Eritrea’s Quiet Revolution in Health Care

Building Access, Equity, and Resilience 

Part II 

By Ghidewon Abay Asmerom

The Horn of Africa’s public-health challenge is not a single disease, but an overlapping crisis driven by infectious disease, malnutrition, weak water and sanitation systems, conflict, displacement, climate shocks, and a growing burden of chronic illness. The region’s heaviest health burden comes from the interaction of malaria, cholera and other diarrheal diseases, measles, tuberculosis, HIV, malnutrition, maternal and child health risks, and rising noncommunicable diseases such as hypertension, diabetes, cancer, respiratory illness, and mental-health disorders. Droughts, floods, unsafe water, poor sanitation, locust infestations, food-price shocks, and mass displacement are not diseases in themselves, yet they repeatedly turn preventable illnesses into humanitarian emergencies.

Against this difficult regional backdrop, Eritrea has worked to build a stable, prevention-oriented health system. In several key areas, it compares favorably with the broader region. Eritrea’s strongest performance lies in routine immunization, malaria control, HIV prevention, maternal-child outreach, and community-based primary health care. Its health model emphasizes primary health care, outreach to remote and nomadic populations, immunization, antenatal and postnatal care, prevention of mother-to-child transmission of HIV, nutrition screening, and integrated management of childhood illness.

In malaria control, although transmission persists in Eritrea’s western lowlands, the country’s multisectoral prevention campaigns have significantly reduced illness and death, contrasting with the heavier and recurrent malaria burden seen across much of the region. In cholera and diarrheal disease, Eritrea has largely avoided the major outbreaks recently reported elsewhere in the Horn, relying instead on preventive environmental health measures, sanitation campaigns, and community-led efforts that have sharply expanded open-defecation-free villages. In immunization and measles prevention, Eritrea stands out as one of the region’s strongest performers, maintaining consistently high vaccine coverage even as conflict and displacement have disrupted services in neighboring countries.

In HIV and tuberculosis control, Eritrea also compares favorably, with very low and declining HIV prevalence among youth and significant progress toward eliminating mother-to-child transmission. Maternal, newborn, and child health indicators likewise show steady gains through expanded antenatal care, skilled birth attendance, and emergency obstetric services. Eritrea’s relative stability has allowed these prevention programs to function more consistently than in conflict-affected parts of the region, where fragile health systems are repeatedly disrupted.

Yet Eritrea’s public-health work remains unfinished. Child malnutrition remains a challenge, partly because it is closely tied to household education, nutrition awareness, and daily caregiving practices. Water and sanitation infrastructure also remain limited. Like much of Africa, Eritrea now faces a “double burden”: continuing the fight against infectious diseases while also responding to the rapid rise of chronic illnesses linked to longer life expectancy and changing lifestyles.

Malaria 

Malaria, once a major public health threat, has been brought under stronger control in Eritrea. Malaria-related deaths fell from 405 in 1998 to only 5 in 2023. Eritrea’s malaria prevalence and mortality indicators are among the lowest in the region.

HIV/AIDS also presents an important achievement. Once estimated at 3.7 percent prevalence, Eritrea’s HIV rate has declined to about 0.3 percent. Between 2019 and 2021, antenatal care coverage, HIV testing among pregnant women, and treatment coverage for HIV-positive mothers all exceeded 95 percent, while mother-to-child transmission of HIV was reported at zero during that period, even with breastfeeding.

Table 3. Comparative Analysis of Eritrea’s Malaria Indicators—Incidence, Confirmed Cases, and Mortality Rates—Relative to the Seven Member States of IGAD

COVID-19: Public Health Discipline, Social Solidarity, and National Resilience

Eritrea’s handling of COVID-19 reflected a strict, early, and highly coordinated public health strategy. From the moment the first case was detected on March 21, 2020, after arrival at Asmara International Airport, the government moved quickly to contain the spread of the virus through mandatory quarantine, border controls, flight suspensions, movement restrictions, and nationwide public awareness campaigns.

Unlike countries that waited until community transmission had already accelerated, Eritrea acted early. All incoming travelers were required to quarantine in designated centers, international flights were suspended, and non-essential movement was restricted under a national lockdown beginning in March 2020. Returning citizens were also placed under mandatory quarantine; by mid-June 2020, more than 3,400 people were still being monitored across 47 quarantine centers.

The response was not limited to regulation. The Ministry of Health and other public institutions used clear and consistent messaging to promote social distancing, handwashing, and public discipline. Awareness campaigns reached the public through media, music, local administrations, and community networks, helping turn prevention into a national responsibility rather than merely a government order.

Eritrea’s COVID-19 response also drew strength from national solidarity. Citizens, businesses, and organizations contributed resources to support the public health effort, while essential services continued and treatment was provided free of charge. The government also issued guidelines to prevent overcharging on basic goods during lockdown, reinforcing the idea that public health protection required both medical and social responsibility.

The results were notable. By the end of the pandemic period, Eritrea had recorded 10,189 confirmed cases, 10,086 recoveries, and 103 deaths. In a region where fragile health systems were expected to face severe pressure, Eritrea’s early containment, centralized coordination, quarantine system, public compliance, and community mobilization helped limit the scale of loss and demonstrated the value of decisive preventive action.

Eritrea’s response to COVID-19 did more than test the capacity of its health system; it revealed the depth of social solidarity and the cooperative culture that has long sustained Eritrean society, both at home and across the diaspora. At a time when fear, uncertainty, and economic disruption were straining communities around the world, Eritreans responded not with panic or fragmentation, but with a remarkable spirit of collective responsibility.

Inside the country, the lockdown became a powerful demonstration of mutual aid. Families shared food, neighbors checked on the elderly and vulnerable, local communities organized support for those whose incomes had been interrupted, and people gave whatever they could, however modest, to ensure that no one faced hardship alone. One of the most striking examples of this solidarity came from property owners across the country. Tens of thousands of Eritrean landlords voluntarily waived rent collection for tenants during the lockdown, easing the burden on families and small businesses at a time of profound economic uncertainty. It was an act not mandated by law, but driven by conscience, community, and a deeply rooted culture of looking after one another.

That same spirit extended far beyond Eritrea’s borders. Eritrean communities across North America, Europe, the Middle East, Africa, and Australia mobilized quickly to support relief efforts back home. Diaspora organizations, community associations, businesses, and individual families raised funds, organized campaigns, and sent substantial financial support to strengthen the national response. When lockdowns started Eritrean communities across the world contributed millions of dollars to relief and public health efforts, driven by a deep sense of national responsibility and the understanding that, in times of crisis, outside assistance, particularly from powerful Western nations, often arrives too late, too selectively, or not at the scale that human suffering demands.

In many ways, COVID-19 became more than a public health crisis for Eritrea; it became a living reminder that the same culture of sacrifice, self-reliance, and collective responsibility forged during the liberation struggle continues to shape Eritrean society today. The virus tested institutions, but it also revealed something deeper: when confronted with adversity, Eritreans, inside the country and across continents, still instinctively respond as one community.

These results did not happen by accident. They reflect a model built around prevention, early intervention, community mobilization, and the insistence that remote communities must not be left behind.

Reaching the Hardest Places

In Eritrea, health care does not stop where the road ends. That principle has been demonstrated most clearly in recent immunization efforts targeting remote, mountainous, and seasonally migratory populations.

A 2020 assessment found that 18 of Eritrea’s 58 sub-regions faced major physical barriers to immunization, including rocky terrain, seasonal movement, and isolated settlements. Rather than accept these obstacles as inevitable, the Ministry of Health designed targeted outreach campaigns with support from WHO, UNICEF, Gavi, and other partners. Around 90 vaccinators and more than 200 community workers and supervisors were deployed alongside Eritrea’s “barefoot doctors,” frontline health workers rooted in local communities.

These teams traveled by vehicle where roads existed, on foot where roads disappeared, and even by camel where terrain made other transport impossible. By the end of 2024 and 2025, Eritrea recorded 95 percent and 97 percent coverage for all 13 routine childhood vaccines, including in hard-to-reach areas. Caregiver health education and tetanus-diphtheria vaccination for pregnant women and women of childbearing age also reached 95 percent.

The same community-based philosophy is central to Eritrea’s RMNCAH and Healthy Ageing strategy. The plan emphasizes country ownership, cultural sensitivity, equity, gender responsiveness, human rights, integrated people-centered care, evidence-informed interventions, strategic partnerships, multisectoral engagement, sustainability, and accountability. Its priorities include strengthening leadership and governance, improving infrastructure, expanding health information systems, training and equitably deploying health workers, improving financing, strengthening quality of care, ensuring medicine and equipment availability to the last mile, building referral systems, and expanding community engagement.

This approach is especially important for maternal, newborn, and child health. The strategy calls for expanded maternity waiting homes in remote areas, stronger emergency obstetric and newborn care, improved postnatal care, better essential newborn care, and stronger monitoring of maternal and perinatal deaths. For children, it prioritizes integrated management of childhood illness, care for sick and small newborns, outreach to hard-to-reach and nomadic populations, school health, nutrition interventions, and child death audits.

The message is simple: health services must go to the people, not wait for the people to come to them.

Resilience, Water, Medicines, and Ageing

Modern health systems must do more than treat illness. They must anticipate outbreaks, manage chronic disease, secure medicine supplies, improve water access, protect children, support ageing citizens, and build resilience against future emergencies.

Eritrea has increasingly focused on these long-term foundations. In 2022, the Ministry of Health adapted WHO’s third edition Integrated Disease Surveillance and Response guidelines to the national context, strengthening early detection, reporting, outbreak investigation, emergency response, and health worker training. The health system has also expanded beyond infectious diseases to address cardiovascular disease, cancer, kidney disease, mental health, nutrition, adolescent health, and healthy ageing. A cardiac treatment center has opened at Orotta Hospital, and dialysis services have been introduced for kidney patients.

Healthy ageing is now part of national health planning. As the proportion of older citizens increases, Eritrea’s strategy seeks to build age-friendly environments, strengthen primary health services responsive to older people, develop community-based care, improve information and research, and establish governance structures for healthy ageing at Zoba and sub-Zoba levels.

Clean water has also become part of the broader health story. Through major investment in drinking-water infrastructure, safe water coverage has reportedly risen to more than 85 percent nationally. Rural coverage, once below 7 percent in 1991, has risen sharply, while urban coverage has reached about 95 percent. The system now includes hand pumps, solar-powered and generator-powered systems, pipelines, distribution points, water-testing laboratories, and thousands of public institutions connected to water services. Because safe water is not only a development issue but a health issue, this expansion directly supports disease prevention and community wellbeing.

Eritrea has also pursued greater self-reliance in medicines and medical supplies. This effort began during the liberation struggle, when the EPLF established a small pharmaceutical production facility in 1983. After independence, pharmaceutical manufacturing became a strategic priority. The Azel Pharmaceutical Factory near Keren now produces medicines in tablet, capsule, and syrup form, while the Fred Hollows Intraocular Lens Factory, established in 1994, produces internationally certified lenses for eye care.

Professional capacity in pharmacy is also being strengthened. The Eritrean Pharmaceutical Association, founded in 1992, continues to promote professional excellence, rational medicine use, research, and public awareness. Its recent scientific conference emphasized the role of pharmacists as a bridge between diagnosis, treatment, and recovery, while also addressing medicine safety during pregnancy, antimicrobial resistance, diarrhea management in children, and reducing unnecessary antibiotic use.

Conclusion

Eritrea’s health story is not one of unlimited resources or effortless success. The system still faces shortages of specialists, equipment gaps, supply-chain pressures, data limitations, and the constant challenge of serving difficult terrain. But what makes the experience significant is not the absence of obstacles; it is the consistency with which those obstacles have been confronted.

From 93 health facilities at independence to more than 350 today; from mothers once delivering far from skilled care to more than 83 percent now giving birth in health facilities; from malaria as a major killer to one of the lowest malaria mortality rates in the region; from isolated mountain communities to vaccination teams traveling by foot and camel; from a fragile postwar system to a strategy that now includes mothers, newborns, children, adolescents, adults, and elders, Eritrea’s health journey reflects something deeper than institutional expansion. It reflects a political choice.

It is the choice that the child in Kerkebet, the mother in Areza, the shepherd in Asmat, the elder in Sheshebit, and the farming family in the highlands should not live or die because of distance, poverty, or geography.

In Eritrea’s health system, the most powerful principle is also the simplest: where a person lives should never determine whether that person gets a chance to live.