Djibouti’s health sector has a limited number of primary, secondary and tertiary health facilities. Medical facilities are largely concentrated in urban areas, with fewer services available in rural areas. Despite these challenges, new policies from the government and external partners – including the World Bank – are expected to support the development of the public health sector to provide greater medical care to both Djiboutians and the country’s refugee population.
Structure & Oversight
Although the government has been gradually developing Djibouti’s health care sector, spending as a percentage of GDP and per capita both remain below the country’s emerging market counterparts. Djibouti’s health care expenditure as a percentage of GDP was 1.8% in 2019, compared to 4.7% for Egypt and 6.7% for Iran, the MENA region’s two most populous countries, while the global average was 9.8% that same year. Per capita spending in Djibouti was $61.81 in 2019, compared to $149.84 for Egypt, $470.43 for Iran and the global average of $1115 for that year. Health care investment by international actors has facilitated efforts to improve care, with external health care expenditure accounting for 20.8% of total health care spending in 2019, compared to 25.9% in 2017. There were approximately 66 medical centres in Djibouti owned by the government or the Ministry of Health (MoH) as of January 2019, comprising 41 health posts, 12 community health centres, eight tertiary hospitals and five hospital medical centres.
The MoH is responsible for implementing the government’s health care policy, as well as overseeing the public health sector and the government’s pharmaceutical policies. The ministry is also responsible for promoting good physical, mental and social health practices. However, the MoH has limited oversight over the growing private health care sector.
While the MoH is responsible for the sector at the national level, medical directors of regional hospitals are essentially responsible for regional-level health care. This highly decentralised model allows for such directors to make decisions tailored to the demands of the communities in which they work. However, there are certain challenges associated with such a system of management, one of which is that it is difficult for these medical directors to both coordinate regional responses and fulfil their existing work obligations.
A May 2022 World Bank report highlighted some of these issues, as the fragmented nature of the segment makes accountability mechanisms for health care facilities and practitioners difficult to implement. Djibouti requires further investment in and training for better reporting systems to improve oversight of public services. The World Bank report found that mechanisms such as official accreditation, licensing, training, supervision, clinical mentorship and clinical audit systems are inconsistent, and improving them would lead to better management at the national level.
The government’s most recent health care policy is the National Health Strategic Plan (Plan National de Développement Sanitaire, PNDS) 2020-24, which seeks to improve the provision of care and accountability at the regional level. The plan has five strategic priorities: expanding quality care to all parts of the country; integrating promotive, preventive and curative care; providing greater accountability and good governance; increasing funding for the sector; and strengthening the country’s Health Management Information System. To that end, the government is working with the World Bank to carry out far-reaching health care reforms through a consultative process with the international organisation to support improvements to the country’s health care system and the quality of services provided, as well as strengthen its human resources.
Pandemic Response
In response to the Covid-19 pandemic, the government closed schools and businesses from March to August 2020. According to official figures, Djibouti had reported 15,690 confirmed cases of Covid-19 and 189 deaths as of May 2023, although no confirmed cases had been reported since June 2022. Djibouti is part of the COVAX initiative – a coalition co-led by the World Health Organisation (WHO), Gavi, the Vaccine Alliance and the Coalition for Epidemic Preparedness Innovations – and received its first Covid-19 vaccine doses in March 2021. As of December 6, 2022, 338,051 doses had been administered, with the country having received 458,880 doses in total through COVAX.
General Indicators
Several health care indicators have improved in recent years. For example, life expectancy at birth – the average number of years a newborn is expected to live if mortality patterns at its birth remain constant, a figure derived from World Bank data – rose from 64.1 years in 2015 to 67.5 in 2020. Djibouti’s place in the UN Sustainable Development Goals Indicator 3.8.1 index, coverage of essential health services – meaning that people receive necessary care without incurring severe financial consequences, a figure derived from indicators such as the average coverage of infectious diseases and service capacity – was 48 out of 100 points in 2019, up from 32 in 2005.
There are several challenges to health care provision in Djibouti. One is that while the population grew, the number of hospital beds per capita dropped from 1.8 per 1000 people in 2002 when the population was 795,000 to 1.4 in 2017 when the population was 944,000. There is also a gap in terms of access to water, sanitation and hygiene services, particularly in rural areas. In 2020, 76% of the population had access to basic drinking water, while 66.7% had access to basic sanitation services. In addition, a dearth of trauma services in the country means that patients with serious conditions must be transported to neighbouring countries for related treatment.
The number of trained medical staff relative to Djibouti’s overall population is low despite recent progress. The number of medical staff rose 103% between 2008 and 2017, with an average of seven skilled medical workers per 10,000 people as of 2017 – a figure well below the WHO’s minimum recommended density of 44.5. These numbers are lower for the rural areas of Tadjoura, Ali-Sabieh and Dikhil, which had on average 0.6 general practitioners per 10,000 people in 2017.
Certain areas of health care for women have seen improvements. For example, the percentage of births attended by skilled health staff rose from 78% in 2007 to 87% in 2012, leading to the maternal mortality rate falling from 507 deaths per 100,000 live births in 2000 to 248 by 2017. However, the rate of 3.2 maternity beds per 1000 pregnant women is below the WHO-recommended number of 10 beds per 1000 pregnant women.
Diseases
While the proportion of communicable diseases in all deaths fell from 51% in 2010 to 37% in 2019, the proportion of non-communicable diseases rose from 40% of deaths to 52% over the same period. The mortality rate for children younger than five years of age was 56 deaths per 1000 live births in 2020, higher than the global average of 37 in 2020 but below the average rate of 64.8 for the Horn of Africa (Djibouti, Eritrea, Ethiopia and Somalia). Communicable diseases and childhood health conditions such as malnutrition comprised seven of the top-10 causes of death for women and girls in Djibouti in 2019.
The prevalence of tuberculosis (TB) has vacillated in recent years, with efforts to eradicate the disease complicated by the large refugee population and migrant flows. Despite these challenges, TB cases fell significantly, from 621 per 100,000 people in 2010 to 224 in 2020, a drop mainly attributed to more vaccinations, with the percentage of fully immunised children at 62% in December 2020, compared to 32% in December 2012.
Climate change, a problem that has impacted Djibouti, seems to be exacerbating health challenges. It is expected that changing global temperatures will increase cases of vector-borne diseases such as malaria and water-borne diarrhoeal diseases. A survey of households conducted from 2017 to 2018 by Djibouti’s Department of Statistics and Demographic Studies found that malaria and fever, and diarrhoea were the top-two reasons households sought medical attention for children in the previous month. This trend continued, with the number of reported cases of malaria rising from 49,402 in 2019 to 72,332 in 2020.
Fourteen health care facilities in Djibouti City were damaged during flash floods in November 2019, and there are concerns that events such as those could become more common as the average temperature rises. Indeed, the Notre Dame Global Adaptation Initiative Index for 2020 ranked Djibouti at 122th out of 182 countries because of its vulnerability to climate change-related effects. Djibouti is likely to face more aridity, less precipitation and rising sea levels, which are expected to lead to greater water scarcity and drought, causing food insecurity and water shortages.
Since Djibouti is a net importer of food, Russia’s war in Ukraine is expected to exacerbate the country’s food insecurity, with wheat prices and other costs spiking due to the conflict. Humanitarian organisations reported increased levels of malnutrition in 2022 because of the ongoing drought and higher food prices.
Private Health Care
The private health care sector is concentrated mainly in Djibouti City, and a relative lack of regulation has led to sector fragmentation. Primary and secondary health services are free in government facilities for Djiboutians and refugees, while tertiary care is mainly paid for out of pocket – a potential deterrent to those seeking medical attention – as are medications. Out-of-pocket spending accounted for 29% of Djibouti’s total spending in 2018, compared to 23% in 2012. The Ministry of Social Affairs and Solidarity offers subsidised health insurance for the poorest households to access tertiary and urgent care. However, few Djiboutians are enrolled in this system, and many seek medical care at free primary and secondary facilities even when they require tertiary care.
Medical Supplies
Medicine in Djibouti is expensive and often in short supply. The Purchasing Centre for Medicines and Essential Products (Centrale d’Achat des Médicaments et Matériels Essentiels, CAMME) requires a reliable cold chain for vaccines and certain essential medicines, which can be difficult due to high outdoor temperatures and extreme weather. As such, it will be important in the coming years to bolster CAMME’s warehousing capabilities, especially considering that the potential effects of climate change are likely to make such storage facilities all the more necessary.
The WHO’s “Service Availability and Readiness Survey 2015” reported that 2% of Djibouti’s essential medical facilities had all of the necessary elements, while 32% had an average level of availability. In July 2022 the US Agency for International Development, the US Embassy Djibouti’s Office of Security Cooperation and US naval base Camp Lemonnier together donated a second mobile field hospital valued at $4m to the MoH. The hospital has a water supply, plumbing, power generators and biomedical equipment, and it can respond to disasters or complement existing medical centres. Such facilities can alleviate the burden on Djibouti’s health care infrastructure until greater funding is available.
Public & Private Investments
In September 2020 the Djibouti Sovereign Fund was launched. The government plans to increase the value of the fund’s portfolio assets to $1.5bn by 2030 to support investment in the economy and in health care in particular.
The World Bank and partner organisations have offered substantial funding and expertise to the government to undertake countrywide reforms that are in line with the World Bank’s Country Partnership Framework 2022-26 and Gender Strategy 2016-23. The May 2022 World Bank report outlined the Djibouti Health System Strengthening Project, which will run until May 2027 at a cost of $19.5m. The objective of this programme is to improve the utilisation of quality reproductive, maternal, neonatal, child, adolescent health and nutrition services, with priority given to underserved areas, refugees and host communities. The MoH will be responsible for managing the project.
Pharmaceuticals
Djibouti largely relies on imports for its pharmaceutical and medical equipment needs. However, efforts are being made to bolster local pharmaceutical production. In November 2022 the African Development Fund announced it had approved a $6.6m grant for the COMESA region. The project, which runs from 2023 to 2025, is expected to contribute to the development of regulatory bodies, product quality control and management systems, as well as research and development institutions. The hope is that this will allow for the manufacture and sale of quality pharmaceutical products in the free trade area.
Outlook
Access to health care in Djibouti has improved in recent years, but challenges remain in rural areas. The public health care system continues to face fragmentation, and there are consistent challenges related to effective data reporting and evaluations of medical services at the national level. However, the PNDS 2020-24 demonstrates the country’s dedication to building a strong health care sector. Greater investment and expert support from the World Bank and other international organisations are expected to help Djibouti develop its health care sector to provide medical care to Djiboutians and the refugee population.
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