Country profiles

Djibouti

Overview

Djibouti, which lies at the southern entrance to the Red Sea, has a coastline of 370 km and an area of 23 000 km². Most of the country is desert and arid, but there is a narrow area of fertile highland. Because of its geographical situation, Djibouti’s economy depends on the services and trades are related to the activities of its airport, its harbour and the railway line connecting Djibouti to Addis Ababa. The overall average gross national product per capita was US$ 480 in 1993. According to the estimates of the National Directorate of Statistics (DINAS), the population was 570 000 in 1994 and the annual population increase was to 6.1% (1994). Additionally, the percentage populations below 15 years of age and above 65 years of age were given in 1996 as 37.6% and 2.1%, respectively. The total adult literacy rate and the adult female literacy rate in 1996 were 57.2% and 40%, respectively. According to the most recent statistics, the infant mortality rate is 114 per 1000 live births (1993) and the maternal mortality rate is 74 per 10 000 live births (1989). The crude birth rate in 1994 was 47.5 per 1000 population. The total life expectancy at birth was given as 48 years in 1993. In 1990, the under-5 mortality rate was estimated at 164 per 1000 live births.

Administratively, the country is divided into five districts.The Ministry of Public Health and Social Affairs has defined its health policy and has implemented a five-year plan (1991-95) for developing health systems. The general objectives of this plan are as follows:

• training of human resources

• strengthening preventive programmes

• improving hospitals

• ensuring the stability of the Djibouti family

• developing community involvement

• recognizing the importance and promotion of urban health services and adopting a national drug policy.

Health activities in the public sector are fragmented and divided among several ministries, with the Ministry of Public Health and Social Affairs bearing the major responsibility.

The health services infrastructure may be depicted as a pyramid of referral institutions. At the first level of contact, the system includes small units, which provide health care to remote or nomadic communities. They also offer some maternal and child health care. The middle tier of the pyramid consists of district hospitals with 283 beds which provide non-specialized inpatient or outpatient care and supervise the activities of the rural health units under their jurisdiction. There is a tuberculosis service attached to each district health centre. In 1998, there were 24 primary health care centres all over the country even though the functioning of those located in northern districts of Tadjourah and Obock were severely impaired during the civil war of 1991-93. At the apex of the pyramid, there is the Hôpital Générale Peltier, the general hospital in Djibouti City, which has 610 beds and which provides primary and specialized inpatient and outpatient services. There is, in addition, a small urban childcare hospital with 25 beds and a maternity hospital with 50 beds. Besides the public health sector, there are three small private hospitals (or clinics) with 61 beds.

Many national and foreign nongovernmental organizations take part in the health programmes; their actions are increasingly more coordinated with those of the health ministry. Community involvement is a significant component of the health-for-all strategy being implemented in Djibouti. Community involvement in effect consists of the contribution, according to needs of the districts committees in order to face specific problems. Efforts have been made in the health field towards better coordination of the various nongovernmental organizations in the country. These are quite numerous and include the Catholic Relief Service, the Red Sea Mission, the French Organization of Volunteers for Progress (AFVP), Médecins sans Frontières, and at the local level, the National Union of Djibouti Women.

The total government health budget in 1998 was 5.65% of the national budget. In 1998, there was a total of 101 physicians (i.e. 1.5 per 10 000 population), 4 medical assistants, 8 pharmacists, 9 dentists, 53 midwives, 214 nurses, 226 auxiliary nurses and 51 laboratory technicians.

In 1990, with the collaboration of WHO, a continuing education unit was set up to take charge of training of nursing personnel in the management of services. Strengthening human resources is an essential component of the national health development plan. This programme aims to:

• improve the qualifications of health personnel

• increase the number of students in medicine, dentistry and pharmacy

• increase the number of trained paramedical workers

• assume responsibility for progressive replacement of the technical staff serving under cooperative agreements

• develop the national centre for the training of health personnel and organize a national programme for continuing education and "recycling".

Djibouti’s health policy has never been clearly defined until recently . A policy has been formulated and adopted by the government, which has incorporated it into the national social and economic development scheme for the next five years. In order to implement this policy, a national health plan has been worked out by the Ministry of Public Health and Social Affairs with the cooperation of WHO on the basis of the health-for-all strategy. This six-item policy gives significant priority to training human resources in order to best serve the objectives and the needs of primary health care, which constitutes the policy’s main pivot. Political commitment to the health-for-all strategy has been expressed by allotting operating resources to primary health care services: the primary health care share of the health budget has increased from 30% in 1982 to 40% in 1990.

Moreover, for the first time in the history of Djibouti’s health ministry, both urban and rural health facilities will themselves manage their own budget; this will contribute to greater efficiency.

MENTAL HEALTH

Mental health problems continuously increasing due to the rapid and profound changes of lifestyle and the decrease of tolerance vis-à-vis mental patients. These facts are particularly noticed in urban areas and traditional culture is progressively abandoned, and western civilization is taken up. The mental patient is given more and more to the charge of public health services and traditional practices are less and less resorted to. Accordingly, it is necessary and urgent to organize mental health services .

Even though no study has been conducted on the role of khat in mental disorders in Djibouti, the consummation of khat by the majority of the population may be a cofactor of mental disorders.

The majority of khat consumers in Djibouti are poor and frequently unemployed. It is then generally believed in Djibouti that the interaction of these physiological effects and social consequences of khat can have, on the long run, an impact on the equilibrium of mental health of the individual.

There is essentially a belief system regarding mental diseases in Djibouti. It relates to djinns and shaytans, spirits of Islamic origin. Djinns can be good or bad: shaytans are always dangerous. The sheikhs make a diagnosis and administer magico-religious treatments. Contrary to what happens in west Africa or in Madagascar, the "attacks of sorcerers" seems rare. Similarly, belief in maraboutage (magic motivated by the deliberate intention of harm) does not seem to be widespread in Djibouti. However, the knowledge of the general public in this regards is very limited and the health personnel are reticent to tackle such problems.

Currently, the system of psychiatric assistance is limited to the department of psychiatry of the Hôpital Peltier in Djibouti. The department has 50 beds, and its dilapidated condition does not make it possible to treat patients while respecting their dignity.

The department of psychiatry at the Hôpital Peltier receives approximately 500 patients every year. The period of hospitalization is one month on average. Ambulatory treatments follow hospitalization. This solution, which yields good results, involves great difficulties for the patients who live far from Djibouti. The hospitalized patients represent only a segment of the people who could profit from psychiatric care. The number of people who seek consultations is more than 2000 every year. These consultations relate to acute or chronic diseases for which hospitalization is either not deemed necessary or is not possible because of lack of space.

There are at present in Djibouti one psychiatrist, one chief nurse and six nurses or assistant nurses.

All psychiatric assistance and care given are centralized in Djibouti. There is no community based psychiatric care. All the patients come to see the treating personnel.

In order to cover the whole country effectively, a national mental health programme will have to use both the existing health infrastructure and the medical and paramedical personnel available. The only problem that should be solved preliminarily is that of personnel training. This may be done efficiently, with limited means, by short-term courses at the department of psychiatry, Hôspital Peltier. In addition to the training of psychiatrists, it is necessary to provide general practitioners with sufficient information on some aspects of psychiatry. This type of training may be conducted in short-term courses at the department of psychiatry.