Eritrea Reproductive Health Commodity Security Situation Assessment

DRAFT

Report of

Eritrea Reproductive Health Commodity Security Situation Assessment

ACRONYMS

AIDS Acquired Immune-Deficiency Syndrome

CCA Common Country Assessment

CEDAW Convention on Elimination of all forms of Discrimination against Women

CPR Contraceptive Prevalence Rate

CSTAA Country Technical Services Team, Addis Ababa

DKB Debubawi Keih Bahri

EDHS Eritrea Defense Force

EHHSUSES The Eritrea Household Health Status Utilization and Expenditure Survey

ELF Eritrea Liberation Front

EPLF Eritrean People’s Liberation Front

ERREC Eritrean Relief and Refuge Commission

ESMG Eritrea Social Marketing Group

FAO Food and Agriculture Organization

FGC Female Genital Cutting

FGDs Focus Group Discussions

FGM Female Genital Mutilation

FP Family Planning

FWCW Fourth World Conference on Woman

GDP Gross Domestic Product

GNP Gross National Product

GSE Government of the State of Eritrea

HAMSET HIV/AIDS, Malaria, STDs and Tuberculosis

HC Health Centers

HDI Human Development Index

HDR Human Development Report

HIMS Health Management Information System

HIV Human Immune Deficiency Virus

ICPD International Conference on Population and Development

IDA International Development Assistance

IMF International Monetary Fund

I-PRSP Interim Poverty Reduction Strategy Paper

IUD Intra-Uterine Devise

MDGs Millennium Development Goals

MOH Ministry of Health

NGAP National Gender Action Plans

NGOs Non Governmental Organizations

NRH National Reference Hospital

NRSZ Northern Red Sea Zoba

NSEO National Statistics and Evaluation Office

NUEW National Union of Eritrean Woman

NUEYS National Union of Eritrean Youths and Students

OAU Organization of Africa unity

ODA Overseas Development Assistance

PLHA People Living with HIV and AIDS

PRSP Poverty Reduction Strategy Paper

PSI Population Service International

RH Reproductive Health

SRH Sexual and Reproductive Health

SRSZ Southern Red Sea Zoba

STIs Sexually Transmitted Infections

TB Tuberculosis

TASC Technical Assessment Committee

TFR Total Fertility Rate

UN United Nations

UNAIDS United Nations Programme on HIV/AIDS

UNCT United Nations Country Team

UNDAF United Nations Development Assistance Framework

UNHCR United Nations High Commission for Refugees

UNDP United Nations Development Programme

UNICEF United Nations Children Fund

UNFPA United Nations Population Fund

UNMEE United Nations Mission for Ethiopia and Eritrea

US United States

USAID United States Agency for International Development

VCT Voluntary Counseling and Testing

WB World Bank

WFP World Food Programme

WHO World Health Organization

BACKGROUND

Eritrea is situated in the Horn of Africa and lies north of the equator. The country is bounded in the east by the Red Sea and in the southeast by Djibouti, Ethiopia in the south and Sudan in the north and west. Eritrean has an area of 122000 square kilometers. The country is divided into six administrative regions also called zones or Zobas. These include: Anseba, Debub, Debubawi Keih Bahanri also called Southern Red Sea, Gash Barka, Maekel, and Semenawi Kieh Bahri, also called Northern Red Sea. The capital is Asmara, and main port cities are Massawa and Assab. Eritrea has nine ethnic groups and the major religions are Christianity, Islam and Traditional religion.

Though there’s never been a population census in Eritrea, the Ministry of Local Government estimates that the total population of Eritrea was about 3.2 million in 2001. The Human Development Report (HDR) estimates the population to be about 3.7 million in 2000, with a projected population of 4 million in 2002 and 5.9 million by 2015. The population below age 15 years has risen from 44.1% in 1999 to 45.5% in 2002, and the population over 65 years has decreased from 2.9% in 1999 to 2.1 in 2002. According to the LSMS survey of 2003, Eritrea has a very high dependency ratio. For every 100 persons in the workforce aged 15-64 years, there are about 116 dependants. Adolescents and young people between the ages of 10-24 years constitute about 33.3% of the population. Over one third of adolescents have begun child bearing and about 24% of those who have started child bearing are in fact less than 18 years old.

Estimates from the State of the World Population 2005 provide a growth rate of 3.7% for Eritrea, a total fertility rate of 5.29 and contraceptive prevalence of 8%. Life expectancy at birth is estimated at 51.1 years for males and 53.7 years for female. Although the demographic and health surveys undertaken in 1995 and 2002 show a decline in fertility from 6.1 to 4.8, this cannot be attributed to increasing use of contraceptives since the contraceptive prevalence rate (CPR) has remained at 8% for any method and 5.1% for modern methods.

Maternal and child mortality in Eritrea as in many other developing countries remain unacceptably high. The Government of Eritrea recognizes this and has in it’s Policy on Safe Motherhood expressed her determination and commitment to reduce maternal deaths. Maternal mortality ratio is estimated at 630 per 100,000 live births, while the infant mortality rate is estimated at 61 per 1000 live births. Complications of abortion contribute to 46% of all obstetric deaths and 5% of all deaths.

A number of factors contribute to this high maternal and infant mortality. These include limited access to and use of reproductive health services compounded by the fact that as the Population of the country increases and the number of people entering their reproductive age also increases, demand and need for reproductive health service will also increase. With HIV prevalence rates of 2.3-3%, reproductive health commodity security necessary for ensuring the availability of essential therapeutic and preventive commodities for combating the further spread is of necessity a major concern.

The Government of Eritrea is making significant efforts to improve the health and well being of her people and to improve the health indicators identified within international frameworks such as the ICPD and Millennium Development Goals. It is inline with these government efforts that the Government of Eritrea requested for technical support from UNFPA in assessing her reproductive health commodity security situation, as a prelude to future support for putting in place effective strategies and mechanisms for ensuring the effective procurement, storage and distribution of essential RH supplies and commodities within the public sector services.

A.2 Demographic, Health and Development Indicators

STUDY METHODOLOGY

Goal and Main Objectives

The main goal and objectives of the study is to assess the reproductive health commodity security situation in Eritrea and to suggest ways of strengthening and improving the system.

Specific objectives: -

·  To collect qualitative information about the status of the RHCS in Eritrea

·  To provide a base line for future assessment of RHCS logistics situation.

·  To identify the strengths and weaknesses of the RHCS system.

·  To make recommendations for strengthening and improving the RHCS system

Study methods: -

The qualitative assessment of the Reproductive Health Commodity situation was carried out within the period October to November 2005. Four methods were used – a joint central/lower level discussion group, key informant interviews, field trips and review of existing literature.

Study instrument: -

The study instrument was the Reproductive Health Commodity Security Situation Analysis (RHCSAT) Tool[1].

Selection and recruitment of participants:-

A pre-assessment capacity building workshop was held with Government partners, UNFPA and other stakeholders to build in-country capacity for conducting an RHCS situation analysis and during which the tools, technique and logistics for the assessment were discussed. The meeting and workshop provided a forum for the selection and recruitment of participants for the assessment. The standard RHCSAT was reviewed with partners and adapted to Eritrea situation and needs prior to the assessment.

Joint Discussion Group

A joint discussion group was constituted from stakeholders who included service providers, and programme managers purposively selected from central and zonal levels and facilities (both service delivery and stores) from all over the country. Using the RHCSAT instrument as a discussion guide, information on all aspects of RHCS and components of the logistic cycle was gathered from the participants. The focus group discussions (FGDs) were conducted over a period of four days. A full list of FGD participants is attached as an appendix.

Key Informant Interviews

Key informant interviews were held with the Director General, Regulatory Services, Ministry of Health, and the Managing Director of PHARMECOR, the government parastatal responsible for drug procurement and distribution and other key officers.

Field Trips

Field visits were made to health facilities, ware houses and service delivery points at both central and zonal levels and on site assessment of RHCS done. Interviews were held with service providers, issues were clarified and validated and more in- depth knowledge of practices obtained

Facilities visited included:-

·  PHARMACOR, the Central Warehouse in Asmara

·  Mendefera Zoba Warehouse

·  Dekemhare Hospital

·  Marhano Health Centre at Galaneti Subzoba, and

·  Dubaruba Health Centre

Review of Existing Literature

Available existing literature on demographic and reproductive health for Eritrea were reviewed and information obtained was used to validate and reinforce collected information and to fill gaps.

Stakeholders briefings

Critical stakeholders and participants meetings were held immediately before and after the assessment. The first meeting was used to inform and seek the support of stakeholders for the assessment. The post assessment meeting was used to share and validate the preliminary findings and recommendations, and agree on future steps.

Key Issues Assessed

The following key elements of Reproductive health commodity security were assessed:

·  Organizational Context

·  Coordination

·  Commitment

·  Capital/Financing

·  Commodities

·  Client utilization and demand

·  Service Access and Utilisation

·  National Capacity

·  Logistic Management Information System

·  Forecasting

·  Obtaining Supplies and Procurement

·  Inventory Control Procedures

·  Warehousing and Storage

·  Transportation and Distribution

FINDINGS

A. CONTEXT:

A.1 Policies and Regulations

Eritrea has several population and reproductive health related policies, documents, and service delivery guidelines in place. Some of these include:

·  Adolescent Health Policy

·  Sexual and Reproductive Health Policy (Draft)

·  HIV/AIDS and STDS Policy and Policy guidelines

·  Eritrean National Clinical Protocol on Safe motherhood

·  PRSP- Interim Poverty Reduction Strategy Paper

·  Macro-Policy

·  Eritrean National List of Medicines (ENLM)

Most of these documents appear to be supportive of family planning and reproductive health. The Adolescent Health Policy in particular emphasized the right of adolescents to reproductive health information and services, while the HIV/AIDS and STDS policy explicitly provided for the supply of both male and female condoms.

The Interim Poverty Reduction Strategy Paper (I-PRSP) shows Government plan and determination to advance the status of women through adoption of a National Plan of Action (NPA) for women with key policy reforms and programmes focusing on women education, skills training, improving family health and nutrition and family planning in rural and urban areas. The document also recognized that the poor have larger families and high dependency ratio and observed a strong positive relationship between dependency ratio and poverty.

The Millennium Development Goal Report 2004 also recognized low contraceptive prevalence rate among others as a constraint towards achieving the Millennium Development goal of reducing maternal mortality ratio and advocated the use of adult literacy programmes to educate women on health issues such as a child spacing, contraception, nutrition and hygiene.

The Macro Policy document stated explicitly that a population growth rate that is conducive to the economic and social development of the country will be promoted.

The Sexual and Reproductive Health Policy is still in the draft form. The Draft as seen however does not seem to sufficiently address issues of RH commodity security.

There is an Eritrea National List of Medicines (ENLM), which includes contraceptives and reproductive health commodities. The female condom is explicitly mentioned within the ENLM. The Eritrean National Clinical Protocol on Safe Motherhood provides guideline on family planning. However though these services delivery guidelines include quality assurance procedures, they contain minimal information on basic logistic principles.

Comprehensive RH/FP training is an integral part of pre-service training in schools of nursing for nurse/midwives. There are also regular in-service refresher training provided periodically. All the responsible providers interviewed at facilities appeared to have received adequate family planning skills and training. There is however pocket of opinions that IUCD and implant should be administered by obstetricians or doctors. This opinion is also countered by argument that this will affect service delivery as there are not many obstetricians.

There is limited use of RH service by adolescents partially as a result of socio-cultural factors, which perceive premarital sexual relationships as culturally unacceptable. Women also are expected by culture to obtain spousal permission to access reproductive health services/commodities.

There is very little private sector involvement in provision of services largely attributed to low capacity within the private sector. The sector is however involved in condom distribution through medicine stores distributed largely within the urban areas.

Recommendation:

1.  RH commodities should be more explicitly addressed in the SRH policy currently being developed.

2.  Support should be provided to increase private sector involvement in the provision of services, and where appropriate the possibility of market segmentation of services should be explored and utilised.

B. COORDINATION:

A number of stake holders are involved to varying degrees in RHCS. These include the UNFPA, WHO, USAID, UNICEF, NORWEGIAN CHURCH AID, Catholic Church, Women Organisations, Youth groups and various ministries of government such as Health, Education, Information and Tourism ministries.