Emergency Health Needs of the Populations

Of Northern Red Sea, Southern Red Sea

and Gash Barka Zobas in Eritrea (A synthesis of findings from rapid assessments,

district health profiles and household survey)

2

August, 2006

1.0 Background ............................................................................................................. 3 2.0 Methodology ........................................................................................................... 7

2.1 Rapid Assessments.............................................................................................. 7 2.2 Compilation of District Health System............................................................... 8 2.3 Household Survey............................................................................................... 9

3.0 Findings................................................................................................................. 10 3.1 Coping Mechanisms for vulnerable groups: ..................................................... 10 3.2 Primary causes of morbidity and mortality....................................................... 12 3.3 Health Services Management ........................................................................... 14

3.3.1 Management structures ............................................................................. 14 3.3.2 Financial management .............................................................................. 15 3.3.3 Health infrastructure, equipment and supplies.......................................... 15 3.3.4 Health information .................................................................................... 15 3.3.5 Human resource ........................................................................................ 16

4.0 Access to Health Services..................................................................................... 16 5.0 Health Services Utilization: .................................................................................. 19

5.1 Skilled Delivery attendance .............................................................................. 19 5.2 Childhood Immunization .................................................................................. 22 5.3 Use of ITNs....................................................................................................... 24

6.0 Knowledge and Practices associated with Health:................................................ 24 6.1 Child Spacing:................................................................................................... 24 6.2 Breast feeding Practices:................................................................................... 25 6.3 Sanitation .......................................................................................................... 26 6.4 Health Behavior and Knowledge ...................................................................... 29

6.4.1 HIV Prevention: ........................................................................................ 29 6.4.2 Treatment Need......................................................................................... 29 6.4.3 Extra fluids................................................................................................ 29

6.5 Female Education and Employment: ................................................................ 30 6.6 Practice of FGM:.............................................................................................. 31

7.0 Needs: ................................................................................................................... 34 8.0 Conclusions........................................................................................................... 35

3

1.0 Background Eritrea consists of three major geophysical zones: the Western Lowlands, the Central and

Northern Highlands, and the Eastern (coastal) Lowlands.

There are two major periods of precipitation in Eritrea. One, from June to September,

covers both the western lowlands and highlands. The second comes between October and

March and covers the eastern lowlands. The annual rainfall in the highlands ranges from

450 mm – 6000 mm. The southern part of the western lowlands receives 600 – 800 mm

of rain per annum, but rainfall decreases substantially as one move northward.

The eastern coastal lowlands receive less than 200 mm per annum.

Gash Barka

NRS

SRS

Anseba

Debub

Maekel

Eritrea: Six Zobas and 58 Sub Zobas

4

The average population-size of a sub-Zoba varied greatly ranging from 13,530 (Araeta,

Southern Red Sea) to 83,568 (Afabet, Northern Red Sea).

The ambient temperature also varied from a low of 150 C to a high of more than 400 C.

Moreover, sizeable areas within the various sub-Zobas were not accessible for varying

periods of the year in the absence of reliable public transport and difficult roads/terrain.

Camels and donkeys are an important mode of transport in the three regions of Eritrea.

Anopheles mosquito was widely distributed in the surveyed sub-Zobas making the

population to be at risk of malaria. Snakes and scorpions were important causes of injury

in all the three sub-Zobas.

The extremely low rainfall in the eastern lowlands causes aridity and a hostile

environment for agriculture, grazing and industry. Of the 620,000 people who live in the

coastal plains, 70% live in the rural areas and depend on agriculture and pastoralism as a

means of livelihood.

Following several years of poor rains and subsequent drought, the costal population of

Eritrea is currently experiencing a severe crisis situation. This regional crisis hit Eritrea

while the country is passing through important changes in its policies related to food aid.

The common immediate goal for all health partners was to reduce the avoidable mortality

and morbidity due to food insecurity, communicable diseases and risks linked to

pregnancy and delivery.

The WHO, with CERF funding proposed and carried out a strategy based on managing

information, convening consensus joining forces, enhancing the cooperation and

coordination of all humanitarian actors and filling critical gaps. The activities were

initiated with CERF 1 funding and continued with CERF 2.

The objective of this response strategy was to reduce avoidable mortality and suffering

due to life threatening health conditions resulting from food insecurity, and strengthen the

capacity of the system to deliver required services to these affected populations.

The information in this document is the result of information gathering during the

implementation of CERF.

5

Daily meetings of the WHO discusses the health situation of the vulnerable populations and the response strategies

6

WHO staffs reach everywhere to offer relief to the vulnerable groups

Assessment teams reach every corner

7

Immunization response teams at static and outreach centers

2.0 Methodology The information analyzed in this document was collected through rapid assessments,

collation of district health profiles and household surveys.

2.1 Rapid Assessments The methodology for the rapid assessment comprised of development of rapid assessment

tool, interview and observation at health facilities and community levels. The rapid

assessments were carried out jointly between the WHO, Ministry of Health, UNICEF,

UNFPA and OCHA.

Mutual consultations needed for better response

8

Community participation key to success

2.2 Compilation of District Health System The compilation of District Health Profiles targeted all the 28 sub-Zobas of the Gash

Barka, Northern Red Sea and Southern Red Sea Zobas. Also to be visited were all the

hospitals, health centres and health stations in each of the sub-Zobas in the selected

Zobas. The Zobas were selected on the basis of vulnerability to emergencies such as

drought, disease outbreaks or cross-border security operations. All managers or members

of management teams at the sub-Zoba, hospital, health centers and health stations were to

be interviewed. In addition for specific questions community leaders were interviewed.

Secondary data was also collected from the Zoba health offices. The WHO tool on

‘Assessment of the Operationality of District Health Systems – District Questionnaire

and Health Facility Questionnaires were adapted and used for the Key Informant

Interviews. Where necessary, the research assistants toured the facility and recorded

findings.

9

2.3 Household Survey The household survey was a cross-sectional epidemiological study conducted over a

period of six weeks. Three border Zobas were purposively selected for the study as they

met the criteria of border Zobas. These were the Northern Red Sea bordering Sudan and

the Red Sea; The Southern Red Sea bordering Ethiopia and Gash Barka that borders

Sudan. Using the recommended 30 cluster -10 household techniques a total of 300

caregivers were enrolled in each Zoba giving a total sample of 900 for the three Zobas.

The sampling frame was based on the design recommended by the WHO. This is a two

stage 30-cluster sampling procedure. Firstly, from the population projections list

produced by the Local Government, all villages in each Kebabi were listed with their

corresponding household census. The households were then cumulated first at the level of

the Kebabi and then for the total in each Zoba. The sampling interval was generated for

the 30 clusters in each Zoba through dividing the total number of households by 30.

Using the table of random numbers the Kebabi containing the first cluster was identified

by blindly selecting a number on the table that fell within the computed sampling

interval. Successive Kebabi level clusters were then selected by using stratified sampling

technique.

The next stage involved the selection of 10 households in each cluster. This was achieved

by randomly selecting a village in each of the identified Kebabis. In order to ensure

inclusion of urban, rural and hard to reach rural villages, the selection of subsequent

villages was alternated across these three categories.

The final stage involved actual visit to the village during the day of the interview. The

supervisor identified the centre of the village and using a sketch map, the village was

divided into four roughly equal parts. Trained research assistants selected the first house

in the first quadrant by spinning a bottle. The team of research assistants then proceeded

to visit the household and enrolled as an interviewee, a caregiver if at the time of the visit

there was a present a child aged 0-59 months, and if the child lived in the household (or

slept in the household the previous night).

The enrolled caregiver was then interviewed using a questionnaire developed for the

survey and following procedures learnt during the training of research assistants. At the

10

end of the interview, the researchers thanked the respondent before moving to the next

household as the crow flies. 2-3 three households are visited in each quadrant until 10

caregivers who met the criteria are successfully enrolled and interviewed. Care was taken

to ensure that at least 7 of the 10 caregivers were women aged between 16 years and 39

years.

The tool was based on tools used previously in the country in joint surveys involving

WHO, UNICEF and the Ministry of Health. Therefore pilot-testing was not considered

necessary.

Data entry was done using EPI Info software and analysed both EPI Info and SPSS.

Descriptive statistics were computed and risk assessed using Odds ratio and 95%

Confidence Intervals.

3.0 Findings

3.1 Coping Mechanisms for vulnerable groups: Rapid assessments carried out in the areas revealed that:

♦ Due to the especially low rain fall in the October 2005 to March 2006 season, the

agricultural yield was very poor and the water reservoir levels are very low.

♦ The main coping strategy for this population and others in Anseba region is

migration to the highlands. More than 80% of the families migrate to the

highlands in search of pasture and water for the animals and food for the families.

♦ The vulnerable groups especially women and children less than five years are not

accessing basic health services especially immunization, ANC and emergency

obstetrics services.

♦ The current health information system is not rapid enough to detect deteriorating

health conditions and increased mortalities.

♦ The acute and chronic malnutrition levels amongst women and children less than

5 years are very high. This is occurring in a period of changing Government

policies in the area of food security.

11

♦ Any disruption of the coping mechanisms as a result of natural causes such as

inadequate rainfall in the highlands or conflicts of any nature will tip the fragile

balance into a major catastrophe.

Poor rains and desert ecology affects pastures and water for humans and animals

Water levels for communities at an all time low

12

Vulnerable communities are the remote and poor villages

3.2 Primary causes of morbidity and mortality Acute respiratory tract infections, diarrhoea, malnutrition and malaria are the

primary causes of morbidity and mortality in Gash Barka, Northern and Southern

Red Sea. HIV/AIDS and tuberculosis are also identified in some sub-Zobas as important

causes of mortality.Another cause of morbidity include skin disease,. This is confirmed

by the rapid assessment reports, district health profiles as well as the annual report of

health management information system.

Water-washed and waterborne diseases are therefore major causes of morbidity and

mortality.

Mortality figures from health facilities are very unreliable as only few deaths are reported

to the system. In addition, the last demographic and health survey was carried out in

2002. A proxy indicator was however in the household survey to determine the level of

infant mortality. According to this survey, 7% of households in Southern Red Sea and

13

Gash Barka Zobas and 13% in Northern Red Sea reported death of a child less than 1

year old in the last 1 year.

As presented in figure 1, diarrhoea and respiratory tract infection constituted the largest

group of symptoms noticed at the time of death.

Figure 1:

Persenting Symptoms at Death for child)

2.75.4

16

8.1

27

Diarrhea Fever Respiratory Malaria Convulsions

Maternal mortality is probably high given the prevalence of the main causes of maternal

morbidity and mortality. According to the HMIS 2005 report, Obstetric Emergencies

were also the third leading cause of admission and the 5th cause of deaths in 2005 that

needs more attention to reduce maternal deaths. The situation may indicate delays in

arriving at health facilities or failure in proper case management.

The household survey also indicated that, a woman died in the last 1 year in 3% of the

households in Northern and Southern Red Sea Zobas and in 6% of the households in

Gash Barka. In 46% of the cases the age of the woman was under 40 years and as shown

14

in figure 2, excessive bleeding is the commonest single symptom at death, accounting for

about 19%.

Figure 2

Persenting Symptoms at death of a woman

18.862.5 12.5

6.3

Excessive bleeding Fast breathing Fever Other

Nutritional problems are a major concern in these areas. The last nutritional surveys

showed global acute malnutrition prevalence in children 6 to 49 months of more than

15.4%, stunting - 26.9% and malnutrition among mothers of more than 50%.

The prevalence of vitamin A deficiency amongst school children was 15% and the

prevalence of anaemia among school children and pregnant women was 53. %.

The household survey has revealed a high prevalence of chronic malnutrition. The

prevalence of underweight children ranged from 45.5% in Southern Red Sea to 62.7% in

Northern Red Sea Zoba.

3.3 Health Services Management

3.3.1 Management structures Less than 30% of the sub-Zobas have all the expected committees and management

teams i.e. Sub-Zoba Development Committee (SZDC), sub-Zoba Health Management

Committee (SZHMC), sub-Zoba Health Management Team (SZHMT) or Facility

15

Management Committee (FMC). Although most of the sub-Zobas have annual plans and

budget none of the sub-Zobas are engaged in long term or strategic planning.

3.3.2 Financial management All health managers are involved in financial management and resource allocation trough

planning, budgeting and collection of user fees. More than 90.0% of the sub-Zobas

charge fees either for drugs or services. They also implement a system of exemptions.

3.3.3 Health infrastructure, equipment and supplies The health infrastructure and equipment was reported to be satisfactory. However all sub-

Zobas considered the facilities and services insufficient and a constraint to provision of

the comprehensive health package. Only a few sub-Zobas reported short periods of drug

shortages. Blood transfusion services were available in only a few sub-Zobas. As a result

surgical, obstetrical and gynecological services are only available in a few urban sub-

Zobas.

3.3.4 Health information Although the IDSR system is in existence in all the sub-Zobas, the health information

systems are weak with little indication that evidence-based medicine is a common

practice

In general, basic socio-economic, epidemiological and service management data is not

easily retrievable or routinely in use at all levels of the health provision hierarchy. As a

result, the

It is noteworthy that results of community or household surveys previously conducted

within the sub-Zobas were not available at the sub-Zoba, Kebabi or facility level.

Other important constraints in terms of health information generation are lack of communication and transport facilities as well as shortage of data processing equipment at the health facilities.

16

Constraints of most health facilities include power supply and life saving equipment

3.3.5 Human resource There is acute shortage of doctors and nurses across all the 26 sub-Zobas surveyed. For

example in Afabet there is 1 doctor for the entire population of over 80,000. Barentu with

a ratio of 1:4,000 has the highest doctor/population ratio.

4.0 Access to Health Services According to the Ministry of Health’s current standard, a health station has to serve about

10, 000 people, a health centre and a sub-Zoba hospital about 50, 000 and a Zoba referral

hospital about 200,000 people. The HMIS 2005 report indicates that, currently, one

hospital serves about 131,000 people, a health centre 64, 000 and a health station 18,000

people. The district health profile shows that Eritrea has a wide network of health

facilities especially health stations. Each sub-Zoba has on average 1-2 health facilities.

Despite all these however, the access to health services are not adequate for the following

reasons:

17

- Bed capacity is low and in-service services are not easily accessible. Thus,

although outpatient utilization is high, inpatient care is very low.

- The most vulnerable groups are not accessing the services due to migratory life

style as well as large and difficult terrain.

- Lack of either human or material capacity for life saving procedures especially

emergency obstetrics care.

- Absence of outreach services due to inadequate and de-motivated manpower and

lack of logistics.

- Deficiencies in essential equipment such as cold chain for immunization.

Frequent power outage also affects the maintenance of cold chain.

Terrain is one of the most common barriers to access to health services

18

Cold chain equipment and hospital waste disposal systems urgently needed

Camels and donkeys essential for outreach services

19

The availability of bed nets at household level in the two malaria endemic areas,

Northern Red Sea and Gash Barka, has increased by more than 40% since 2002 (DHS).

According to the EDHS, 34% of households in Eritrea had mosquito nets. The household

survey indicated that, 78% of the households in Gash Barka and 80% in Northern Red

Sea own a mosquito net, about 80% of the nets being ITNs (Table 1).

The information not collected is on whether the ITNs have been re-treated recently. Since

the use of ITNs is high, the option of supplying long lasting ITNs should be considered.

Table 1: Availability of Bed net

Availability of Net Gash Barka

(N 270)

NRS

(289)

SRS

(N 287)

Any Net 78.5%

(73.1 – 83.3)

80.6%

(75.6 – 85.0)

39.4%

(33.7 – 45.3)

ITN 81.2%

(75.4 – 86.1)

78.9%

(73.4 – 83.7)

27.9%

(20.4 – 36.5)

5.0 Health Services Utilization:

5.1 Skilled Delivery attendance Although 70% of pregnant women in Eritrea receive antenatal care, only 26% deliver in health facilities and 73% deliver at home. Comparing the data with the findings from 2002 EDHS, there has been a significant increase in number of births attended by health personnel in Gash Barka and SRS, although the data for Gash Barka is still lower than the one from SRS (Table 2).

20

Table 2: Skilled Delivery Attendance by Zoba

Delivery attendance

Gash Barka

(N 271)

NRS

(N 290)

SRS

(N 290)

Skilled 23.6%

(18.7 – 29.1)

39.3%

(33.7 – 45.2)

47.2%

(41.4 – 53.2)

Non Skilled 76.4%

(70.9 – 81.3)

60.7%

(54.8 – 66.3)

52.8%

(46.8 – 58.6)

The non skilled attendance is still high despite the fact that, in over 70% of the cases in

all Zobas as shown in figure 3 the decision on where to deliver is taken either by the

women or jointly with the husband. The reasons for delivering at home as shown in Table

3 is mostly either cultural or distance (Table 3). Any interventions to address this issue

therefore must be targeted at the women.

Figure 3

010203040506070

Perc

enta

ge o

f Fem

al

Gash Barka NRS SRS

Decision Responsibility on where to deliver

Self Husband Husband and Self Together Mother- in- Low Father-in-low Others

21

Table 3: Reason for Home Delivery by Zoba:

Reason Gash Barka

(N 198)

NRS

(N 171)

SRS

(N 135)

Culture 31.3%

(24.9 – 38.3)

37.4%

(30.2 – 45.1)

27.4%

(20.1 – 35.7)

Distance 24.7%

(18.9 – 31.4)

19.3%

(13.7 – 26)

15.6%

(9.9 – 22.8)

Health worker attitude 1.5%

(0.3 – 4.4)

0.0%

(0 – 2.1)

1.5%

(0.2 – 5.2)

Health worker gender 0.5%

(0 – 2.8)

2.3%

(0.6 – 5.9)

0.7%

(0 – 4.1)

Transport 4.5%

(2.1 – 8.5)

20.5%

(14.7 – 27.3)

22.2%

(15.5 – 30.2)

Other 37.4%

(30.6 – 44.5)

20.5%

(14.7 – 27.3)

32.6%

(24.8 – 41.2)

Some women also prefer to deliver at home even with the availability of skilled delivery

attendance facilities mostly for reasons of culture or convenience (Figure 4)

22

Figure 4

0

10

20

30

40

Perc

enta

ge o

f fe

mal

e

Gash Barka NRS SRS

Reasons for preference to Deliver at home by Zoba

Culture Moreconvienent lack of transportationDistance Attitude of health Workers Sex of Health WorkersLack of family approval Other

5.2 Childhood Immunization Universal immunization is one of the main strategies to reduce infant and child mortality

and MOH in Eritrea vaccinates children against seven vaccine preventable diseases-

tuberculosis, diphtheria, whooping cough, tetanus, polio, measles and hepatitis B. The

Eritrean Expanded Program on Immunization follows the WHO guidelines for

vaccinating children. Information collected are restricted to children 12-23 months of

age in order to focus on recent coverage levels and a child is considered to be fully

vaccinated if received Polio3 (OPV3), DPT3, and measles vaccines in order to compare the data

to the previous ones. Data from the 2002 EDHS showed that 69.2% of children 12-23

months were fully vaccinated by the age of 1 and comparison with the 1995 EDHS in

Figure 1 shows that there had been a substantial improvement in coverage for all

vaccines.

Data from the recent household survey show surprisingly low vaccination coverage by

the age of 1, especially in Zoba SRS (Table 4). It is worth noting that the source of

23

information on childhood immunization in the EDHS included both vaccination card and,

if not available, mother’s report, while in the household survey only child’s vaccination

card was used. Those children where card was seen ranged from about 60% in Southern

Red Sea to about 84% in Gash Barka. The low figures of those who completed

vaccinations tallies with the rapid assessments findings that show a high drop out rate that

reached over 50% in some areas.

Table 4: Children age 12-23 months who are fully vaccinated before the first

birthday.

Fully vaccinated 12-23 months

old children

Gash Barka

(N=73)

NRS

(N=100)

SRS

(N=76)

Yes 41.1%

(29.7-53.2)

49.0%

(38.9-59.2)

36.8%

(26.1-48.7)

No 58.9%

(46.8-70.3)

51.0%

(40.8-61.1)

63.2%

(51.3-73.9)

The survey finding regarding the measles vaccination coverage of children 12-23 months

old, including its confidence limits, is consistent with the previous data from EDHS 2002

(68.2%). However, the best estimate of the true proportion of children 12-23 who

received a measles vaccination in Zoba Northern Red Sea and Gash Barka is higher that

the previous one. The target coverage according to WHO (= or >80%) has been reached

only in Zoba NRS.

Tetanus toxoid vaccine is provided to pregnant and non pregnant women of childbearing

age in Eritrea to prevent tetanus in newborns and women during delivery in unhygienic

environments. For the last birth in the 23 months before the survey about 72% of mothers

received at least two doses of TT and were therefore protected against tetanus. These data

show a significant increase in TT immunization coverage in the last 4 years when

24

compared to the corresponding figures from 2002 EDHS. This could be the result of pilot

project of antenatal care at community levels.

5.3 Use of ITNs

The use of mosquito nets by children <23 months is much higher when compared to the

DHS (30.1%), while the percentage of children <5 who slept under a mosquito net the

night before the survey has not increased significantly. (Since both the EDHS and the

household survey were conducted during the dry season, the estimates of mosquito nets

use reflect the low-malaria risk season levels.) Table 5 shows the proportion of children

less than 5 years who slept under ITN from the household survey. The low proportion

from Southern Red Sea is not surprising because of this is not a malaria endemic Zoba.

Table 5: Proportion of children 0 -23 months who slept under ITN

6.0 Knowledge and Practices associated with Health:

6.1 Child Spacing: Birth intervals appear not to be changed in the recent years: the data reported from EDHS

2002 showed that the proportion of children born at least 24 months later than the

previous child was 73.8 % for SRS, 79% for NRS and 82.7 % for Gash Barka. Table 6

shows that these figures did not significantly change during the household survey.

Children 0-23 months old Slept under treated net

Gash Barka (N=162)

NRS (N=188)

SRS (N=165)

No 32.7% (25.6-40.5)

28.7% (22.4-35.8)

86.7% (80.5-91.5)

Yes 67.3% (59.5-74.4)

71.3% (64.2-77.6)

13.3% (8.5-19.5)

25

Table 6 Children age 0–23 months that were born at least 24 months after the

previous surviving child

Spacing GASH BARKA

(N = 98)

NRS

(N 102)

SRS

(N = 78)

Less than 24 Months 25.5%

(17.2 – 35.3)

20.6%

(13.2 – 29.7)

26.9%

(17.5 -38.2)

At least 24 months 74.5%

(64.7 – 82.8)

79.4%

(70.3 – 86.8)

73.1%

(61.8 – 82.5)

6.2 Breast feeding Practices: Regarding the breastfeeding practice the evidence from the household survey show that:

♦ The rates of early initiation of breastfeeding are among the highest in sub-

Saharan countries, but the percentage of children breastfed within one hour of

delivery has not improved since 2002. (see table 7)

♦ The percentage of children that are being breastfed during the first 2 years has

increased, especially in the age group 12-23 months. The duration of

breastfeeding is therefore significantly higher if compared to the data of 2002

EDHS.(see table 8)

♦ Despite the universal prevalence of breastfeeding of newborn in Eritrea, the

percentage of children 0-6 months who are fed in compliance with

WHO/UNICEF recommendation, that is, are exclusively breastfed, is very low

especially in NRS. The reason for not having a higher prevalence of exclusively

breastfeeding according to previous data available seems to be the early

supplementation of breast milk with plain water

26

Table 7: Breastfeeding initiation: percentage of children aged 0-11 months who

were breastfed within the first hour after birth. .

Table 8: Continued Breastfeeding. Percentage of children aged 12-23 months

who are still breastfeeding.

Data Source Continued Breastfeeding

DHS 38.7 Household Survey

92.6%

Table 9: Children age 0-6 months who were exclusively breastfed during the

last 24 hours.

Exclusive breastfeeding Gash Barka (N=58)

NRS (N=57)

SRS (N=59)

NO 100.0% (93.8-100)

98.2% (90.6-100.0)

79.7% (67.2-89)

YES 0.0% (0.0-6.2)

1.8% (0.0-9.4)

20.3% (11.0-32.8)

6.3 Sanitation

According to DHS 2002, only 32.2% of the population had access to safe water supply.

Rapid assessments results showed that water levels have gone down in the water

reservoirs due to continuous drought. Available water is shared at the rate of about 60

litres per family per day. The average distance between water source and the settlement is

ranges from about ½ Km to 2.5 Km. Water is collected by any available member of the

family using donkey.

Breastfeeding Initiation (within 2 hours) Gash Barka NRS SRS

DHS 77.7 82.3 81.2 Household Survey 72.2% 87.5% 90.8%

27

Hygiene practices are very poor which probably explains the high prevalence of

diarrhoeal diseases.

The proportion of mothers who reported they wash their hands in all the situations

considered in the questionnaire is extremely low Table 10. A bias may be that in order to

consider the answer as positive all of the situations needed to be spontaneously

mentioned by the respondents.

More than half the sampled households in all the Zobas don’t own any kind of toilet

facility. This proportion has reached over 80% in Gash Barka (Table 11).

Another poor hygiene practice is poor disposal babies waste as presented in figure 5.

Table 10 Mothers with children age 0-23 months who report that they wash

their hands with soap/ash before food preparation, before feeding

children, after defecation and after attending to a child who has

defecated.

Washing of Hand Gash Barka

(N=162)

NRS

(N=188)

SRS

(N=165)

No 95.7%

(91.3-98.2)

80.9%

(74.5-86.2)

89.1%

(83.3-93.4)

Yes 4.3%

(1.8-8.7)

19.1%

(13.8-25.5)

10.9%

(6.6-16.7)

28

Table 11 Availability of Toilets in households

Type Of Toilet Gash Barka

(N 268)

NRS

(286)

SRS

(N 288)

Flush toilet 0.7%

(0.1 – 2.7)

4.5%

(2.4 – 7.6)

24.0%

(19.1 – 29.3)

Pit toilet 13.4%

(9.6 – 18.1)

28.7%

(23.5 – 34.3)

19.8%

(15.3 – 24.9)

No facility/field 84.7%

(79.8 – 88.8)

66.4%

(60.6 – 71.9)

55.6%

(49.6 – 61.4)

Other 1.1%

(0.2 – 3.2)

0.3%

(0- 1.9)

0.7%

(0.1 – 2.5)

Figure 5

0

10

20

30

40

50

pers

enta

ge d

ispo

sed

Gash Barka NRS SRS

Disposal of Babies waste

Thrown in toilet Buried in yard Not disposed Other

29

6.4 Health Behavior and Knowledge:

6.4.1 HIV Prevention: The data regarding the knowledge of two HIV protective behaviors among women cannot

be compared with those from EDHS, since the data collected in the latter included

answers to both a open question and to a prompted question. The household survey

showed the proportion of women who are aware of at least two HIV related behaviours is

much higher in Zoba Gash Barka (51.2%) compared to 37.6 in Southern Red Sea – Table

12.

Table 12 Mothers with children age 0-23 months that cite at least two known

ways of reducing the risk of HIV infection.

Know 2 or more protective

behaviors for HIV

Gash Barka

(N=162)

NRS

(N=188)

SRS

(N=165)

Yes 51.2%

(43.3-59.2)

43.1%

(35.9-50.5)

37.6%

(30.2-45.4)

No 48.8%

(40.8-56.7)

56.9%

(49.5-64.1)

62.4%

(54.6-69.8)

6.4.2 Treatment Need The findings related to mothers’ knowledge of at least two signs of childhood illness that

suggest the need for treatment show a considerable lower awareness in mothers from

Zoba Gash Barka. It is worth observing that C-IMCI has not yet been introduced in any

of the considered Zobas.

6.4.3 Extra fluids It is recommended that children be given more liquids to drink during diarrhea and that

food intake not be reduced. Mothers of children who had diarrhea were asked about

30

feeding practices during their children’s illness. The data related to feeding practices

during illness in Zoba Gash Barka and NRS according to the recent household survey are

consistent with the previous DHS data, while data from SRS show that the percentage of

mothers giving more fluid than usual is significantly lower and the percentage of mothers

giving more fluid is significantly higher when compared both to Zoba Gash Barka and

NRS and to previous national data – Figure 6.

Figure 6

0

20

40

60

80

Perc

enta

ge to

ok fl

uid

Gash Barka NRS SRS

Fluid intake during illness

Less than usual more than usual Same amount

6.5 Female Education and Employment: Level of education plays a crucial role in many health activities. It is associated with

reproductive health by delaying age of marriage and therefore age of first pregnancy.

Those that are highly educated are also likely to have higher socio-economic status by

getting better Job. The data shows that, more than half of the women in all the Zobas had

no schooling at all (Figure 7).

Table 13 shows the employment status by Zoba. In all the Zobas, more than 80% of the

women are full time housewives without any form of employment.

31

Figure 7

0

10

20

30

40

50

60

70

Perc

enta

ge o

f wom

en

No Schooling InformalEducation

1-6 grade 7-9 grades 10-12 grades PostSecondary

Level of education

Education by Zoba

Gash barka NRS SRS

Table 13 Employment by Zoba

Employment Status Gash Barka

(N 271)

NRS

(N 290)

SRS

(N 290)

Housewife 93.4%

(89.7 – 96)

89.0%

(84.8 – 92.3)

83.8%

(79 – 87.8)

Employed 6.6%

(4 – 10.3)

11.0%

(7.7 – 15.)

16.2%

(12.2 – 21)

6.6 Practice of FGM: Female genital mutilation is widely practiced in Eritrea as shown by previous studies

including the 2002 DHS.

32

The household survey shows that, FGM is practiced by more than half of the women with

girl child less than 15 years in the sampled households – Table 14. As shown in figure 8,

this proportion reaches more than 75% in some Sub Zobas.

Table 14: Proportion of Women with Girl Child who practice FGM

Practice FGM Gash Barka

(N 162)

NRS

(N 161)

SRS

(N 159)

No 46.9%

(39 – 54.9)

34.8%

(27.5 – 42.7)

27.0%

(20.3 – 34.7)

Yes 53.1%

(45.1 – 61.0)

65.2%

(57.3 – 72.5)

73.0%

(65.3 – 79.7)

Figure 8

Eritrea: Practice of FGM by Sub Zoba

Prevalence of FGM practice(%)

50% and above

< 50%

NO data

33

The practice cuts across all religions (Table 15) but is practiced more by Muslims than

Christians. The practice is performed before the girl reaches 5 years of age in most

instances as shown in figure FF.

Table 15: Practice of FGM by Religion

Practice FGM Muslim

(N 360)

Orthodox

(N 117)

No 28.1%

(23.5 – 33.1)

59.8%

(50.4 – 68.8)

Yes 71.9%

(67.0 – 76.5)

40.2%

(31.2 – 49.6)

Figure 9

0

10

20

30

40

50

perc

enta

ge o

f Circ

umci

sion

Gash Barka NRS SRS

Age of Circumcision

1 yr and less 2-4 yrs 5-9 yrs 10-15 yrs

34

7.0 Needs: The health partners in Eritrea under the guidance of the WHO have compiled enough

information on the vulnerable populations of Northern and Southern Red Sea Zobas as

well as Gash Barka.

The major health needs are associated mostly to migratory life style forced by

unfavorable weather conditions complicated by socio-cultural practices. The needs

therefore could be summarized into the following categories:

1. Life saving interventions for mothers and children in the form of emergency

obstetrics services (Skills and equipment) available at strategic locations as well

as community level.

2. Life saving child health interventions in the form immunization, IMCI and

nutrition support. This should be preferably delivered as an outreach activity in a

sustainable manner.

The 2 activities above should be planned in such a way that the migratory nature and

pattern are addressed. Mapping of the migratory route and pattern would be an

important first step.

3. Addressing the route of the major causes of morbidity and mortality – diarrhoea

and ARI, in this case the poor sanitation status. This could be addressed in the

form of a functional strategy like the PHAST.

4. Health behavior change strategy to address negative health behaviors especially

poor hygiene practices, poor knowledge on HIV/AIDS prevention, poor health

seeking behavior for child illnesses and female genital mutilation.

5. Strengthening and sustaining the health information system especially sentinel

registration for deaths and further strengthening of IDSR especially at sub Zoba,

facility and community levels. The laboratory confirmation human and supplies

capacity also needs further strengthening.

6. Addressing major defects in the health system especially non functional

equipment and electricity supply. Alternatives sources of energy such as solar

power could be considered.

7. Improving emergency response capacity by stocking and regular replacement of

essential emergency drugs.

35

8. Addressing the issues of logistics and supplies especially communication between

the different levels.

9. Addressing general development issues that negatively affect health. In this

regard, safe water supply and women education should be top on the agenda.

The WHO has comparative advantage in Eritrea to lead the health sector response. The

technical and logistic capacity of the organization, its access to all the vulnerable

population, positive working relationship with the Government at all levels and its

understanding of the situation will greatly assist in implementing any response.

8.0 Conclusions Through a combination of rapid assessments, compilation of district health profiles and

household survey, the emergency and other health needs of the populations of Northern

Red Sea, Southern Red Sea and Gash Barka Zobas of Eritrea have been identified.

Though the process has the limitation of not covering the whole country, most of the

vulnerable groups have been covered.

The available information shows that, there are serious gaps in filling the health needs of

women and children. There may be high levels of mortality especially among children,

but the health system may be under reporting these deaths as they may be occurring at

community level without being reported to the health facilities.

An urgent response is needed to address these issues and with availability of funds, the

WHO is strategically placed to lead this response.