Immunizing hard-to-reach populations in Eritrea

Asmara-Eritrea's mountainous central region is home to seasonally migratory populations. Nomadic lifestyle complicates access to basic services, especially among women and children who face higher health risks such as maternal mortality and immunization gaps due to geographic isolation, mobility and at times cultural norms.

Overcoming these barriers requires adapting services delivery through flexible, community-led outreach endeavours. A 2020 Expanded Programme on Immunization coverage and equity assessment found that 18 of Eritrea's 58 sub-regions presented physical barriers to immunization access, such as rocky and mountainous terrain.

In response, Eritrea's health authorities, with support from World Health Organization (WHO), partners, civil society organizations and local management teams devised a comprehensive plan to improve routine immunization coverage among children under the age of 2 years, girls of 9 years of age and women of childbearing age.
The strategy involves deploying around 90 vaccinators and over 200 community workers and supervisors in a village or group of villages alongside Eritrean's barefoot doctors-front line health workers who provide essential health services to people in the most remote communities of Eritrea.
The concept of barefoot doctors emerged in China in the 1960s as part of a national effort to address the severe shortage of medical professionals in rural areas. A range of people, from farmers to recent graduates, were given basic medical and paramedical training and would provide basic medical care and preventative services to communities. The term "barefoot" reflects the fact that many of the practitioners were farmers who worked barefoot in rice paddies while providing medical care.
This model has been used by Eritrea during the Eritrean War of Independence and post-independence with improved training and equipment.
"Our barefoot doctors make house calls to educate families about our vaccination efforts. They also escort children who have missed their appointments to health stations or guide our team to those in need," says Milkias Negash, Head of Dirfo Health Station in central Eritrea.

These efforts have increased Eritrea's immunization coverage. According to country data, Eritrea recorded 95% and 97% vaccination coverage of all 13 antigens recommended for routine childhood immunization among children aged under 12 months and between the ages of 24 and 35 months, respectively, at the end of 2024 and 2025. These high immunization rates are also recorded in hard-to-reach areas.

"The government's programme shields our children from disease. They are healthier now, and for that we are grateful," says Amna Omar Mohammed, a resident of Dirfo village.

Additionally, 95% of caregivers had received health education and 95% of pregnant and other women have received essential tetanus-diphtheria vaccinations.

"This success was obtained by high-level government commitment," says Tedros Yehdego, Expanded Programme on Immunization Manager at Eritrea's Ministry of Health. "We also have partners in our country that are closely working with us, that is WHO and UNICEF. As a result of this joint work, the immunization coverage has increased at this time."

Gavi, the Vaccine Alliance, covers annual vaccine costs for twelve vaccines, procured via UNICEF's supply division. In 2024 and 2025 WHO funded operational costs for four rounds of periodic intensification of routine immunization (PIRI) services with support from Gavi Targeted Country Assistance and UN's Central Emergency Relief Fund. The costs include accommodation, training, daily allowances and transport for vaccination teams.

"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," says Dr Mary Stephen, WHO representative in Eritrea.

WHO provided technical support to develop 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 Ministry of Health at the national level and distributed to all regions.

"Every two months, we organize outreach activities to serve seven remote villages," says Saidia Ibrahim Suleman, assistant nurse at Dirfro Health Station. "While four of these can be accessed by vehicle, albeit with difficulty, the remaining three are only reachable on foot or by camel. Despite these challenges, we are ensuring that no child is left behind."

These successes are also boosting health worker morale. "There's no greater joy than knowing every child is protected," says Daniel Haile, an assistant nurse at Dirfro Health Station. "Our ultimate goal is to ensure each child receives their vaccines, overcoming any obstacle in our path."