Ministry of Health s1

ERITREA

EPI PROGRAM

REVIEW REPORT

NOVEMBER 2000

THE STATE OF ERITREA

MINISTRY OF HEALTH

With support from

WHO UNICEF NORAD

TABLE OF CONTENTS

1 EXECUTIVE SUMMARY 3

1.1 Purpose of Review 3

1.2 Methodology 3

1.3 Key recommendations 3

1.4 Proposed Next Steps 4

2 INTRODUCTION AND BACKGROUND 6

2.1 Introduction 6

2.2 Background Information – Eritrea 6

3 OBJECTIVES OF THE REVIEW 8

4 METHODOLOGY 9

5 CENTRAL LEVEL: FINDINGS AND RECOMMENDATIONS 10

5.1 Health systems 10

5.2 Service provision 14

6 VISITS TO ZONE, SUB-ZONE AND FACILITY LEVELS: 17

6.1 Health Systems 17

6.2 Service delivery 22

7 List of sites visited and persons interviewed 33

7.1 List of review team members 34

8 ANNEXES 35

8.1 Summary of the review pre-assessment 35

2

1  EXECUTIVE SUMMARY

1.1  Purpose of Review

The overall objectives of the 2000 EPI review are to:

·  Analyze the strengths and weaknesses of the immunization program, including service delivery aspects and the functionality of the health information system for EPI;

·  Review the health system capacity in terms of provision of guidance, service provision, communication and financing;

·  Assess the ability of the immunization program to introduce specific innovations such as Hepatitis B vaccine and auto disable syringes;

·  Propose recommendations of strategies and interventions that will enhance the achievement and sustainability of EPI planned activities.

1.2  Methodology

Six teams were selected for the review, each comprising one international reviewer and one national staff from the MOH or an NGO partner. International partners included representation from NORAD, UNICEF and WHO. Each team reviewed one Zone, or region. In total, 7 hospitals, 1 mini-hospital, 12 health centers and 24 health stations were visited and health facility staff interviewed. Interview sites were selected based on a range of diverse criteria, including size of catchment area, immunization program performance, and other external characteristics. A common assessment tool that was developed by WHO was used to collect both qualitative and quantitative data.

1.3  Key recommendations

Health Systems

1. Over the next ten years, the Government of Eritrea should strive to finance a portion of its vaccines (target of 10%) and define a timeline when all aspects of the EPI program will be fully managed by the Government and the community.

1. The MOH should assess staffing levels of the National EPI and health facilities and resolve personnel shortages.

Supervision

1.  The MOH/EPI should ensure that supervision at all levels is conducted in a more structured manner and train supervisors in systematically using documentation to follow-up on weak areas of performance.

Training

1.  The MOH/EPI should ensure that all health workers, including facility supervisors, receive formal EPI training and that refresher training in EPI occurs at regular intervals. The analysis and use of data for decision making must be incorporated into training at all levels. Formal two-week “Train the Trainer” courses should be held for EPI supervisors in coordination with UNICEF and WHO.

2.  For long-term planning, the MOH/EPI should assemble a comprehensive list of all training gaps (cross-cutting and technical) and prepare a master training plan addressing overall health system needs. National and Zone training could occur in phases, based upon system priorities.

Immunization Services

1.  The MOH should greatly increase the number of mobile and rotating outreach sites for immunization, particularly in Zones with traditionally under-served and unreached groups (i.e., vulnerable groups, nomadic and semi-nomadic populations).

2.  The MOH/EPI should promote screening of all children and women who visit health facilities, regardless of reason for visit, including inpatient, outpatient and MCH services.

3.  The MOH/EPI should review the use of population denominators at the sub-Zone and Zone levels to ensure that they are truly representative of target populations and to ensure consistency in data analysis and compilation. The Government of Eritrea should provide more accurate population estimates by conducting a population census or another demographic survey.

Safety of Waste Management

1.  The MOH must develop a national injection safety plan that includes the effective management of infectious waste. The MOH/EPI must ensure that all facilities are supplied with safety boxes, outfitted with incinerators, and that all health facility staff sensitized to the importance of safe waste disposal

Logistics

1.  The MOH should ensure that all health centers have access to a dedicated “ambulance” to perform critical activities related to disease surveillance, outreach, follow-up of defaulters, etc. Depending on the size of the catchment area, specific health stations may also merit use of dedicated transport.

2.  The MOH should ensure adequate funding for the proper maintenance of all vehicles.

Vaccine Supply and Quality

1.  The MOH/EPI should ensure that the “Open Vaccine Vial Policy” is understood and adopted in all facilities. This should be reinforced in every supervisory visit and with the collection of vaccines from the Zonel and sub-Zonel vaccine stores.

2.  The MOH should design a formal reporting and surveillance system for Adverse Events Following Immunization (AEFIs) to be included in the SEMISH monthly reporting system and train health workers on the actions required to follow-up on an occurrence of an AEFI.

3.  The MOH/EPI should ensure that the vaccine stock of central cold chain is reviewed quarterly such that there is no understocking (not enough vaccines for the next six months), no overstocking (more than 12 months of stock in place), and no vaccines within four months of expiry date.

Disease Surveillance

1.  The MOH/EPI should emphasize the importance of disease reporting and feedback at every level. Additionally, the MOH/EPI should promote the analysis and use of surveillance data to plan routine services and inform disease control strategies.

2.  The MOH/EPI must continue to strengthen its surveillance of acute flaccid paralysis (AFP) to ensure that certification of indicators for eradication of wild polio virus are achieved.

3.  The MOH/EPI should train health workers in the proper investigation, reporting and interpretation of case incidence of EPI target diseases, especially AFP, measles and neonatal tetanus.

Advocacy and Communications

1.  The MOH should provide the necessary support to central level, Zones and sub-Zones to ensure that good communication and close collaboration is a routine part of planning and implementing EPI activities.

2.  The MOH should encourage the participation of communities by supporting the development of village health committees to collaborate with health facilities in raising public awareness about health issues, including immunization.

3.  The MOH should promote the training of additional multi-disciplinary community health agents and trained birth attendants (TBA) to reach broader segments of the population and to participate in disease surveillance and IEC activities.

Innovation

1. The MOH/EPI must begin social promotion campaigns to increase the understanding of the value of vaccination against hepatitis B through community meetings, radio, media, posters, etc. These advocacy efforts must occur at all levels.

Performance Monitoring

1.  Every six months, each level of the health care system should analyse data gathered on changes in routine coverage, BCG-DPT3 drop-out rates or additional performance indicators to assess program performance.

2.  The MOH should prepare, twice yearly, reports showing performance of these indicators by Zone and sub-Zone. Where performance is poor, corrective measures should be implemented.

3.  The MOH should encourage the involvement of administrators, religious and community leaders at Zonel, sub-Zonel and village level in the planning, implementation, monitoring and evaluation of health service delivery.

1. The EPI Steering Committee (ICC mechanism) should strengthen its role in EPI program monitoring and performance evaluation.

1.4  Proposed Next Steps

1.  The MOH and EPI Steering Committee (ICC mechanism) should review the assessment recommendations, assess cost implications, establish priorities and identify available resources and funding shortfalls. After key activities are identified for implementation, the multi-year immunization plan should be drafted to address gaps.

2.  A selected group of those who participated in this assessment should meet third or fourth quarter 2001 to review, in collaboration with MOH, the implementation of key recommendations and specifically, to assess progress in increasing immunization coverage and improving surveillance.

2  INTRODUCTION AND BACKGROUND

2.1  Introduction

The Expanded Program on Immunization (EPI) was launched in Eritrea in 1980. However, its operations were limited and national expansion was only possible after achieving independence in 1991. Even then, progress has been slow as the infrastructure was ill-equipped to enable adequate delivery of the program.

In June 1995, the Ministry of Health of the State of Eritrea conducted a comprehensive assessment of its EPI. The assessment consisted of a comprehensive program review and immunization coverage survey in all the regions of the country. It revealed that the coverage at national level was about 40% and the following problems were identified:

·  low access to immunization services, high drop-out rate and missed opportunities;

·  low level of EPI knowledge and skills among health workers and lack of an EPI policy manual;

·  unsatisfactory involvement of the community and low awareness of the public on EPI due to weak IEC activities;

·  no system established for maintenance and repair of cold chain;

·  highly centralized planning and budgeting and no strong supportive supervision;

·  weak health information system for surveillance;

·  doubt about the sustainability of the installed refrigerators;

·  shortage of skilled human resources both in quality and quantity;

·  weak inter-agency collaboration.

Relevant recommendations were provided in relation to the above problems.

Although there was a problem of getting reliable data on number of children under 1 years old, the reported EPI coverage after independence in the past 5 years, was increasing as seen below.

In addition to the 1995 review, other studies (e.g. injection safety study) have examined EPI in Eritrea. However, the implementation of prior recommendations has been difficult to realize without addressing other managerial and operational issues. Therefore, in this review, a more comprehensive approach is adapted to identify the details behind the problems and facilitate the development of more balanced recommendations. In the current assessment approach, immunization operations, the health system and the external environment are included.

2.2  Background Information – Eritrea

This part of the report will briefly provide information on important factors that may lead to variation in the incidence of different infectious diseases such as measles, malaria, meningitis, pertussis, among others.

Geography and climate

Eritrea has an area of about 124,000 square kilometers and lies on the Horn of Africa. It is bounded by Sudan to the North and West, the Red Sea to the Northeast, Djibouti to the Southeast and Ethiopia to the South. It has a long border (over 1200 kms) along the East on the Red Sea Coast.

Eritrea’s proximity to the Red Sea and its varying physical features account for the varied climate. The country has three distinct climatic Zones: the central high lands, the coastal plains and the western lowlands. The central highlands have temperatures of 170 – 300C and annual rainfall ranges between 400 – 700 mm. The eastern coastal plains have temperatures as high as 480C in the months of July and August with very little rainfall. Similarly, the Western lowlands can reach high temperatures, 450C, and annual rainfall ranges between 300 and 400 mm.

Population size and demographic characteristics

Since there has not been a country-wide survey conducted in Eritrea other than the Eritrean Demographic Health Survey (EDHS) or census, no precise population size and distribution is known. Some estimate the population to range between 2.5. to 3.5 million people.

The population is essentially rural (80%). The urban population is presently characterized as having rapid growth (around 5 – 7% per annum), partly as result of returning refugees from neighboring countries and deportees from Ethiopia. The population is not uniformly distributed throughout the country.

The fertility rate is high and marriage is almost universal in Eritrea. The fertility rate as calculated by the EDHS is 6.7. The natural population growth rate is around 3% per annum. Almost half of the population is in the age range of less than 15 years old. The population of females aged 15 - 49 and children under 5 years old are respectively 20% and 18% accounting for over one-third (37%) of the total population.

Socio –economic situation

In Eritrea there are 9 ethnic groups (Afar, Billen, Hedarib, Kunama, Nara, Rashaida, Saho, Tigre and Tigrigna) with different cultures and languages affecting the health and other social services accessibility and subsequently determining the health status of mothers and children.

Primary school enrolment in Eritrea is low, at 48%. There are differences in the enrollment between rural (35%) and urban (Asmara 92%) and between males (52%) and females (46%). The Eritrean economy is largely agrarian. Over 70% of the population is dependent on traditional subsistence agriculture including crop farming, livestock raising and fishing. The country has a per capita income of less than US $200.

Health services

The Eritrean health care organization is comprised of a five tiered system consisting of community health services, health stations, health centers and rural hospitals (mini-hospitals), and central/referral hospitals. There is a referral system, although not strong, which delineates the distinction across each level of health service.

The country has 23 hospitals, 49 health centers and 191 health stations mostly (74%) run by the Ministry of Health and less than a quarter of them run by churches and NGOs. (SEMISH 1999 Annual Report)

The number of Zonel health facilities by type and distribution per 10,000 population 1999 was as follows:

* Calculation is based on one health station serving 10,000 clients

Eritrea has 145 medical doctors, 735 nurses and nurse midwives, 84 pharmacists, 21 sanitarians, 132 laboratory technicians, 40 X-ray technicians and 1292 health assistants. The medical doctor population ratio is 1:19,000 while the ratio between nurses and the population is about 1:3,700 and that of health assistants is 1:2,100.