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All photos: ©WHO Designed in Asmara, Eritrea Acknowledgements Abbreviations VIIVI VIII X 76726641 32 38 46 52 56 8076 96 72 92 66 88 62 84 ©WHO IV Message from the WHO Country Representative to the Government of the State of Eritrea Contents Driving impact through strengthened governance for health systems: WHO’s health leadership and governance approach in Eritrea Case study 5: Charting a malaria-free future: five ways WHO is backing Eritrea's advancement toward malaria elimination Case study 10: Multi- age HPV campaigns: the collaborative effort to safeguard girls and women against cervical cancer in Eritrea Case study 15: WHO and Eritrea unify actions to launch flagship initiatives for emergency preparedness and response Case study 1: Development of Eritrea Essential Health Package Case study 6: How Eritrea is stepping up the fight against AMR Case study 11: Risk communication and community engagement (RCCE): key pillars in Eritrea’s effective COVID-19 pandemic response Case study 16: Strengthening procurement to drive progress to universal health coverage in Eritrea Case study development and overview of case studies by theme Case study 2: Development of Eritrea’s National Health Sector Strategic Development Plan Case study 7: Improving maternal and child health: the impact of maternity waiting homes in Eritrea Case study 12: MenA vaccination campaigns: the collaborative effort to safeguard against meningitis in Eritrea Case study 17: Health observatories: how Eritrea is using health observatories to strengthen national health information system Key highlights (infographic) Case study 3: Development of Eritrea’s Human resources for health strategic plan 2023-2027 Case study 8: Strengthening District Health Services for Universal Health Coverage in Eritrea Case study 13: Leaving no one behind: collaborative effort to reach Eritrea nomadic and hard-to- reach population with immunisation services Introduction Case study 4: Development of Eritrea’s National Priority Health Research Agenda Case study 9: Impact stats and insights from Eritrea’s national EPI program review 2021 Case study 14: How WHO is strengthening health security in Eritrea through development and Implementation of the National action plan for health security Message from the WHO Country Representative The WHO Country Office in Eritrea (WCO) has implemented high-impact programmes and interventions to support the State of Eritrea in its efforts to achieve the three Thirteenth General Programme of Work 2019–2025 (GPW 13) goals: universal health coverage (UHC), protection from health emergencies and promoting healthier populations. The resulting impact of WHO’s efforts in Eritrea is a testament to the extensive engagement and cooperation by the Government and other health partners across all levels of the health system. Collaboration among WHO staff at the regional and global levels has also been instrumental in shaping the effectiveness of WHO approaches in Eritrea. These successes are further bolstered by the deep commitment and strong country ownership demonstrated by the Government of Eritrea, in line with the principles outlined in the Paris Declaration on Aid Effectiveness. Since gaining independence, Eritrea has endeavoured to build resilient health systems at all levels to address national health priorities. At the core of this health system is a robust foundation of primary health care, in which Eritrea takes great pride.. Despite the significant disruptions caused by the COVID-19 pandemic, WHO has maintained crucial support. It has remained instrumental in guiding Eritrea through the pandemic, resulting The report underscores the Ministry of Health's (MOH) pivotal role as the primary implementers of health initiatives in Eritrea, with WHO providing dedicated support and collaboration. Dr Martins OVBEREDJO WHO Country Representative A compendium of Eritrea health sector impact case studies 2019 - 2023 IV This compendium of impact case studies, spanning 2019–2023, showcases the dedicated efforts of WHO staff in Eritrea. It emphasizes their commitment to supporting Eritrea’s response to the COVID-19 pandemic and other health threats, as well as proactive measures to address future pandemics. Additionally, it highlights WHO’s ongoing work in essential health services, including immunization, health system governance, leadership and initiatives to improve maternal, child and neonatal outcomes. The report underscores the pivotal role of the Ministry of Health of Eritrea (MoH) as the primary implementers of health initiatives in Eritrea, with WHO providing dedicated support and collaboration. It highlights the collaborative effort between the MoH and WHO in achieving substantial impact through accountability, trust-building and transparency. The systematic outline of WHO's support emphasizes the MoH's leadership in advancing towards UHC, promoting healthier populations and strengthening health emergency preparedness and response mechanisms. Moving forward, our priority is to ensure that the MoH remains at the forefront, driving progress, while WHO continues to provide meaningful support, focusing on areas critical for the health and well-being of Eritreans. I thank the Honourable Minister of Health of Eritrea and the MoH leadership at every level for their continued support and commitment. I also thank all staff at the WHO Country Office in Eritrea, and other health partners, who continue to demonstrate the values of commitment, integrity, collaboration, compassion and excellence to promote health and keep the world safe. Dr Martins OVBEREDJO WHO Country Representative in Eritrea A compendium of Eritrea health sector impact case studies 2019 - 2023V Acknowledgements The project manager and editor-in-chief for this compendium of case studies was Joel Motswagole, the Programme Management Officer at the WHO Country Office (WCO) in Eritrea. The lead author and researcher was Okikiolu Badejo, the impact case study Consultant at WCO Eritrea. Technical and programme staff of the WCO were contributing editors. The compendium was developed in a collaborative and iterative process in October and November 2023. Its contents were informed by findings from field visits, desk reviews, as well as experiences and perspectives of WCO Eritrea staff, senior officials of the Eritrea Ministry of Health (MoH), health facility administrators and service beneficiaries from selected health facilities. Particular thanks are due to all MoH officials, health providers and care beneficiaries of the State of Eritrea who provided their perspectives and feedback on the activities of WHO and their impact. The WHO Representative, Dr Martins Ovberedjo, provided coordinating support throughout the process. This support was indispensable in the successful development of this compendium. A compendium of Eritrea health sector impact case studies 2019 - 2023 VI Abbreviations Africa CDC: Africa Centres for Disease Control and Prevention COVID-19 Coronavirus Disease 2019 EEHCP: Eritrea Essential Health Care Package EPR: Emergency Preparedness and Response WHO GPW 13: World Health Organization’s 13th Global Programme of Work HEPR: Health Emergency Preparedness and Response HRHSP: Human resources for health strategic plan HSSDP: Health Sector Strategic Development Plan HMIS: Health Management Information System IDSR: Integrated Disease Surveillance and Response MMR: Maternal Mortality Rate MOH: Ministry of Health NAPHS: National Action Plan for Public Health Security NHO: National Health Observatory NRASP: National Research Agenda Strategic Plan PHEOC: Public Health Emergency Operation Centre PHC: Primary Health Care SURGE: Strengthening and Utilizing Response Groups for Emergencies TASS: Transforming African Surveillance Systems TWG: Technical Working Group PROSE: Promoting Resilience of Systems for Emergencies WHO: World Health Organization UHC: Universal Health Coverage AHO: African Health Observatory AMR: Antimicrobial Resistance AVW & CHNW: Active Village Worker and Community Health Nurse Worker CCS: Country Cooperation Strategy CPD: Continued Professional Development DG: Director General DHIS2: District Health Information Software 2 ECAMM: External Competence Assessment of Malaria Microscopists EDHS: Eritrean Demographic and Health Survey EPC: Eritrean Pharmacovigilance Center EPHS: Essential Packages of Health Services EPR: Emergency Preparedness and Response EHCP: Essential Health Care Package EPDS: Essential Package of Health Services GAVI: Global Alliance for Vaccines and Immunization GAP: Global Action Plan GPW: General Program of Work HSSDP: Health Sector Strategic Development Plan HPV: Human Papillomavirus HRH: Human Resources for Health ICSR: Individual Case Safety Reports ICT: Information and Communication Technology IDSR: Integrated Disease Surveillance and Response IHR: International Health Regulations IST/ESA: Inter-country Support Team for Eastern and Southern Africa JEE: Joint External Evaluation KAP: Knowledge, Attitude, and Practice LFP: Lithium Ferrous Phosphate MAC: Multi-Age Cohort MACV: Meningococcal A Conjugate Vaccine M&E: Monitoring and Evaluation MIS: Malaria Information System MNTs: Maternal and Neonatal Tetanus MWH: Maternity Waiting Home NAP: National Action Plan NMFA: National Medicines and Food Administration NHO: National Health Observatory NTDs: Neglected Tropical Diseases PBM: Pre-Birth Mortality PHEOCs: Public Health Emergency Operational Centers RCM: Rapid Convenience Monitoring RCCE: Risk Communication and Community Engagement SDG: Sustainable Development Goal SDGs: Sustainable Development Goals SOPs: Standard Operating Procedures ToT: Training of Trainers TOT: Trainer of Trainers TWGs: Technical Working Groups UHC: Universal Health Coverage UI: Uncertainty Interval UNICEF: United Nations Children's Fund A compendium of Eritrea health sector impact case studies 2019 - 2023VII Case study development and overview of case studies by theme GPW13 Triple Billion Goals This compendium documents the tangible impacts of WHO’s programme in Eritrea, achieved through close collaboration with the Government of Eritrea and other stakeholders. It details the facilitators of WHO's implementation strategies, resulting impacts and lessons learnt. The compendium is organized thematically, drawing upon desk reviews of programmatic and national documents, policies and guidelines, along with data analysis and interviews with key stakeholders. The first section focuses on four case studies of WHO's core impact strategies for strengthening governance for health systems. Subsequent case studies highlight successful implementation related to impact in line with the triple billion themes goals of UHC, health security and promoting healthier populations, together with GPW13 outcomes. Table 1 presents an overview of the case studies by theme. A compendium of Eritrea health sector impact case studies 2019 - 2023 VIII Table 1: Overview of case studies by theme and GPW outcomes UHC Emergencies GPW outcome Healthy population Outcome 1.1 Outcome 4.0 Outcome 1.3 Outcome 1.1 Outcome 1.3 Outcome 1.1 Case Study 2 Case Study 1 Case Study 3 Strengthening governance for health systems Cross - cutting Case Study 4 Case Study 5 Case Study 6 Case Study 7 Case Study 8 Case Study 9 Case Study 10 Case Study 11 Outcome 1.2 Outcome 1.1 Outcome 1.1 Outcome 2.1 Outcome 1.1 Outcome 1.1 Outcome 2.1 Case Study 12 Case Study 13 Case Study 14 Case Study 15 Case Study 16 Case Study 17 Outcome 2.1 Outcome 4.1 Outcome 4.1 A compendium of Eritrea health sector impact case studies 2019 - 2023XIX
The WHO GPW 13 defines its strategic agenda for the 2019–2023 period, focusing on three interlinked priorities: achieving UHC, responding to health emergencies and promoting healthier populations. Since 2019, various levels of WHO have aligned their strategies and operational plans with GPW 13 priorities. Ultimately, this report aims to provide governments, partners, and the public with an overview of the progress, accomplishments, and successful practices in executing GPW 13 by the WHO Country Office in Eritrea from 2019 to 2023 Introduction WHO’s core functions In Eritrea include: • Providing leadership on critical health matters; • Fostering partnerships for joint action; • Shaping research agendas; • Setting and overseeing the implementation of norms and standards; • Advocating evidence-based policy options; • Offering technical support; • Catalysing change; • Building sustainable institutional capacity; and • Monitoring health situations and trends. ©WHO Like many other countries, Eritrea faced significant challenges and disruptions owing to the COVID-19 pandemic. However, the pandemic also marked a period of unparalleled support from WHO to Eritrea. This support was multifaceted, aiming to ensure the uninterrupted provision of essential health services and the reinforcement of the country's health care system. While not exhaustive, this compendium of case studies illustrates the extensive efforts of WHO to position and advocate for health across various national processes. It also showcases the impact of the effective implementation of WHO’s core functions, resulting from close collaboration with the Eritrean Government and other stakeholders. The compendium highlights WHO’s substantial contribution to realizing the objectives of GPW 13 during its first biennium phase in Eritrea. Ultimately, this report aims to provide governments, partners and the public with an overview of the progress, accomplishments, successful practices and valuable lessons learn in the implementation of GPW 13 by WCO Eritrea from 2019 to 2023. ©WHO A compendium of Eritrea health sector impact case studies 2019 - 20232 WHO strengthening the health system through supportive supervision in hard to reach areas in Gash-Barka and Southern Red Sea Regions ©WHO ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 3 Driving impact through strengthened governance for health systems: WHO’s health leadership and governance approach in Eritrea Dr Martins Ovberedjo Mr Joel Motswagole Programme Management Officer, WCO Eritrea GPW 13 underscores health governance as one of the core functions of WHO, aligning seamlessly with one of the six WHO health system building blocks. It is important to emphasize effective leadership and governance, as this building block plays a crucial role in realizing improved outcomes in health systems. It encompasses the establishment of strategic policy frameworks and their integration with robust oversight mechanisms, coalition-building, regulatory frameworks, system design and the implementation of accountability measures. WHO efforts in strengthening the leadership and governance of health systems in Eritrea have taken various forms. Central to these efforts are five distinct stages that guide the co-design process, with emphasis on collaboration, fostering trust and cultivating mutual understanding among partners. This approach is instrumental in steering towards shared objectives and driving positive health outcomes. Country Representative, WHO Eritrea A compendium of Eritrea health sector impact case studies 2019 - 20234 Practices/ProcessesGovernance Outcomes WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 5 Stage 1: Engage - Fostering Collaborative Partnerships for Effective Governance: The “Engage” stage signifies the initiation of WHO's process for strengthening governance, a vital component that lasts throughout the partnership. This stage centres on fostering relationships, clarifying contextual factors and establishing a shared workplan and procedural framework. Underpinning this engagement strategy is the WHO Country Cooperation Strategy 2023–2027 which serves as a mechanism for formalizing partnerships and engagements between WHO, the Eritrean MoH and collaborating agencies. This structured setup facilitates cohesive action across different sectors, governmental levels and communities, thereby fostering unified efforts aimed at achieving collective health and developmental objectives. In Eritrea, WHO's engagement strategy capitalizes on existing mechanisms, events or established processes, building upon ongoing collaborations among diverse UN agencies, government agencies and developmental partners. This engagement is typically triggered by direct requests from the Government or from identification of opportunities within various working groups. WHO Eritrea Staff during one of the Quarterly Inter-Cluster Strategic Planning Meeting ©WHO A compendium of Eritrea health sector impact case studies 2019 - 20236 Stage 2: Gather Evidence - Methodical Collection and Analysis for Informed Decision-Making The "gather evidence" stage is immensely important, acting as a cornerstone to ensure that decisions regarding governance are rooted in evidence. This stage encompasses a thorough and collaborative review of both quantitative and qualitative data as well as extensive literature, ensuring a comprehensive and rigorous approach to evidence collection. To this end, a range of specifically tailored tools is utilized. These tools include literature reviews/ scans, pathway analysis, stakeholder mapping, qualitative and quantitative research and economic modelling. This iterative process employs flexible methodologies that can adapt to specific policy issues, available resources and the local populations affected. A key aspect of this stage involves identifying gaps in knowledge and evidence concerning particular issues. Collaborative efforts with partners are then systematically employed to address these gaps, generating new evidence where necessary. WHO consistently employs diverse practices and methods in addressing policy issues, continuously evolving in response to feedback, legislative changes, strategic opportunities and direct requests for evidence from government agencies. This adaptability is crucial, ensuring that WHO's approach remains robust and relevant in addressing the intricate challenges posed by complex health policy issues. WHO Representative for Eritrea, Dr Martins Ovberedjo and Mr Tewelde Yohannes, Director of Planning and Policy at MOH checking a VTC attendance register at a health facility in Eritrea. ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 7 Stage 3: Co-create or generate The "generate" stage focuses on identifying solutions and crafting shared recommendations for action, built upon the bedrock of the evidence accumulated in prior stages. It employs a co-design approach, enabling an exploration of policy issues from diverse perspectives. Through this collaborative process, solutions are discerned that not only address specific concerns, but also offer mutual benefits to both the public sector and the community. This stage simultaneously involves guiding recommended solutions through governmental decision-making channels to ensure that there is national ownership of these solutions. It considers strategic and political factors that might impact the endorsement or implementation of solutions. It plays a critical role in ensuring that proposed solutions align with broader national strategic objectives in the Health Services Sector Development Programme (HSSDP) III 2022–2026 and other sector and programmatic strategic documents. The solutions also take account of evolving geo-political imperatives, influencing collaborative efforts throughout WHO’s engagement. By incorporating these factors, this stage aims to ensure the seamless alignment of proposed solutions with overarching strategic goals and political realities, thereby bolstering the potential for successful implementation. WHO team on a support supervision mission at the Pharmacy of Massawa ©WHO A compendium of Eritrea health sector impact case studies 2019 - 20238 Stage 4: Evaluate - Demonstrating Impact and Value The "evaluate" stage plays a key role within the WHO approach, emphasizing the importance of accountability and recognition as essential drivers for sustaining long-term initiatives. It serves as a platform for WHO to support the Government of Eritrea to demonstrate the impact and value this support brings not only to the public sector but also to the broader community in Eritrea. Evaluation is deeply embedded within WHO's commitment, ensuring consistent review of progress and fostering collaborative learning to enhance shared accountability. The "evaluate" stage plays a key role within the WHO approach, emphasizing the importance of accountability and recognition as essential drivers for sustaining long-term initiatives. It serves as a platform for WHO to support the Government of Eritrea to demonstrate the impact and value this support brings not only to the public sector but also to the broader community in Eritrea. Evaluation is deeply embedded within WHO's commitment, ensuring consistent review of progress and fostering collaborative learning to enhance shared accountability. Case studies 1-4 illustrate the practical application of this approach to governance functions of establishing norms, guidelines and procedures for the effective operation of different aspects of the Eritrean health system. . v A compendium of Eritrea health sector impact case studies 2019 - 2023 9 The following case studies (Case studies 1-4) illustrate practical application of this approach to governance functions of establishing norms, guidelines and procedures for effective functioning of different aspects of the Eritrean health system Case study 1 Development of Eritrea essential health care package GPW Theme: UHC GPW Outcome: Outcome 1.1 Policy issue: The United Nations Sustainable Development Goals (SDGs) identify UHC as a key target, striving to ensure that everyone has access to essential health services. Recognizing the evolving health needs of the people of Eritrea, the National Health Policy 2020 was formulated to align with the UHC objectives outlined in the SDGs. Central to this policy is the prioritization of a comprehensive essential health care package (EHCP) over vertical disease-specific programmes. This strategic shift aims to alleviate disease burdens and improve overall health conditions across diverse demographics in the country. In response, the MoH of Eritrea embarked on the development of a standardized set of services tailored to address disease burdens and life-cycle needs, ensure equitable access to health services and the realization of UHC. This comprehensive framework identifies essential services at each level of care, catering to every age group and specifying interventions necessary for effective and equitable health service delivery. Additionally, it aims to establish functional referral systems and allocate appropriate funding for priority interventions, thereby laying the groundwork for an inclusive and efficient health care system. Dr Francis Magombo (Health System Strengthening Advisor, WCO Eritrea) A compendium of Eritrea health sector impact case studies 2019 - 202310 Policy approach and processes: Employing its governance strengthening approach and leveraging its leadership role within the health sector in Eritrea, WHO played a pivotal role in providing strategic support to bolster the leadership capacity of the MoH to effectively organize and mobilize input from various stakeholders in the design of an EHCP, ensuring that stakeholder involvement was structured, purposeful and aligned with broader health care objectives. Engage: The EHCP development process began with a comprehensive consultation, initiated with technical and financial backing from WHO, through the establishment of a multi-disciplinary core team responsible for overseeing and coordinating this significant initiative. This core team organized extensive consultations and engagements via retreats and workshops involving a wide array of stakeholders from various sectors and levels of the health care system, including MoH programmes, national and regional hospitals, lower-level health facilities, health training institutions and development partners. To ensure that a comprehensive range of expertise and expert groups was actively engaged in this process, WHO channelled guidance and support from three levels of the organization: the WCO, the WHO Regional Office for Africa (WHO AFRO) and the Inter-country Support Team for Eastern and Southern Africa (IST/ESA). These entities jointly provided invaluable technical assistance throughout the EHCP development process. WHO Country Representative,Dr OVBEREDJO giving key remarks during the launch of the African Vaccination Week in Asmara in 2019.In attendance was MOH officials, health partners and beneficiaries ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 11 Gather evidence: The evidence-gathering process commenced with an orientation workshop held from 18 to 24 February 2019. During this workshop, crucial data from the 2017 burden of disease estimates for Eritrea were shared, shedding light on the leading causes of death, disability and major risk factors across diverse age groups. Based on this data, a strategic decision was made to prioritize the EHCP around the top 15 conditions responsible for mortality and morbidity. Additionally, major risk factors and public health concerns were emphasized in this prioritization approach. Special attention was devoted to conditions targeted for eradication, such as polio, and those for elimination, including maternal and neonatal tetanus (MNTs) and neglected tropical diseases (NTDs). Specific health issues pertinent to distinct age groups, such as pregnancy and newborn care, as well as concerns specific to various regions within the country, were also taken into account. To facilitate this prioritization strategy, five distinct groups were formed based on age brackets: under 5 years, 5–14 years, 15–49 years, 50–69 years and above 70 years. Each group was tasked with identifying relevant interventions for specific health conditions. Group leaders assigned sections to draft and finalize interventions. The groups painstakingly planned interventions spanning the continuum of health care services, encompassing promotion, prevention, curative and palliative measures. Their focus areas included addressing the burden of disease by targeting causes of mortality and morbidity, tackling risk factors associated with mortality and morbidity and addressing conditions posing significant public health concerns. This structured approach ensured a focused and comprehensive strategy in tackling critical health challenges across diverse demographics and geographical regions. A compendium of Eritrea health sector impact case studies 2019 - 202312 Generate: The outcome of this comprehensive process was a zero draft document, which went through assessment by WCO Eritrea, WHO IST and WHO AFRO. To move the draft through governmental decision-making processes, the EHCP appraisal process consisted of three sequential levels: 1. Core Team Coordination: The initial appraisal was managed by the core team overseeing the EHCP design. Its primary objective was to ensure coherence and alignment among the diverse products generated by the different teams involved in the EHCP development process, harmonising and incorporating their contributions. 2. Internal Appraisal by Technical Programs: The second level involved an internal appraisal involving various technical programmes within the MoH. This phase focused on ensuring the interventions reflected appropriate language, scope and comprehensive integration into the EHCP. Meaningful participation of all stakeholders was encouraged to validate the relevance and applicability of the proposed interventions. 3. Consultation with External Stakeholders: The third level of internal appraisal involved consultation with external stakeholders, including training institutions, specialized centres and health associations. This step was crucial for validating the proposed interventions, ensuring their rationality, alignment with citizens' expectations and consistency with community engagement. A compendium of Eritrea health sector impact case studies 2019 - 2023 13 This comprehensive three-tiered appraisal process was designed to validate, refine and authenticate the EHCP interventions, ensuring their consistency, relevance, and responsiveness to the diverse needs and expectations of Eritrea's population. Upon completion of the external reviews, the document was internally appraised by a broader group of MoH experts to ensure its alignment with national health priorities and global health standards. This systematic approach ensured a well- vetted and comprehensive set of interventions covering various age groups and health concerns within Eritrea. Evaluate: With WHO's technical support, monitoring and evaluation (M&E) plans were carefully developed when reforming the essential packages of health services (EPHS). The M&E for EPHS is nested within a larger M&E framework encompassing all of Eritrea's Health Sector Strategic Plan (HSSP) goals. This integration is achieved through the coverage of the essential services sub-index, which contributes to the broader UHC index. The data sources for these indicators are clearly defined in the health sector indicator manual, offering comprehensive details that include baseline data, mid-term and end-term targets, as well as the sources for these indicators. The framework relies heavily on population-based surveys, while also incorporating data from health information systems (HIS). These indicators are vital in tracking the progress of UHC-related objectives within the essential packages of health services (EPHS). To effectively monitor UHC objectives, the MoH selected 16 tracer service coverage indicators aligned with the WHO service coverage index and SDG 3.8.1. Additionally, the overarching M&E framework includes a proposed list of tracer indicators expressly designed to monitor equity in service provision across various dimensions such as gender, wealth and geographical location throughout the EPHS implementation period. A compendium of Eritrea health sector impact case studies 2019 - 202314 The MoH intends to evaluate the impact of the EPHS by tracking annual estimates of age-standardized death and disability-adjusted life-year rates. Moreover, the M&E framework incorporates mechanisms to assess the adoption of the EPHS within different strategic and planning activities, including the national essential drugs list and the development or revision of clinical guidelines. This comprehensive M&E framework, supported by WHO's technical guidance, aims to provide a robust mechanism for monitoring, evaluating, and assessing the impact of the EPHS implementation while ensuring alignment with national health priorities and international health standards. Policy Impacts: The development of the EHCP had a significant policy impact, reshaping the health care landscape in Eritrea in several key ways: 1. Health Benefit Package Development: The EHCP laid the groundwork for formulating a health benefit package that delineates the scope of interventions to be provided based on current or planned resources. Initially, this benefit package might not encompass every EHCP intervention. However, the strategy aims for a gradual expansion of the benefit package to include more interventions, aligning with the country's available resources. This progressive coverage approach ensures a realistic and feasible implementation plan in accordance with resource availability. A compendium of Eritrea health sector impact case studies 2019 - 2023 15 2. Integral Role in HSSDP III Implementation: The EHCP plays a pivotal role in implementing the HSSDP III. It acts as a blueprint by clearly outlining the services expected to be delivered at each level of the health system. This clear delineation facilitates the advancement of UHC and significantly contributes to achieving SDG 3. By comprehensively defining interventions for every age group, the EHCP serves as a fundamental guide to promoting the health and well-being of the population. 3. Influence on Health Governance Decentralization Efforts: Operationalizing the EHCP has impacted various health care policies, including the development of a health benefit package, guidelines, standard operating procedures (SOPs), health investment norms, service standards, human resource requirements, licensing and accreditation protocols and service charters. The EHCP's influence on these areas underscores its pivotal role in shaping Eritrea's health care policies, contributing to decentralization efforts and governance frameworks aimed at delivering quality health care services across the country. Overall, the EHCP's multifaceted impact on policy development and implementation reflects its pivotal role as a foundational document guiding health care provisions, resource allocation and the attainment of health care goals within Eritrea's health system. A compendium of Eritrea health sector impact case studies 2019 - 202316 Caption " WHO staff member planting trees on occassion of the National Tree Planting Day" ©WHO Case study 2 Development of Eritrea’s HSSDP GPW theme: UHC GPW Outcome: Outcome 1.2 Policy issue: Eritrea has recorded remarkable improvements in many health care indices, notably reducing neonatal, infant and under-five mortality rates to 17.82, 30 and 40 deaths per 1000 live births respectively by the end of 2021 (MoH HSSDPIII 2023). Similarly, the MMR has decreased to 184 per 100 000 births (MoH, 2019), while healthy life expectancy rose to 65 years in 2020. Despite these achievements, which are consistent with SDG targets for neonatal and child mortality, there remains a need for accelerated progress in reducing maternal mortality, aiming for the target of 70 deaths per 100 000. Furthermore, challenges posed by the COVID-19 pandemic and existing health care gaps emphasize the urgency for greater efforts to expedite progress towards UHC, SDG 3 and other health-related SDGs. In response to these challenges, Eritrea has developed the HSSDP III, outlining the strategic agenda for the country from 2022 to 2026. Aligned with the National Health Policy 2020, the HSSDP III aims to enhance the health status, well-being, productivity and quality of life of Eritreans. It emphasizes four key aspirations: reducing disease burden, minimizing health risk factors, strengthening emergency response systems and improving the duration and quality of healthy lives. This strategic plan is pivotal, especially leading up to the 2030 deadline for the SDGs, addressing key health challenges and leveraging targeted interventions to further improve health outcomes and access to quality health care services across Eritrea. Policy approaches and processes: WHO played a significant role in providing technical support during the development of the HSSDP III. This collaboration with WHO showcased the practical implementation of the WHO approach to policy guideline formulation. Dr Francis Magombo (Health System Strengthening Advisor, WCO Eritrea) A compendium of Eritrea health sector impact case studies 2019 - 202318 Engage: Through WHO's technical leadership, the development of the HSSDP III in Eritrea followed a comprehensive consultative process involving key stakeholders within the health sector. At the highest technical level, the HSSDP III development was guided by a steering committee, with day- to-day supervision conducted by the Department of Policy, Planning and Human Resources Development (DPP&HRD) at the MoH. At the MoH level, consultations involved the Minister of Health and senior management officials, including directors general (DGs), directors, heads of programmes and their respective technical staff. Extensive consultations were also conducted with various line ministries and agencies, such as finance, agriculture, labour and social welfare, land, water and the environment, as well as the National Statistical Office. Collaboration with UN agencies, including the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Development Programme (UNDP), the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), and the Resident Coordinator's Office (RCO), further enriched the consultative process. MOH and WHO Joint-Workplan implementation meeting held in the Ministry of HEALTH. The standing half-yearly meeting is jointly chaired by the State of Eritrea Hon Minister of Health and WHO Country Representative. ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 19 Additionally, visits were undertaken to two zobas (Debub and Northern Red Sea) and three sub-zoba health offices (Dubarwa, Foro, and Ghindae), facilitating discussions and engagements with the zoba and sub-zoba health offices. These visits allowed for in-depth discussions and inputs from regional and local health authorities. Furthermore, the consultative process involved visits to several health facilities, including Orotta National Referral and Teaching Hospital, Mendefera Regional Referral Hospital, Ghindae Regional Referral Hospital, Massawa Hospital, Dubarwa Health Centre and Foro Health Centre. Engagements at these health facilities provided insights and perspectives from frontline health care providers, contributing to the development of a more comprehensive and practical strategic plan. A compendium of Eritrea health sector impact case studies 2019 - 202320 Fathers at a health facility with their children for antenatal care services (ANC) ©WHO Gather evidence: WHO spearheaded a national situation analysis that served as the analytical foundation and evidence base informing the policy decisions outlined in the HSSDP III. This comprehensive analysis encompassed the entirety of the health sector, establishing a logical connection across various elements impacting the health of the population. It built upon the findings derived from the midterm review of the previous plan, HSSDP II, during the 2017–2021 period. This involved a critical assessment of achieved milestones, identification of existing gaps or unfinished agendas, and an exploration of new strategic directions and orientations necessary to accelerate progress towards achieving the health-related SDGs. Moreover, this WHO-led analysis was anchored in a thorough examination of the health policy landscape, seeking to align strategic directions with the imperative of advancing towards the attainment of SDG health targets. By leveraging these insights and evidence-based findings, the HSSDP III was informed by a robust analysis aimed at steering policy decisions in the health sector towards more effective, targeted and impactful interventions to improve the health and well-being of the population. Co-create: The process of generating solutions and policy directions for the HSSDP III followed the WHO approach of consensus building, involving multiple steps and stakeholders. Below is a breakdown of the steps involved. Collaborative Development and Reviewing the Draft HSSDP III: The collaborative development and review of the draft HSSDP III, which aimed to internalize and gain a comprehensive understanding of the content and identified gaps within the plan. Configuring the One Health Costing Tool: The one health costing tool was adapted to suit the Eritre- an context and an Excel spreadsheet cost input tool prepared. This tool was subsequently shared with the MoH. Confirmation and Finalization of Baselines and Indicators: Baselines and indicators relevant to the HSSDP III were confirmed and finalized as part of the planning process. Collecting Input Data: Stakeholders collected input data necessary to feed into the one health tool for the estimation of costs and resource requirements. Determining Relevant Unit Costs: Emphasis was placed on establishing key assumptions and deter- mining unit costs pertinent to various interventions outlined in the plan. Populating the One Health Tool: Stakeholders populated the relevant sections of the one health tool with collected data and calculated cost estimates for the proposed interventions. A compendium of Eritrea health sector impact case studies 2019 - 2023 21 The engagement of several stakeholders in this co-creation process was essential. Initial one-on-one consultations were held with MoH officers responsible for different disease programme areas and key departments. During these consultations, the officers actively participated in exercises to select intervention coverages, provide baseline and annual targets for selected interventions, detail cost items for each intervention and indicate the implementation year. Following these consultations, a meeting was convened with the steering committee to present the preliminary cost estimates. The committee provided valuable observations. It suggested that costs for infrastructure and NCDs were low and advised that pre-service training costs be excluded from human resources for health (HRH) calculations. Subsequently, projections were revised and presented again to the steering committee, which deemed reasonable the total cost estimates of ERN 6 billion for the five years. The costs of interventions were analysed based on assumptions about capacity and infrastructure investments, service expansion and achievable target coverage necessary to meet the objectives for the plan period. “The World Health Organization deserves special thanks for providing and coordinating the required technical support to the Ministry of Health throughout the process. Their support was pivotal in the successful completion of developing this third sector strategic and development plan. Special thanks should go to the WHO Representative, Dr. Martins Ovberedjo for his support towards this whole process.” – Dr. Berhane Debru, A/DG, PP and HRD The World Health Organization deserves special thanks for providing and coordinating the required technical support to the Ministry of Health throughout the process. Their support was pivotal in the successful completion of developing this third sector strategic and development plan. Special thanks should go to the WHO Representative, Dr. Martins Ovberedjo for his support towards this whole process. . . . .. . . .. . . . . . . . “ – Dr. Berhane Debru, A/DG, PP and HRD ” A compendium of Eritrea health sector impact case studies 2019 - 202322 Evaluate: WHO's technical assistance included facilitating the incorporation of midterm reviews and end evaluations for the HSSDP III. Under this framework, the national and zoba M&E Division or equivalent entities will be responsible for overseeing M&E activities at their respective levels. Their role includes day- to-day implementation and coordination of M&E activities to monitor the strategic plan. Within the M&E framework, various processes for data review and performance monitoring have been established. These include joint periodic data and performance reviews involving key health stakeholders. The aim is to ensure comprehensive assessments that produce targeted and actionable recommendations. Programme-specific reviews will be synchronized with the overall health sector review in terms of timing and methodology, contributing to the overall sector performance assessment. To facilitate effective monitoring, all health sector planning entities and M&E structures will maintain an implementation tracking plan. This plan will track reviews, evaluations, agreed follow-up actions and their status. There will also be a robust feedback mechanism which will be inclusive to enhance accountability. These processes will be detailed in the M&E frameworks at the sub-zoba, zoba and national levels, emphasizing enhanced data sharing and utilization for decision-making purposes. Additionally, WHO has supported the integration of the principle of joint assessments at all levels of the health sector during performance reviews. This inclusive approach involves both government and nongovernmental stakeholders in reviewing performance. At the community level, a community health services stakeholder forum will be responsible for joint assessments. At subnational levels, zoba and sub-zoba M&E units will take the lead in conducting joint assessments. The zoba management teams, in collaboration with stakeholders, will organize quarterly performance review forums. At the national level, the national M&E Division will organize an annual health national meeting to bring together all health stakeholders for the joint annual review of the sector's performance. These joint assessments will review performance, identify priorities, action plans, and allocate resources for the subsequent period, ensuring a collaborative and participatory approach to health sector planning and decision-making. A compendium of Eritrea health sector impact case studies 2019 - 2023 23 Policy impact: The HSSDP III in Eritrea is built upon a results framework focusing on three primary outcomes: UHC, health security and optimizing the utilization of determinants influencing health. These outcomes are supported by a robust and functional health system. Moreover, the plan places specific emphasis on modernizing medical services and expanding resilient and comprehensive public health services. The HSSDP III introduces four indices that serve as crucial tools for monitoring and measuring progress towards achieving the main outcomes and ensuring the functionality of the health system. These indices are designed to assess and evaluate advancements in the health sector in Eritrea, with a view to promoting and sustaining good health and well-being across all age groups of the population. Additionally, the plan outlines specific strategic objectives aimed at achieving the following outcomes: Enhancing health systems functionality to modernize medical services and expand resilient and comprehensive public health services. Optimizing synergy on the determinants of health for improved health and well-being, such as access to water and sanitation, from 54% in 2019 to 76% by 2026. Enhancing health security through strengthened prevention, detection, and response, aiming to improve the International Health Regulations (IHR) core capacity from 57% in 2020 to 63.5% by 2026. Increasing achievement of UHC from 54.9% in 2019 to 60.1% by 2026, leaving no one behind. (4)(3)(2)(1) A compendium of Eritrea health sector impact case studies 2019 - 202324 Each of these strategic objectives is accompanied by a set of strategic directions aimed at guiding and implementing initiatives to achieve these goals. There are four strategic directions for determinants of health, three for UHC, three for health security and seven for health systems functionality. They act as a roadmap to steer efforts towards achieving these critical strategic objectives. Health Outcome Strategic Directions A compendium of Eritrea health sector impact case studies 2019 - 2023 25 Case study 3 Development of Eritrea’s HRH strategic plan 2023–2027 GPW theme: UHC GPW Outcome: Outcome 4.0 Policy issue: The Human Resource for Health Strategic Plan (HRHSP) 2017– 2021 is a substantial commitment to enhancing human capital and aligning efforts with the SDGs and UHC. This strategic plan, developed by the MoH, was crafted to address challenges in human resource management within the overarching frameworks of the National Development Plan and the HSSDP. The primary objective of the HRHSP was to provide a framework for the health sector and associated stakeholders, aiding in effective planning, development, management and utilization of human resources. It outlined five key strategic objectives and strategies to optimize workforce management and ensure a skilled, efficient and well-distributed health care workforce by the end of 2021. However, its implementation was beset by significant challenges owing to the considerable stresses exerted on the health system by the COVID-19 pandemic. The disruption caused by the pandemic resulted in the inability to conduct a mid-term evaluation originally scheduled for 2019/2020 and hindered the achievement of many outlined strategic objectives. An implementation status review conducted by the HRH Technical Working Group (TWG) highlighted that most planned activities could not be realized owing to pandemic- related interruptions, which included disruptions in coordination platforms, mechanisms, and a redirection of resources to address immediate needs occasioned by the pandemic. Dr Francis Magombo (Health System Strengthening Advisor, WCO Eritrea) A compendium of Eritrea health sector impact case studies 2019 - 202326 With the guidance and financial support of WHO, the MoH embarked on a fresh initiative to extract lessons from the previous HRHSP and craft an updated HRHSP aligned with current realities. Policy approach and processes: Engage: Under the WHO's technical guidance, the development of the HRHSP was a collaborative and consultative process that engaged crucial stakeholders within the health sector, guided by a steering committee. At the MoH, consultations took place with the Minister of Health, senior management and heads of programmes alongside their technical staff. Furthermore, consultations involved UN agencies including UNICEF, UNFPA, UNAIDS, UNDP, and RCO, zoba health teams and leadership representatives from health facilities. Focus group discussions were conducted with senior MoH officials and HRH stakeholders, ensuring a comprehensive and inclusive process in shaping the HRHSP. Group photo of participants who attended a virtual training of trainers on clinical management of Visceral Leishmaniasis. Training was facilitated by AFRO and HQ ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 27 Gather evidence: Under WHO's technical guidance, the HRH TWG conducted a comprehensive analysis of Eritrea's health care workforce. This analysis, crucial for the HRHSP, covered various aspects such as current HRH supply, data gaps, posting policies, distribution patterns, production capacities and workforce performance management. In addition to assessing the current HRH scenario, the group conducted projection analyses to anticipate future health care personnel needs. These projections factored in population growth, evolving health demands and changes in health care settings. Furthermore, WHO's support facilitated the creation of costed strategic objectives and specific activities aimed at addressing identified gaps and challenges within the HRH sector. These strategies were designed to enhance the efficiency, distribution and overall effectiveness of the health care workforce. Health workers undertaking a surgery at Orotta National Referral Hospital in Asmara ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202328 Co-create: The development process for the HRHSP 2023–2027 followed a structured approach, guided by WHO principles of consensus building, and involved various stakeholders. This process was initiated by forming a steering committee, which included a TWG responsible for formulating the plan. The initial phase involved reviewing the goals, objectives and implementation of the previous HRHSP status using predetermined indicators. Subsequently, there was a collaborative effort to develop and review the draft HRHSP, allowing stakeholders to understand its content and identify any existing gaps. Integral to this process were one-on-one consultations with MoH officials overseeing different disease programmes and key departments. These consultations were interactive, with officials actively engaging in efforts to select intervention coverages, set targets, outline cost details and designate implementation timelines for various interventions. Finally, the process included the confirmation and finalization of baselines and indicators relevant to the HRHSP, ensuring comprehensive planning aligned with the identified priorities and needs. A Doctor under taking Ultrasound examination at Hazhaz Hospital. ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 29 Evaluate: Under the guidance of WHO, a comprehensive M&E plan was incorporated into the HRHSP. This plan was designed to establish indicators that would effectively track progress, measure outcomes and evaluate the efficacy of implemented interventions in the HRH sector. These indicators served as vital tools for assessing the impact of initiatives and determining the success of strategies outlined in the plan. The M&E framework included the creation and monitoring of annual implementation plans through regular reviews and evaluations. Additionally, a midterm evaluation was scheduled to provide insights into the ongoing progress and challenges encountered. A TWG was organized specifically for this evaluation, reporting to the DG of the DPP&HRD and the MoH, ensuring high-level oversight. To sustain effective monitoring, the M&E framework required regular information gathering and analysis, facilitating the creation of quarterly and annual HRH reports. These reports were disseminated to senior management for review and the M&E information was shared with policy-makers and managers for informed decision-making. At the regional and zoba levels, the monitoring of the implementation plan was integrated into existing routine health planning and monitoring systems to ensure comprehensive oversight and evaluation. Policy Impacts: The implementation of successive costed national HRH strategic plans in Eritrea has led to several positive impacts on the country's health care workforce, as described below. A compendium of Eritrea health sector impact case studies 2019 - 202330 1. Improved Data Management: A comprehensive HRH database has been established, providing detailed figures by cadre and deployment location. From 2017 to 2020, there was an 18.5% rise in MoH staff strength, reaching 11 068 by the end of 2020. This includes 41.3% of technical staff, offering a clearer view of HRH trends over time. 2. Policy Development and Guidelines: Several policies have been developed for areas such as licensing and certification, philanthropic health professionals and continued professional development (CPD). However, expedited implementation is crucial to regulate health care providers, facilities, and training institutions, ensuring safety and quality standards. 3. Training and Education: The HRH training plan targets an annual enrolment of 390 students, primarily focusing on nursing and midwifery. Orotta Medical School now graduates 30 to 40 doctors annually, with additional graduations in other health cadres, including associate nurses. 4. Specialization Initiatives: Residency programmes in core medical specialties like internal medicine, surgery and gynaecology-obstetrics have been initiated at Orotta National Referral and Teaching hospital, paving the way for specialized health care training. 5. Recruitment and Deployment: The MoH oversees the recruitment of health professionals, ensuring that all graduates are absorbed into the health care service. Moreover, efforts have been made to deploy both local and expatriate health workers to hospitals across the country, totalling 709 workers to zobas and national referral hospitals in 2020. 6. Retention Strategies: The government has augmented remuneration for health care workers, acknowledging the influence of remuneration on retention. However, it recognizes that factors like social amenities and educational opportunities also significantly impact retention rates. These outcomes highlight the strides made in bolstering the health care workforce in Eritrea, demonstrating increased staffing, strategic training initiatives and efforts to regulate and support the HRH system, while emphasizing the need for continuous improvement in implementation and retention strategies. A compendium of Eritrea health sector impact case studies 2019 - 2023 31 Case study 4 Development of Eritrea’s national priority health research agenda GPW theme: UHC GPW Outcome: Outcome 1.3 Dr Francis Magombo (Health Systems Strengthening Advisor, WCO Eritrea) Policy issue: Research is a cornerstone for accumulating knowledge, fostering learning, problem-solving and shaping policies and decisions that guide health care interventions, policies and strategic directions. The effectiveness of research in shedding light on health care challenges lies in its ability to painstakingly document, disseminate, manage and utilize evidence and findings for decision-making processes, thereby optimizing the strategic course of the health sector. Therefore, well designed, executed and reported health research addressing critical issues can offer vital information and evidence for public health and health system interventions. Recognizing the pivotal role of research, the MoH established the Division of Health Research and Resources Centre within the DPP&HRD. In line with Eritrea's 2006 health research policy and guidelines, the country's research endeavours emphasize operational inquiries and concentrate on priority health research areas crucial for understanding emerging diseases and complex health system challenges. To achieve these objectives, the Ministry has been formulating a five-year health research priority agenda, aligned with the national health policies and research framework. This agenda is tailored to Eritrea's specific needs, respecting contextual nuances and sociocultural norms. Its goal is to enhance effective resource allocation and ensure that research initiatives target the most pressing health care challenges. A compendium of Eritrea health sector impact case studies 2019 - 202332 Engage: Through WHO's technical leadership, an advisory committee of representatives from the MoH and the WCO was formed to lead the process. The committee then undertook extensive consultation and collaboration, engaging key stakeholders within the health sector. Its work was overseen by a steering committee established by the DPP&HRD, composed of experts from different departments of the MoH, academic institutions, professional associations, UN agencies and other relevant partners. At the MoH, consultations were conducted with the Minister of Health, senior management officials, heads of programmes and their respective technical teams. The DPP&HRD spearheaded the revision of the national health research priority agenda designed for the upcoming five years (2022–2026). This revision process demanded extensive effort, involving all departments within the MoH, hospitals, zonal medical offices, relevant ministries, academic institutions and UN agencies. This inclusive approach ensured that diverse perspectives were considered. Policy approach and processes: Dr Martins OVBEREDJO giving keynote address during the consensus meeting to strengthen the Research Agenda in Eritrea. ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 33 Gather evidence: During the evidence-gathering phase, WHO led a comprehensive situation analysis, which involved assessing the national research priorities and evaluating the implementation status of the previous health research priority agenda. This extensive analysis included a review of proposals and completed research projects submitted to the protocol review and ethics clearance committee of the MoH, aimed at identifying both barriers and facilitators. Additionally, research priority agendas from other countries were consulted to gather insights and best practices. Subsequently, a collaborative approach was adopted, inviting all MoH departments and zonal medical offices to submit their identified top priority research areas intended for implementation between 2022 and 2026. Employing a framework thematic analysis using an inductive approach, themes and sub- themes were developed, culminating in the categorization of these concepts into five broad research domains and several sub-domains. Generate: The process of enriching, optimizing, and refining the contents and structure of the broad domains and sub-domains involved a sequence of consultative workshops. These workshops were held both in Asmara and in specific zobas, including Anseba and Debub, purposely selected to ensure diverse perspectives and inputs. During these workshops, extensive discussions were conducted, incorporating inputs gathered from the comprehensive situation analysis and research priority lists from all zobas. The collective insights and feedback obtained through these workshops formed the foundation for drafting the national research agenda. The core team then reviewed the collated input from the consultative workshops and crafted a second version of the document. This revised version of the agenda comprised four distinct broad domains: research to enhance and extend healthy lives; research on health systems; research on social, educational, and behavioural health determinants; and research on health care innovations. A compendium of Eritrea health sector impact case studies 2019 - 202334 Evaluate: To ensure the effective implementation of the research agenda, the draft incorporated a robust framework for regular M&E. This comprehensive framework encompasses several essential components. Firstly, it includes monitoring of the quality management systems of the protocol review and ethics clearance committee, ensuring their adherence to established standards and procedures. Secondly, it encompasses tracking the compliance of stakeholders and researchers with the research agenda. It evaluates the degree of adherence to the set priorities and guidelines, ensuring alignment with the objectives of the agenda. Thirdly, the M&E framework assesses the transparency level maintained throughout the research process, scrutinizing the quality of documentation and the effectiveness of mechanisms employed for research dissemination. It also monitors the availability of grants and regular capacity-building activities to support researchers involved in the agenda. Lastly, this comprehensive M&E framework incorporates input, process, outcome and impact indicators. These indicators serve as pivotal metrics for monitoring and evaluating the effectiveness, progress, and impact of the research agenda, ensuring that it aligns with its set goals and contributes to the enhancement of health care and research practices. Minister of Health of State of Eritrea, Ms Amina Nurhusein on a support supervision mission to monitor and evaluate vaccination registries in a health facility in Asmara ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 35 Policy Impacts: With the implementation of the new research agenda and its accompanying M&E framework, Eritrea has significantly enhanced its capacity to address substantial gaps in research initiatives. The agenda's introduction has led to several salutary advancements, notably in the mobilization of research resources and the allocation of grants towards the most urgent research priorities. Furthermore, the dissemination of the priority national health research agenda across public domains and various levels of MoH staff has substantially increased awareness. This dissemination ensures that stakeholders and relevant personnel are well-informed about the outlined research priorities. Another impactful aspect is the heightened focus on monitoring and reporting completed research projects based on approved proposals, making for a systematic and comprehensive record of completed research activities and facilitating visibility and transparency. Additionally, there are plans to establish a dedicated website or online database that will serve as a repository for these completed research projects, further enhancing their visibility and accessibility. Ultimately, the implementation of this agenda is expected to improve substantially the utilization of research findings within health policy and practice in Eritrea. By ensuring that research outcomes are effectively translated into actionable policies and practices, the agenda is poised to positively impact health care delivery and decision-making processes within the country. A compendium of Eritrea health sector impact case studies 2019 - 202336 MOH health worker in a malaria and vaccination campaign to reach hard to reach areas in Gash-Barka as part of Integrated Sustainable Outreach Services ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 37 Case study 5 Charting a malaria-free future – five ways WHO is backing Eritrea's advancement towards malaria elimination GPW theme: UHC GPW Outcome: Outcome 1.1 Dr Assefash Zehaie (National Professional Officer, WCO Eritrea) Eritrea, historically prone to malaria epidemics, faced a devastating outbreak in 1998 triggered by heavy rains linked to the 1997–1998 El Niño event. However, thanks to effective malaria control initiatives, the country has achieved its lowest recorded levels of malaria disease incidence and related fatalities. National surveys conducted between 1998 and 2019 demonstrate a substantial decline in malaria cases from 157 to 25.6 per 1000 population/year and deaths reduced from 404 to fewer than five—a remarkable 99% decrease. The 2012 malaria indicator survey estimated the malaria prevalence at 1.1 to 1.5%, reflecting significant progress towards malaria elimination. Eritrea's successful efforts owe much to the guidance, support, and collaboration of WHO, utilizing the global technical strategy for malaria (GTS) 2016–2030. The GTS, endorsed by the World Health Assembly in 2015, sets ambitious global targets for 2030, aiming to reduce malaria-related mortality and incidence by at least 90% from 2015 levels and to eliminate malaria in at least 35 countries where it was prevalent in 2015. Aligned with GPW 13, the triple billion targets, the SDGs and the global UHC agenda, the GTS is structured around three pillars and two supporting elements to guide efforts towards malaria elimination. A compendium of Eritrea health sector impact case studies 2019 - 202338 Despite a recent upsurge in reported malaria cases and threats of resurgence due to climate change and cross-border transmission, there is growing optimism in Eritrea's ability to transition successfully from malaria control to elimination. This optimism is backed by strong country ownership and joint commitment with WHO to expand the implementation of the GTS. WHO is supporting Eritrea in three pillars and other elements of the GTS to advance Eritrea's progress in controlling and ultimately eliminating malaria. This support is described below. A compendium of Eritrea health sector impact case studies 2019 - 2023 39 1. Supporting enhanced malaria risk stratification. The first pillar of the GTS recommends ensuring access to malaria prevention, diagnosis and treatment as part of UHC. Given Eritrea’s varied geographical features, seasonal fluctuations and annual case probabilities, WHO has been supporting efforts to better stratify malaria risk across the country in order to guide precise allocation of tailored intervention packages according to need. A pivotal aspect of this support is the implementation of a malaria information system (MIS), enabling the timely collection of malaria case data at the community level across the country. The MIS initiative initially focused on malaria endemic sub-zobas, before expanding to cover all six zobas and 58 sub-zobas as part of the national malaria control strategy. Ongoing efforts, especially in high-transmission areas like Gash-Barka, aim to refine the MIS for detailed mapping at the sub-zoba level. The MIS and strategic national mapping are already instrumental in guiding targeted interventions and precise allocation of tailored intervention packages to specific areas, optimizing vector control, early detection, accurate diagnosis and effective case management. WHO's support extends to building the capacities of vector control teams through continuous training of entomologists and technicians in providing essential entomological impact data to regularly update national malaria entomological maps. 2. Strengthening Malaria Case Detection and Management The second pillar of the GTS recommends that countries accelerate efforts towards elimination and attainment of malaria-free status. In areas with decreasing malaria transmission rates, there is an urgent imperative to intensify case detection and management to advance towards malaria-free status. WHO has supported case finding by contributing to training initiatives for both passive and active malaria case detection. A compendium of Eritrea health sector impact case studies 2019 - 202340 Most notably, WHO provided technical and financial support to the external competence assessment of malaria microscopists (ECAMM) programme, which ensures availability of competent microscopists, maintaining the gold standard in clinical diagnosis and management of malaria. Between 2018 and 2023, WHO's support for ECAMM resulted in the certification and recertification of 47 proficient malaria microscopists who are pivotal to Eritrea's national malaria control and elimination goals. To further enhance national diagnostic capabilities, WHO is implementing distance learning courses for malaria microscopists with the aim of improving diagnostic performance through a self-learning and self-evaluation process. Additionally, in 2023, WHO AFRO and Amref Health Africa jointly delivered a trainer of trainers (ToT) programme for newly certified microscopists to increase the pool of facilitators and equip microscopists with advanced skills like assembling validated slides and grading microscopy assessments. The ToT programme will also be integrated into the national supportive supervision and quality assurance initiative at both national and subnational levels across Eritrea's health care system. 3. Strengthening malaria surveillance The third pillar of the GTS recommends that countries transform malaria surveillance into a key intervention. Several key interventions demonstrate WHO’s commitment to improve malaria surveillance in Eritrea. Since 2010, WHO has been instrumental in supporting Eritrea's efforts to enhance malaria surveillance through various key interventions. One such initiative involves the conduct of annual therapeutic efficacy studies (TES), with WHO technical and financial assistance. These studies serve as a critical component of surveillance, evaluating antimalarial drug efficacy Demonstration of Malaria testing in a health facility in Asmara ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 41 and drug resistance. To further enhance drug efficacy surveillance, WHO is supporting the integration of molecular marker testing into the routine surveillance system. This integration ensures that data collected from all malaria cases contribute to a comprehensive understanding of drug efficacy in the country. These concerted efforts have led to significant outcomes that have influenced national malaria treatment policies in Eritrea. For instance, Eritrea was the first African country to confirm a high prevalence of parasites exhibiting histidine- rich protein 2/3 (HRP2/3) deletions (Mihreteab et al., Sci Rep 2021; 11:21 082). This discovery prompted a crucial change in the rapid diagnostic tests (RDTs) employed for malaria diagnosis in the country. Moreover, recent confirmations have revealed the widespread presence of parasites carrying the R6221 Kelch13 mutation, associated with partial artemisinin resistance. These findings have played a pivotal role in shaping WHO's strategy to respond to antimalarial drug resistance, particularly in high burden countries like Eritrea. Within Eritrea's MoH, stakeholders are actively exploring the feasibility of developing malaria early warning systems (MEWS) to improve malaria surveillance. This initiative aligns with WHO's framework for creating integrated MEWS, incorporating vulnerability monitoring, seasonal climate forecasting, environmental and meteorological monitoring and epidemiologic surveillance. This proactive approach aims to improve capacity to anticipate and respond promptly to potential malaria outbreaks. 4. Strengthening Malaria Reference Laboratory The global strategy for combating malaria emphasizes the need for countries to expand malaria research and establish high-quality reference laboratories. To achieve these goals, WHO actively supported the creation of a malaria reference molecular laboratory in Eritrea. This laboratory plays an important role in the timely detection of and response to drug-resistant parasites. WHO assessed Eritrea's national health laboratories (NHL) to evaluate their capacity for malaria molecular surveillance. The assessment identified both strengths and areas needing improvement. Eritrea's laboratories demonstrate commendable proficiency in conducting routine diagnostic tests; facilities are well-equipped and power supply is continuous. A compendium of Eritrea health sector impact case studies 2019 - 202342 However, challenges persist, such as limited operational wings, lack of essential devices such as PCR, gel electrophoresis, sequencing tools and ice-making equipment, even after recent funding and renovation efforts. Efforts are under way to address these and other gaps in routine competency assessment systems for NHL staff, quality assurance of stock management systems and maintenance practices across NHL laboratories. These improvements involve instituting fixed schedules or records for routine equipment servicing and post-service validation. Additionally, there are plans to create space adjacent to the NHL microscopy lab for a dedicated malaria molecular surveillance programme. Once operational, this new laboratory will serve as the hub for all malaria-related molecular surveillance activities. . 5. Strengthening the national malaria program management The global strategy for malaria eradication underscores the importance of creating a conducive environment to ensure sustainable and equitable malaria outcomes. In this regard, WHO has been played a key role in fostering an environment conducive to expanding malaria interventions in a sustainable and impactful manner. These efforts have focused on garnering political support and encouraging national leadership to commit to equity, resilient health systems and to ensuring access to essential interventions without imposing financial burdens. A notable demonstration of this commitment was through the collaborative technical and financial support provided in conducting a comprehensive review of Eritrea's five-year malaria strategic plan 2017–2021. The review critically assessed national and local strategies, considering prevailing malaria situations, historical trends, tools and socioeconomic dynamics affecting disease transmission. It also evaluated the effectiveness and cost- efficiency of malaria control interventions. A young mother being trained on malaria prevention measures ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 43 Source: www.ohchr.org/en/countries/eritrea Source: www.ohchr.org/en/countries/eritrea ©WHO Case study 6 How Eritrea is stepping up the fight against antimicrobial resistance (AMR) GPW theme: UHC GPW Outcome: Outcome 1.3 Dr Assefash Zehaie (National Professional Officer, WCO Eritrea) AMR has emerged as a pressing global and national health concern. Recognizing the gravity of this threat, Eritrea's government has embarked on a transformative journey since 2017 to bolster its capabilities in addressing AMR. This commitment stems from the 67th World Health Assembly declaration of AMR as a world health threat in 2014. The potential consequences of inaction are staggering, with estimates suggesting 10 million annual deaths worldwide and an economic burden of $ 100 trillion by 2050. In response to the Global Action Plan (GAP) on AMR adopted in 2015, which urged Member States to establish national action plans on AMR, Eritrea has developed its own comprehensive national action plan (NAP) A collaborative approach to counter a multifaceted threat Eritrea's collaborative NAP, developed under the One Health approach, fosters coordinated efforts from multiple ministries, including health, agriculture, land, water and the environment and marine resources. This plan also benefits from the expertise of partners like WHO, the Food and Agriculture Organization (FAO), and universities. The NAP is founded on a comprehensive situational analysis with the following goals: Reducing infection incidence by promoting sanitation, hygiene and infection prevention Improving awareness and comprehension of AMR through effective communication and training; Curbing the rising AMR and contributing to the global fight against AMR; 4.1. Strengthening evidence-based knowledge through surveillance and research; 3.2. A compendium of Eritrea health sector impact case studies 2019 - 202346 Enhancing the judicious use of antimicrobial medicines in human, animal and plant health; 5. 6. Developing a sustainable economic framework, addressing Eritrea’s needs and boosting investment in new medicines 7. A committee, co-chaired by DGs of departments in the Ministries of Health and Agriculture, comprises members from relevant ministries, universities and key UN agencies (WHO and FAO). Additionally, an AMR secretariat, including representatives from health, agriculture, the environment and WHO, consolidates technical group reports for committee consideration. This strategic plan aligns with five core objectives derived from the GAP. Raising awareness, regulating antimicrobial use, bolstering research and surveillance and fortifying infection control measures. A compendium of Eritrea health sector impact case studies 2019 - 2023 47 Implementation Efforts Eritrea has already taken steps to implement the NAP, focusing on country priorities and addressing gaps identified in the situational analysis. In addressing the first objective to improve awareness and understanding of AMR through effective communication and training, attempts have been made to improve awareness of AMR by incorporating it into the curriculum of colleges and conducting awareness raising activities. Public campaigns through AMR awareness weeks have been conducted. Within the health system, awareness efforts are complemented by efforts to integrate pharmacovigilance into the health system. The integration efforts are led by the Eritrean Pharmacovigilance Centre (EPC), which coordinates the national pharmacovigilance system. Eritrea commences the development of the third health sector strategic and development plan III (2022- 2026) ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202348 The EPC has embraced a collaborative approach to achieving this integration by collaborating with WHO and other major stakeholders, including universities and health facilities, health care consumers, patient representatives and pharmaceutical industries to promote safe use and reduce the risks of medical products. The mandate of the EPC to monitor the safety of medical products creates a platform for a synergistic relationship with all stakeholders who share the goal of improving patient safety. Through these partnerships, the EPC has strengthened existing systems related to spontaneous reporting of adverse events and reactions to all medicines and biological products, including by setting up systems and processes for feedback to providers, while also strengthening the national database for adverse reactions and submission of adverse reaction reports to the WHO global individual case safety reports (ICSR) database, Vigibase. The success of the EPC has been demonstrated in more integrated pharmacovigilance in relation to Eritrea’s different disease programmes within the health system . A nationwide survey conducted in 2017 revealed that the pharmacovigilance system is well established in the Eritrean health care system. In addition, Eritrea ranks high in terms of country reporting for number and completeness of reporting to Vigibase, including an increase in the number of safety signals generated and the resulting recall of substandard and falsified medicines, which indicates improved effectiveness of pharmacovigilance in the fight against AMR. A compendium of Eritrea health sector impact case studies 2019 - 2023 49 The reinforced reporting system has significantly contributed to the second NAP objective of strengthening the knowledge and evidence base through surveillance and research. The enhanced reporting processes for the EPC has enabled evaluation and research of ICSRs rather than their mere collection. Most notably, research on antimalarial drug resistance monitoring has also yielded policy-changing findings. For example, following the WHO-supported malaria therapeutic efficacy study (TES) in Gash-Barka from 2011 to 2016, genetic mutations were discovered that were associated with partial resistance to artemisinin. Similarly, the mutations were confirmed in the 2019 TES in selected sites in Gash-Barka, confirming the emergence of partial artemisinin resistance in Eritrea due to genetic polymorphism and slow metabolization. Based on these findings, the EPC was able to articulate and effectively implement a risk management plan including by rolling out new dosing regimens, making Eritrea the only country with a tailored dosing regimen for malaria in the world and thereby significantly reducing the incidence of the mutation to just six cases within a region. Similar TES have been conducted for HIV and TB drug resistance monitoring. Eritrea conducted its first nationally representative HIV and TB drug resistance survey in 2016. Although Eritrea is committed to implementing all aspects of the NAP, ongoing key areas of support by WHO include the digitization of the consumer reporting system for pharmacovigilance, setting up an AMR stewardship programme to further the implementation of the NAP and thus improving AMR surveillance systems. In addition, WHO is supporting experience sharing with local and regional stakeholders, the drafting of a national action plan on HIV, TB and malaria drug resistance aligned to the strategic objectives outlined in five key pillars of the GAP. Although much remains to be done, the progress made increases optimism that Eritrea can win the battle against AMR. A compendium of Eritrea health sector impact case studies 2019 - 202350 Pregnant women in a maternity waiting home in Adi Quala. Maternity waiting homes have been impactful in reduction of maternal and child mortalities in Eritrea ©WHO Case study 7 Improving maternal and child health – the impact of maternity waiting homes in Eritrea GPW theme: UHC GPW Outcome: Outcome 1.1 Dr Assefash Zehaie (National Professional Officer, WCO Eritrea) Many women in low- and middle-income settings must choose between delivering at home and embarking on a long and daunting journey to reach a health facility. In many cases, there is not enough time to reach a facility and women sometimes deliver in transit, increasing the risk of complications or death for both the mother and the child. In Eritrea, maternity waiting homes (MWHs) are an important component of efforts to tackle pregnancy- or delivery-related maternal and child deaths. MWHs are residential facilities near a qualified medical facility, where women coming from far and hard-to-reach areas can await their delivery and be transferred to a nearby medical facility shortly before delivery. MWHs are considered a cost-effective intervention to bridge the geographical gap in obstetric care between rural and urban areas because they do not require high technology and rely on human resources already present in many communities. A compendium of Eritrea health sector impact case studies 2019 - 202352 Driving partnerships and collaboration to pilot MWHs In 2006, a collaborative effort led by WHO and UNICEF was vital in establishing MWH in Eritrea. The effort began with extensive consultations and engaging stakeholders at multiple levels towards initiating pilot MWHs in the country. The process commenced with a thorough needs assessment to evaluate the availability and accessibility of quality emergency obstetric and newborn care (EmONC) within various zobas and sub-zobas. The assessment included factors such as the availability of transportation means and the functionality of referral systems. To ensure community buy-in and support, an inclusive community engagement strategy was adopted, aiming to secure the endorsement of local communities. This involved establishing local steering groups comprising representatives from local hospitals, zoba administrations, and community health committee councils. These groups played a pivotal role in co-creating plans for the management of MWHs, including critical decisions regarding staffing, defined criteria for identifying and referring pregnant women, and addressed various operational aspects such as living conditions, health education activities and community-wide awareness programmes. Upon completion of this comprehensive assessment and engagement process, the implementation of MWHs was piloted in selected locations, based on jointly agreed criteria and strategies developed in collaboration with the government, including for identifying and referring women through trained traditional birth attendants (TBAs) and mobile obstetric outreach teams. A compendium of Eritrea health sector impact case studies 2019 - 2023 53 In 2010, buoyed by positive feedback from pilot communities, WHO and UNICEF secured approval to expand the MWHs strategy. As of June 2023, a total of 43 MWHs had been constructed and were operational in five of the six zobas of Eritrea. Scale-up efforts included quality improvement interventions during the pilot phase. Some of WHO’s interventions include the provision of 20 sets of solar suitcases and lithium ferrous phosphate equipment. These sets included 12-volt replacement batteries intended to ensure reliable electricity within MWHs, especially in rural settings where access to simple, dependable and affordable electricity was crucial. These solar suitcases, which are climate-friendly, substituted fossil fuel-based sources for lighting and electricity, enabling health care workers to allocate time more efficiently, providing timely and effective emergency obstetric health care for pregnant women, mothers and infants and thereby mitigating maternal deaths. Additional support included the supply of essential medical equipment such as 20 foetal Doppler machines, 40 rechargeable headlamps with micro-USB cables, 20 multi-tip phone chargers, along with maternal and baby care kits including pyjamas and blankets. Complementing this, UNICEF contributed financial resources and technical expertise to construct physical infrastructure for MWHs equipped with bed furnishings, mosquito nets, cooking utensils and bathrooms, enhancing the comfort and utility of these spaces. Improved quality and scale-up efforts for MWH have had a remarkable impact in different ways. Firstly, skilled birth attendance measured by health facility delivery increased from 34% when the MWHs were introduced to more than 70% by the end of 2019. Administrative data also reveals that MWHs accounted for about 30% of the national health facility delivery rate. Consequently, Eritrea has witnessed a substantial decline in maternal mortality rates which fell sharply from 486 deaths/1000 live births in 2007 to 184 deaths/1000 live births by 2019. Scaling MWHs quality and impact A compendium of Eritrea health sector impact case studies 2019 - 202354 Sustainability and scalability: The sustainability of MWH in Eritrea is a subject of ongoing attention and efforts by various stakeholders. These efforts involve multifaceted approaches, including the incorporation of MWH data into the national health management information system (HMIS) by the Eritrean Government. This step aims to standardize MWH reporting and monitoring, allowing for better tracking of their impact on maternal health. Community engagement is another vital aspect of sustaining impact of MWHs. In Eritrea, WHO and UNICEF are leading initiatives focused on mentoring community governance committees, emphasizing their roles in managing finances and ensuring accountability. Communities have shown remarkable commitment by actively participating in the construction and management of MWHs using local resources. This local involvement has played a crucial role in sustaining MWH activities, even in the face of reduced external support. Other potential areas of sustainability include standardization of MWH practices. The absence of standardized MWH models in Eritrea has led to diverse practices, showcasing the adaptability of MWHs to local cultural environments and available resources. While embracing the positive aspects of this diversity, the establishment of guidelines defining the Eritrean standard for MWHs is essential to maintain consistency while allowing for contextual flexibility. ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 55 Case study 8 Strengthening district health services for UHC in Eritrea GPW theme: UHC GPW Outcome: Outcome 1.2 Dr Eyob Frezghi (District Health Systems Officer, WCO Eritrea) Health management and governance capacities at the subnational level are essential to the performance of health systems in a bid to achieve the twin goals of UHC and the health-related SDGs. HSSDP II and HSSDP III advocate for the implementation of a district health management (DHM) approach as part of a national strategy to enhance evidence-based health governance and management practices at the district level. Eritrea operates a three-tier governance system (national, zoba, sub-zoba) comprising six zobas and 58 sub-zobas. Most decision-making regarding service provision occurs at the national and zoba levels, where the widest decision space exists. The DHM approach aims to expand decision-making capabilities to the sub-zoba level. This expansion brings overall management and stewardship functions closer to the implementation level (health facilities and communities). Moreover, it broadens sub-zoba decision-making authority regarding service provision to facilitate the broader implementation of priorities within a zoba. These adjustments are anticipated to reduce health system bottlenecks and ultimately enhance the coverage of high-impact health interventions over the longer term. A compendium of Eritrea health sector impact case studies 2019 - 202356 WHO key contributions To support Eritrea's DHM goals, WHO devised a comprehensive intervention package based on its 2010 agency-wide strategy for establishing district health systems (DHS). The WHO approach aimed to tackle specific issues, including suboptimal data use practices for effective planning, limited capacity in data use for management decision-making and general management skills needed to optimally implement plans. Moreover, this initiative directly aligns with Eritrea's second and third HSSDP concept of DHM-centred investment in middle-level health system managers. 1. Establishing annual Zoba health profiling: In collaboration with the MoH, WHO conducted a comprehensive assessment of each zoba, resulting in the development of a district health profile. These profiles, which will be conducted annually, offer insights into each zoba’s health care scenario and establish necessary baseline data to measure the impact of improved subnational health management on subnational population-level health intervention coverage. The annual profile exercise also collects qualitative information on the uptake and quality of implementation of the DHM and acts as an evaluation resource to continually fine-tune and improve intervention design and inform decisions about future investment and scale-up, by establishing evidence of result and impact. Health impact indicators will in particular track the situation of underserved groups, including girls and women. Using a stepwise approach, WHO is actively supporting Eritrea's MoH in executing a multifaceted intervention aimed at establishing and improving the performance of DHM teams in various core functions, in the following ways. A compendium of Eritrea health sector impact case studies 2019 - 2023 57 2. Establishment of sub-zoba health management teams (SZHMT): WHO, in collaboration with the MoH, initiated a phased creation of management teams responsible for overseeing health services within each sub-zoba. The process commenced by designing an organizational structure optimized for effective execution of management and governance actions at the sub-zoba level. These governance actions, prioritized by the MoH, include policy/strategic focus, regulatory mechanisms, social and technical accountability, integrity, public confidence and stakeholder engagement modalities. The development of the organizational structure involved extensive stakeholder engagement, representing various levels, from national to zoba and sub-zoba. The finalized structure of the DHM office placed the sub-zoba medical officer in an overarching leadership role, overseeing operations across four departments: public health, clinical services, administration/finance, and planning and monitoring. This leadership is answerable to the sub-zoba Administrator through the social affairs unit. Sub-zoba medical officer Auxillary Services Clinical Services Public Health Services Planning, Monitoring Services Administration & Finance Services Organizational Structure for Service Coordination and Management at Sub-Zoba Health Officess A compendium of Eritrea health sector impact case studies 2019 - 202358 3. Capacity-building and joint supportive supervision: With WHO's technical assistance, the MoH conducts integrated supportive supervision in sub-zobas and their health management offices. This process aims to identify gaps, enhance service delivery, ensure adherence to policies, guidelines and standards and support their implementation. The focus of capacity-building includes establishing monitoring capabilities in each sub-zoba using indices for UHC, health security, determinants of health and health system functionality. Various cross- learning approaches have been employed to strengthen planning, coordination and evaluation processes across departments, based on collective outcomes. Employing WHO's evidence-based planning methodology in target sub-zobas involves identifying health system bottlenecks and formulating and monitoring plans to address them. Key bottleneck indicators, particularly those related to demand and quality determinants of coverage, are gathered through routine information systems. WHO is dedicated to refining interventions in targeted sub- zobas by embedding approaches in governmental systems, building capacity to adopt these approaches independently and fostering alignment among the MoH and its partners. WHO Staff, Eyob FREZGHI during a supportive supervision mission to strengthen the Serejeka and Berik DHMTs ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 59 4. Infrastructural support: In addition to offering technical assistance, WHO is actively providing conducive and enabling physical and office environments for the DHM teams (DHMTs). This support encompasses the provision of IT infrastructure necessary for effective operation, ensuring that these teams have the essential tools required for optimal functionality. This includes providing them with basic office equipment, such as computers, printers and communication devices, facilitating seamless administrative processes within the teams. Moreover, WHO is also contributing to furnishing these offices, ensuring that they have the necessary furniture to create conducive work environments for the DHMTs to fulfil their responsibilities properly. WHO Staff, Eyob FREZGHI during a supportive supervision mission to strengthen the Serejeka and Berik DHMTs One of the Health facility in the Serejeka and Berik sub zoba ©WHO ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202360 Impact The DHM intervention encountered challenges, notably during the COVID-19 pandemic, leading to a temporary halt in activities across some sub-zobas. However, progress was evident in establishing sub- zoba teams and enhancing their capabilities. As of November 2023, 33 out of 58 sub-zobas had operational health management teams (HMTs). While efforts continue to expand to the remaining sub- zobas, initial assessments, including discussions with DHMTs and stakeholders, highlight various positive impacts. Relevance: DHM is perceived by both DHMTs and zoba stakeholders as essential in addressing district planning gaps at the national and district government levels. Stakeholders emphasize its significance in bolstering competencies for data utilization and implementing national planning guidelines. Furthermore, DHM is recognized for its role in raising awareness about planning importance and fostering an enabling environment for district planning processes. Coherence: Stakeholders observe that DHM implementation is closely aligned with government planning processes. This alignment is evident in supporting the utilization of national planning guidelines and templates, increased data utilization, enhanced stakeholder engagement and more effective prioritization, resulting in focused activities that respond to genuine needs. This coherence has notably enhanced the quality and timely execution of planned activities. A compendium of Eritrea health sector impact case studies 2019 - 2023 61 Case study 9 Impact statistics and insights from Eritrea’s national expanded programme on immunization (EPI) GPW theme: UHC GPW Outcome: Outcome 1.1 Kidanemaryam Yihdego Tzeggai (National Professional Officer, WCO Eritrea) In 2017, Eritrea set out a list of targets to boost immunization across the country for the 2017–2021 period. Through these targets, Eritrea committed to increase the equitable and sustainable use of vaccines to boost immunization across the country. The national EPI review was an opportunity to take stock of the progress made since the country made those commitments, celebrate achievements and identify areas for improvement. Below are key statistics on Eritrea’ progress between 2017 and 2021 against national, regional and global targets. A child ready for vaccination at one the health facility in Asmara ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202362 1. Facts High coverage of immunization to reduce vaccine-preventable diseases and eradicate them as a public health concern: Eritrea has sustained Penta 3 Immunization coverage > 95% at National level Eritrea has increased measles coverage (MCV1 & MCV2) from 85% to >95% Eritrea has sustained Pent 1 and Pent 3 dropout rate <10% and reduce dropout rate at high risk and less accessible areas from 15% to 5% Eritrea has reached 90% national coverage and 80% in every district or equivalent administrative unit for all vaccines in national programmes 2. Key strategies Comprehensive EPI with the following strategies Provision of static services within health care facilities. More than 85% of Eritrea's 341 health care facilities are open six days a week, providing vaccination services with remarkable consistency (HMIS, 2020). Use of outreach services to ensure that hard-to-reach areas and nomadic populations have access to immunization. Specialized approaches like reaching every district/reaching every community and sustainable outreach services (SOS strategies are deployed to reach regions and populations that A compendium of Eritrea health sector impact case studies 2019 - 2023 63 The integrated management of newborn and childhood illnesses (IMNCI) ensures that children's immunization status is checked whenever they visit a health care facility. There is also the African Vaccination Week and Child Health and Nutrition Week (AVW & CHNW) strategy, which focuses on tracing vaccine defaulters to ensure that no child is left Collaborative partnerships Vital technical and financial support from WHO, UNICEF and GAVI, the Vaccine Alliance (GAVI). Supporting routine provision of routine immunization and national immunization outreaches. Planning and executing national immunization surveys. WHO introduced new and enhanced survey methodologies, to provide a more precise representation of immunization coverage at the national, zoba and urban-rural levels. Expert oversight: The technical committee providing effective oversight and coordination included the EPI Unit of the MoH, WHO and UNICEF, providing collective expertise in executing relevant vaccination surveys. A compendium of Eritrea health sector impact case studies 2019 - 202364 Regional oversight: Zoba EPI coordinators emerged as the linchpin in overseeing the data collection protocol and administrative processes within their respective regions. Their dedication and vigilance played a significant role in streamlining the data collection and administration procedures, ensuring efficiency and accuracy throughout the process. Vaccination outreach services in one of the hard to reach areas in Southern Red Sea ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 65 Case study 10 Multi-age human papillomavirus (HPV) campaigns – the collaborative effort to safeguard girls and women against cervical cancer in Eritrea GPW theme: UHC GPW Outcome: Outcome 1.1 Kidanemaryam Yihdego, Tzeggai (National Professional Officer, WCO Eritrea) Eritrea has a population of 1.14 million women aged 15 years and older, who are at risk of developing cervical cancer. Cervical cancer ranks as the second most frequent cancer among women between 15 and 44 years of age in Eritrea, often diagnosed late with a high mortality rate. Of the 178 women diagnosed with cervical cancer every year in Eritrea, at least 130 die from the disease. These statistics are mirrored elsewhere. Each year, approximately 560 000 new cases of cervical cancer occur worldwide, making it the fourth most common cancer among women globally in 2020. According to WHO, 90% of the estimated 604 000 new cases and 88% of the 342 000 deaths in 2020 occurred in low- and middle-income countries. More than 95% of cases are associated with HPV, meaning that almost all cervical cancers are preventable by means of the HPV vaccine. A compendium of Eritrea health sector impact case studies 2019 - 202366 To safeguard girls and women against cervical cancer, Eritrea signed up to WHO's global strategy to accelerate the elimination of cervical cancer, launched in 2020. A three-level national preventive strategy is being mounted: vaccination against HPV at early puberty for girls aged 9 to 15 and introduction of HPV into routine immunization, backed by screening in women to catch and treat of pre-cancerous lesions. In 2022, Eritrea conducted a multi-age cohort (MAC) campaign for girls 9-14 years of age, targeting 300 000 girls with the aim of reducing the incidence of cervical cancer to less than four cases per 100 000 women per year. The main objectives were to achieve at least 95% first dose of HPV vaccination coverage among girls 9-14 years of old; to raise awareness on the benefit of HPV vaccination among girls and women; and to address anxiety, fear and hesitancy towards HPV vaccination among girls and women. Key WHO collaboration to reach every girl Capacity-building and technical expertise: WHO provided technical and financial support for assembling and training human resources for the HPV campaign. This support included a national-level ToT programme, cascade trainings and detailed planning sessions, extending from the national to subnational levels. Advocacy, communication and social mobilization activities were also organized at both the national and subnational levels before the campaign. A substantial number of people were trained, including 1457 vaccinators, 647 teachers and 1449 community health workers. To maintain high standards during the campaign, 92 zonal supervisors and 142 district coordinators were trained and deployed to various districts. Additionally, 40 trained national supervisors from diverse units within the MoH and its partners were deployed to offer technical support to zonal and district supervisors and coordinators. As part of ensuring campaign quality, WHO supported the implementation of rapid convenience monitoring (RCM). This assessment aimed to evaluate the campaign's quality, estimate HPV A compendium of Eritrea health sector impact case studies 2019 - 2023 67 vaccination coverage and identify any missed girls. The RCM covered 41 clusters within 15 Lots across six zobas, assessing the vaccination status of 544 eligible girls. In addition to assessing vaccination status, exit interviews were conducted among vaccinated girls to gauge their level of awareness and identify sources of information. A total of 600 girls aged 9-14 years were included in these interviews as part of the assessment process. Uniting health and education for increased HPV access: WHO played a crucial role in facilitating strong coordination between Eritrea's health and education sectors, essential for the success of the HPV vaccination strategy. The Eritrean government recognizes the significance of HPV vaccination in empowering girls and strategically utilized primary and secondary schools as vital platforms for administering the vaccine. The collaboration between health and education sectors yielded significant advancements. School staff were actively engaged in orienting and raising awareness among eligible girls, in planning and registration, also functioning as members of vaccination teams within the school premises. This involvement substantially enhanced acceptance levels for the vaccine. Additionally, the extensive network of primary and secondary schools served as primary points for vaccine administration. This joint effort was led by the Ministries of Health and Education and supported by GAVI, UNICEF and WHO. A compendium of Eritrea health sector impact case studies 2019 - 202368 During the initial round of the HPV MAC vaccination campaign held between November 2022 and 2023, 647 All 58 sub-zobas in Eritrea's six Zobas were covered. vaccination posts, and other community-based locations. The campaign utilized 405 distributed across Schools300 vaccinators, To reach harder-to-access 1382 mobile teams were deployed in 22 districts, specifically targeting out-of-school eligible girls.65 38.2% 8.0% and 6.4% 26.3% community health staff teachers The campaign engaged a total of Out of the effectively covering primary, junior, and high schools, health facilities, and outreach sites. girls aged 9-14 years, an impressive The awareness level regarding the national HPV vaccination campaign was remarkably high, standing at 1457 1449 241 838 224 607 (93%) Health workers Conversely, radio and television were cited less frequently received both doses of the HPV vaccine. Primary sources of information Schools among girls and caregivers. Local administration 99.4% 61.8% health facilities Impact With of respondents respectively. Data from the RCM indicated a vaccination coverage of and provided insights into reasons for missed vaccinations. 94.4% ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 69 Despite challenges, Eritrea remains steadfast in its commitment to achieving 100% coverage, acknowledging valuable lessons learnt in the process. The collaborative model involving the health and education sectors emerges as a powerful tool in the battle against cervical cancer, reflecting the nation's determination and collaborative efforts to combat this health challenge effectively. A compendium of Eritrea health sector impact case studies 2019 - 202370 ©WHO Case study 11 Risk communication and community engagement (RCCE) – key pillars in Eritrea’s effective COVID-19 pandemic response GPW theme: Emergencies GPW Outcome: 2.1 Venus Hailesilassie (Health Promotion and Social Determinants Officer, WCO Eritrea) RCCE is a key pillar in public health emergency response, involves sharing accurate health information, promoting protective behaviours among affected people and engaging stakeholders, especially local community groups. WHO recognizes RCCE as one of eight vital capacities in responding to COVID-19. However, even before the COVID-19 pandemic struck, Eritrea had developed strong RCCE capacities, as shown in multiple evaluations, like the Joint External Evaluation (JEE) of IHR core capacities. This case study outlines Eritrea's successful RCCE approach, detailing its key features and demonstrating how this structured plan helped navigate the challenges of the COVID-19 pandemic. A compendium of Eritrea health sector impact case studies 2019 - 202372 Leveraging Prior Outbreak Experience for Effective Whole-of-Society Approach in RCCE Efficient coordination mechanisms are essential for effective RCCE. WHO's extensive experience and support in outbreak response had a significant impact on Eritrea's preparedness. Previous experience with controlling cholera, meningitis, measles and polio outbreaks at its border with Ethiopia meant that Eritrea had pre-existing mechanisms, structures and partnerships. Eritrea's MoH, equipped with pre-established structures and alliances, took the lead in emergencies, supported by health-focused TWGs, including a WHO-coordinated RCCE segment. This readiness facilitated a rapid response to COVID-19. When the pandemic struck, Eritrea adapted and centralized former coordination entities into a single structure, using a federal, whole-of-government approach with the WHO-supported national communication commission and pre-existing mechanisms. Within this framework, the MoH established a multi-partner committee for risk communication and community engagement to oversee and ensure RCCE quality. The government-led COVID-19 high-level task force managed outbreak communications, while the RCCE subcommittee handled crafting and reviewing behaviour-focused information. This approach centralized government leadership in coordinating responses, aiming to uphold public trust through targeted information dissemination, to prevent redundancy and to synchronize communications. In recognition of WHO and UNICEF expertise in RCCE, they became pivotal partners in leading Eritrea's RCCE response. Eritrea had standby agreements with diverse entities, complementing WHO and UNICEF capacities, which were promptly activated during emergencies. Blending risk communication (RC) and community engagement (CE) for trust and responsiveness Eritrea effectively combined RC with CE to ensure responsive communication and build trust while addressing community concerns. Initially, community engagement relied on traditional media and radio programmes for direct interaction, facilitating a two-way flow of information. This method was complemented by involving volunteer networks, community health workers and civil society organizations to gather feedback. Over 30 000 behavioural change facilitators and health promoters were recruited for this approach. A compendium of Eritrea health sector impact case studies 2019 - 2023 73 As the pandemic evolved, traditional face-to-face engagement became impractical, leading to a lack of behavioural data. To address this, Eritrea swiftly adapted by leveraging technology. The country established a 24/7 call centre, a first in Eritrea, enabling bidirectional information flow, real- time information sharing, contact tracing and referral services for health needs. Moreover, Eritrea incorporated social listening platforms, initially limited but quickly improved through partnerships and technological investment. WHO's support was pivotal, providing technological aid, reports, dashboards and training for social listening. Various technological tools were employed, including an offline android- based application for health workers, covering infection prevention, personal protective equipment (PPE) use, contact tracing guidelines and stress management. Another offline android-based application for communities offered COVID-19 prevention guidance, immunization reminders, travel history, self-diagnostic tools and a direct link to the 24/7 call centre. These applications targeted over 530 000 Eritrea Telecom users. The technology platforms featured multilingual messages and a link to the 24/7 call centre. Triangulating data from diverse sources enriched information availability. Eritrea's utilization of feedback systems and innovative communication technologies demonstrated effective real-time community engagement. Utilizing social and behavioural data for community-focused responses Eritrea's response to the COVID-19 crisis highlights the crucial role of gathering social and behavioural data to steer community-focused actions. By scrutinizing data through RCCE TWGs and dynamic listening sub-groups, Eritrea conducted comprehensive assessments of trends, concerns and rumours, resulting in actionable recommendations. A compendium of Eritrea health sector impact case studies 2019 - 202374 Conducting a knowledge, attitude and practice (KAP) survey offered pivotal insights into public perceptions and understanding of COVID-19. These findings not only gauged knowledge levels, but also pinpointed factors driving positive behavioural changes. Leveraging social and community networks, such as young people’s and women's unions, proved effective in building trust and spreading health promotion and advocacy programmes. Moreover, Eritrea performed a socio-ecological analysis of barriers to immunization services alongside the KAP survey. This abundance of behavioural data empowered Eritrea to swiftly adjust its COVID-19 strategies. This adaptation aimed to address fear, restore trust, uphold positive social norms, strengthen health facility connections with community based platforms and customize access to suitable social listening platforms. Eritrea pursued an inclusive approach, enhancing the environment for RCCE by employing a systemic method, ensuring fair outreach, adhering to SOPs, guidelines and supplying necessary resources. In SOS in Zoba Gasb barka hard to reach area_.png ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 75 Case study 12 MenA vaccination campaigns: the collaborative effort to safeguard against meningitis in Eritrea GPW theme: UHC GPW Outcome: 1.1 Venus Hailesilassie (Health Promotion and Social Determinants Officer, WCO Eritrea) Meningococcal meningitis (MenA) is a global concern, with significant outbreaks primarily occurring in the "meningitis belt" of sub-Saharan Africa, spanning 26 countries from Senegal to Ethiopia. Eritrea falls within this belt, making it susceptible to these outbreaks. In response, WHO launched a roadmap in 2021 with the ambitious goal of "defeating meningitis by 2030".A key intervention outlined in this roadmap is the utilization of the meningococcal A conjugate vaccine (MenACV), a cost-effective and temperature-stable vaccine administered in a single dose to individuals aged 1-29 years, aimed at curtailing the impact of meningococcal meningitis. The Ministry of Health Eritrea launches the National Measles Rubella Vaccination and vitamin A supplementation campaign for children under 15 Collage of activities during the African Vaccination week in 2020 ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202376 Key WHO interventions WHO has been actively supporting Eritrea in implementing the global roadmap, especially in expanding the vaccine's coverage to protect against meningitis. The first major nationwide intervention was a mass vaccination exercise. To prepare for this vaccination effort in 2021, WHO led an in-depth epidemiological risk assessment in Eritrea. This assessment aimed to strategically plan the vaccine introduction and other preventive measures. WHO, across its three levels – the WCO and joint teams from WHO Headquarters and WHO/AFRO – visited Eritrea in August 2016. Collaborating closely with the MoH, they analysed historical data on meningitis outbreaks dating back to 1982. Recent data spanning 2002 to 2016, such as IDSR, national laboratory data and pre-birth mortality data, were also thoroughly reviewed. Based on the comprehensive assessment, the recommended strategy for MenACV introduction involves two primary approaches. Firstly, a mass vaccination campaign targeting a wide age group (aged 1–29 years) aims to create herd immunity by reducing bacterial transmission, significantly lowering meningitis incidence for immediate public health benefits. Eritrea's specific objectives included conducting a nationwide MenA vaccination campaign for the age group of 1-29 years, targeting over 95% coverage, and providing vitamin A capsules to children aged 6-59 months, also aiming for over 95% coverage. WHO Country Representative Dr Martins OVBEREDJO administrating Polio drop during the African Vaccination Weekv ©WHO ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 77 Secondly, the plan involves integrating MenACV into routine childhood immunization within five years after completing mass campaigns. This integration ensures sustained protection for new birth cohorts, maintaining population immunity. WHO recommends countries that finish mass campaigns to introduce MenACV into routine immunization programmes within 1–5 years, along with a catch-up campaign for birth cohorts born after the initial vaccination but before its implementation. Aligning with the global roadmap to "defeat meningitis by 2030", WHO encourages all countries in the meningitis belt to incorporate routine immunization with MenACV by the end of 2023. Regarding the nationwide vaccination effort in 2019, WHO supported Eritrea in conducting the MenA vaccination campaign. This campaign targeted children and young adults aged 1–29 years, alongside vitamin A supplementation for children aged 6–59 months. Considering Eritrea's geographical and environmental factors, the campaign was strategically organized in two phases with a two-week interval. Phase 1 covered the Northern Red Sea, Southern Red Sea, and Maekel zobas from 15 to 30 November 2019. Phase 2 encompassed the Debub, Anseba, and Gash- Barka zobas from 15 to 30 December 2019 Honourable Minister of Health of State of Eritrea, Ms Amina Nurhusein administrating Polio drop during the African Vaccination Week in Asmara in 2020 ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202378 In 2021, more than 1 254 202 children aged 1–4 years and individuals up to 29 years received the MenACV vaccine. Administrative coverage achieved an impressive 95%, while a rapid survey estimated coverage at 96%. In 2020, a catch-up campaign targeted individuals excluded from the initial mass campaign owing to age restrictions, alongside administration of vitamin A supplementation. Despite disruption by the COVID-19 pandemic, Eritrea also incorporated the vaccine into its national immunization programme in 2021, with a primary focus on children aged 9 months. Following the initial mass immunization campaign, Eritrea witnessed a rapid increase in coverage among the previously unvaccinated population, reaching an estimated coverage of 93.9% for ages 1 –4 and 1–29 after the 2019 campaign. However, there was a subsequent decline in coverage over time, particularly in the 1–4 age group, as children aged out annually, leading to a rise in new susceptible individuals. Despite this decline, Eritrea has sustained coverage above the 60% threshold after the vaccine's incorporation into the national immunization programme. By the end of 2021, estimated coverage for ages 1–4 stood at 73.82%, while for ages 1–29, it reached 90.45% (95% UI 85.89–94.2). Eritrea was among eight out of the 12 meningitis belt countries that completed the rollout of routine immunization, surpassing the critical threshold of 60% coverage needed in preventing MenA epidemics. Impact SOURCE: Meningococcal A conjugate vaccine coverage in the meningitis belt of Africa from 2010 to 2021: a modelling study. The Lancet https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(22)00526- 0/fulltext 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 Time trend of Men vaccination in Eritrea 1 to 4 1 to 29 A compendium of Eritrea health sector impact case studies 2019 - 2023 79 Case study 13 Leaving no one behind: collaborative effort to improve access to immunization in hard-to-reach areas and population in Eritrea Despite Eritrea's generally strong performance in immunization, four out of its six zobas recorded immunization rates below 60% in 2022 and before. In these zobas – which are primarily located in the country's eastern and western lowlands – rural, nomadic and seasonally mobile communities experience significant obstacles to accessing routine immunization services. To tackle this issue, integrated sustainable outreach services (SOS) were implemented to improve routine vaccination coverage among children under two years old and women of childbearing age. By December 2022, over 92% of caregivers had received health education and most zero-dose and under-immunized children, along with mothers of reproductive age, had been reached with vaccinations. Among children under two years, vaccination coverage rates were high with Penta, oral polio vaccine (OPV), inactivated polio vaccine (IPV), rotavirus, and pneumococcal (PCV-13) vaccines at 95%, and coverage rates for measles and rubella vaccines at 92% and 89%, respectively. In addition, 95% of both pregnant and non-pregnant women had received essential tetanus diphtheria vaccinations. GPW theme: UHC GPW Outcome: 1.1 Kidanemaryam Yihdego, Tzeggai (National Professional Officer, WHO Country Office Eritrea) A compendium of Eritrea health sector impact case studies 2019 - 202380 Key WHO contributions Collaborated with the MoH to identify target outreach areas in Eritrea. 1) Supported the MOH, to advocated for resources mobilization from partners and directly covered all operational costs for the four rounds of the campaign. 2) 3) Provided technical support and essential tools for macroplanning, microplanning, and training. Co-led consensus- building meetings with the MoH. 4) Conducted routine structured monitoring and post-campaign reviews. 5) 6) Initial planning and work plan development were jointly conducted by WHO and the MoH in January 2022. Given the lack of a comprehensive population census and civil registration and vital statistics system in Eritrea, a 2020 equity assessment, and an Expanded Programme on Immunization (EPI) coverage survey were used to identify target areas for outreach services. The assessment indicated that 18 of Eritrea's 58 sub-zobas presented physical barriers such as rocky and mountainous terrain, which hindered health care access and complicated the delivery of routine immunization. To tackle this, WHO Eritrea worked with the MoH, partners, civil society organizations and local management teams to formulate a comprehensive macro plan and training plan, complete with a budget. This groundwork enabled WHO to garner financial and logistic support from stakeholders. GAVI, covered the vaccine costs and vaccines were procured via UNICEF's supply division. WHO directly funded operational costs including accommodation, training, daily allowances and transportation. A compendium of Eritrea health sector impact case studies 2019 - 2023 81 Meetings were led by WHO and the MoH EPI manager to build consensus among health directors and managers. WHO provided technical support in developing management protocols and standards for outreach immunization services and supplied essential planning tools to all districts. WHO Technical officers were assigned for close monitoring and evaluation. Field guides, reporting tools and supervisory checklists were prepared by WHO and the MoH at the national level and distributed to all zobas. Finally, four rounds of outreach immunization services were conducted between February and May 2022 in the 18 targeted districts. In each round 18 rental vehicles, 32 camels, 90 vaccinators and 216 community volunteers and supervisors were deployed. Local community volunteers assisted health workers in carrying vaccines and supplies and guided them during outreach visits to recommended villages. Health education sessions were held to raise vaccine awareness. Vaccination outreach services in hard to reach areas in Northern Red Sea Vaccination outreach services in hard to reach areas in Southern Red Sea ©WHO ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202382 In total, 42 907 children and 152 054 mothers were vaccinated against EPI target diseases; health education was also provided. Monitoring and post-campaign reviews showed a significant uptick in vaccination rates, attributed to community involvement, political commitment, early planning and dedicated health workers. Recommendations for future initiatives include the continuation of outreach services, integration of other health services and detailed mapping. Having garnered the support of partners, committed health workers, community volunteers and local government, the outreach programme has laid a strong foundation for future efforts. Collage of vaccination outreach services in Northern and Southern Red Sea ©WHO ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 83 Case study 14 Strengthening health security in Eritrea: WHO's role in developing and implementing the National Action Plan GPW theme: Health emergencies. GPW Outcome: 2.1 Dr Nonso Ejiofor (Health Security Advisor, WCO Eritrea) Eritrea is highly vulnerable to public health emergencies (PHEs) owing to several factors, including its geographical location near the biodiverse Congo Basin, a known source of infectious pathogens. Moreover, the country is situated in areas endemic to various diseases such as meningitis, diseases caused by flaviviruses (e.g., yellow fever and Zika virus disease), and diseases caused by filoviruses (e.g., Marburg virus disease, Ebola virus disease). This susceptibility is compounded by the potential for significant refugee influx, creating an environment conducive to PHEs. To assess its capacity to respond to PHEs, Eritrea in 2020 conducted a JEE of the IHR core capacities and followed up with an in-country evaluation in 2022. Drawing from the assessment recommendations, the country has initiated the development of its National Action Plan for Health Security (NAPHS), set to be implemented until the end of 2026. The NAPHS will inform interventions to strengthen the national capacity for prevention, early detection, response and recovery from PHEs within this period and beyond in Eritrea. A compendium of Eritrea health sector impact case studies 2019 - 202384 WHO key interventions Establishment of PHEOCs: PPHE operation centres (PHEOCs) serve as vital platforms for strategizing, coordinating and monitoring emergency response strategies at both the national and subnational levels. Beyond the immediate response, these centres facilitate systematic documentation of response mechanisms and essential outbreak aspects. WHO laid the groundwork for establishing PHEOCs in Eritrea through the provision of funding and technical support to the MoH to conduct a PHEOC needs analysis to assess functional PHEOC needs across the country, including coordination, policymaking, operations management, information management, logistics management and planning. Following the result of the needs assessment, the recommendation was to establish one national- and three zoba-level PHEOCs. Investment and procurement: While the Government of Eritrea has already provided space and infrastructure in the three locations selected, WHO has made a significant investment to support the Government's effort. WHO procured equipment worth $ 195 000 including IT and communications equipment, with furniture procurement under way. IT infrastructure includes wired and wireless Internet connections, a firewall, virus-protected servers, a toll-free telephone service, projectors, laptops and TV monitors to project up-to-date PHE information from zobas and sub-zobas. Beyond funding, WHO is providing technical support for the basic design of the PHEOC, including workstations for staff and the incident management team, a PHEOC manager’s cubicle and a boardroom. A compendium of Eritrea health sector impact case studies 2019 - 2023 85 Human Resources and Capacity Building: Although most of capacity- building efforts are planned for when the PHEOCs are operational, WHO has already taken steps towards implementation. This includes training core staff and responders in public health emergency management and conducting simulation exercises to validate existing plans and procedures. WHO AFRO has facilitated regional-level training for MoH staff on various aspects of PHEOC operations. Thanks to WHO's significant contributions in planning, infrastructure development, capacity-building, and documentation, Eritrea was on track to launch its PHEOCs by the end of 2023. These contributions enhance Eritrea's readiness to manage future PHEs effectively. Participants during the launch of the flagship initiatives for emergency ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202386 Participants during the launch of the flagship initiatives for emergency ©WHO ©WHO ©WHO Case study 15 WHO and Eritrea unify actions to launch flagship initiatives for emergency preparedness and response GPW theme: UHC GPW Outcome: 2.1 Dr Nonso Ejiofor (Health Security Advisor, WHO Country Office Eritrea) The health and economic impacts of the COVID-19 pandemic have underscored the existing challenges and weaknesses in health emergency preparedness and response (EPR) and health security in African countries. The African Region reports more than a hundred major public health events annually, significantly damaging the health and economic systems of its countries. Implementation of frameworks related to EPR remains a struggle for many countries in the African Region, hindering the rollout of other programmes and systems to assist these countries. Additionally, less than 10% of countries in the African Region possess optimal and sustainable human resources to prepare for, detect and respond to public health risks and emergencies. The existing workforce also has limited technical health emergency knowledge, particularly within rapid response teams, and there is a shortage of emergency supplies, compounded by poorly financed EPR work. A compendium of Eritrea health sector impact case studies 2019 - 202388 WHO AFRO Flagship Programs To address these challenges, WHO AFRO, in collaboration with the Africa Centres for Disease Control and Prevention, launched three flagship programmes in 2022. These programmes–Promoting Resilience of Systems for Emergencies (PROSE), Transforming African Surveillance Systems (TASS), and Strengthening and Utilizing Response Groups for Emergencies (SURGE)–have commenced extensive consultations with Member States. The activities planned under these programmes will cover various aspects, including the development of evidence-based policies, workforce development, sustainable financing, operations support, risk communication, data systems and integration with existing frameworks in the EPR sector. Taking a collaborative approach to create an impact In October 2023, Eritrea hosted a scoping mission by WHO AFRO which was aimed at raising awareness the Eritrean government and stakeholders on EPR flagship initiatives, collaboratively identifying resources and priorities, and drafting a national costed roadmap for the EPR flagships. The scoping mission embraced a collaborative approach, involving stakeholder engagements and multisectoral technical working sessions to align with national priorities and develop a costed roadmap. Stakeholders identified Eritrea's strengths in IHR core capacities within each flagship pillar. Source: Ensuring Health Security in the African Region. WHO AFRO. https://www.afro.who.int/publications/ensuring-health- security-african-region A compendium of Eritrea health sector impact case studies 2019 - 2023 89 Leveraging Strengths from previous investments: To lay the groundwork for the EPR initiative, stakeholders collaborated to conduct a rapid situation analysis of Eritrea's IHR situation, to identify the key strengths that could be leveraged. The situation analysis revealed a wealth of strengths, notably stemming from previous investments made by WHO to enhance IHR core capacities. These investments have not only led to the establishment of valuable infrastructure and skilled human resources but have also fostered robust community networks with trusted relationships among local leaders. Notable strengths identified across the flagships include the following. PROSE: Eritrea boasts the availability of a strategic plan, NAPHS 2022–2026, building upon a completed country risk profile. The country has initiated capacity-building efforts within the health workforce, notably initiating a comprehensive 4-month course in epidemiology and entomology. Additionally, Eritrea has established a procurement procedure. The National Medicines and Food Administration has streamlined procedures for the rapid importation and registration of essential medical supplies. Moreover, the country has developed a tax exemption policy and secured agreements for tax exemption on donated medicines, medical supplies, PPE and disaster-related equipment. TASS: Eritrea possesses a robust national surveillance system, incorporating One Health surveillance that encompasses facility, community and event-based surveillance methodologies. SURGE: Eritrea has a comprehensive One Health coordination mechanism and has developed a robust risk communication and community engagement strategy. A compendium of Eritrea health sector impact case studies 2019 - 202390 AFRO WHE,WHO Eritrea and MOH Facilitators during the launch of the flagship initiatives for emergency preparedness and response in Eritrea 2023 ©WHO Eritrea's strengths across these flagship programmes signify a strong foundation and readiness to align with and benefit from the WHO AFRO initiatives. These strengths serve as invaluable assets for propelling the successful implementation of the programmes. Specific outcomes were developed from the mission, notably the formulation of a comprehensive draft national costed roadmap for the implementation of the EPR flagship programmes. This draft plan strategically prioritizes key initiatives under each flagship pillar. WHO has allocated $ 1 million as seed funding to catalyse activities outlined in the roadmap. This initial investment aims to galvanize further contributions from the government and partnering entities to bridge the funding gap. The next important steps will focus on implementation of the costed flagship roadmap, including resource mapping and mobilization efforts aimed at bridging existing gaps, with key priorities including identifying and assembling a multi- disciplinary SURGE workforce and the establishment of a PHEOC. Achievements and next steps: A compendium of Eritrea health sector impact case studies 2019 - 2023 91 Dr Martins OVBEREDJO during the African Vaccination Week ©WHO Case study 16 Strengthening procurement to drive progress to UHC in Eritrea GPW theme: More Effective And Efficient WHO Providing Better Support to Countries GPW Outcome: Outcome 4.1 Joel Motswagole (Programme Management Officer, WCO Eritrea) Lemlem Asfaha (Administrative Assistant, WCO Eritrea) Milka Neamen Tekeste (Procurement officer, WCO Eritrea) Zaid A Gebremeskel (Administrative Assistant, WCO Eritrea ) Access to medical resources and technologies is a vital pillar within the six WHO health system building blocks. Transparent and strong procurement systems are indispensable for ensuring the cost-effective delivery of essential goods and services, thereby advancing UHC. Recognizing the transformative potential of efficient procurement practices within health systems, WHO, in close collaboration with the MoH of Eritrea, implemented initiatives aimed at fortifying health-related procurement practices. These efforts focus on establishing comprehensive monitoring across all procurement processes and creating evidence-based monitoring reports. These reports act as early warning mechanisms, identifying deviations from standards and allowing for targeted improvements. Some of the laboratory equipments purchased with WHO support to strengthen the national laboratory service in Eritrea ©WHO A compendium of Eritrea health sector impact case studies 2019 - 202392 In 2021, the WHO Eritrea procurement team, working closely with the Government of Eritrea and the MoH, developed a robust quality improvement system, using a three-stage procurement monitoring and quality improvement system. 1. Bottlenecks analysis using a problem tree approach: A joint task force, comprising members from WHO and the MoH, conducted an extensive analysis employing a problem tree approach to assess procurement cost-efficiency. This involved evaluating average procurement timelines and operational efficiency trends using various assessment tools. Detailed scrutiny of procurement documents was carried out to ensure compliance with the WHO global strategy for procurement guidelines. The assessment revealed significant shortcomings in the existing procurement system, impacting planning, efficiency and control mechanisms. These issues included duplication, inconsistent supply chains, challenges in negotiation for competitive pricing and timely deliveries, and discrepancies in staff roles. Additionally, disjointed consignment pre-clearance processes and limited coordination among ministries, WHO planning and inter-cluster collaboration compounded these challenges, directly impacting health outcomes for the people of Eritrea. 2. Analysis of stakeholders' readiness for change: This analysis involved assessing stakeholders’ responses and concerns regarding the implementation of new systems. It allowed for tailored consultations, awareness-building and customized training programmes. In recognition of stakeholders' attachment to existing inefficient systems and potential resistance among staff and suppliers in adopting new methodologies, a nuanced approach was adopted. Proactive acknowledgment and addressing stakeholder sentiments through persistent engagement and comprehensive interaction effectively mitigated resistance to change. Focused on stakeholder engagement and clear objectives, an innovative procurement solution tree was painstakingly developed to meet the diverse needs of procurement process stakeholders. The procurement unit also developed a feedback analytical tool to facilitate nationwide submission of reports by procurement monitors. These reports underwent multifaceted analyses, ensuring accountability and adherence to procurement regulations. Moreover, the system provided real-time procurement advice, enhancing the capabilities of observers and stakeholders by offering accurate, timely and detailed information within the procurement system. Procurement monitoring and quality improvement system Handing over of Ambulances from the WHO Country Representative to the Hon. Minister of health Ms. Amna Nurhusein. ©WHO Source: www.ohchr.org/en/countries/eritrea 3. Procurement quality improvement plan: This plan was developed based on the findings of the bottleneck analysis and the assessment of stakeholders' readiness for change. This plan comprised the following three initiatives aimed at enhancing the quality, efficiency and responsiveness of the procurement process. Online Procurement Information Sharing Platforms: Designed for stakeholder engagement, these platforms facilitated the creation of procurement reports and data analysis, focusing on monitoring quality indices. Their main goal was to enhance coordination among various sectors involved in procurement within health care. They aimed to streamline data sharing, ensuring accessibility for informed decision- making. The platforms aimed to establish clear communication channels, boosting both intra- and inter- cluster coordination, while promoting transparency in reporting. Collaborative Planning with Inter-Ministerial Teams and WHO: This initiative emphasized joint planning sessions involving different ministries and WHO. Their purpose was to synchronize strategies and resource allocation, aligning objectives for improved procurement effectiveness. These sessions aimed to create a unified approach, eliminating overlaps and optimizing resource utilization. The collaborative planning fostered agreement on shared priorities and synchronized strategies to achieve common procurement goals. Enhancing Procurement Practice Capacity: This comprehensive programme aimed to improve the skills and expertise of procurement professionals. Training covered procurement regulations, negotiation skills, contract management and compliance standards. The objective was to empower professionals with the necessary tools for effective execution of their roles, ultimately strengthening the procurement workforce. This strategy aimed to enhance efficiency, accuracy and compliance within procurement processes. 1 2 3 Some of the ambulances purchased with WHO support to strengthen the national referral system in Eritrea ©WHO Source: www.ohchr.org/en/countries/eritrea While the procurement monitoring and quality improvement system is a work in progress, it is already yielding appreciable outcomes for improved procurement systems. Improved Responsiveness and Timeliness in Procurement: Analysis conducted before and after the implementation of the quality improvement plan revealed a noticeable reduction in procurement lead times. This resulted in expedited deliveries for various procurement requests. Instances of notable improvements include the swift delivery of IT infrastructure for establishing sub-zoba district health offices, PHEOCs, ambulances, and EmONC products. Enhanced Compliance: The quality improvement plan facilitated the development of SOPs and precise item specifications. It also delineated clear roles and responsibilities for procurement staff, ensuring adherence to WHO procurement SOPs. Additionally, an established segregation of duties matrix has significantly improved procurement workflow management. Capacity Building The quality improvement process involved comprehensive training for WHO and MoH staff in various aspects of procurement. This training equipped them with reporting support and access to critical procurement information. Modules covered diverse topics such as the Public Procurement Act, bid evaluation, complaints mechanisms and codes of conduct. Enhanced capacity has notably improved the quality of reporting, contributing significantly to the overall quality improvement cycle. 1 2 3 Outcomes and achievement MOH staff during handover of laboratory equipments purchased with WHO support ©WHO A compendium of Eritrea health sector impact case studies 2019 - 2023 95 Case study 17 Health observatories – how Eritrea is using health observatories to strengthen the national health information system GPW theme: More Effective And Efficient WHO Providing Better Support to Countries GPW Outcome: 4.1 Azmera Gebreslassie Asfeha (Health Information Officer, WCO Eritrea) The establishment of the African Health Observatory (AHO) by WHO AFRO in 2011 has opened new avenues for enhancing health information systems (HIS) across the continent. Simultaneously, the urgent need to fortify national HIS for evidence-based decision-making has become apparent. national health observatories (NHOs) are increasingly recognized as crucial elements in strengthening these systems. Eritrea’s National HIS (NHIS) Strategic Plan emphasized the significance of creating an NOH as a fundamental component. This initiative aimed to enhance data availability, monitor health trends and track progress towards major health goals related to governance, financing and HRH. A compendium of Eritrea health sector impact case studies 2019 - 202396 ©WHOParticipants during the launch of flagship initiatives to strengthen emergency response in Eritrea WHO has been a consistent partner in Eritrea's pursuit to establish a health observatory. Beginning with a high-level meeting advocating for and highlighting the importance of NHOs, WHO engaged key stakeholders, including the Minister of Health, directors and officials from line ministries and the National Statistics Office. Subsequently, technical support was provided, offering training on data analysis and Tableau software to national focal persons. In 2021, the formation of a TWG and steering committee facilitated data verification coordination. WHO offered necessary guidelines for NHO establishment and data verification, with the steering committee forming the central network responsible for coordination. Eritrea's health sector leadership endorsed NHOs by investing resources, raising awareness and advocating for their establishment. Support from WHO and other partners aligned with the country's initiatives for NHO establishment. A crucial aspect was supporting the selection of appropriate technology and solutions was, involving the choice of database management systems, visualization tools, content management systems and networking software. The objective was to seamlessly integrate with existing ministry websites and the NHIS data warehouse, positioning the NHO as the core of the NHIS. Besides technical support, WHO funded infrastructure, office equipment and stationery. WHO facilitated ongoing education by developing training materials for collaborative learning, including e-Learning and traditional forms for continuous professional development. Regional and country-level training sessions were conducted for designated NHO focal individuals on NHO knowledge production. All essential components for NHO functionality were carefully put in place and prepared for launch. The WHO ensured comprehensive capacity-building across sectors, ensuring adequate training for all members involved in coordinating NHO platforms, extending to local and external academics, researchers and experts. The path to Eritrea's NHO A compendium of Eritrea health sector impact case studies 2019 - 202398 The Eritrea NHO was established and activated in 2020 and has substantially strengthened the NHIS in various areas: Outcomes and achievements of Eritrea's NHO Reducing Fragmentation: NHO efforts have significantly decreased fragmentation in health information initiatives at national and subnational levels. This has alleviated the workloads of authorities and health workers, minimizing the need for additional data reporting to partners. Innovative networking platforms have improved stakeholder participation and collaboration. Leveraging technology, Eritrea streamlined health management information onto the DHIS2 platform, conducting regular data quality assessments through the NHO. This enhanced the country's capacity for timely information generation, analysis and access, ensuring sufficient quantity and quality of data. Strengthening Data and Information Resources: Eritrea bolstered its data and information resources, enhancing national capability for data management and evidence generation. Collaboration among stakeholders, including academic and research institutions, was instrumental. Enhancing information capabilities such as online searching, filtering, retrieval, storage, indexing and sharing became a focus for the NHO. A compendium of Eritrea health sector impact case studies 2019 - 2023 99 Strengthening Capabilities for Data Sharing and Application: The NHO addressed weaknesses in health systems' capability to share, interpret or apply available information for decision-making. Serving as platforms for multi-stakeholder collaboration, the NHO of Eritrea acts as a repository of the best available information and offer tools to monitor health status and trends in the country. Joint Data Quality Assessment: Eritrea's NHOs stimulated joint data quality assessments by the MoH in collaboration with WHO, using standardized tools. Covering all zobas and selected districts, this collaborative effort guides improvement plans at various health service levels, enhancing reporting timeliness and completeness. High-quality data is crucial for evidence-based decision- making and monitoring health trends and SDG targets. ©WHO ERITREA A compendium of Eritrea health sector impact case studies 2019 - 2023100 Participants during the National Research Agenda meeting supported by WHO ©WHO Forward L king Ongoing collaboration at the national and regional levels is intended to review and enhance all published data. Eritrea is actively refining analytical country profiles based on NHO data, essential for monitoring and evaluating national policies within the development cycle. Efforts continue to develop content for country profiles and to support regional and subregional networks on various health themes. Despite remaining work, the NHO initiative is significantly contributing to Eritrea's roadmap to strengthen its HIS WHO and MOH during a supportive supervision mission to support GODAIF community Hospital with health information/ data management A compendium of Eritrea health sector impact case studies 2019 - 2023 101 ©WHO Telephone: +291 11 41 71 /75 /67 Email: afwcoer@who.int Website: https://www.afro.who.int/ World Health Organization Country Office in Eritrea Adi Yacob Street No.173, House No.88/89, Geza Banda,Asmara P.O. Box 5561, Asmara, Eritrea The WHO Regional Office for Africa The WHO Regional Office for Africa The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Africa is one of the six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Algeria Angola Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon Central African Republic Chad Comoros Congo Côte d'Ivoire Democratic Republic of the Congo Equatorial Guinea Eritrea Eswatini Ethiopia Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Madagascar Malawi Mali Mauritania Mauritius Mozambique Namibia Niger Nigeria Rwanda Sao Tome and Principe Senegal Seychelles Sierra Leone South Africa South Sudan Togo Uganda United Republic of Tanzania Zambia Zimbabwe