In this newsletter, I will provide an overview of Djibouti's healthcare system, covering it's history, shortfalls and reforms that were carried out over the past 30 years to improve access to healthcare to the population.
History of the Healthcare system
Since the arrival of the French, healthcare became more centralised with the first healthcare facility officially opening by the Franco-Ethiopian railway company in the late 1890s and was designed to provide healthcare services for the French colonisers. Healthcare services slowly grew throughout the 1900s and facilities expanded to indigenous peoples. Such expansion included increased number of beds & improved infectious disease management services (i.e.: Tuberculosis, Malaria). Although improvements to these services occurred, they were relative to what existed before, and services remained largely inaccessible due to the language barrier and price of care & medications.
In addition to services remaining inaccessible, this was compounded by mistrust towards healthcare staff who were largely of French origin, this mistrust was mainly bred by the act of colonisation. The locals resorted to alternative traditional medicines that were more inexpensive and accessible. This mistrust towards “Western” medicine lingers till this day.
As Djibouti City became more urbanised in the 1970s through to the 1980s, there was an increase in infectious diseases such as cholera, malaria, tuberculosis & AIDS. Outbreaks of infectious diseases were amplified by poor water supply, non-existent wastewater evacuation systems & uncontrolled urbanisation. Improvements on wastewater evacuation systems have been made since these times, but it still remains an issue in larger neighbourhoods that tend to be overpopulated with the majority of inhabitants living in poverty.
In the 1990s, the civil war saw increases in poverty and unemployment which further set up barriers for the people to access adequate healthcare services. This contributed to the outbreaks of cholera & malaria in 1993 and pushed the government to implement reforms to the healthcare system as it became apparent the system couldn't handle stressful.
From the late 1990s, the government took steps to restructure the Ministry of Health to serve as a focal point for all aspects of Djiboutian life pertaining to health. The government also invested heavily in women's health and wellbeing to improve political representation, access to education, literacy and reduce infant mortality rates. These efforts were broadly successful, but work remains to be done.
Hopital Général Peltier - Established in 1900 & Renamed in 1950s in honour of General Peltier
The Modern Healthcare System
Reforms over the past 30 years have been supported by multimillion-dollar foreign grants, but the net government expenditure has hovered around the 6% mark of GDP for a while. These reforms and expansion of healthcare services have not managed to keep up with population growth, which has ballooned over the past 30 years. With a population largely unemployed, healthcare & medication costs became a large problem for the people to seek healthcare services when they need. The mistrust and language barriers were now largely overcome with a new generation of local healthcare professionals who trained locally for the most part.
Now, the main issues were the rise in healthcare & medication costs and the need to further increase the number of healthcare staff.
In 2008 the government announce the creation of a new institution that falls under the authority of the Ministry of Employment and Administrative Reform, termed CNSS (Caisse Nationale de Securité Sociale - National Social Security Fund ). This body would emerge from the fusion of two other institutions responsible for allocation of retirement funds & social protection. This body would oversee the establishment & operation of public healthcare insurance programs for registrants. These included programs for students, retirees and employees.
Through to 2015, the government would promulgate legislation setting the foundations for the different programs to be operational. However, various factors would see these services being undersubscribed to by the population I detail below. So despite the existence of healthcare insurance programs, only a fraction on the population would be covered.
Such factors include lack of formal employment where the employee, employer and government opt-in and contribute to a pool for the registrant insured and provides coverage. Many of those who initially registered were civil servants working in government, teachers and members of the army - members of society with the highest job security & stability. Their spouse and children under 18 would also be covered in these schemes.
However, the registration process would be more difficult for those working informally as their income fluctuates significantly, so even if they opted-in through the proposed self-employment schemes, they would not be able to contribute regularly & save enough for basic tests. This created a gap between a large portion of the public and access to healthcare services.
The less fortunate have the opportunity to access basic healthcare services through the Social & Health Assistance Programme (PASS). However, in order to qualify for this assistance program, the relevant government authorities need to assess their income and classify them as having "no income". This lack of nuance makes it more difficult for members who are underemployed, or employed in the informal sectors of the economy, receive healthcare support.
Fortunately, over the years since it's introduction, people have become increasingly aware of the importance of these services and actively took steps to register. However, the government needs to improve it's administrative efficiency and ensure the population are registered onto these services and aware of the options they have, as poor access to information seems to be a barrier between the people and available services.
The Next Steps
Moving forward, it's important the government widens access to healthcare services and better inform the public on the different options available to them. Additionally, it's important that the government improves the efficiency within administrative tasks, in both hospitals and offices. Improved organisation & transparency of data will facilitate the identification of where needs attention.
Furthermore, it's essential the government improves access to better jobs and takes steps to formalise the informal sectors of the economy. This will allow the government to capture a wide-margin of the population, collect much needed tax revenue and facilitate their coverage under the various health insurance programs. Also, there needs to be stronger enforcement of laws and hospital quality checks to ensure standards of treatment & medications are up to par.
Finally, Djibouti needs more specialised services such as psychiatric facilities, mental health services remain largely non-existent and is taboo. We also need to improve access to healthcare facilities in the rural areas that suffer from underfunding and administrative inefficiency.
Extra Reading & Sources:
http://digicollection.org/hss/documents/s17292e/s17292e.pdf
https://tel.archives-ouvertes.fr/tel-00842675/document
http://www.cnss.dj/index.php
You’re a legend for your continuous efforts in shinning light on Djibouti