk factors for high maternal mortality and morbidity: relatively low age at first birth (about 21 years), absent or inadequate prenatal care, inadequate obstetrical care, high TFR, and low maternal nutritional status. Forty-one (41) percent of women had a body mass index (BMI) of less than 18.5 kg/m2in 1995 (EDHS 1995), indicating acute need for nutrition supplementationand education inthe country. Complications of pregnancyand childbirth, most of which are easily preventable, are the leading causes of death and disability among women of reproductive age in developing countries. In order to maintain continued improvements in maternal (and infant and child) health, Government focus should be on appropriate health care programsfor women. Some highlights are as follows: Antenatal coverage improved from only 49 percent of pregnant women in 1995'lto 70 percent in 2002 (Figure 2.13). Since 1995, antenatal coverage in rural areas and among uneducated women increased by at least 45 percent. Despite the substantial progress which must be acknowledged, urban-rural differences still persist, with 91 percent of women in urbanareas receiving care from a trained health professional, comparedto only 59 percent of ruralwomen. In 1995, 85 percent of urban and 40 percent of rural women visited a modern provider for antenatal services. In 1999, overall, about 40 percent of the target population of new pregnant women were registered in all health facilities22.This figure declined to 37.3 percent in 2000, although the 2000 EPI coverage survey reports a higher rate of 77.8 per~ent?~, Figure 2.13 Selected Countries,Percentageof PregnantWomen ReceivingAntenatal Care, 1995 Kenya 92 Uganda 1 Sudan E w t Erinea Tanzania Yemen Ethiopia 0 I O 20 30 40 50 60 70 80 90 IO0 Percent Source: UNICEF. Global Database on Antenatal Care, 2001, (online) UNICEF Website. Women's immunization coverage remains low. Twenty-eight (28) percent of pregnant and women of child-bearing age received full immunization of at least two doses of Tetanus Toxoid (TT) in 2000, a decrease from 34 percent in 1998 (health facility routine reports, 1998-2000). The 2000 EPI coverage survey indicates a higher figure of 66 percent. Although the EDHS 2002 reports on women who have had at least a single dose of TT (51 percent), the results may also indicate an increase in the number of women who manage to receive two doses of TT. WHO recommends 90 percent coverage for three doses of TT; for ''UNICEF. " Global Database on Antenatal Care, UNICEF Website, New York, 2001. MOHISEMISH. Annual Health Service Activity Report (Jan-Dec 1999), June 2000, Op. cit. l3 MOHISEMISH. Annual Health Service Activity Report (Jan-Dec 2000), June 2001. EPI Coverage Survey cited in MOH. Eritrea Health Profile 2000, May 2001. 17 neo-natal tetanus to be eliminated, a high routine coverage of women of child-bearing age, DPT for children and Td boosters. Between 1985-2000, deliveries attended by skilled health personnel were considerably lower than in neighboring countries, except for Ethiopia (Figure 2.14). Only 21 percent of deliveries received assistance from trained health professionals in 1995 (EDHS 1995), increasing only slightly to almost 29 percent by 2000 (2000 EPI coverage survey). In 2002, 28 percent of all births occurring in the five years prior to the survey were attended by a health professional; 26 percent of births occurred in a health facility comparedto 17 percent in 1995. The proportion of rural women who deliver at a health facility is still below 10 percent (from 7 percent in 1995 to 9 percent in 2002). In urban areas, the proportion of women who deliver at a health facility increased from 58 percent in 1995 to 62 percent in 2002. Figure 2.14 Selected Countries, Births Attended by Skilled Health Personnel 1985-2000 Sudan 86 EDPt Kenya Uganda Tanzania Yemen 22 Errtrea 21 Ethiopia 0 10 20 30 40 50 60 70 80 90 100 Percent Source: UNICEF.Global Databaseon BirthsAttendedby Skilled Health Personnel, 2001, (online) UNICEF Website. Women's average age at first birthwas 21 years in 1995. Although this is above the average age for the sub-SaharanAfrican countries (EDHS 1995), it is almost at borderline for pregnancy-relatedrisk. The Maternal Mortality24Ratio (MMR) is estimatedto be well over 1,000 reporteddeaths per 100,000 live births (1993-9q2'. Eritrea has one ofthe highest rates insub-SaharanAfrica (Figure 2.15 ). 24MaternalMortality is usually defined as deathoccurring while the woman is pregnant or within forty-two days of terminationof pregnancy, WHO. 25MOHISEMISH. Annual Health ServiceActivity Report (January-December 1999),June 2000. The report shows a facility-basedMMR of 240 per 100,000 births in 1999. 18 Figure 2.15 Global Trends in Maternal Mortality 1,600 - '' ' 4 1,400 - 4 y = 58557~-'858 R2=0.6314 1,200 - Eritrea 1,000 - ge: 800 - 600 - 400 - Tanzania 200 ~ 0 I Source: World DevelopmentIndicators, World Bank, Washington, D.C., 2001 Female genital cutting (commonly known as female circumcision) seems to be widespread, and its impact on women health needs to be assessed. Since the EDHS 1995, prevalence of female circumcision appears to have declined from 95 percent to 89 percent (EDHS 2002). The decline is notable among women under 25, indicating that some changes in practice are taking place. With respect to attitudes towards elimination or continuation of the practice, women were equally divided, with 49 percent for, and 49% against, continuation of female circumcision, HEALTH CONDITIONS OF ERITREA'S NOMADIC COMMUNITIES~~ About 30 percent of Eritreans are semi-nomadic or agro-pastoralists. Health conditions of women and children among the nomadic communities are below average for Eritrea. Among nomadic children, the most common health problems are anemia and A N . Among women, immunization coverage is low, CPR is low, and abortion is common. Post-partum sepsis, bleeding and Cephalopelvic disproportion are common causes of mortality and morbidity during labor. Poor nutritional status and anemia are common occurrences among pregnant women. Maternal and infant mortality are above the country average. Malaria is endemic in the lowlands of Eritrea. Although Leishmaniasis is not endemic in Eritera, both cutaneous and visceral Leishmaniasis are prevalent in the low-lands and in some highland areas. Tuberculosis prevalence is highas well. Further assessment is required for this sub-population. CHANGING EPIDEMIOLOGICALPROFILE This previously isolatedcountry is now opento trade, andEritreans from the Diaspora as well as foreign investors travel in and out of the country. The armed border conflict of the past two years has displaced close to 10-25 percent27of the internal population, adding to the 200,000 26Data is taken from a report by Tekeste, Assefaw, G.Tsehaye, and M.Dagnew, Health Needs Assessment ofthe Eritrean Nomadic Communities. MOH, PENHA and University of Asmara, 1999. 27Estimatesvary depending on the source. 19 returnees. The combination o f varied geography, high mobility, and openness after isolation has contributed to the spread o f communicable diseases and has complicated MOH's capacity to reach the population. ERITREAAND THE MILLENNIUMDEVELOPMENTGOALS (MDGs) As one of the poorest countries in the world, Eritrea faces a number o f challenges with regard to achieving the MDGs. Table 2.3 summarizes Eritrea's current status and the MDGs by 2015. These indicators suggest that concerted and strategic efforts are needed in various sectors for Eritrea to successfully address poverty and enhance the well-being o f its population. Table 2.3 Millennium Development Goal Indicators Indicators Current Target (2015) Poverty Rate (%of populationbelow $l/day) 53a 20 or 22b Net Primary Enrollment Rate (%) 33 100 Infant Mortality Rate(per 1,000 live births) 48 27 or 34 Child Mortality Rate (per 1,000 live births) 93 48 or 52 RatioofGirls to Boys inPrimary & Secondary Education 90& 80 100 %Births Attended by Skilled HealthPersonnel 28 90 Use of Contraception -Any Method (Men) N A NA Use o f Contraception -Any Method(Women) 8 25 % o f Populationwith Access to an ImprovedWater Source 7 25 or 75b aSome estimatesrange from 60 to 70. Targets vary dependingon the source. With regard to Infant Mortality and Child Mortality Rates, one o f MOH's major achievements under strengthening o f the PHC programs is improved immunization services. Of children aged 12-23 months, 76 percent are fully immunized. Accessibility to immunization services within five kilometers has increased from 40 percent in 1995 to 97.4 percent in 2000 (MOH 2000). The Government has also adopted the Safe Motherhood and Integrated Management o f Childhood Illnesses (IMCI) programs, which have also contributed to the reduction o f IMR and CMR, IMR and CMR have improved since the EDHS 1995 results. In 1995, IMR and CMRs were 72/1000 and 136/1000, respectively, while 2002 rates are now 48/1000 and 93/1000, respectively. Whether the MDGs for IMR and CMR could be achieved may prove to be a challenging task. While decline in IMR has been significant in recent years, decline o f CMR in Eritrea has been relatively slow, and the country has not made much progress relative to comparable countries because o f local resource and staffingconstraints. To stem the high rates o fMaternal Mortality and Morbidity, MOH has adopted the safe motherhood program together with other complementary activities that include: increasing coverage o f reproductive health services, adolescent health services and family planning services, as well as creating awareness on avoiding harmful traditional practices, such as FGM. More in- depth analysis is needed to ascertain whether the MDGs regarding increases in percentage of births attended by health personnel and contraceptive prevalence are realistic. At least three hospitals are presently under construction in Asmara, Barentu, and Mendefera, in addition to increased number of staff across all health facilities. Increases in the number o f hospitals and health personnel are expected to have a positive impact on the availability o f reproductive and maternal care services, especially for emergency care during delivery. Nonetheless, the expectation that the percentage o f attended births would increase by almost 300 percent from 2000 to 2015 may be unrealistic, given the country's existing capacity. 20 A more detailed table o f Eritrea's current status with regard to the MDG indicators for which data are available is in Annex 7. The data gaps suggest an urgent need for baseline information on many of the MDG indicators and for the Government to confirm/establishactual targets towards which their efforts may be directed. Completingthe gaps in baseline information, establishing realistic targets, and agreeing on steps to attain them will be part of the second phase of the health sector strategypreparation. Complementary eforts are also needed in all other sectors. Establishing key priorities andtargets is essential inthe education sector to efficiently and effectivelyimprove the skills and knowledge of the population. At the same time, improvements in infrastructure, business, and trade are also necessary to generate employment and productivity, and accelerate economic growthand development. 21 3 ERITREA'SHEALTHSYSTEM This chapter describes the Eritrean health system. It is organized along the following questions: What is the policy and governance context inwhich health care is delivered? What is the structure o f the system in terms o f public health care programs, delivery system includingphysical and human resources? How is the system financed? What methods are usedto pay medical care providers? Given the demographic and epidemiological characteristics o f the population, and the structure and financing o f the system, what is the service utilization pattern? As only limited data are available on the private sector and other public institutions involved in health care provision (such as the military which has its own health care operations), this chapter will mostly highlightthe structure and delivery ofthe MOH. POLICY AND GOVERNANCECONTEXT After independence, the Government of Eritrea established a comprehensive macro- policy including strategies for food security, human resource development, with education and health as key inputs, physical and social infrastructure development, and environmental restoration and protection. The Eritrean health policy supports the macro policy and aims to (a) minimize, and eventually eliminate, easily controlled diseases; and (b) enhance awareness o f good health practices to improve the productivity o f the workforce. The main areas o f focus o f the healthpolicy are: ensure the equitable distribution of health and social services to rural and urban areas, support primary health care, inparticular improve and expandmother and child-care services; give special attention to major health hazards and promote health care services; encourage the private sector to actively participate in the provision of health services, following rules and regulations and operational modalities provided by MOH; promote community and beneficiary contribution infinancing health services; introduce national health insurance schemes: and actively promote information dissemination on health practices28, '*Tseggai,A. "Human Resource Development: Priorities for Policy". InPost Conflict Eritrea: Prospectsfor Reconstruction and Development, ed, by M.Doombosand A. Tesfai. New Jersey: Red SeaPress, 1998. 22 According to the Proclamationfor the Establishmentof Regional Administrations2', MOH role is to: formulate policies, prepare regulations, directives, standards, integratedplans and developmentof budgets, as well as supervise their implementationthroughout the country; undertakeresearchand studies, compile and collect statistical data; provide technical assistance and advice to regional programsand administration; comply with national policy, standards and regulationsand, upon agreement of the Ministry of Local Government, assign regional executives, recruit, transfer, promote and dismiss employees; and seek external funding for regional developmentprograms. At the zoba3' level, the main functions ofthe Zonal Medical Officers are: Planning, including the preparation of annual plans and budgets, project monitoring and, to limited extent, evaluation. Coordination of all development activities includingthose of the private sector and external agencies, Implementation a core function at the zonal and sub-zonal levels. This involves managing - relations with sub-regional and community administration officials, mobilization of community resources, handling contracts and financing mechanisms and providing support for operationand maintenance. The Zonal Medical Officers report to both MOH and the Zonal Governor. For health sector matters, Zonal governors report directly to MOH. A detailed description of MOH (central and zonal levels) is inAnnex 3. PLANNINGAND BUDGETING At the national level, Government coordination is through the Cabinet of Ministers. All funds are gathered through the revenue department of the Ministry of Finance and distributed through the Department of Treasury to the different line Ministries. No funds for health go directly from the National Government to the Zones. Funds flow from the Ministry of Financeto the Zones, but with the information also submitted to the line Ministry.Planning is consolidated at the national level. Salary paymentsand procurement have beendecentralizedto the Zones. Planning for health - an exercise introduced three years ago is made at the Zonal level - (with contributions from lower levels down to the community3'). These plans are consolidated and summarized at the national level. Similarly, the national level divisions and departments develop their own plans. 29Governmentof Eritrea, ProclamationofEritrean LawsNo 8611996: Establishmentof Regional Administrations. 30The zoba is the administrativedivision, corresponding to aregion. Eritrea is divided into 6 zobas. 3'According to the HeadofZonal Affairs, Ministry o f Health. 23 Budgeting is divided into capital and recurrent budgets, the former with a five-year perspective and the latter with an outlook for the coming three years. Recurrent budget estimates are based on historical figures. Once approved by the Ministry o f Finance, the funds are made available to the zones on a monthly basis. Supplementary funds can be added each month at the request o f the zones, upon approval by the Ministry o f Finance. An internal audit is conducted each year. DECENTRALIZATION The Government and M O H are committed to decentralization. In May 1996, the government adopted a policy to decentralize its operations, but implementation o f the policy has been hampered by lack o f skilled human resources at the zonal level. To date, fiscal decentralization has not been undertaken in the form o f decentralizing budget expenditure decisions: whether government budget for health will be earmarked in general, and/or for specific programs; zonal governments cannot reallocate funds between sectors or retain revenues collected from health facilities. HEALTHSYSTEM STRUCTURE,COVERAGE,AND CAPACITY M O H is responsible for public health, sector management and planning, health care delivery, and to a large extent, financing o f health care for those who cannot afford it. In addition, Government regulates and controls the provision o f private and NGO-operated health services. PublicHealth While the Primary Health Care Policy and Policy Guidelines32provide guidance regarding priority areas for programmatic intervention, the prescribed activities under this policy document are not supported by either cost estimates o f providing these services, nor the cost- effectiveness o f the strategies proposed. Health services in Eritrea are based on the principles of PHC and are made available to the entire population. They include promotive and preventive services, inter-sectoralactivities, and community participation inhealth. M O H is supporting several public health programs: child health; EPI; reproductive health program; nutrition, environmental health, and IEC; and community health services (CHS). Details about major public health programs are in Annex 3. Limited information about the cost- effectiveness o f some o f the programs is inAnnex 5. HealthCare Delivery System The public sector is the major provider o f health care. Private clinics exist only in larger cities and serve a limited proportion o f the population. At the village and district levels, the PHC network consists o f health posts and health centers staffed with one or several nurses. Health centers have a laboratory and limited in-patient and delivery facilities. Many remote villages have no health facility. Every village or cluster o f villages has teachers, extension and social workers, and malaria agents. They often work in cooperation with health facilities, sometimes referring patients. At the regional level, the recently established Zoba health team manages the PHC network. The Government is completing a network o f referral hospitals (one ineach Zoba). 32MOH, September 1998. 24 Limited field ob~ervation~~show that the health system is in place and health facilities are well kept, clean and stocked with supplies, with the exception of the more remote facilities that need refurbishment and lack adequate staff, equipment, and supplies. M O H reports34also note overcrowding in referral hospitals and the underutilization o f lower health facilities indicating possible quality issues, such as lack o f adequate staff and services in these facilities. This issue needs further assessment. Infrastructure Health care services are delivered usinga three-tier system: Primary Levelfacilities include Health Stations, the first contact for health services and the smallest health units, ideally serving a population o f approximately 10,000. A registered nurse and one or two associate nurses staff the health stations. They provide mainly preventative care focusing on immunization, antenatal care, control and care o f communicable diseases, health education and basic curative services. Health Centers are larger than Health Stations and serve populations of about 50,000. They have 25-30 beds and provide curative and preventative care, including polyclinic services, mother and child clinics, environmental sanitation, epidemic disease control and outreach services. Health Center staff may consist o f two or three nurses, a laboratory technician, sanitarian, and a number o f Associate Nurses, depending on the population of the catchments area. Staff at the health centers also supervise Health Stations and provide training to Community Health Agents and Traditional BirthAttendants. Secondary Levelfacilities. First-contactor sub-zoba hospitalsserve populations o f at least 50,000 and provide general medical and obstetric care and basic laboratory support services. Each hospital should have at least one general physician, a pharmacy technician, and several nurses, associate nurses, and laboratory technicians. They have facilities for minor surgical procedures and deliveries, and beds for in-patients. They are responsible for supervision o f health centers in their locality. Zoba referral hospitals cater to populations o f at least 200,000 and are typically located in zoba capitals. They provide general surgery, deliveries, laboratory, ophthalmic care, radiology, dental, obstetric, and gynecological services. They are also usedas clinical training sites. Tertiary Level facilities . National referral hospitals (NRH) are specialized facilities located in Asmara and serve the entire country. These include: Halibet Hospital for medical and surgical cases for adults, Mekane Hiwot Pediatric Hospital, Physiotherapy Center, Behan Aini Ophthalmic Hospital, St. Mary's Psychiatric Hospital, Mekane Hiwot Obstetrics and Gynecology Hospital, and HansenianHospital, managed by an NGO, M O H intends to re-categorize the above health facilities into the following: health stations, community hospitals (formerly health centers), regional hospitals, and national referral hospitals. 33Lagerstedt, A. Trip. Report on Health Sector Visionand Health Policy Review, 24 August 2000. 34MOH. Eritrea Health Profile 2000,May 2001. 25 Expansion of Health Facilities In 1993, Eritrea had about 16 hospitals, four health centers, and 106 health stations. M O H owned 46 percent o f the total health facilities inthe country. Since 1993, M O H embarked on PHC coverage expansion and decentralization policies that resultedina significant increase o f its share o f health facilities. Between 1993-2000, 48 new health centers, 64 new health stations and 55 new clinics were constructedhpgraded. Table 3.1 illustrates the growth in health infrastructure from 1990 to 2000. In 2000, MOH owned 88 percent o f the total health facilities, and the remaining 12 percent were divided among the Catholic Mission (10 percent), the Evangelical Church (0.06 percent), and other NGOs (1 percent). The Catholic Church and other partners mostly own health centers, health stations and specialized clinics, such as MCH. Out of the sevenhospitals inAsmara, at least one isprivately owned, Table 3.1 Growth of Health Infrastructure, 1990-2000 Total Growth Facility Type I990 I995 I999 2000* (1990-2000) Population Numbers per Facility Numbers Numbers Percent Hospital 16 16 18 222,000 18 2 13 Mini-Hospital 0 4 5 798,000 5 5 1,200 Health Center 4 40 49 81,000 52 48 60.3 Health Station 106 130 154 26,000 170 64 Clinics 0 31 37 108,000 55 37 Total 126 221 263 300 174 138 Sources: Ministry of Health, Annual Health Service Activity Report (January-December 1999), June 2000. $2000data from Ministryo f Health Eritrea, Eritrea Health Profile 2000, 2001. Figure 3.1 MOHHealthFacilities,1990-2000 180, 160 140 120 ah 100 zf 80 60 40 20 0 Hospitals Mini-Hospitals Health Center Health Station Healthclinics HeaIth FaciIities Source: MOH, Annual Health Service Activity Report (Januaty-December 2000), June 2001, 26 Access to Health Facilities Despite the increase in health facilities, and the vast improvement in coverage of the population for basic health care, access to facilities is still limited. For example, although MOH aims to have 10,000 people covered per health station, in 2000, on average, 24,000 persons were covered per health station. Health facilities are fairly well distributed across zones (Table 3,2), but there are high and low concentrationsof health stations in some sub-zones (for example, there are places inZoba Anseba where the distance to a healthfacility is more than 100 km). Table 3.2 Distribution of Health Facilities by Type and Zone, 2000 Gash Facility DKB SKB Anseba Barka Debub Maakel NRH Total Hospital 1 4 1 3 3 0 7 19 MiniHospital 1 0 0 0 2 1 0 4 Health center 3 11 8 12 10 8 0 52 Health station 14 24 23 38 45 26 0 170 Clinic 3 8 7 5 3 29 0 55 Pharmacies 0 3 2 2 2 22 0 31 Drugshops 4 1 2 1 2 18 0 28 Drugvendors 2 23 30 64 68 3 0 190 Source: MOH, Annual Health Service Activity Report (January-December ZOOO), June 2001. In 1991, only about 10 percent of the Eritrean population had access to a health facility within a 10-kilometer travel distance. With the growth in PHC facilities since independence, by 1998 approximately 70 percent of the population had access to a health facility within 10 kilometers. The EDHS 1995 provides information on the median distance of the survey respondents to service delivery points for EPI, FP, and MCH services. The median distance is between 7 and 9 kilometers, There is, however, wide regional variation in the accessibility to these basic health services. For example, the median distance to a facility providing delivery services by zones range from 2.5 km in the Central region to 20 kilometers in the Gash Barka region. The Government has also developeda map illustratingthe distribution of health facilities over the country (Annex 4). This is an excellent tool to get an impression of the geographical distribution of health facilities in and betweenregions, but in a mountainouscountry like Eritrea, it needs to be interpreted with caution. Even though it may seem as if facilities are well distributed, equity in terms of access may be difficult to achieve due to the non-availability of roads or the topography ofthe country. Hospital Beds A total of 3,126 hospital beds were reported for 2000, which translates into 0.76 beds/1,000 population. This is a small improvement from 1999, in which a total of 3,022 hospital beds were reported, or a 0.75 beds/1,000 persons (assuming a population of approximately 4 million). The total number of beds is expected to increase considerably, following the construction of new hospitals. Nevertheless, Eritrea's hospital bed-to-population ratio is below average for the sub-Saharan Africa region of 1.37 beds/1,000 persons (see Table 6.3, Annex 6), and also below average for other countries worldwide with comparable income levels (figure 3.2). 27 Figure 3.2 Global Trends in Bed Capacity per 1,000 Population 18.0 - y = 0 . 1 1 5 6 ~ ~ ~ ~ ~ ~ 16.0 - R2= 0.3989 10 100 Tanzania I 1,000 10,000 100,000 Per Capita GDP, US% Source: WorldDevelopment Indicators, 2001, World Bank, Washington, D.C. Bed Occupancy Rates (BOR) for 2000 range from only 11 percent in Tio Hospital to 129 percent in St, Mary's F'yschiatric Hospital inAsmara (Table 3.3). The optimal BOR is at least 80 percent but only three out of 22 hospitals had BORs above 80 percent: Saint Mary, Adi Keyh, and Halibet hospitals. BORs in zones are considerably lower than the NationalReferral Hospitals (NRH) and show wide variations. This could indicate a weak referral system, or patient preference to directly visit the NRH because of the perceived higher quality of care offered at these hospitals. Table 3.3 Number of Beds and Bed Occupancy Rate by Zones, 2000 Zones Name of Health Facility No. of Beds Bed Occupancy Rate DKB Tio 59 11.3 Asseb 113 62.6 SKB Massawa 187 22.6 Ghinda 80 38.1 Afabet 52 20.5 Nakfa 93 26 Ameba Keren 186 60.7 Debub Senafe 42 29.4 Dekemhare 60 N.A. Mendefera 102 32.2 Adi Keyh 99 83.8 Adi Quala 65 34.6 GashBarka Aqurdat 103 26.8 Tesenei 84 44.3 Barentu 41 52.9 Maakel Edaga Hamus 54 36.3 National Referral Mekane Hiwet Pediatric 200 52.9 Mekane Hiwet Maternity 80 61.9 Merhane Aynee Opthalmic 151 55.5 St. MaryPsychiatric 170 129.2 Hensennian 40 N.A. Halibet 336 80.5 Source: MOH, Annual Health Service Activity Report (January-December 2000), June 2001, 28 HumanResources Between 1991-2000, the total number of staff in the MOH system increasedfrom 387 to 4,906 persons, or by 1,168 percent (Figure 3.3). During that period, the number of physicians increasedby almost 200 percent, from 58 to 173; only 44 percent were specialists. The number of nurses increasedby 181 percent, from 288 to 811, while health assistantshanitariansincreased from 0 to 1,333. Administrative staff increased from 0 to 2,079 in the same period. Table 3.4 shows the development of humanresources inMOHbetween 1991-2000. Out o f the total staff employed in 2000, 3 percent were physicians, 17 percent were nurses, and 27 percent were health assistants. Administrative staff represented 42 percent of MOHwork force. The increase inthe number of physiciansand health assistants was mainly due to the return of professionals from exile overseas. The increase inthe number of other categories was mainly due to continuous local training35. Approximately 60 percent of MOH staff were women, mostly employed as nurses, health assistants, and CustodiaVmanual staff. The distribution of private health professionals are not known at this time. Future inventories will include non-MOH, private, and NGO staff to give a more complete picture of all health professionals, although observations show that most private clinics may be staffed by public medical personnel, mostly physicians, working intheir spare time to supplement their income. Figure 3.3 MOHHuman Resources, 1991-2000 2,500 - 5z 2,000 - -d +Physicians i 1,500 - 1,000 - +Nurses p' L 500 - -Health Assistants 2 0 - 1991 1995 2000 Source: MOH, Annual Health Service Activity Report (January- December 1999), June 2000. Table 3.4 Growth of Human Resources in the MOH, 1991-2000 Total Increase Category 1991 1995 1999 2000 (1991-2000) Number Percent Physicians-GPs 58 108 100 100 42 72 Physicians-Specialist 0 0 45 73 73 Nurses 288 391 735 811 523 181 HealthAssistants 0 539 1,292 1,333 1,333 Pharmacists, Technicians, Druggists 8 17 84 85 77 960 Sanitarians 0 15 21 21 21 Lab Technicians 15 35 132 133 118 786 X-Ray Technicians 18 18 40 40 22 122 Other healthprofessionalstaff 0 0 245 231 231 Administrative Staff 0 1,425 1,790 2,079 2,079 Total 387 2,548 4,239 4,906 4,519 1,167 Source: MOH, Annual Health Service Activity Report (January-December 2000), May 2001. ~~ 35 MOHISEMISH. Annual Health Service Activity Report (January-December1999), June 2000. 29 Each physician covered a population of 23,033 persons, or 0.43 physicians per 10,000, and each nurse covered about 5,055 persons, or 1.97 nurses per 10,000 population. There were 4.5 nurses per physician and 7.5 health assistants per physician (or 1.6 health assistants per nurse) inthe MOHsystem. Eritrea's physician-to-population ratio is below average for the sub-Saharan Africa region, and also lies below the average for other countries worldwide with comparable income levels (Figure 3.4). Figure3.4 GlobalTrends of Physiciansper 1,000 Population 5 .o1 y = 0 . 0 0 3 8 ~ ~ ~ ~ ' ~ 4 . 5 4 .O . . .. 3 . 5 3 .O 2.5 2 .o 1 * r 1.5 1 .o 0.5 0 .o 7 1,000 10,000 100,000 Eritrea lY- per capita GDP (US%) Source: World Development Indicators, World Bank, Washington, D.C.,2001. Even though the categories of health staff have increased each year, there are still acute shortages among some essential categories, especially internists, psychiatrists, ENT specialists, ophthalmologist, radiologist, and dentists. About 26 percent ofthe physicians employed by MOH in2000 were expatriatesfrom Russia, Sudan, Australia, China, Italy, the United States, and India. Of the total health personnel in MOH, 42 percent are in the Center, with the remaining 58 percent distributed in the Zones. Maakel and the NRHs have the highest number of health personnel. Of the total staff, the following work in the NRHs: 46 percent are physicians, 36 percent are nurses, 19 percent are associate nurses, 22 percent are pharmacists and pharmacy technicians, 40 percent are x-ray technicians, and 26 percent are administrative staff. Taking into account only hospital staffing at the center and the zones, 68 percent of physicians, 68 percent of NRHs. nurses, and 54 percent of associate nurses are assigned to the Maakel Mini hospital and the There is also a wide variation of health staff by Zone (Table 3.5). For example, in 2000 there were 8 physicians (GPs) in Maakel and 17 in Gash Barka. There were also hospitals without doctors (Tio Mini hospital, Afabet, and Nakfa hospitals) and midwives (Tio, Ghinda, Tesennei and Barentu). 30 Table 3.5 Distribution and Category of Available Health Personnelper Zone, 2000 Unknown Category DKB SKB Anseba B a r b Debub Maakel NRH Residence Total General practitioner 9 11 11 17 15 8 27 2 100 Specialist 1 2 3 2 5 6 50 4 73 Nurse 29 52 55 76 98 141 292 68 811 Health Assistants 56 178 109 187 228 121 253 201 1,333 Pharmacist/ pharmacy technicians 5 7 9 7 12 26 19 0 85 Sanitarian 3 2 3 3 4 6 0 0 21 Lab technician 5 12 6 14 16 23 56 1 133 x-ray technician 2 5 4 6 6 1 16 0 40 Other health technicians 1 4 6 9 11 12 7 0 51 Other health orofessionals 2 15 13 32 17 51 44 6 180 Ahministrative staff 153 167 184 217 373 402 539 44 2,079 Total 267 455 403 570 785 797 1,303 326 4,906 Source: HMIS and HumanResource Inventory (R & HRD),cited in Ministry of Health, Annual Health Service Activity Report (January-December ZOOO), June 2001. Note: Unknown Residence indicates that the current work place o f some health personnel was not specified in their file. Staffing norms per health facility are currently under development and review and were not readily available. However, local hospitals are expected to be staffed with a General Practitioner with training in minor surgery and competence to conduct a Caesarian Section, and equippedwith laboratory services and x-rays. A Zonal hospitalwill have the four basic specialties (surgery, internal medicine, Obstetric and Gynecology and Pediatrics). The NRH will be the national medical center for the country36. Continued expansion o f health facilities should take into account the need for all health facilities to have qualified staff and in sufficient number. In this regard, future developments must be guided by Eritrea's new Human Resources Development Policy. Training of Health Professionals Training activities are coordinated by the recently established Research and Human Resources Development Center in Asmara, which deals with training, continuing education, human resources planning, research, and Health Management Information System. Most health professionals are trained at the Instituteo f Health Sciences in Asmara. The Institute includes the Asmara School o f Nursing, the School o f Medical Technology, Asmara School o f Midwifery, and the Asmara Health Assistants School. Some are also trained at the University o f Asmara, College o f Health Sciences, which provides degree-level courses in nursing, pharmacy, and medical laboratory technology. However, none of the medical doctors are trained in the country. Between 1994 and 1999, about 54 percent o f graduates from national institutions were females. Most trained professionals were employed by the Government after graduation For pre-service training, M O H recently merged and reorganized the five professional training schools (Asmara Nursing School, Asmara Health Assistant Training School, Midwifery School, School o f Medical Technology, and Gejeret School o f Nursing) and upgraded them to a 36Discussion with Mr.Berhane Gebrintsae, Director General, Health Services Department (Lagerstedt, A. Trip Report on Health Sector Vision and Health Policy Review, 24 August 2000 ). 31 College of Nursing and Health Technologies3'. The purpose of this merger and upgrade was to standardize the quality of education and use resources more efficiently. Construction of a satellite campus for training of Associate Nurses in the College in Barentu is expected to start shortly. As part of its continuing education activities, MOH has introduced a distance education program in collaboration with the University of SouthAfrica. However, issues regarding limited information, communication, technology (ICT) capacity would need to be addressed before this program can be fully implemented. In 1998, MOHconducteda comprehensivestudy to evaluatethe training curriculum and presented the results in a workshop in December 1998. All curricula used to train health professionals were revised based on these results. It is important to assess how this training curriculum can be made more responsive and relevant to the needs of the population. The assessment could be done in line with the on-going preparation of the ten-year Human Resource Development Plan for Health and the review and ratification of the draft Human Resources Development Policy and Plan. PHARMACEUTICALS Procurementand Distribution Eritrea relies on imports for all its pharmaceuticalneeds. Drugs and medical supplies are imported through PHARMECOR, a parastatalagency, and private firms. There are currently six importers and six wholesalers for drugs andor medical supplies. Donated drugs are received in the Central Medical Stores and distributed to primary health care levels. The Department of PharmaceuticalServices within MOH is responsiblefor the control and distribution of drugs. A new factory was expected to begin production and packaging o f drugs in 1998 in Keren. The factory is nearly fully equippedbut has not yet startedproduction. Private Sector Role Private sector involvement in pharmaceuticals has been mainly through ownership of drug retail shops. In 2000, there were altogether 259 retail drug outlets, which included 31 pharmacies run by pharmacists, 32 drug shops run by pharmacy technicians, and 196 rural drug shops run by barefoot doctors, health assistants, and nurses. In 1996, 36 percent of PHARMECOR's drug expenditures were financed through the private sector. Total private sector expenditures for pharmaceuticals are not readily available, although according to MOH, they can be obtainedfrom the importers themselves. Financing Public sector budget for pharmaceuticals was Nafka 35 million in 1999. MOH covered Nafia 16.6 million, or 47 percent of the total budget, and donors coveredNafka 18.4 million, or 53 percent. However, this budget was inadequate to cover the population's needs, and several in- kind donations of drugs were provided to the country by external partners. The Government has recently introduced a cost-sharing mechanism, through which patients pay for the drugs prescribed in the secondary and tertiary levels of health care. Evaluation is needed on cost- 37MOH, Eritrea HealthProfile 2000, May 2001. 32 recovery through cost-sharing for drugs, as well as on government pricing and exemption policies, especially for the poor. Current Status and Action Plan The Department of Pharmaceuticals at the MOH has been actively strengthening institutional capacity and formulating drug procurement and distribution norms and standards. Since 1993, the following actions have taken place or are under review: Drafted the Eritrean National Drug Policy (1997), drafted and published the drug law, drug policy, standard list of drugs and treatment guidelines. EstablishedProclamationNo. 3611993 to control drugs, medical supplies and sanitary items. Developed Inspection Guidelines and Good Manufacturing Practice for private and public sector. Developedand distributed company registration guidelines, and Product Registration guidelines. Established the National Drug Quality Control Laboratory, introduced new drug tests, and developedstandard laboratory operational procedures. Improved the distribution of retail pharmacy outlets, registration and licensing proceduresof drugs and medical supplies importers; set requirements for licensing, and initiated licensing of wholesale importers;. Established and published the third edition of the Eritrean National List of Drugs in 2001. Publishedthe Eritrean StandardTreatment Guidelines and drafted the EritreanNational Drug Formulary in 1998. The National List is generally well adheredto. Inthe public sector, more than 90 percent of drugs prescribed are from the list. Compliance with the list in the private sector is lower. For drug management, the following actions were taken: introduced and established as a routine task - - quantification of drugs and medical supplies requirements for the health facilities of the MOH; upgraded in 1998 computerized stock control system in the Central Medical Store; improved distribution efficiency and reduced the stock of expired drugs; and improved communication and reporting systems at both central and zonal levels; published in 1998 for the first time, Guidelines on rational storage and inventory control management for Central and Zonal Drug warehouses; computerized stock control system in the Central Medical stores in 1994 and upgraded in 1998,introduced computerization of stock control system at the zonal level in 1998; published guidelines on rational storage for lower health facilities in 1998; developed standard storage operative procedures; proposed design for the constructionof 3 standard zonal drug warehouses. The following key activities are in the pipeline: a survey of traditional medicine practices; construction ofthree standardzonal drugwarehouses; publication of the third edition of Eritrean National List ofDrugs andNational Formulary; registration of products; strengtheningof drug quality control and the introduction of new drug tests; inspection guidelines for drug manufacturing plants; disposal guidelines for expired and obsolete items; improvement of logistics and MIS; cabling of computerized stock control system at the central level, and upgradingof computerizedstock management system at zonal level warehouses. 33 Laboratory Services The national health laboratory structure o f Eritrea is based on a three-tier system o f peripheral, intermediatehegional, and central hospital laboratories, with the Central Health laboratory as the national reference. The Central Health Laboratory includes standardization o f test methods, development o f new technologies, implementation and monitoring o f national quality control (include external proficiency testing) programs, in-service training o f technical staff by conducting workshops and other forms o f training. As a preliminary step towards quality accreditation, the laboratory participates in international external quality control programs. While this has served the country's needs to date, it is insufficient to support the momentum o f expanding national health services. Issues related to shortages in personnel, equipment and supplies; needfor training and standardized internal quality control and preventive maintenance and repair; and lack o f networkingacross different levels o f health services facilities would need to be addressed. An in-depth study of laboratory services inEritrea will be undertaken shortly. 34 HEALTH SECTOR FINANCING FinancingSources Overall, healthcare spendingincreased innominal and real terms between 1995 and 1999 (see Annex 5 for details). Donor contribution increased in absolute terms and as a percent oftotal health spending, from 20 percent in 1995 to approximately 30 percent between 1996 and 1999 (Donaldson 2000). Total health care spending was estimatedat 2 percent of GDP, with a public sector share of 55 percent (or 1.1 percent of GDP) and a private sector share of 45 percent (or 0.9 ercent of GDP). Public sector contribution, as a percentage of GDP, increased to 2.9 percent in 1997, Y* excluding all foreign assistance. The currenttotal health spendinginEritrea is not known. Public sector spendingon health is estimatedat about 65 percent of total health spending for 1999, with donor contribution at 27 percent, and household contribution at 8 percent (excluding the private sector). Per capita health spending was estimated at Nafia 49. Detailed information on all private contributors, such as firms and private payments for drugs, as well as information on all public entities, such as the military and others, is unavailable. Exclusion or under-reporting of expenditures made by the Ministry of Local Government and donors is likely, as well as the value of in-kind donations of drugs. This issue will be addressed in Phase 2 of the Health Sector Strategy Options Preparation. Trends InPublicHealthCapitalAnd RecurrentExpenditures Eritrea's per capita GDP is below average of the sub-SaharanAfrica region, Eritrea's per capitatotal health spending is not known, since private sector contribution to the health sector is not known. Eritrea's public health expenditure as a percentage of GDP is above average for sub-Saharan Africa region, and above average for other countries worldwide with comparable income levels (Figure 3.5). Eritrea's per capitapublic spendingon health is below average for sub-Saharan Africa region, but close to the average for other countries worldwide with comparable income levels (Figure 3.6). 38The World HealthReportestimatesEritrea's total expenditure on health for 1997 to be 3.4 percent of GDP, of which 55.7 percent is public sector contribution, and 44.3 percent is private sector contribution, mainly in the form of out- of-pocket expenditures. Per capita healthexpenditureis estimated at US$6, andPPP US$24. The World Health Report 2000, Health Systems: Improving Performance, WHO, 2000. 35 Figure3.5 Global Trends in PublicHealth Expenditure,as Percentof GDP l4 1 y = 0.6551Ln(x) - 1.5543 4 R2=0.2565 0 , ~ 10 100 Tanzania 1,000 10,000 100,000 per capita GDP, US% Source: World Development Indicators, World Bank, Washington, D.C., 2001. Figure 3.6 Global Trends in Per Capita Public Health Expenditure 100 xgB .k0" 90 y = 0 0059~'2046 i R2= 0 9112 ~ 80 -3 i 70 + .e 60 - $ g 5 0 - 5.- 'k 0 - 40 - Tanzania 30 .-3n 20 -- 3 10 - 0 0 . 10 100 1,000 10,000 100,000 per capita GDP,US% Source: World Development Indicators, World Bank, Washington, D.C., 2001 Note: Only countries with aper capitaPublic Sector Health Expenditure of less than US$lOO are shown here Total capital budget amounted to Nafka 24 million in 1999, representing an increase in real terms o f 182 percent compared to the 1995 capital budget, but remained more or less constant in real terms between 1996 and 1999. Donor contribution remained high during the same period, and represented 63 percent of the total health sector capital budget in 1999, while Government contribution was 37 percent. 36 Total recurrent budget amounted to Nafka 133 million in 1999 and remained fairly constant in real terms for 1995-1999, with the exception o f a sharp decline in 1996. Except in 1995 where a large portion o f the recurrent budget financed back payment o f ex-fighters, about 50 percent o f the 1995-1999 recurrent budget was spent on salaries, 20 percent on drugs, and about 30 percent on other inputs, including operations and maintenance. Donor support increased from 7 percent in 1996 to 22 percent in 1999, mainly for pharmaceuticals. The country's dependency on external contribution for pharmaceuticals, and the long-term effects on maintaining constant drug delivery, needs to be assessed. Since 1'996,MOH revenues have increased in nominal and real terms, mainly due to an increase in registration and drug fees at health facilities. Revenues collected through such fees amounted to about 4 percent o f the 1995 recurrent budget, and increased to an average o f about 12 percent o f the 1996-1999 recurrent budget. Historical details on revenues are not readily available. What is known is that in 1998-99, 80 percent o f revenues came from registration, diagnostic, care and "hotel'' services fees at MOHhealth facilities, and 20 percent were from drug fees. Estimates o f low, medium, and high scenarios o f aggregate public health sector costs and financing from all sources (in real 2001 Nafka)39for the next five years indicate a financing gap between projected costs and available financing from public revenues and donor support for recurrent budget. The low scenario projects a shortfall o f Nafka 58.1 million o f a total budgeted cost o f Nafka 204.7 million by 2007 (in real 2001 terms). The medium scenario projects a shortfall o fNafia 27.4 million o f a total budgetedcost o f Nafka 230.9 million. The high scenario projects a shortfall o f Nafia 12.1 million o f a total budgeted cost o fNafka 269.8 million. Possible recommendations to address the above scenarios and bridge the financing gap include a careful assessment o f number o f beds and other capacity needs, taking into account existing and planned infrastructure; intensifying efforts to identify additional donors for recurrent financing; and seeking ways to increase user fee revenue, with that increase being budgeted with the existing level of public financial support to the sector. However, given Eritrea's high rate o f poverty, increases in user fees will need to be assessed carefully, especially in relation to PHC care, i.e., how much can really be charged vis-&-vis how much people are willing to pay. Alternative strategies for health care financing will needto be identified to ensure universal coverage, especially for the poor. Prioritization of interventions and minimization of ineflcient use of resources would need to be carefully assessed during Phase 2 of the sector strategy preparation. 39 The low scenario assumed a low rate of real GDP growth (l%), the medium scenario assumed a moderate rate of GDP growth (3%), and the high scenario assumed a high rate of growth (7%). Other key variables influencing healthsector costs were ratesof population growth and changes in the number of hospital beds. On the financing side, the same GDP assumptions applied to government budgetary resources for health, and increasing per capita levels of donor financing were assumed. User fee revenue was generally assumedto grow with GDP and population growth, but the "high" scenario assumedan ambitioustarget of collecting fees equivalentto 1 percentof GDP by 2010. The results of the "high" scenario shouldbe regarded as the upper limit for the expansion of the costs and financing for the sector. Given historical rates of economic growth in sub-SaharanAfrica, it is unclear that Eritrea will experience an average annual real rate of GDP growth of 7 percent. It is also difficult to predict trend in donor financing for health, and the real per capita level of donor financing may not remain constant considering population growth. Finally, while it is feasible that the population, on average, could pay 1 percent of GDP for health services, it is unlikely that the public sector will be able to mobilize this level of fee collection without altering access and quality of service (Donaldson 2002). 37 Concerned with the financing of the health sector recurrent budget, especially in view of the large share of the public sector, MOH developed a health financing policy in 1996, which was updated in 1998. Implementation of the policy was however postponed because of the conflict with Ethiopia. By early 2002, MOH decidedto reconsider its health financing policy and the roles and likely levels of financing from Government, donors, andthe population usinghealth services. In assessing the health financing policy, MOH needs to closely evaluate the proposed incentives to improve revenue collection at health facilities as well as the introduction of correspondingchanges to ensure a smooth transition and sustainability of the new system. At the same time, efforts must be made to ensure that good quality health care is available to the poor and those unable to pay. The provision of good quality and affordable health care becomes particularly challenging because of the high poverty rate inEritrea. HOUSEHOLDHEALTHCAREUTILIZATIONAND EXPENDITURES HealthCare Utilization The Government does not regularly collect data on illness incidence, household health seeking behaviors, and household expenditures for health. Two household surveys were undertaken in the 1990s. They are: the Living Standards MeasurementSurvey (LSMS) in 1996 for which results are not readily available, and the 1997 Eritrea Household Health Status, Utilization and Expenditure Survey (EHHSUES) conducted in the Debub and Gash-Barka zones4'. Informationinthis section is mostly based on the EHHSUES, The EHHSUES study found that most of those for whom illness was reported sought some healthtreatment. MOHhealth stations are an important source of health advice and service, with at least 40 percent of patients receiving care in those facilities. Private facilities were used as a source of care by fewer than 20 percent of medical care seekers (figure 3.7). Figure 3.7 Sources ofTreatment for the Ill,1997 ( in percent) Government Government Hospitals- IP r Medicine Hospitals 4% \ / Traditional 4% lC0, - OPD\ Pharmacies l J / O 14% Health Centers IP - 2% Health Stations Source:Eritrea HouseholdHealth Status, Utilization and ExpendituresSurvey, 1997 Note: Figuresare rounded-ofc and therefore may not addto 100 percent. 40Analysis of the data for the remaining four zones was not carried out due to the disruption of the conflict with Ethiopia. The preliminary draft report of the study inthese two zones was based on interviews with 1,248 households, of which 686 (55 percent) indicated that they had a household member who was ill during the month prior to the survey. 38 On the other hand, a 2001 MOHreport underscores the major problem of overcrowding in referral hospitals and the underutilization of many lower-health facilities, because of understaffing in the lower level facilities and/or that "some services have not yet acquired a high level of acceptance in local communities.yy41 HealthCare Expendituresand Methodsof Payment Fee for service is the most common payment method used for health care. However, health care fees are heavily subsidized by the Government at MOH health facilities. Health insuranceis almost non-existent. The EHHSUESshows that: (i)most patients pay for health care, even if a small amount; (ii)themajorityofthepopulationpaylittlefortreatmentasidefromaregistrationfeeanddrugs; (iii)onaverage,householdsspendabout4percentoftheiraveragemonthlyconsumption(Nafka 11 per household per month) on health services; and (iv) of those households reporting illness, expenditure for health was about 6 percent of total household consumption (Nafka 28 per household per month, probably excluding travel and pharmaceutical costs). Compared to findings from other developing countries which show that poor households could be spending from 3 to 5 percent of their household consumption on health, consumption of poor Eritrean households on health care may be higher. As MOH is embarking on new pricing and cost- recovery strategies, a closer look of its effects on consumers is required, particularly on the poor and vulnerable groups42. In 1996, on average, 11 percent of MOH recurrentcosts were recoveredthrough user fees. In 1998, MOH developed a new Health Care Financing Policy, for which implementation was delayed because ofthe border conflict. The policy major objectives is to revise user charges for different categories of patients and review exemption scheme issues and cost assessments of different health care services as a basis for fee calculations. There is currently hardly any insurance scheme in Eritrea. The policy document also reviews the different areas of health insurance. It concludes that it would be difficult to implement an insurance scheme in Eritrea, partly because of low demand from, and equally low awareness of, the population to health care costs. However, application o f the new fee schedule at MOH health facilities would increase annual government revenue from medical fees from the current level of Nafka 17 million to approximately an estimatedNafka 52 million, or by 206 percent43. The Health Care Financing Policy needs to be assessed in light of current and projected health sector needs, together with estimated financing sources and the expected roles of the Government, external partners and the private sector, within the context of the country's high poverty rate, in order not to leadto a decrease inutilization of services by the poor. 4`MOH,Health Profile, 2001. 42Donaldson, 2000, Op. cit, recommendsthat, based on current findings from Eritrea, the scope for increasinghealth fees be restrictedto the higher income households in Eritrea. 43This estimated amount is simply the current level of about 17 million, plus an additional 200%. 39 PERFORMANCE OFTHE HEALTHSYSTEM This chapter summarizes some of the strengths and challenges in the Eritrean health care system that emerge from the previous analysis, It assesses the system interms of how well that system performs in meeting the underlying health system goals of: improving health status, ensuring equity and access, promoting macroeconomic and microeconomic efficiency, assuring quality of care and consumer satisfaction, and being financially sustainable. Reform policies should build on the strengths while addressing the challenges facing the system, Inaddition, they will needto address the impending demographicand epidemiological changes facing the country. STRENGTHS Health Programs The Government is committed to improving the health status ofthe population, as reflected in the macro and health policies, as well as in the Strategic Concerns. Program specific strategies and policy guidelines have been developed for all PHC components and for other areas. Government's commitment is also demonstrated by the increase in health care coverage since independence. In addition, most of the important public health programs are either being developedor implemented. The MOH is supportive of basic health care coverage and control of communicable diseases, as demonstrated for example by the active community participation and emphasis given to PHC inthe health policy. Child immunizable disease incidencehas decreased, and no cases of polio or diphtheria have beenreportedinthe past few years. Tuberculosis treatment and policies are being developed, malaria vector control programs are being introduced, and iodine deficiency is being addressed through iodized salts. MOH also considers the prevention and control of HIV/AIDS a priority. It is working with other ministries, government institutions, NGOs, and external partners to curb the spread of HIV/AIDS, primarily through behavioral change. Health Systems Subsidizedhealth care services are available at public health care facilities. MOH has initiated a new quality assurance program that includes technical efficiency and consumer satisfactionas two methods of assessingquality. The budgeting process and accounting system are in place with financial controls and auditing, although a performance-basedbudgeting process does not exist. The new H M I S is inplace and is being followed by almost all local health facilities. Facilities of higher education exist for nurses and for paramedics. All physicians are, however, trained outside Eritrea. 40 CHALLENGES Public Health Despite existing PHC programs, communicable diseases remain high: perinatal and maternal health conditions, diarrhea among children and acute respiratory infections comprise 50 percent ofthe share ofthe burdenof disease. HIV/AIDS has emerged as the second and first leading cause of in-patient mortality among adults in 2000 and 1999, respectively, compared to its position as the fifth cause of death in 1998. Availability of contraceptivesis high, althoughutilization rates are low. Malnutrition and anemiaamong children and pregnant women continue to remain high. Immunization coverage, especially amongwomen, needs to be further expanded. Maternal mortality is one of the highest in the region. According to the MOH 2000 Report, only 30 percent of women had met needs for health services in labor and delivery (including abortion). PhysicalAccess Poor access to improvedwater and sanitation, particularly inrural areas, is an issue. b Poor access to health services for certain segments of the population, especially among the rural population and the nomadic communities, needs to be addressed. Although coverage has improved over time, there is still a wide variation betweenurban and rural areas. In addition, health service utilization continues to remain low for certain segments of the population, such as women and the nomadic communities. For example, few pregnant women avail of antenatal care services, and very few women deliver under the care of skilled health professionals. This issue needs to be further assessed, however, because poor utilization might be related to service quality issues. For example, MOH finds that hospitals are overcrowded while many lower-level health facilities are underutilized, partly because of understaffing in these facilities and perceived lower quality in services. Moreover, building more facilities might not necessarily be the right answer to the coverage problem. Differentways of service delivery, suchas mobile services, might be needed. Human Resourcesand Infrastructure The overall number of physicians and beds are low in comparison to the region and to the country's income level. The skills mix among health staff needs to be improved: there is a high ratio of administrative to medical staff, and low ratio of medical specialists. b Shortage of managerialstaff, or staffwith appropriatetraining inmanagement. 41 Insufficient development of human resources. For example, job descriptions need to be updatedand clear career growth tracks (including ranks and corresponding salaries) are not in place. Low salaries, lack o f incentives and motivation for staff, as well as poor infrastructure and accommodationinrural areas. Increase in the number of hospitals, without proper attention to capacity and availability of humanresources, needs immediate consideration. EnvironmentalManagement The current state of waste management system is inadequate. Health care waste and contaminated health care waste handling, storage and disposal raise serious environmental and social concerns. At present, household and health care waste, both solid and liquid, are collected, transported and disposed by the municipality in urban and semi-urban areas in the country. It appears that there is no segregation at the generation and disposal sites of any types of medical waste. Household and health care solid waste are disposed on the same sites with inadequate waste site protection. Financing The recurrent cost implications of the rapidly increasing number of hospitals needs to be urgently and carefully examined. Health spending overall, and public sector health spending, remain low by international standards, suggesting the need for Government to assess ifit is adequately meeting the underlying health needs of the population. Increase in spending may not be possible, however, because of resource constraints. Significant increases in revenues from user fee increases may also not be realistic, given the country's high poverty rate. Ways to increase efficiency need to be explored, and priorities in interventions and services assessed and established. Most health facilities are reportedto be experiencing a shortage of funds. Household health expenditure as percentage of their consumption may be high indicating the needto explore risk poolinghharing mechanisms. There is no national health insurance, Private Sector Role Little is known about private delivery of health services, except that most private clinics are located in the urban areas, and that the private sector is mainly involved in the procurement and distribution of drugs. Public medical employees may be practicing in the private sector as well as a way to supplement their salary. Inthe absence of coordination betweenthe public and private sectors, there is a serious risk that a two-tier health system could emerge, with the public sector providing the poor with 42 mediocre quality services because of insufficientresources, and the private sector responding to the needs of the better-off segment of the population. This could become increasingly apparent with costs associated with non-communicable diseases becoming more prevalent and more expensive to treat, particularly ifpublic services are becoming increasingly budget- constrained. Health Sector Management It is likely that increased autonomy and professionalmanagement of public health facilities could increase the efficiency and quality of service delivery. Because healthfacility directors do not have full authority to manage the institutions, they lack the flexibility to adapt to changing local conditions and underlyingneeds ofthe population they serve. Capacity will need to be built in local and regional health administration to enhance effectiveness of the decentralizationof financial and managerial functions. Pharmaceuticals At present, all drugs and medical supplies are being imported, although some local production is expectedto start shortly, mostly for packaging. Eritrea relies considerably on externalassistancefor drugs and medical supplies and will need to explore avenues to lessen its dependency. No information is readily available from MOH on private sector involvement and on the expenditures incurred by that sector. Insufficientand inadequate drug storage space and distribution procedures and management systems, as well as transport for drug disbursement, needto be addressed. Quality assurance issues will require focus and would need corresponding improvements in the amount and quality of trained personnel, facilities and equipment to ensure that quality improvementtakes place. Laboratory Services Laboratory services are insufficient to support the on-going efforts to improve and expand national health services. Issues related to shortages in personnel, equipment and supplies, need for training, and lack of standardized internal quality control and preventive maintenance and repair, as well as inadequate networking across different levels of health facilities needto be addressed. The HealthManagementInformation System There is limited data analysis or feedback provided to service providers and program implementers. Critical data for decision-making, such as national health accounts and unit cost information for facilities, are missing and/or inadequate. Information on the private sector is lacking. Further data will be needed (some population-based) for policy making. There is potential to strengthenthe HMIS. 43 Special Situations The great number o f the population affected by the border conflict, as well as those living in nomadic communities, require special attention. Destruction o f health facilities, displacement o f people, as well as mass repatriation o f Eritreans living abroad combined with a large influx o f refugees from Sudan, have added to the burden on the health care system. The impact of the recurring drought also needs to be assessed. In collaboration with external partners and international and national NGOs, MOH has successfully managed the provision o f health services despite these difficult circumstances. However, the management o f physical and psychological trauma needs to be further assessed. According to MOH, between 1999 and 2000, the total number o f reported cases o f mental and behavioral disorder inhospitals and health centers has increased by 74 percent. 44 5 RECOMMENDED NEXT STEPS Any possiblereform agenda should build on the strengths and address the challenges of the current health care system. Based on this very preliminary analysis of the health sector, the following priorities appear to emerge for the future. It is important to keep inmind that work on the medium- and long-term priorities should start in the near future for their implementation to take place inthe next few years. SHORT-TERMPRIORITIES There is an urgent need for baseline information on many of the MDG indicators, and an equally urgent need for the Government to establishtargets towards which its efforts may be directed. Given that 70 percent of the BODare attributable to preventable, communicable diseases, there is an urgent need to focus on improving the provision and/or upscaling of preventive and other critical programs to address MCH, HIV/AIDS, sexually transmitted diseases, malaria and nutritional issues. Inthis regard, it is also important to evaluatetheperformance and cost-effectiveness of specific health programs to better assess the health care needs of, and interventions for, target populations, such as women, children, nomadic communities, and war-stricken population. Further population health care assessmentsmight be required to direct resources to needy populations and improve critical programs. Estimatethe National HealthAccounts (NHA) to better assess health expenditures incurred in Eritrea. While rough estimates are provided insome reports for 1999,data available does not permit an analysis of patterns of health expenditures by health program, health facility, and geographical zone. Analysis of public expenditures, including donor resources, is a priority. Evaluate alternative sources of revenues includinguser charges, public and private insurance options, to sustain the current health system. Evaluate health care pricing, subsidies, user charges, and fee exemption policies. Specifically, on the proposed user fee policy, carefully assess the following: what will the policy impact be on utilization of services, especially by the poor? what is the expected level o f revenue? will local governments be able to support the costs of care for those to whom they issue indigency certificates? what mechanisms can be utilized for averting the problem of provider-induced demand for services? what will the impact of the proposed user fee policy be on the growth of the private sector and the distribution of health resources geographically? what are the recommended implementation guideline steps? Note: work has recently started in developing aJinancia1 model that MOH can usefor planningpurposes. Undertake a needs-basedmaster plan of health facilities and equipment to include the private sector. This will help re-evaluate the public (and private) investment strategy in the health sector, A thorough analysis should be made of the recurrent Jinancing requirements of the sector, based on current planned investment, and of the likely possible resources available to meet those requirements. 45 Explore ways to expand private sector involvement, particularly privatization of hospital services. Undertake a study of the management and organization of the health system including the staffing and operations of MOH, other public and private entities, and the referral system. More specifically, to recommend: 0 Human resource development to: (i)finalize staffing patterns for different kinds of institutions and harmonize them with the services to be delivered in the system; (ii) compare the existing staff to the total staff needs based on staffing patterns of existing facilities, both public and private; and (iii) base training needs on the categories necessary to man the system, includingprivate sector staff needs. o Equity in Access to: analyze the tier system in the country's public health system in relation to the services to be provided and in terms of levels of care; (ii) existing adapt facilities, over time, to this rationalized health system by down- or upgrading their function to the services needed for the catchment population; and (iii)analyze private facilities and their role in the future system in terms of what capacity they may have in the referral chain. Quality and Availability of Resources: aiming to achieve quality does not begin at the point of services delivery. It begins with the design of the interventions to be implemented (design quality) and in ensuring that the quality and quantity of resources are matched with the design of the interventions. Thus, the four questions to be addressed are: (i)are planned interventions designed in such a way that they will ensure technical quality? (ii)are the resources allocated for the interventions sufficient, both in terms of quality and quantity, to achieve the quality aimed for? (iii)do patients perceive the services delivered to be appropriate to their needs? (iv) are the interventions implemented insucha way that expected technical quality is achieved? Once decisions on what health care interventions are provided at each level ofthe referral system, define the drugs to be used at each level of care. Estimate and prioritize drug supply within the total resource envelope. This may lead to a revision of both the essentialdrug list and treatment guidelines. Explore alternatives, such as telemedicine, to address human resource constraints in service delivery, particularly with regardto the insufficient number of physicians. National environmental policies andregulationsneedto incorporate a strategy for health care waste management. This strategy needs to be accompanied by a health care waste management plan that includes budget requirements, authorities in charge, identification of capacity needs, and a monitoring plan. In addition, partnerships involving relevant stakeholders inthe public and private sectors and civil society is needed. While the H M I S is one of the strengths of the Eritrean system, it continues to be a challenge, as there is a need to strengthen the flow of information, carry out an analysis to identify program needs, and establish a monitoring, supervision and evaluation system. Operationalizing ways to improve the monitoring of data quality is important. Training is also very important because the availability of trained personnel has been identified as a 46 major constraint in the further development of H M I S and the other components of Information, Communication, Technology inEritrea.44 MEDIUM-TERMPRIORITIES Undertake unit costing studies in select public hospitals and ambulatory care facilities to evaluate the technical efficiency of the public system. Such information will serve as the basis for the developmentof efficiency-basedprovider payment systems. Provide the framework for a comprehensive and coherent development of the health sector, with the respectiverole of the public sector, private providers andNGOs clearly defined. Explore the potential for hospital privatization. LONG-TERMPRIORITIES Develop financing options for universal coverage including: (i)a national health insurance system, (ii) financing some care through MOH, and (iii)financing care through a combination ofpublic and private insurancemechanism. Develop, experiment, evaluate and implement modern incentive-based provider payment mechanisms including appropriate MIS and quality assurance systems to be used by all payers for purchasingbothpublicly and privately provided care. Promote private sector integration by providing incentives and through mechanisms such as certificate ofneed. Develop a rational policy towards private sector development. At the facility level, improve case management quality, focusing on hospital hygiene with patients; and integrate advancements/innovations made regarding Information, Communications, and Technology inservice delivery. Increase autonomy of public health facilities to take financial and management decisions, including the revision of the statutes and staffing patterns at different levels of the health system. 44EwanTechnology. Zntegratedinfirmation Systems Reporffir the Eritrea iECD Projecf. December 2001. 47 Annex 1: ERITREA Ministryof Health - Organization and Process for Establishing A Health Policy and StrategicHealth Sector DevelopmentPlan (expected to be completed inone year) !7-4 DeskReview completed in STEP 1 May 2001. Additional Input: 1. List o fexisting Desk Review of Health Sector relevant documents, including policies, Lead: World Bank evaluations, studies, plans, technical assistance reports. 2. A matrix organizing Circulated to Stakeholders the existing documents according to the MOH Sub-Sector Working Groups for the HealthFinance Stakeholder Meeting Health Sector Analysis (Step 2). (Need to start soon) 3. Outcome: Reportbased on existing Information. Process as originally planned. May be STEP2 delayed during implementation. Begin June 15" (2 to 3 months) 1. SteeringCommittee Health Sector Analysis - 2. Sub-sectorWorking Groups (7) Lead: M O H 3. Analytic guidelines for the with participation of all I working groups. Stakeholders 4. Staffand Consultants for the study - 5. Draft Outline 6. Questions to be answeredinthe analysis 7. Matrix of who is doing what according to the Sub- Sector Working Groups 8. Action Planand Timetable 9. Outcome: Report: Status o fthe Processmay be delayed depending on Health Sector inEritrea. implementation of activities in Step 2. (Provides the Rational for Step 3. (Identify options) I I I I Steering Committee Endby September 15'. 1 STEP3 1. 2. Vision Statement (completed) Health Policy 3. Policy Framework 4. Draft Outline Strategic Health Sector 5. Macro-Economic Development Plan Framework 6. StrategicIncremental InvestmentPlan 7. Outcome:Plan 8. Plan ofAction 48 Annex 2: Eritrea Trends in Macroeconomic Indicators, 1993-2000 - Indicators 1993 1994 1995 ~ Population (millions) 3.39 3.48 3.57 3.67 3.77 3.86 3.96 4.0' %BelowPoverty Line 69.0% % Employed 42.8% %Adult Literate 48.3% %Urban 18.0% GDP Nominal (million Nakfa) 2,866 3,730 4,031 4,538 4,713 5,028 5,828 7,091 NominalKapita(Nakfa) 845 1,072 1,125 1,237 1,252 1,301 1,470 1,74: NominalKapita(US$) 185 174 176 169 17: Real 92 Nakfa) 2,628 3,294 3,136 3,397 3,467 3,172 3,395 RealKapita ('92 Nakfa) 775 947 878 926 921 821 857 %Annual Change 22.1% -7.2% 5.4% -0.5% -10.8% 4.3% % GDP Agriculture 17.8% 20.9% 17.7% 15.1% 14.5% a17.1% Industry 3.7% 3.8% 3.6% 3.3% 3.1% a29.2% Distribution 33.9% 31.8% 33.4% 33.7% 32.7% Other Services 19.7% 24.1% 23.2% 22.6% 23.0% b53.7% Government Expenditures Kominal (million Nakfa) 1,415 1,602 2,702 2,557 2,532 3,832 4,629 4,94~ Capita1 455 430 57: 839 1,119 1,496 1,984 1,64. Recurrent 861 1,018 1,672 1,523 1,402 2,337 2,644 3,30 %GDP 49.4% 42.9% 67.1% 56.3% 53.7% 76.2% 79.4% 69.70/ Real(1992 Nakfa) 1,298 1,415 2,102 1,914 1,863 2,418 2,697 %RealAnnual Change 9.0% 48.6% -9.0% -2.7% 29.8% 11.5% Government Revenue (million Nakfa) 893 1,027 1,521 1,420 2,044 1,751 1,700 2,lO Net Government Deficit -522 -575 -1,182 -1,137 -488 -2,081 -2,929 -2,84 Yoof GDP -18.2% -15.4% -29.3% -25.1% -10.4% -41.4% -50.3% -40.13 Public Debt (millions Nakfa) 1,758 3,263 5,601 7,59 Domestic (% GNP) 28.1% 47.3% 67.5% 67.29 External(%GNP) 9.2% 17.6% 28.6% 39.80, I 1 %GNP 37.3% 64.9% 96.1% 107.09 Debt Service as %of Exports 0.4% 1.0% 2.9% 9.3% 27.09 CPI (1992 = 100) 109.04 113.24 128.56 133.58 135.93 158.49 171.65 /ExchangeRate (NakfalLiS$) 0'4% 6.7 7.2 7.4 8.7 10. aWorld Bank, EritreaAt a Glance,2000. AHservices. 49 i_:& & I.. I v, 3 I 50 Chart 2: Proposed OrganizationalStructureof the Ministry of Health LegalAdvisor - Administration AdmistrativeAssistant Auditor- 1 Minister ofHealth 1 IEC I I HealthServices I RegulatoryServices I ~ Research ~ Clinical Services AIDSABMalaridSTDs IHumanResourcePlanniq N o n e o d e a b l eDiseases 1 i r ~ Family Health& Nutrition Zobal HealthOfficers ~ ~ \ HealthServiccs - , Monitoring Services Source: MOH. 51 The Ministry o f Health under the guidance o f the Minister o f Health manages the National Health System. Since the private sector and community health services are not fully developed, MOH is the principal provider o f health services in Eritrea. The Division of Administration and other support staff, together with the Offices of International Cooperation, Zonal Affairs Coordination and Public Relations assist the Minister in the Ministry's day to day operations. Personnel, Finance and Property and General Services and Maintenance are under Administration. The Departments o f Health Services (Primary Health Care, Communicable Disease Control, and Clinical Services), Pharmaceutical Services, the Division o f Research and Human Resources Development, and Central Health Laboratory are directly accountable to the Minister, The roles o f the Ministryo f Health are as follows, according to the Proclamation for the Establishment o f Regional Administrations (Proclamation o f Eritrea Laws No. 86/1996: Establishment o f Regional Administrations): To formulate policies, prepare regulations, directives, standards, integrated plans and development budgets and supervise their implementation; throughout the country To undertake research and studies, compile and collect statistical data, To render technical assistance and advice to the regional administration Complying with nationally issues policy, standards and regulations and upon the agreement of the Ministry o f Local Government, shall assign regional executives and place the necessary facilities, recruit, promote and dismiss employees; Transfer o f line ministry employees (with the knowledge o f Ministry o fLocal Government) To conduct training, and render technical assistance for regional programs requiring professional input. To seek external fundingfor regional development programs. The organization structure for the zonal levelhas the following outline: CHART 3 c OUftS -1Z*odministrator n a l L e v e l I.................. E aito C h i e f o f the E x e c u t i v e 0 ffice s up p o rt P I a nn ing P inan ce I I E c o n o m IC S o c i a l A f f a i r s I n f r a s t r u c t u r e D e v e l o p m e n t I D e v e l o p m e n t I * H e a l t h I .Agriculture .Education D e v e l o p m e n t and -Industry * T o u r i s m in frastruc ture *Trade *Refugees Source: Lagerstedt, Adam. Trip Report, Health Sector VisionandHealth Policy Review, 2001, 52 The main functions o f the Zonal level can be summarized as follows: Planning: this includes preparation of annual plans and budgets, project monitoring and to limited extent evaluation. Co-ordination: This mainly involves overall co-ordination of all development activities includingprivate sector and external supporting actors as well as project beneficiaries. Implementation:This function appears to be the core function at the zonal and sub-zonal levels. It includes a wide range o f tasks such as managing relations with sub-regional and community administration officials, mobilizationo f community resources, handling contracts and financing mechanisms and providing support for operation and maintenance. The organizationfor the healthservicesat the zonal level hasthe following outline: CHART 4 Z o n a l h e a l t h organisation IZonal Health Officer 1 Pharmacy Administration Planning and Statistics i Family & Malaria TB+HIV/AIDS Environmental community Health Control Unit Unit Health Unit Health Facilities .Hospitals -Health Centers *Health stations Source: Lagerstedt, Adam. Trip Report, Health Sector Visionand Health Policy Review, 2001. The Zoba Health Services (ZHS) are part o f the Department of Social Services o f the Zoba. They are administratively accountable to the Zoba Administration which is directly under the Ministry o f local Government. However, on technical matters, they are accountable to the MinistryofHealth. The ZHS is headed by the Zonal MedicalmealthOfficer who leads the Zonal Health Management Team. The Government has adopted decentralization as a national policy. Thus, MOH is inthe process o f establishing a decentralized health system in which the major portion o f the duties performed at the central level will be executed at the zobas. At present, the Zonal medical officer, together with his Health Team, plans for the activities o f the Zone in an annually revised 5 year plan, which is sent to the Ministry for evaluation and consolidation. Financingo f the action plan is done through the Ministry o f Health. The Zonal Governor cannot reallocate funds between different sectors. Planningand Budgeting At the National level, the Government is coordinated through the Cabinet o f Ministers. All funds are gathered through the revenue department of the Ministryo f Finance and distributed 53 through the accounts department to the different line Ministries. No funds for health go directly from the National Government to the Zones. Funds flow from the Ministry of Finance to the Zones, but with the information also submitted to the line ministry. Salaries are paid directly from the central Government to the staff employed. Planning is also consolidated at the national level. All procurement for the sector is also made centrally. Planning for health is made at the Zonal level (with contributions from lower levelsdown to the ~ommunity~~).These plans are consolidated and summarized at the national level. The national level divisions and departments also develop their plans. Planning at Zonal level was introduced four years ago and has been developed as an actiodlearning approach. No real guidelines exist, as the formats have been developed based on dialogue betweenparticipants inthe planningprocess. Budgeting is divided into capital and recurrent budgeting, the former with a five year perspective and the latter with an outlook for the coming three years, Even though each zone submits its own budget, these budgets are not compiled and submitted a the annual budget proposalfor MOH. Rather, the recurrent budget estimates are based on historical figures. These estimates once approved by the Ministry of Finance is made available to the zones on a monthly basis. Supplementary funds can be added each month at the request of the zones upon approval by the MOF. An internal audit is conductedeach year. MAINSTRATEGIC CONCERNS OF THE MINISTRY OFHEALTH Equity in the distribution of health facilities, medicine, medical equipment, health workers and other public health activities under the PHC and CDC programs. This strategy aims to ensure universal access to available resources and services in order to provide coverage of the most important health needs ofthe population, with care provided accordingto need. In majority of the cases, construction of health facilities is based on need as determined by population density and availability o f health facilities and other factors including feasibility and status of being an administrative center. The number of new hospitals, health centers and health stations have increased by 92 percent, 58 percent, and 165 percent over the number of health facilities that existedbefore independence. MOH estimates that access to health service (within 10 km radius or 2 hour walk) has improved from 46 percent in 1991 to 70 percent in 1999. More than half of the Eritrean population live within 5 km from a healthfacility. Comprehensiveness of services so that preventive, promotive and curative health care measurescan be provided inan integratedmanner. Appropriateness and cost-effectiveness of technology used and services provided. The kind and level of health facilities established, drugs and equipment used, and health professionals trained should be appropriate to the need and socio-economic status of the country. For example, drug procurement is restricted to a list of essential drugs purchased through a competitive process. Also requires a shift from hospitals with costly specialist services toward peripheral levels of healthsystem. 45According to the HeadofZonal Affairs, Ministry of Health. 54 The Government does not accept assistance that does not adhere to its development policies and priorities. CommunityParticipationin identifyingproblems, prioritizing, planning and monitoring and evaluating programs/projects. Promotion of inter-sectoral collaboration at the local levels in many aspects of primary health care. M O H recognizes health is closely related to other aspects o f development and therefore there is a need to coordinate its actions with other sectors. Also communities tend to respond more readily to broad approach to development as opposed to fragmented sector by sector approach. At present, at the zonal level, all social services and development programs are directly accountable to the local government -health, education, labor and human welfare are under one Director General in the local government which could facilitate multi-sectoral approach to social services and development programs. Heads o f various sectors in the zones are also members o f the zonal council. Though the structure o f the local government is conducive to inter-sectoral coordination at the zonal and sub-zonal levels, capacity for effective coordination needs to be strengthened. There is also a need to clearly define the coordination mechanism at the central level. The HAMSET Control project has been cited in M O H documents as a good example o f inter-sectoral collaboration. Quality assurance so that performance standards are met. Since the initiation o f the quality assurance program in 1998, the focus o f quality assurance has expanded from concern with hospital patients to a concern for the total health system and from inspectiodcontrol activities by MOH to assigning responsibility to all health workers and the public. M O H has established a National Quality Assurance Committee (NQAC) as a focal point to facilitate quality assurance developments. A technical sub committee o f the NQAC has been established to assist in daily work until a unit is established in MOH. Zonal quality assurance committees have also been established in all the zones. Facility based QA teams are also beingestablished. Almost all high and mid-level managers from the center and zones and heads o f most health facilities have attended at least a one week training course on QA. Development o f policies and guidelines, clinical protocols, treatment guidelines and manuals are underway to establish national standards for quality and safety, Human resource development. The major guiding principles o f the HRD planning in MOHare: (a) establishinga national framework o f training and development of health personnel, (b) optimal use o f skills, experience, and expertise o f all health personnel to ensure maximum coverage, cost effectiveness and quality o f care; (c) minimize the mal-distribution o f health personnel; (d) decrease imbalances among various types o f health workers by ensuring the appropriate manpower mix; (e) Provide health workers with an appropriate career path through continuing education and different other training programs including in-service training, upgrading, distance learning, post-basic or specialized training; (f) establish a system o f certification, registration and re-certification by assessing credentials and other methods by a certification and accreditation committee; (g) gradual decentralization o f human resource management and administration including recruitment, deployment, promotion, etc, and (h) institutionalize regular performance appraisal and monitoring and using performance assessmentiappraisal reports as the basis for staff career development and promotion. 55 To date, M O H has standardized and streamlined the different categories of health workers. It has also developed a standard training curriculum. The number o f programs offered by the Institute o f Health Sciences has increased from three (nursing, health assistance and midwifery) to ten to include laboratory and pharmacy technicians, physiotherapy and ophthalmic nursing, advance nursing, nursing, associate nurse, upgrading of associate nurses and medical technology. M O H is also involved in developing curriculum and improving the standard o f teaching in the Faculty o f Health Scienceso fAsmara University. M O H is also making an effort to increase training opportunities through scholarships, fellowships and short courses abroad. It is also considering special admission criteria for candidates that come from the under-served communities are willing to work for their community, Healthresearch. The over-all objective of health research policy inEritrea is to develop a national health research program, in general, and to provide policy guidelines for health research and direct research efforts to: address the priority health problems in the country, promote health and contribute to the socioeconomic development o f the country, and enhance equity and socialjustice and promote a healthy society. Main areas o f concern have been identified; strategies have been drawn and some institutional capacity buildingmeasures such as building and equipping a central medical library. The Central Health Laboratory has been rehabilitated, equipped and staffed for some basic research work inmedicine and public health. Health management information system. The objective o f the National HMIS is to provide accurate, relevant, complete, and timely health information to support informed and appropriate health service, planning, and decision making at all levels o f health care. Under the Research and Human Resource Division, a MIS unit was established. The National Automated HMIS was developed and started in all zones in 1998.Post installation support supervision were conducted in 1998 and 1999. Among the recent additions to improve completeness o f data are information on community health services, environmental health, military health, and necessary administrative activities. Decentralization.The GOE and MOH state that they are committed to decentralization. Health services should be provided with the participation o f decision-makers at different levels. M O Hbelieves that strengthening o f management capacity o f zonal and sub-zonal level services is a precondition for effective decentralization. Decentralization should be accompanied by provision o f resources and authority to the zonal, sub-zonal and health facility levels. At the same time, some health programs may benefit from a greater degree of centralized direction than others. MOH will seek to establish an appropriate balance between centralized guidance and local adaptation o f policy to fit local realities. Health financing. In 1996 and 1998,MOHwas engaged in introducing and revisingthe system of user chargers for government provided health services. The 1998 health care financing policy seeks to provide improved guidelines to empower communities to share inthe financing o f health care costs. User charges will be part o f a package o f measures to improve service quality while maintaining accessible and affordable health services to those who cannot pay and ensuring that those who can pay do so. This necessitates a clear exemption policy. Public consultation and 56 awareness creation regardingthe fee increases are also necessary. In addition a mechanism must be established so that a proportion o f collected hnds is retained at the health facility level to finance service improvements. Local money handling arrangements need to be reviewed when fees are increased. The 1998 health care financing policy seeks to (a) upgrade the user's share o f health care costs at secondary and tertiary levels and to replace the nominal fees by user fees at the primary levels; (b) achieve full cost recovery for clients who have health care coverage; and (c) grant exemptions for emergency cases for the first 24 hours, hazardous and contagious diseases, and people who are unable to pay and have indigence certificates. Interms of measurable objectives, the 1998HCF policy seeks to (a) increase health care cost recovery o f recurrent costs by 40%; (b) improve health care efficiency, quality and equity by 50-60%; (c) decrease clients who pass the referral system by 60% so that they will be encouraged to use preventive health care services and discourage the use o f expensive hospital care service for common and mild illnesses; and (d) increase community's participation in their own health care services by 70%. Although health care financing reform was done in 1998, for a number o f reasons which include the escalation o f the border conflict, it has not yet been implemented and the 1996 policy is still beingused. Involvement of the private sector. M O H is encouraging private practice to be more effective and to ensure that it complements M O H services. It developed a policy on the Private Sector in 1995 and revised it in 1998. Individual practitioners who were given licenses to open "one-doctor" clinics were directed to change their mode o f practice to provide comprehensive services with a number o f physicians in the form o f polyclinics. Practitioners are encouraged to get into contractual agreements with M O Hto runstate-owned institution^^^. Provisionof drugs and medicalequipment. One o f the major responsibilities o f MOH is to ensure the availability o f safe and effective drugs o f acceptable quality at a reasonable cost and the rational use o f such products. The department o f Pharmaceutical Services is the body entrusted to coordinate and supervise the implementation o f the Eritrean National Drug Policy. As a regulatory arm of MOH, the Department o f Pharmaceutical Services regulates all drug related issues based on existing regulatory system and policy. Structurally it has two divisions: DrugControl and DrugManagement. The Department has five units: (i) Inspectorate Services, (ii)Quality Control Laboratory, (iii)DrugInformation Services, (iv) DrugRegistration and Evaluation, and (v) Licensing Unit. The immediate task o f the Department is to develop a five- year action plan that outlines the approaches and activities in detail, including the budget and establishment o f an advisory council and expert committees. The extent to which objectives are beingmet will be monitored and evaluated periodically. OVERVIEW OF PUBLIC HEALTHPROGRAMS A. PrimaryHealth Care Health services in Eritrea are based on the principles o f Primary Health Care and aim at making PHC services available to the entire population. It includes promotive and preventive services, inter-sectoral activities, and community participation in health. The major public health programs are as follows: 46PHC division, MOH5-year strategic plan, 2000. 57 Child Health. The overall objectives of the IntegratedManagement o f Childhood Illness (IMCI) program are: (a) to improve the quality o f care provided to children under five years o f age at health facility and household levels; (b) strengthen the health system in order to sustain I M C I implementation; (c) empower communities to improve community and family practices to prevent child morbidity and mortality. Expanded Program on immunization (EPI). The five-year EPI national strategic action plan is dividedinto 3 sections: (a) strengthen and implement routine activities, (b) organize supplemental immunization activities, and (c) strengthen integrated disease surveillance system and conduct active AFP (all suspected cases o f polio) surveillance. Its goals for 2004 are to: (a) achieve and maintain immunization coverage o f at least 90 percent for all antigens, (b) reduce measles morbidity by 90 percent and mortality by 95 percent compared with pre-immunization levels, (c) reduce the rate o f neonatal tetanus (NNT) to less than 1 case per 1,000 live births with 100 percent reporting in all zones, (d) eradicate polio by 2000, and (e) introduce Hepatitis B vaccine with EPI routingby 2000. ReproductiveHealth Program. This program includes: (a) safe motherhood (prenatal care, safe delivery, essential obstetric care, peri-natal and neonatal care, postnatal care and breastfeeding); (b) family planning information and services; (c) prevention and management o f infertility and sexual dysfunction in both men and women; (d) prevention and management o f of reproductive tract infections, especially STD's and HIV/AIDS; (0promotion o f healthy sexual abortion complications and provision o f safe abortion services; (e) prevention and management maturation from pre-adolescence, responsible and safe sex throughout life, and gender equality; (g) elimination o fharmful practices such as female genital mutilation(FGM), premature marriage and domestic and sexual violence against women; and (h) management o f non-infectious conditions o f the reproductive system such as cervical cancer, complications o f FGM, etc. The program seeks to develop a comprehensive program to reduce maternal mortality, improve the quality o f antenatal care, and improve the use o f family planning services. Attention will be focused on improving the quality o f comprehensive reproductive care at all levels and on integrating reproductive services with child health services. Nutrition. The long-term objectives of the nutrition program are to improve the nutritional status o f the population especially women and children, and to ensure food security in all households, The Nutrition program is comprised o f five sub-programs that deal with: (i) integrated PHC services, (ii) micronutrients which cover initiatives to reduce deficiencies inIDD, vitamin A, and iron, (iii)breastfeeding and complementary feeding; (iv) school health, and (v) food security and related strategies. The short-term goals for 2003 are to: (a) eliminate iodine deficiency disorders (IDD), (b) eliminate vitamin A deficiency, (c) reduce iron deficiency anemia by 33 percent, (d) achieve national food security, and (e) incorporate food and nutritionobjectives within health, agriculture, poverty alleviation, education, industry and other sectoral priorities. Environmental Health. The strategies and activities adopted under environmental health will emphasize the following areas: (a) prevention o f diarrhea and intestinal parasite infestations through: excreta containment, water source protection and handling, maintenance and use o f safe water, and food safety and hygiene; (b) prevention o f ARI through interventions that reduce indoor air pollution, and include promotion o f fuel-efficient stoves, substitution of biomass levels, promotion o f improved kitchedhousehold ventilation; (c) collaboration in the prevention o f malaria and other vector borne diseases through environment impact assessments, residual spraying, personal protection such as insecticide impregnated bed nets, and larvacides; (d) prevention o f accidents in residences and public areas, (e) continuous hygiene education 58 aimed at all community members, and (0 collaboration and coordination at the community, sub- zoba, zoba and national levels. Information, Education, and Communication (IEC). The aims of IEC are to: (a) rationalize planning coordination and implementation of IEC for health promotion, (b) expand and strengthen partnershipsfor health promotion to increase the research of IEC efforts and their effectiveness, and (c) strengthen the health promotion infrastructure of MOH and its capacity to plan and deliver audience-basedIEC activities at all levels. Community Health Services (CHS). MOH is responsible for training community health workers (CHWs), providing refresher courses, technical assistance, continuous supportive supervision and monitoring, and providing CHWs with initial medical supplies and drugs to start the CHS programs. Communities are responsiblefor electing CHWs who will serve them. They are also responsible for remunerating them and providing them with a work place, furniture, equipment, and drugs after the initial medical supplies and drugs provided by MOH have been utilized. The community also decides whether drugs will be sold or given to patients for free, or at a subsidized rate. The CHS program seeks to: (a) enhance the links between conventional healthservices and community; (b) facilitate training of CHWs by training trainers and preparing training manuals; (c) establish mechanisms that encourage communities to take responsibility for their own health and be involved in planning, implementation and evaluation of health services; (d) improve community understandingof the healthservices system and how CHWs can improve the health of the community; (e) facilitate establishment and active involvement of health committees at every level; (f) enable health workers at all levelsto support the implementation of the program; (g) promote sustainability ofthe program; (h) increase the number of births attended by trained birth attendants; (i)improve the technical support systems for provision of supplies, supervision, and referral, and 0) strengthensupportive supervision, monitoring and evaluation. B. Communicable Diseases Control The Division ofCommunicable Disease Control has the following units: Malaria Control Unit. This unit is responsible for the implementation of MOH malaria control strategy which emphasizes case management, epidemic management and control, environmental control and selective vector control. An integratedhealth service approach is used in supervisingthe implementation ofthis strategy which is endorsed by WHO Roll Back Malaria Program. It involves early detection and prompt treatment of malaria cases, decreasing human- mosquito contact and protecting patients during medical proceduressuch as bloodtransfusions. Tuberculosis Control Unit. This unit seeks to reduce morbidity, mortality, transmission and resistance to treatment throughout the country by training health personnel, increasing the number of properly equipped health facilities, enforcing uninterrupted drug treatment, and improving diagnostic capabilities. It is implementing the WHO treatment strategy of Directly ObservedTreatment Short Course (DOTS). Quarantine and Epidemics Control. This program aims to prevent epidemics and to monitor their outbreak, as well as the transmission of infectious diseases, to improve sanitation around the ports and to prevent the spread of disease vectors by developing appropriate legislation and quarantine strategies. After the resolution of African Nations to strengthen Integrated Disease Surveillance, MOH is planning to implement the program in Eritrea. IDS is mainly concerned with regular collection of data and flow of information on selected priority diseases for surveillance purposes. 59 HIV/AIDS and STD Control. This program seeks to curb the spread o f HIV/AIDS primarily through behavioral change. The main components o f the strategy are behavioral change, STI control, community mobilization, voluntary counseling and testing and condom promotion. Clinical Services. The Division of Clinical Services is responsible for the supervision of diagnostic, curative, and rehabilitative services which complement the preventive and promotive aspects o f PHC. It oversees the provision o f health care and supervises the treatment and care given in all the health facilities o f MOH. It also collaborates with associations o f health professionals to regulate professional conduct. The division is also responsible for the development o f policy and guidelines for medical practice, in accordance with M O H Quality Assurance Program. It has three units: (1) Medical Services Unit which is primarily responsible for supervision o f diagnostic and curative services, (2) the Treatment and Care Unit which focuses on nursing services, and (3) the Licensing Unit which primarily deals with the licensing o fprivate clinical practice. Departmentof PharmaceuticalServices The Department o f Pharmaceutical Services is responsible for the implementation and monitoring o f the National Drug Policy. Its basic functions include developing policies and guidelines, control of narcotic and psychotropic substances, drug information, and drug quality control. The department has two divisions: Drug Control which is responsible for the enforcement o f national and international regulations pertaining to drugs including narcotics, psychotropic and other controlled substances, inspection and licensing drug outlets and quality control o f drugs Drug Managementwhich aims to ensure effective drug management and rational drug use at all levels. It also aims to improve overall logistics management by designing a drug consumption reporting systemespecially for the primary levels o f health service. Divisionof Researchand HumanResourcesDepartment This division is responsible for the improvement o f health services through development o f human resources for health, research, and provision o f accurate, timely and relevant information for informed decisions and interventions. It consists o f five units, three o f which involve Human Resource/trainingactivities. Training which is responsible for pre-service education of health professionals, particularly that o fmiddle cadre health workers. Continuing Education which is responsible for capacity building and upgrading o f MOHstaff. Human Resources Planning which is charged with the development o f a Strategic Human resource Development Plan for Health and for the monitoring and evaluation o f HRD programs. Research which seeks to instituteregulatory mechanisms for health research, strengthen research capability o f health workers and nurture a research culture. It also coordinates and conduct health related research, Some o f the main achievements o f this Unit are the following: 60 (a) development and ratification o f Health Research Policy and Guidelines, (b) identification of priority health research topics in Eritrea, (c) establishment o f a central medical library and zonal satellite libraries, and (d) conducting and facilitating research on various topics include a collaborative project with the University o f Leeds on the Practice of Strategic PlanninginHealth Sector Reform. Some of its future activities include: conducting further training in health systems research methodology to build a critical mass o f health workers capable o f conducing research independently; organization of annual health research days, publication o f the Health Policy Research Policy and National Health Research Priorities for Eritrea, and establishment o f an Internet service inthe Medical Library to facilitate literature searches. Health Management Information Systems (HMIS) which aims to provide accurate, relevant and timely information to help make informed decisions and interventions. Some o f its main achievements include: establishment o f a network o f data collection, processing and dissemination, computerization o f data entry and processing up to the zonal level, publication o f Annual Health Service Activity Reports since 1998, and development and installation o f Local Area Network and Wide Area Network Programs to expedite data and information transfer, and training o f health workers in data collection and use. Future plans include: development o f a computerized Decision Support System for MOH and development o f a Health Information website for the Worldwide Web. National Laboratory Services The national health laboratory structure o f Eritrea is based on a three-tier system o f peripheral, intermediatelregional, and central hospital laboratories, with the Central Health laboratory as the national reference. The Central Health Laboratory includes standardization o f test methods, development of new technologies, implementation and monitoring of national quality control (include external proficiency testing) programs, in-service training o f technical staff by conducting workshops and other forms of training. As a preliminary step towards quality accreditation, the laboratory participates in international external quality control programs. Laboratory tests in hospitals tend to be limitedto rudimentary, simple routine tests. For example, microbiology culture and sensitivity, histology and cytology, most immuno-serology and clinical chemistry laboratory tests are performed in the Central Health Laboratory only. While this has served the country's needs to date, it is insufficient to support the momentum o f expanding national health services. Issues related to shortages in personnel, equipment and supplies; need for training and standardized internal quality control and preventive maintenance and repair, and lack o f networking across different levels of health services facilities would need to be addressed.47 According to the Head o f HRD, an in-depth study o f laboratory services in Eritrea will be undertaken shortly. 47MOHCentral Health Laboratory. Eritrea Health Laboratory Survey, 1998/99. 61 62 ANNEX5: HEALTHCARE FINANCING4' Table 5.1 and Figure 5.2 show results from a study capturing some public sector and some private sector spending towards health care. Table 5.1 provides break-down of the total health spending betweenthe public and private sectors, and by donor contribution. Table 5.1: Eritrea, Health SpendingEstimatesin NominalNafia and Percent, 1999 I Expenditure Categories I Amount (Nakfa in millions) I Percent I Capital Costs 24.0 14% Government 9.0 5% Donor 15.0 9% RecurrentCosts 133.3 78% Government 103.2 60% Donor 30.1 18% Household Expenditurel / 13.6 8% TOTAL (Nafka, millions) 170.8 100% Per capita mafia) 48.8 Figure 5.1: Eritrea, Source of Health Care Financing, 1999 (Percent) GOE 65% Source: Donaldson, Dayl, Technical Report, Economic and Financial Analysis, September 2000 Table 5.2 and Figures 5.3 and 5.4 give a historical trend of MOHexpenditures. 48 This Annex is mainly basedon Donaldson, D. TechnicalReport, Economic and Financial Analysis, September, 2000. Further economic and financial analysis is beingundertakenas partof Step 2 ofthe HSNprocess. 63 MOHExpenditures HistoricalTrends - 'able 5.2: Eritrea. Public Sector Reviewof Health, 1995-1999 (in Nominal and Real Nafka) ~~ Expena'iture 1995 1996 1997 1998 1999 - Categories Nafka Nafka Najlia Nafka -% Najlia -% CAPITAL COSTS Govt. 5,428,578 5,578,664 8,966,737 Donor 6,365,283 19,111,42: 10,348,789 20,714,850 18.8 15,010,258 Total -Nominal 6,365,283 19,111,42: 15,777,368 26,293,5 15 23,976,995 otal Real'92 NaRa - 4,95 1,216 14,307,095 11,606,980 16,590,O 15 - 13,968,53 8- DAnnual Change 189 -18.9 42.9 - -15.8 - RECURRENT COSTS Govt. 80,347,845 58,242,03( 82,102,321 96,036,663 103,170,555 Salary 61,304,21: ?2,264,161 53,742,339 58,930,907 i0.2 63,487,006 g7.t Drugs 9,074,440 12,601,635 1,3 13,2180 18,030,014 .5.4 1,659,6164 122 Other 9,97 1,197 13,376,227 15,227,803 19,075,742 .6.2 23,087,384 17.: Donor 11,501,778 4,183,542 23,211,672 21,3 56,439 30,072,373 Salary Drugs 10,181,05C 2,142,680 510,2629 11,377,111 9.7 18,386,680 13.1 Other Non-specified 1,320,722 2,040,862 18,109,043 9,979,328 - 8.5 11,685,693 - 8.8 Total Nominal 91,849,625 52,425,572 10,531,3993 117,393,102 100 133,242,927 1oc otal Real '92 Nafka - 71,444,95C 16,732,722 77,476,637 7,406,972 1 - 77,624,776 - IAnnual Change -34.6 65.8 -4.4 - 4.8 - REVENUE RegistrationFees 10,604,399 18.8 12,739,858 82.t DrugFees 2,745,486 !0.4 2,569,3 18 16.' Other 110,088 - 0.8 118,788 - 0.8 Total Nominal - 3,704,223 8,325,239 12,164,203 13459,973 100 15,427,963 1oc %ofRecurrent 4% 13.3 11.6 11.5 11.6 2tal- Real'92 Nafka 288,13 18 6,232,399 8,948,873 8,492,632 - 8,988,036 - IAnnual Change 1,16,3 43.6 -5.1 - 5.8 - PI (1992=100) 12,8.56 13,3.58 13,5.93 15,8.93 - 171.65 - mrce: FinanceOffice, h! )H, cited ir dson, Day1 nicalReport Analysis, September 2000. 2Note:SalaG figures include back-payments tofighters 64 Figure 5.2: Public Sector Health Expenditure, 1995-1999 (in Nominal Nafka, Thousands) 180,000, 160,000 140,000 120,000 B 0 100,000 2E 80,000 60,000 40,000 20,000 0 1 1995 1996 1997 1998 1999 +Total -W- Gon Donors Source: Finance Office, MOH, cited in Donaldson, Dayl. Technical Report, Economic and Financial Analysis, September 2000. Figure 5.3: Public Sector Review of the Health Sector, GOE versus Donor Contribution, 1995-1999 (Percent) 100% 90% 80% 70% 60% 50% wB 30% 20% 10% U% 1995 1796 1997 1978 1799 I Goa. Donors I Source: FinanceOffice, MOH, cited in Donaldson, Dayl. TechnicalReport,Economic and Financial Analysis, September 2000. 65 Figure 5.4: Eritrea, Public Sector Review ofRecurrentExpenditure for Health, 1995-1999 (Percent) 100% 90% 80% 70% 60% 50% Drugs 40% 30% 20% 10% 0% 1995 1996 1997 1998 1999 Source: Finance Office, MOH, cited inDonaldson, Dayl. TechnicalReport, Economic and Financial Analysis, September 2000. Estimates o f low, medium, and high scenarios o f aggregate public health sector costs and financing from all sources (in real 2001 Nakfa) for the next 5 years indicate a financing gap between the projected costs o f the health sector, and available financing from government combined with donor recurrent budget support. According to Table 5.3, The low scenario projects a shortfall o fNafka 58.1 million of a total budgeted cost o fNafka 204.7 million by 2007 (in real 2001 terms), the medium scenario projects a shortfall of Nafka 27.4 million of a total budgeted cost o f Nafka 230.9 million by 2007 (inreal 2001 terms), and the highscenario projects a shortfall o fNafka 12.1 million o f a total budgeted cost o f Nafka 269.8 million by 2007 (in real 2001 terms, O O O ) . ~ ~ 49The low scenario assumes a low rate of real GDP growth (l%), the medium scenario assumes a moderate rate of GDP growth (3%), and the high scenario assumes a high rate of growth (7%). The other key variables influencing health sector costs were rates of population growth and changes in the number of hospital beds. On the financing side, the same GDP assumptions applied to government budgetary resources for health, and increasing per capita levels of donor financing were assumed. User fee revenuewas generally assumedto grow with GDP and population growth, althoughthe "high" scenario assumed an ambitious target o f collecting fees equivalent to 1 percent of GDP by 2010. 66 Table 5.3: MOHFinancing Projection Results, 2001- 2007, Real 2001 Nakfa (`000) Donaldson (2002) proposesthe following actionsto address the above scenarios and bridge the financing gap: Low Scenario: The size of the recurrent financing gap in this scenario is due to the addition of 400 beds, low provision o f donor financial support, and low economic growth providingincreases ingovernment financing. Ways to narrow this gap include: reviewingthe bed and other capacity needs of existing and future infrastructure, re-doubling efforts to identify donor recurrent financing, and seekingways to increase user fee revenue and require that it be budgetedas part of the existing level of government financial support to the sector. Medium Scenario: The results of this scenario interms of higher levels of costs (and presumably more health services) and financing, provide greater flexibility in developing and adopting a revised user fee policy. The objectives of the policy should be to match the growth of fee revenue to the growth of the economy and the growth of utilization (proxied by the growth of the population). High Scenario: The results of the high scenario should be regarded as upper limits for the expansion of the costs and financing for the sector. Given historical rates of economic growth in sub-Saharan Africa it is unclear that Eritrea will achieve an average annual real rate of GDP growth of 7 percent. It is also difficult to predict the trend in donor financing for the sector and the real per capita level of donor financing may not remain constant considering population growth. Moreover while it is feasible that the population, on average, could pay 1 percent of GDP for health services, it is unlikely that the public sector will be able to mobilize this level of fee collection without altering access and quality of service. 67 COSTS OF HEALTH SERVICES UnitCost Analysis Unit costs of health services are not readily available. This section uses results from a study by Yoder (1995)50,which was conductedover 6 years ago in 19965'. Table 5.4 provides the estimated average unit costs of selected services provided by the sample facilities in 1994. The unit cost estimates for visits to government health centers and stations were higher for inpatient care, but lower for outpatient visits. Estimates suggest that an inpatient day unit cost would be Nafka 1,261 to 4,115 at health centers and health stations respectively, compared to Nafka 82 at provincial hospitals, and an outpatient visit unit cost would range between Nafka 15 to 31 at health centers and health stations respectively, compared to Nafka 36 at provincial hospitals in 199452. There was considerable variability in the actual point estimates for individual facilities, which suggests that using unit cost figures to set user fees, or project recurrent costs of facilities, may require utilizing a range of estimates, rather than one average figure. Moreover, the high average unit costs at health centers and health stations as compared to hospitals suggests that utilization is low relative to the fixed costs of these facilities. Further, more recent cost studies will be required. Table 5.4: Unit Cost Estimates in Nafka for Health Facilities by Type of Service, 1994 53/ Source: Yoder, R. Eritrean Health and Population Project, Health Facilities Cost Estimates Study, BASICS Project. 1995. Cost-effectiveness of Public Sector Health Interventions A burden of disease (BOD), and a cost-effectiveness (CE) study was carried out in 199454. This study calculated the burden of disease from 10 disease groups (which were estimated to account for 59 percent of total deaths and 73 percent of the discounted years of life lost in Eritrea), and then the cost-effectiveness of community, preventive and curative interventions to reduce the burden of disease from these illnesses. The cost-effectiveness ratios 50 Yoder, R. Eritrean Health and Population Project, Health Facilities Cost Estimates Study, BASICS Project, 1995. The study calculatedthe cost of delivering out-patient (OPD) health services at health stations, health center, and at the OPDs of provincial hospitals. The sample size was 15 health facilities selected through a cluster samplingmethodologyused in four areas ofEritrea. 5'Another study estimates that the unit cost of an inpatient day at government (tertiary?) hospitalswere Birr 54, and outpatientvisits at government tertiary hospitalswere Birr 18. Source of this study is unknown. This study was cited in World Bank, Project Appraisal Document for Eritrea Health Project, Washington, D.C., World Bank, Human DevelopmentIV/AfricaRegion, pp. 11plus annexes (Report No. 16501-ER), November 17, 1997. 53 /Care must be taken in the use of these unit cost estimates, as they reflect the "technology" and services being provided in 1994 which would affect total costs, and the size and composition of the market which would affect utilization. 54 Bebhatu, M. et.al. (August 17-19, 1994) Eritrea, Summary Report in: Proceedings of the East Africa Burden of Disease, Cost-Effectiveness of Health Care Interventions and Health Policy. Regional Workshop, pp. 33-42. 68 for these interventions appear inTable 5.5". The results recommend a preventive or community treatment intervention for 9 out o f the 10 diseases. Table 5.5: Cost-Effectiveness of DiseaseInterventions (Birr/Discounted LifeYear Saved) I Source: Sebhatu, M. et.al. "Eritrea, Summary Report" In: Proceedings of the East Africa Burden of Disease, Cost- Effectiveness of Health Care Interventions and Health Policy. RegionalWorkshop, August 17-19, 1994. Note: * indicates a recommended intervention. The BOD/CE study also relates the share o f government expenditure for a particular disease to the share o f BOD contributed by the specific illness. The results o f this analysis are presented in Table 5.6. The study analysis suggests that financial resources for the health sector should be reallocated to better match the share o f BOD, and towards interventions which are more cost-effective. For example, diarrheal diseases, and immunizable diseases contribute significantly to the BOD, but receives a lower proportionate share o f health expenditures6. " Thereareseverallimitationstothisstudy, whichtheauthorsacknowledge. Theseincludefailure to include:the burden of disease from the disability arising from any of the illness, disabling chronic illnesses such as diabetes and hepatitis, the externality and synergistic benefits from community or preventiveinterventions, andthe costs oftransport for curative services. The authors also recognize that the poor quality of data limit the validity of the results, In addition, the study calculates point estimates of cost effectiveness without providing information as to the scale for each intervention(Le., is it the cost-effectiveness ratio related to anational program?). 56 This example points to another of the limitations of the study, namely that investments in improving water supply and sanitationare not included in health expenditure, but would certainly contribute to reducing the burden of disease from diarrhea. 69 Table 5.6: Share of Burden ofDiseases versus Share ofBudgetary Spending, 1994 Source: Sebhatu, M.et.al. "Eritrea, Summary Report". In:Proceedings ofthe East Afvica Burden of Disease, Cost-Effectiveness of Health Care Interventions and Health Policy. RegionalWorkshop, August 17-19, 1994. The BOD/CE study also proposes a policy package of cost sharing, privatization, and decentralization. While these policies do not follow from the findings ofthe BOD/CE study, these may be consideredon their own merits, and will be taken up in other sections of this report. HEALTHCARE EXPENDITURESAND PAYMENTMETHODS Fee for service is the most common payment method used for health care. However, health care fees are heavily subsidized by the Government at MOH health facilities. Health insuranceis almost non-existent. Table 5.7 shows that most patients paid for health care. Thirty-five percent of health facility users paid no registration fees while 9 percent of users paid over Nafka 100. However, the report did not indicate the total amount paid by householdsfor all treatmentshputs used for the illness reported. The results suggest however that the majority ofthe population pay little for treatment aside from a registration fee and drugss7. Table 5.7: Percent of Households Reporting an Illness who made Various Levels of Payment by Type of Source: Eritrea Household Health Status, Utilizationand ExpendituresSurvey (EHHSUES), 1997. NA= NotAvailable /Not Applicable. The EHHSUES study showed that on average, households spend about 4 percent of their average monthly consumption (Nakfa 11 per household per month) on health services. Of only those households reporting illness, expenditure for health was about 6 percent of total household consumption (Nakfa 28 per household per month), and this probably did not include travel and pharmaceutical costs. A study by Weaver (1997) reanalyzed some of the EHHSUES data to estimate the proportion of household income that was spent for health. Table 5.8 shows that householdswith health facility intown or village are relatively better-off comparedto households '' The report does not give a distribution ofhouseholds' expenditures for drugs. 70 with no health facility in town or village. On a per capita basis, the estimated monthly health expenditure was more or less the same betweenthese two groups, Nafka 37 for those with health facility, and Nafka 40 for those with health facility. However, households without health facility who were also better-off spent on average about 6 percent of householdconsumptioncomparedto the less fortunate who spent 10 percent of household consumption on health care on a monthly basis. Compare to literature from developing countries which show that poor household could be spending from 3 to 5 percent of their household consumptionon health, poor Eritrean households may be spendinga lot on health care. The MOH is embarking on new pricing and cost recovery strategies, a closer look will be required of its effects on consumers, and particularly the poor and the vulnerable groups5', NEW PROPOSEDHEALTH CAREPRICINGPOLICY AT MOH In February 1996, the MOH introduced user fees (registration fees, and daily hotel fees) at all public health facilities. The fees were introduced in order to: 1) provide substantial subsidies for primary care, 2) charge patients the full costs of care at tertiary facilities, and 3) encourage patients to use the referral system appropriately. Table 5.9 gives the referred and the by-pass prices charged at the MOH health facilities, and the percent of unit costs recoveredfrom revenue. In 1996, on average, 11 percent of MOH health recurrent costs were recoveredthrough user fees. Percent of Health Facility Level Referred Price in Bypass Price in Unit Cost Najka Najka Recovered Hospital-OPNisit 7 16 18 to 36 Hospital-IP Day 9.5 19 54 to 82 HealthCenter-OPNisit 5 8 31 Health Station-OPNisit 3 N A 15 58 Donaldson, 2000, Op. cit, recommendsthat, based on current findings from Eritrea, the scope for increasinghealth fees be restricted to the higher income households in Eritrea. 71 exemption scheme issues, and cost assessments o f different health services as a basis for fee calculations. The document also reviews the different areas o f health insurance and concludes that an insurance scheme would be difficult to implementinEritrea, partly due to the low demand from and low awareness o f the population to health care costs. Table 5.10 provides the proposed schedule for user fees at the different levels o fthe health system. The objectives o f this new financing policy are to achieve the following targets: Increase revenue by 200 percent over current levels; Improvethe efficiency, equity, and quality o f healthcare; Create incentives for patients to use preventive and PHC services as first entry points into the health care system; e Encourage the community to become more responsible and self-reliant for their own health care. To ensure efficient collection o f user fees, and to ensure the proper use o f revenue from user fees, MOH has outlined the following proposed policies: M O HHealth centers and stations will retain 30 percent o f revenue collected; M O HHospitals will retain 20 percent o f revenue collected; The Zonal HealthOffice will retain 10percent ofthe revenue collected; and The remaining revenue will be transferred to the Central Treasury, Ministry o f Finance. Retainedfees may be usedsolely for the purchase o f supplies and facility maintenance, but not for the purchase o f drugs or for providing financial incentives to employees. The health financing policy document estimated that the application o f the new fee schedule at the MOH health facilities, would increase the annual earnings from Nakfa 17 million to approximately Nafka 52 million, or by 206 percent5'. 59This estimated amount is simplythe current levelofabout 17 million, plus an additional 200%. 72 Table 5.10: Schedule ( User fees at different health fac Typeof Patient Hospital Health Center Health Station 3/ Ordinary Citizens 1/ 50% labor cost 65% labor cost 70% labor cost 100% consumables 100% ofnon-hotel 100% ofnon-hotel 30% equipment cost operatingcosts operatingcosts 100%hotelcost Naflca3.00/day 105%drug cost 110%drug cost 110% dmg cost lab fees accordingto price list Serviceon Credit 75% labor cost 100% consumables 30% equipment 100%hotelcost 110% drug cost InsuredCitizens 100%of all costs ForeignCitizens 100%labor cost 100%consumables 100%equipment 100%hotel cost 125%drug Cost 100%ancillary servicescost Expatriates 21 200%labor 200% consumables 200% equipment 200% hotel cost (+50% special accommodation) 140%drug cost 250% ancillary servicescost Source: SOEMOH. He !h Care Financing Policy, Asmara : MOH, October 1999. l/AtMOHhospitals,childrenarecharged50percentoftheregistration,consultation,andhotelchargesonly. 2/ Payment is expected inUSdollars. 3/ No exemptions will be provided for acute, curative healthservices at healthstations as the services under the proposedpricing guidelinesare believedto be highly subsidized. Note; The policy specifies certain illnesses or services which will be exempt from fees, These are: antenatal services, well baby services, immunizations,leprosy, mental illness, STDs, HIV/AIDs, emergency cases for first 24 hours, injuriesfrom explosives. Inaddition, those who can obtain acertificate of indigenousfrom the local MOLG offce will receive free care. The costs oftheir care howeverwill haveto be paid by the local government which issuedthe certificate. 73 Annex 6 : INTERNATIONAL COMPARISON TABLES Table 6.1: Sub-SaharanAfrica, Glo 11DemographicIndicators, 1999 Population - 1999 I Growth (%) 1999 I TFR - 1999 12,356,900 2.88 6.68 6,114,050 2.75 5.60 1,588,120 1.68 4.14 10,995,700 2.44 6.56 6,677,950 1.96 6.08 14,690,500 2.67 4.86 427,790 2.96 3.75 3,539,810 1.70 4.74 7,485,610 2.75 6.32 544,280 2.50 4.38 49,775,500 3.18 6.24 2,858,760 2.70 5.94 15,545,500 2.57 4.94 442,680 2.58 5.33 3,99 1,000 2.85 5.56 62,782,000 2.44 6.26 1,208,410 2.35 5.08 1,251,000 2.84 5.46 18,784,500 2.27 4.26 7,250,520 2.29 5.33 1,184,670 1.99 5.54 29,410,000 2.13 4.51 2,105,000 2.27 4.51 15,050,500 3.09 5.56 10,787,800 2.39 6.31 10,583,700 2.39 6.36 2,598,330 2.70 5.26 1,174,400 1.26 2.02 17,299,000 1.95 5.18 1,701,330 2.33 4.73 10,495,600 3.39 7.28 123,897,000 2.52 5.21 8,3 10,000 2.50 5.98 Sa0 Tome and Principe 145,260 2.27 4.53 9,285,3 10 2.69 5.44 80,030 1.49 2.10 4,949,340 1.93 5.87 9,388,250 3.38 7.13 42,106,200 1.69 2.92 28,993,300 2.25 4.52 1,019,470 2.89 4.50 32,922,600 2.44 5.43 4,566,940 2.42 5.08 21,479,300 2.75 6.36 988 1.210 2.21 5.38 11,903;700/ 1.821 3.61 13,391,9351 2.431 5.21 Source: World Bank, World Development 1 licators 2001 Washington, D.C. 74 Table 6.2: Sub-Saharan Africa: Healt ~ 127 208 1,500 4 87 145 500 5 58 95 250 3 105 210 930 4 105 176 1,300 4 77 154 550 5 96 151 700 4 101 189 840 4 85 161 870 4 89 144 890 4 111 180 810 4 109 177 570 4 104 170 5 60 105 1,000 5 104 180 1,400 4 84 133 500 5 75 110 1,050 5 57 109 740 4 96 167 880 4 127 214 910 4 76 118 650 48 92 141 610 45 90 149 500 54 132 227 620 39 120 223 580 43 88 142 800 54 19 23 110 71 131 203 1,100 43 63 108 220 50 116 252 590 46 83 151 1,000 47 123 203 1,300 40 47 66 65 67 124 510 52 9 15 72 168 283 37 62 76 230 48 67 109 370 56 64 113 46 95 152 530 45 77 143 640 49 88 162 550 42 114 187 650 38 70 1181 2801 40 89.35 151.31 715.25 48.78 Source: World Development Indicators 2001, `odd Bank, Washington, D.C., and WHO, 2000. 75 d Beds per 1,000 Population (1990-1999) Physicians Beds per 1,000 per 1,000 Population Population (1999) (1998) 0.04 1.2: 0.03 0.2: 0.19 1.51 1.4: 0.06 0.6( 0.06 2.5: a1African Republic 0.03 0.8' 0.02 0.7: 0.09 2.71 0.05 1.4: 0.21 3.31 0.07 0.8( 0.13 2.5 0.22 0.02 0.7: 0.03 0.21 0.23 3.1' 0.02 0.6 1.4( 0.11 0.5: 0.18 1.41 0.04 1.6: 0.04 1.14 0.91 0.03 1.3' 0.06 0.2' 0.06 0.6 0.86 3.0 0.8' 0.23 0.03 0.1. 0.19 1.6' 0.04 1.6 0.42 4.7. 0.04 0.41 1.03 0.62 0.10 1.O' 0.08 0.04 0.8' 0.06 1.5 0.171 1.3' Source: World Bank, World Development Indicator, !001, Washington, D.C. 76 Table 6.4: Sub-Saharan Africa, Health I Ienditure Pattern, 1990-1998 Per Capita PublicSector Per Capita PublicSector Health Exp. GDP, US$ Health Exp, US$ % of GDP Country (1998) (1998) (1998) Ingola 1,272 50 3.9( 3enin 388 6 1.6( 3otswana 3,123 78 2.5( 3urkina Faso 240 3 1.2( 3urundi 134 0.80 0.6( 2ameroon 608 6 1.O( 2entral African Republic 301 6 2.0( :had 23 1 5 2.3( :omoros 374 12 3.1( :ongo, Dem. Rep. :ongo, Rep. 701 14 2.0( :ote d'Ivoire 742 9 1.2( !quatorial Guinea 1,184 36 3.0( Critrea 173 5 2.9( ltiopia 107 2 1.7( jabon 3,913 82 2.1( jambia, The 343 7 1.9( ;hana 407 7 1.8 iuinea 506 11 2.21 hinea-Bissau 222 2 1.11 Lenya 398 10 2.41 ,esotho 484 16 3.41 hadagascar 256 3 1.11 dalawi 165 5 2.81 4ali 25 1 5 2.11 4auritania 396 6 1.41 dauritius 3,512 63 1.81 dozambique 230 6 2.81 Jamibia 1,831 75 4.11 tiger 205 2 1.21 iigeria 267 2 0.81 :Wanda 250 5 2 01 ao Tome and Principe 345 21 6 l i enegal 516 13 2.61 eychelles 6,789 367 5.41 iena Leone 138 1 0 91 outh Africa 3,236 107 3.31 udan 370 3 0.71 waziland `anzania ogo iganda ambia imbabwe .frica Region Average= ource: World Bank, WorldDevelopment Ifi 77 78 BIBLIOGRAPHY College of Health Science. 2001. Revised Curriculum of Bachelor of Pharmacy Program, University of Asmara. Department of Pharmaceutical Services, Ministry of Health of Eritrea. 2001. Annual Report. Asmara. . 2000. Annual Report 2000. Asmara. . 2001. Action Plan2001. Asmara. ,2002, EssentialDrugs & Medical Supplies, Logistics Managementfor HealthCenters and Stations, 2"ded. . 2002. SemiAnnual Report. Asmara. Donaldson, Dayl. 2000. Eritrea, Health Sector Note: Economic and Financial Analysis. Asmara: Ministry of Health. . 2000. Technical Report: Economic and Financial Analysis. Asmara: Ministry of Health. . 2002. Eritrea, Health Sector Investment and Finuncing Analyses. Asmara: Ministry of Health. Ewan Technology. 2001. Integrated Information Systems Reportfor the Eritrea IECD Project. Government of Eritrea. 2001. Constitution of the Eritrean Pharmaceutical Association. Second Revision. Asmara. . Gazette of Eritrean Laws, Proclamation No. 36/1993, A Proclamation to Control Drugs, Medical Supplies, Cosmetics and Sanitary Items. Asmara. , Proclamation of Eritrean Laws No 86/1996: Establishment o f Regional Administrations. Asmara. Hill, Kenneth, C. Abou Zahr, and Wardlaw, T. 2001. "Estimates of Maternal Mortality for 1995". InBulletino fthe World HealthOrganization. Geneva. IMF. 2001. Eritrea StaffReport. Washington, D.C. Lagerstedt, Adam. 2000. Trip Report on Health Sector Vision and Health Policy Review. Asmara: Ministry of Health. Macro International, Inc. 2002. Eritrea Demographic Health Survey 2002, Preliminary Report. Maryland. 79 Management Sciences for Health. International Drug Price Indicator Guide, 2001 ed. , 1997. Managing Drug Supply. Ministry of Health. 1997. Eritrea: Household Health Status, Utilization and Expenditures Survey. Asmara. . 1997. EritreanNational Drug Policy, State of Eritrea. FinalDraft. Asmara. , 1998. Eritrean Standard TreatmentGuidelines. Asmara. . 2000. Annual Health ServiceActivity Report (January-December 1999). Asmara. , 2000. ConceptPaperfor the Health Sector Review. Asmara. . 2000. Health ManagementInformation SystemsReport. Asmara. . 2001. Annual Health ServiceActivity Report (January-December 2000). Asmara. . 2001. Eritrea Health Profile 2000: EPI CoverageSurvey. Asmara. . 2001. EritreanNational List of Drugs. 3rdEdition. Asmara. . 2001. HealthproJile 2000. Asmara. . 2002. Finance Office. Sources and Uses of Revenuesfor the Health Sector, 1999 and 2002. Asmara. Sebhatu, M.et.al, 1994. "Eritrea, Summary Report". In Proceedings of the East Africa Burden of Disease, Cost-Effectiveness of Health Care Interventions and Health Policy. pp. 33-42. RegionalWorkshop. August 17-19, 1994. Asmara. Tekeste, Assefaw, G. Tsehaye, and M.Dagnew. 1999. Health Needs Assessment of the Eritrean Nomadic Communities. Asmara: Ministry of HealthandUniversityof Asmara. Tseggai, A. 1998. "Human Resource Development: Priorities for Policy". In Post Conflict Eritrea: Prospectsfor Reconstruction and Development, ed. by Doombos, Martinand A. Tesfai. New Jersey: Red Sea Press. UNAIDS/WHO. 2001. Epidemiological Fact Sheet for Eritrea on HIVAIDS and Sexually TransmittedInfection. 2000 Update, (online) UNAIDS Website. Geneva. UNFPA. 2000. TheState of WorldPopulation, (online) UNICEFWebsite. NewYork. UNICEF. 2001. Global DatabaseonAntenatal Care,(online) UNICEFWebsite. NewYork. . 2001. Global Database on Births Attended by Skilled Health Personnel, (online) UNICEFWebsite. NewYork. WHO. 1993. How to Investigate Drug Use in Health Facilities,Action Programme on Essential Drugs. Geneva. 80 . 1994. Indicators for Monitoring National Drug Policies, Action Programme on Essential Drugs. Geneva. . 2000. The Use of Essential Drugs. Ninth Report of the WHO Expert Committee. Geneva. . 2000. Global Summary, Department of Vaccines and Biological (online) WHO Website. Geneva. . 2000. WorldHealth Report 2000. Health Systems: Improving Pevformance. Geneva. . 2000. Global Databaseon Child GrowthandMalnutrition, (online) WHO Website. . 2000. VaccinePreventableDiseases: Monitoring System. Geneva. World Bank. 1997. " EritreaHealthProject: ProjectAppraisalDocument". Washington, D.C. . 2001. World DevelopmentIndicators. Washington, D.C. . 2002. Eritrea-HealthSector Note. Washington, D.C. . Yoder, R. 1995, "Health Facilities Cost Estimates Study." In Eritrean Health and Population Project, BASICS Project. 81 Annex 9: ERITREA HEALTH SECTOR PERFORMANCE - OUTLINE OF STUDY REPORT Introduction 1.1 The healthcare system inEritrea 1.2 Performance o f the health system: effectiveness and efficiency Policy and Strategy Framework 2.1 Health Sector Reform and Strategy 2.2 EritreaHealth Sector Vision and GuidingPrinciples The PharmaceuticalsSector 3.1 TheNational DrugPolicy 3.2 The EritreanDrugLaw 3.3 The EritreanNationalList ofDrugs 3.4 The Eritrean Standard Treatment Guidelines 3.5 Organization o f the DrugAdministration, M O H 3.6 Humanresources 3.7 Drugprocurement 3.8 Drugstorage, distribution, and use o f drugs 3.9 The parastatal drug sector and PHARMECOR 3.10 Erithro pharmaceutical factory, Keren 3.11 The private pharmaceuticalsector 3.12 The NationalDrugBill 3.2 Drugaccessibility, availability, and affordability 3.3 Major problems and issues 3.3 Future options 4. Health Care Financing 4.1 The Health FinancingPolicy of 1996198 4.2 Levels and composition o f financing 4.2.1 Share o f health sector expenditures intotal national budget 4.2.2 Public expenditure on health (evolution/trends, by category, by type, technical and economic efficiency) 4.2.3 Resource allocations inthe health sector (by region, by facility, by programs, efficiency and cost-effectiveness) 82 4.3 Householdhealth spendingand services utilization patterns 4.3.1 Householdhealth spending and utilization by income quintiles and by health care provider (private/public/traditional) 4.3.2 Householdhealthspending and utilizationby income quintiles and by health facility type 4.3.3 Householdhealthspendingby health facility type andby region 4.3.4 Householdhealthspending by gender and age of householdmember 4.3.5 Trends inhouseholdhealthspendingand service utilization 4.3.6 Determinantsofhouseholdhealthspendingandhealth service utilization 4.4 Sources of financing 4.4.1 Public revenues 4.4.2 User fees (impact on growth of private sector, utilization of services, health facilities) 4.4.3 Health insurance 4.4.4 Other private sources 4.5 Cost recovery 4.6 Donor support (loans and grants, by programs, effectiveness and efficiency) 4.7 Equity and Efficiency Analyses 4.8 FutureOptions 5. HealthSector Planning for Facility-basedServices 5.1 Structureof the current healthsystem 5.2 Infrastructure 5.3 Demography 5.4 Key issues 5.5 Health Planning Standards and Guidelines 5.5.1 Future organization 5.5.2 Planningcriteria including issues to be addressed 5.5.3 Human resources 5.5.4 Health infrastructure (buildings, equipment, furniture) 5.5.5 Economic resource requirement 5.5.6 Health support facilities 5.6 The health care services rightsizing master plan 5.5.1 Overall area profile 5.5.2 Inventory and mapping of existing services 5.5.3 Service delivery requirements 5.5.4 humanresources 5.5.5 Implementation plan 5.5.6 Planof action