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Economics & Development | Global Arab Network
Djibouti - significant progress in improving health services
Global Arab Network - - Amina Murtada
Thursday, 23 September 2010 23:45
Djibouti_Health_Sector_Development_Project
Djibouti has made significant progress in improving its health services, which nearly a decade ago were facing a growing threat from the spread of HIV/AIDS while they struggled to cope with high child and maternal mortality rates. Working with the World Bank, Djibouti had brought down the child mortality rate to 67 deaths per 1000 live births in 2006 from 124 in 2002, while HIV/AIDS prevalence among young pregnant women (15-to-24 years old) decreased to 2 percent in 2009 compared to 2.9 percent in 2002.

Challenge
Despite improvements in health status in the last few years, Djibouti’s health indicators remained among the lowest in the world. Both the infant mortality rate and maternal mortality rate were among the highest in the region, with an infant mortality rate of 124 per 1,000 live births and an maternal mortality rate of 546 per 100,000 live births in 2002. The tuberculosis rate of 588 cases per 100,000 persons was among the highest in the world. Malaria was also on the rise, with over 4,000 confirmed cases each year. In terms of capacity, the sector was in dire need of strengthening its health service delivery system and management capacity in order to achieve the Millennium Development Goals (MDGs).

Approach
The project was designed to address the need for strengthening Djibouti’s health service delivery system and management capacity in order to achieve the MDGs. The project’s main focus is on improving the health service delivery performance by supporting the delivery of (i) child health services such as immunization, Integrated Management of Childhood Illnesses, and treatment of malnutrition; (ii) maternal child health services such as perinatal care, family planning, skilled-attended delivery, and emergency obstetric care. The project was also granted an additional financing to support additional activities, originally supported under the HIV/AIDS, Malaria and Tuberculosis Control Project which closed in 2008, related to the delivery of (iii) prevention and treatment of HIV/AIDS and other prevalent communicable diseases through services such as Voluntary Counseling and Testing, and Directly Observed Treatment Short-course (DOTS). The project is also focusing on strengthening of health systems and management capacity.

Results
The project aims to improve the quality of health services in a sustainable manner in order to contribute to the progress towards achieving the health-related MDGs of reducing child and maternal mortality and combating communicable diseases.

* Child mortality rate was reduced to 67 deaths per 1,000 live births in 2006 from 124 deaths per 1,000 live births in 2002.
* Medically-assisted delivery reached 87.3 percent in 2006 compared to 44 percent in 2002
* Moreover, the proportion of children 12-23 months of age who are vaccinated with DPT3 before 12 months of age increased to 89 percent in 2009 from 45 percent in 2002
* HIV/AIDS prevalence among young pregnant women (15-to-24 years old) has decreased to 2 percent in 2009, compared to 2.1 percent in 2007 and 2.9 percent in 2002
* Moreover, the total number of students enrolled in the High Institute of Health Sciences has increased to 798 students in 2010 compared to 420 students in 2008.
* The total number of insecticide treated bed nets distributed to households in high transmission areas has increased to 404,000 bed nets in 2010 compared to 136,000 bed nets in 2008.

Bank Contribution
The Bank has been the leading donor in the health sector through two major projects: the ongoing US$15-million Health Sector Development Project (HSDP), and the HIV/AIDS, Malaria and Tuberculosis Control Project, including a grant of US$12 million, which closed in 2008. Based on the need for strengthening the health sector capacity and at the request of the Government of Djibouti, the International Development Association (IDA) granted an additional financing to the HSDP in the amount of US$7 million to continue and expand the HSDP initiative by adding some activities that were supported by the completed HIV/AIDS project.

Partners
There is a strong partnership among key development agents in the health sector in Djibouti. Periodic development partners’ meetings, led by the Ministry of Health, help coordinate investments and analytical work. IDA’s US$22-million credit/grant for the HSDP, is complemented by US$6 million from the Islamic Development Bank, US$10 million from the African Development Bank, US$15 million from the Global Fund to Fight AIDS, Tuberculosis, and Malaria, US$12 million from the United Sates Agency for International Development (USAID), and US$7 million from the French Development Agency (AFD). Coordinated support increases the momentum of sector reforms while promoting improved transparency and accountability in national systems.

Moving Forward
Ongoing IDA support is addressing the health-related and HIV/AIDS challenges within the context of the additional financing of the Health Sector Development Project, launched in 2009. Moreover, the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria stepped up its support to Djibouti’s National HIV/AIDS Program following the completion of IDA’s HIV/AIDS Control Project in 2008, and USAID’s ongoing support is addressing malnutrition challenges. However, despite the contributions of different development partners, financial sustainability of health sector and HIV/AIDS programs remains a challenge.

Beneficiaries
Djibouti has an extremely high incidence of poverty as reflected by 42 percent absolute poverty rates. It is estimated that the poor constitute about 40 percent of the urban population and 60 percent of the rural population. The standard of living is very low, particularly in rural areas as manifested by the high incidence of informal and sub-standard housing and low rates of access to basic services. Most of the project service activities are limited to the primary and secondary health facility levels in rural and peri-urban areas (usually settlements on the outskirts of cities), which are mostly utilized by the poor (more than 73 percent of users of health posts are considered poor). This has been a key design feature to improve access and health outcomes among the poor.

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