Addressing challenges and facilitating universal health care in Djibouti's urban and rural areas

Meeting the health care needs of Djibouti’s citizens in both concentrated urban areas and diffuse rural populations has led to differentiated policies based on region. To achieve the goal of universal coverage, the government of President Ismaïl Omar Guelleh has committed itself to improving health care access in the inner regions, providing care to vulnerable populations and boosting coordination with global partnerships in support of its Vision 2035 development strategy, which aims to grow Djibouti’s economy in part by prioritising investment in human capital through education and health care.

Government Policy

The development of Djibouti’s health care sector is guided by the 2018-22 National Health Development Plan (Plan National de Développement Sanitaire, PNDS), which is grounded in a results-based management approach that prioritises accountability and implementation over financial input. The Ministry of Health (Ministère de la Santé, MoS) has been tasked with implementing the strategy with an operating budget comprising 6.73% of total government expenditure. The PNDS is primarily concerned with providing quality care and accessibility, carrying out disease and sickness prevention campaigns, and strengthening governance and information management. While the government’s strategy to improve the quality of provision has taken the form of fairly straightforward ICT integration, equipment updates and foreign partnerships in the medical field, its moves to increase accessibility have been more complex. In addition to reaching vulnerable populations via periodic medical caravan excursions, the government has also committed itself to bringing refugees into its health care system, prioritising care for mothers and children, and establishing universal access in the country.

The MoS has focused greatly on providing curative services in 2017 and 2018, which include a polio vaccination campaign, and the initiation of traveling clinics and medical caravans to reach rural populations. The MoS also ran a project in November 2017 to bring modern medical technologies to hospitals and community health centres in the five inner regions, which include most of the county’s territory excluding Djibouti City and its urban surroundings.

Medical Staff

The sector has benefitted from an increase in the number of health care professionals in the past 10 years. In 2007 the country’s first faculty of medicine opened at the University of Djibouti. The facility currently trains approximately 40 general practitioners per year to serve in locally, while the publicly run Higher Institute of Health Sciences, which opened in 2007, has recruited and trained over 800 paramedical staff in total.

The opening of higher education avenues has gone a long way in boosting the number of qualified staff. In 2008 the overall sector workforce amounted to 1664 individuals, by 2017 that number had more than doubled to 3381 personnel, including 110 general practitioners and 129 specialist doctors. There were 1.35 general practitioners, 3.35 nurses and 2.15 midwives per 10,000 people in 2017, according to the MoS. While the availability of specialist doctors is largely confined to the capital city, the MoS has announced its intention to open specialisation courses at the University of Djibouti. Currently, the ministry sends around 20 doctors abroad each year to receive specialisation training.

Key Indicators

As of 2015 Djibouti was home to seven hospitals providing tertiary-level health care. This includes the main referral hospital in the capital city, Peltier General Hospital (Hôpital Général Peltier, HGP). At present, HGP is the pilot hospital for a government-run project that is looking to extend total management autonomy to all tertiary-care facilities to improve services and efficiency.

The MoS is also in the process of opening five new polyclinics to bolster intermediary and secondary care provision between community health centres and hospitals. It is expected that limiting the number of hospital referrals given to patients while providing care at polyclinics will reduce strain on large hospitals. With the help of World Bank financing and guidance, the first clinic opened in March 2018.

In terms of capacity, as of 2016 there were 10.68 general hospital beds per 10,000 people, according to officials from the MoS, The region of Arta has the highest ratio with 21.37 beds per 10,000 people, followed by Djibouti City with 12.55. Provision is uneven, however, with the five interior regions recording figures ranging between 3.91 and 8.24 hospital beds per 10,000 individuals.

Government policy, in tandem with funding and direction from the World Bank, has emphasised the importance of maternal and children’s health care. World Health Organisation (WHO) standards suggest around 10 maternal hospital beds per 1000 pregnant women. Across the country, however, this figure averages out to 3.22. Arta, again, outperformed other regions, with 9.25 beds per 1000 pregnant women.

The country’s average life expectancy has recorded steady growth for nearly 20 years, according to the World Bank, coming in at 62.5 years in 2016, up from 60.36 in 2010 and 57.01 in 2000. Current figures put it ahead of both the sub-Saharan average of 60.4 and regional neighbour Somalia with 56.3, but behind Eritrea (65.1) and Ethiopia (65.5). UNIVERSAL HEALTH SYSTEM: Since the launch of the Universal Health Insurance (Assurance Maladie Universelle, AMU) system in 2014, authorities have strived to provide heath care access to 100% of its citizens. Djibouti’s AMU, which was implemented by the National Social Security Fund (Caisse Nationale de Sécurité Sociale, CNSS), consists of two main components: Compulsory Health Insurance ( Assurance Maladie Obligatoire, AMO), which is based on individual contributions, and the Social Health Assistance Programme (Programme d’Assistance Sociale de Santé, PASS) for people without income.

The AMO requires social contributions on the part of Djiboutian civil servants and employees hired under the Djiboutian Labour Code of up to 7% of their gross annual income. Generally, 2% is charged to the employee while the remaining 5% is paid by the employer. PASS, which was launched in 2016, is geared specifically towards providing health care for vulnerable households, people with special needs and the elderly poor. From 2016 through April 2018 the CNSS registered 37,435 individuals, 34,671 of whom reside in rural areas, which coincides with the MoS’s pivot towards providing care for the inhabitants of Djibouti’s rural interior regions.

Accessibility

While the health care infrastructure in Djibouti is concentrated in the capital, the accessibility of care for rural inhabitants has been a continuous struggle. However, this issue is being met with direct government action. Since 2017, the MoS has prioritised the provision of health and medical services to the 29% of the population living outside of the capital city. In 2017 the MoS began sending out medical-surgical caravans to rural areas in an effort to deliver health care to underserved populations. While the first initiative in November 2017 covered the southern regions, the second in January 2018, addressed the needs of residents in the Obock and Tadjourah regions, where approximately 6000 patients were seen by around 30 specialised physicians and senior technicians.

Financial accessibility to pharmaceuticals remains a key challenge. The MoS attributes this difficulty to a lack of harmonisation of prices in the private sector, and is currently in the process of undertaking a major reform of the Purchasing Centre for Medicines and Essential Products (Centrale d’Achat des Médicaments et Matériels Essentiels, CAMME). The government, through the MoS, has tasked CAMME with the supply, distribution and sale of medicines in both the private and public sectors since 2004.

Refugee Camps

Adding to the burden of health care provision, Djibouti has taken in over 27,800 refugees from its neighbouring countries, particularly from Somalia and Yemen — a number that amounts to 3.1% of the country’s total population. As such, Djibouti has one of the highest densities of refugee populations in the world. To address this, the government has been active in promoting the integration of refugees into the country’s health care system.

With funding from the EU, Djibouti’s MoS launched a programme of mobile medical assistance for migrants in collaboration with the International Organisation for Migration (IOM) in December 2017. The traveling clinics, mobilised along the country’s migratory corridor, provide both primary and emergency medical support to vulnerable populations.

The IOM also assisted the MoS in establishing a medical centre with 20 hospital beds, an infirmary, pharmacy, as well as consultation and observation rooms, which opened in March 2018 at its Migration Response Centre in the Obock region. The opening of the centre, which also caters to the needs of local residents, is part of a wider commitment to the Better Migration Management programme, an EU initiative intended to make migration in the Horn of Africa region safer by addressing, in particular, the needs of vulnerable migrants, with an emphasis on women and children. The programme was launched for a three-year period in April 2016, with financial backing from the EU and Germany’s Federal Ministry for Economic Cooperation and Development.

International Support

The Djiboutian health sector has been the subject of considerable international intervention, particularly on the part of Turkey, which has financed a series of educational institutions and programmes. One such example involves the Turkish Cooperation and Coordination Agency (Türk Isbirligi ve Koordinasyon Ajansı Baskanlıgı, TIKA), the department responsible for organising and implementing development projects abroad. The agency has committed to the financing and construction of a new paediatric hospital in recognition of the Djiboutian government’s prioritisation of maternal and child health services. Official documents were signed by TIKA and Djiboutian officials in July 2018.

Turkey has also supported the MoS’s medical caravan programme, and in May 2018 sent its own medical mission of between 20 and 30 Turkish specialist doctors and paramedics to assist. In addition to gifting five ambulances and helping 3100 patients during the four-day mission, Turkish and Djiboutian officials committed to pursuing a partnership between the two countries on pharmaceutical and drug policy.

The US and China have also been making their own interventions in the Djiboutian health sector. Both countries have military bases in Djibouti, and use their presence to leverage their humanitarian interventions. Since 2016, for example, the US Kentucky Army National Guard has been visiting Djibouti and sharing their medical expertise with doctors as part of Kentucky’s State Partnership Programme with the country. In conjunction with the Texas Army National Guard, medical practitioners met with local health care professionals in February 2018 to share best practices for diagnosis and treatment.

On the part of the Chinese, the government sent their Daishan Dao (Peace Ark) naval hospital ship to Djibouti in August 2017 in order to provide free medical services to residents over a nine-day period. The medical vessel was commissioned in 2008 to conduct humanitarian assistance operations in peacetime, with 300 hospital beds and eight operating theatres.

Nutrition

One of the other pressing health challenges currently facing Djibouti is that of nutrition. Food insecurity remains a persistent issue, mainly due to the country’s lack of arable land, low rainfall and limited ground water resources, all of which contribute to an almost non-existent agricultural sector. Approximately 200,000 people, mainly in rural areas, are in need of urgent food aid with 30% of children between six months and five years suffering from chronic malnutrition, according to a report issued by the World Food Programme in July 2018.

In an effort to mitigate food shortages, the government and the MoS validated a new strategy aimed at preventing malnutrition, stunting and food waste in January 2018. This new approach to preventing malnutrition will coincide with Djibouti’s Vision 2035 strategy for national development and emphasise the need for multi-sectoral solutions to address its many causes. For example, the MoS is working closely with the Ministry of Agriculture, Livestock and Fisheries to improve food security issues in rural areas by encouraging sustainable agricultural practices. However, until the country’s new approach is able to fully come into affect, Djibouti will remain highly dependent on food imports and international financing provided by developmental partners.

The World Bank has committed an additional $15m to the Towards Zero Stunting in Djibouti Project to help the government in its efforts to build a healthy population. The project was launched in June 2018 with the intention of reducing growth and development problems in children under the age of five. According to the WHO, the stunting rate in Djibouti is 29.7%, exceeding the critical threshold of 40% in three regions: Obock (45.9%), Dikhil (44.2%) and Tadjourah (40.8%). Aimed at providing 100,000 women and 50,000 children with health and nutrition support, this project focuses on the first 1000 days from the beginning of pregnancy to the child’s second birthday, when stunting becomes largely irreversible. The programme also encourages breastfeeding and looks to ensure that 80% of children are fully immunised by the age of one.

Water Resources

Rainfall has decreased by 50% over the past decade, leading to chronic drought since 2008. According to UNICEF, a severe lack of water affected 200,000 people in 2017, up from 130,000 in 2016, 20,000 of who were children under the age of five. While between 1990 and 2015, the percent of the population with access to safe water increased from 78% to 90%, the urban-rural disparity is particularly significant. Around 97% of urban populations had access to safe water sources in 2015, compared to 65% of rural populations. A $7m World Bank project entitled Financing for the Rural Community Development and Water Mobilisation has been in effect since 2012 in two iterations, with aims to increase access to water for rural populations and develop community management of agro-pastoral resources through December 2019.

Additionally, the government is also overseeing the completion of a 374-km water pipe between Ethiopia and Djibouti, financed by a $322m loan from the Chinese Import Export Bank and built by Chinese construction and engineering company CGCOC Group.

Communicable Disease Prevention

The World Bank’s Improving Health Sector Performance project aims at preventing and improving treatment of communicable diseases such as HIV/AIDS, tuberculosis and malaria. While the HIV-positive community in Djibouti is 1.3% of the country’s population, this rate has steadily declined since reaching a high point of 2.8% in 2002. The epidemic has stabilised since 2003, when the World Bank initiated its five-year, $12m Djibouti HIV/AIDS, Malaria and Tuberculosis Control Project, which spread preventative awareness through campaigns and the engagement of religious and community leaders. A $12m grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) in 2005 build upon this momentum and further curbed the epidemic by scaling up access to antiretroviral treatments.

Malaria, on the other hand, has become increasingly threatening as its incidence rate per 1000 at-risk individuals increased from 7.7 in 2010 to 25.4 in 2015, according to World Bank figures. The reasons for this increase are rooted in both climate change, which has caused malaria seasons to intensify and fluctuate, and the influx of migrant populations from neighbouring countries, a proportion of whom bring the disease into the country. Approximately half of Djibouti’s population lives in at-risk zones, and in May and June 2018 the government conducted a door-to-door spraying campaign in these zones in order to prevent the disease’s spread.

Tuberculosis is also a particular concern in Djibouti, with an incidence rate of 335 out of 100,000 people. The country’s crowded refugee camps are particularly fertile grounds for outbreaks, and in January 2018 the government partnered with the UN Development Programme, UN High Commissioner for Refugees and the Global Fund have together worked to bring diagnosis and treatment services into these spaces. Thanks to efforts like these, the number of confirmed cases of tuberculosis in the Ali Addeh refugee camp have decreased by half since 2013. This new partnership intends to build on this progress towards the ultimate goal of ending the country’s tuberculosis epidemic by 2030, in line with the UN Sustainable Development Goals. While Djibouti’s incidence rate is still comparatively high, it has lowered considerably since 2007, when it was estimated by the WHO to have the second-highest incidence rate per capita in the world.

Outlook

As the population increases, there will be a rising demand for health care services, particularly in rural settings. While sustained economic growth will eventually lead to a reduction in the amount of international aid required in the long term, significant global intervention in the sector appears set to improve overall indicators, in terms of nutrition and maternal health particularly. The ambitious goals of the PNDS 2018-22 to provide quality universal health care in both urban and rural areas, and stem the prevalence of communicable diseases may prove to be a challenge, especially given the influx of refugees. However, the government has been active in boosting the sector’s capacity to provide sufficient care, which points to a positive outlook in the medium term.