Climate and Health Vulnerability Assessment DJIBOUTI CLIMATE INVESTMENT FUNDS © 2024 International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory, or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. The World Bank encourages the dissemination of its knowledge; thus this work may be reproduced, in whole or in part, for noncommercial purposes, as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover image: Djibouti, Etiopía, children at Lake Abbe. February 9 of 2024. DJIBOUTI Climate and Health Vulnerability Assessment April 2024 CLIMATE INVESTMENT FUNDS TABLE OF CONTENTS ACKNOWLEDGMENTS.........................................................................................................................................vi LIST OF ABBREVIATIONS...................................................................................................................................vii EXECUTIVE SUMMARY...................................................................................................................1 INTRODUCTION .............................................................................................................................5 Country Context.................................................................................................................................................... 5 Aims of this Assessment and Conceptual Framework.................................................................................. 6 I. CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS.............................................9 Djibouti’s Geography............................................................................................................................................ 9 Observed and Projected Climatologies..........................................................................................................10 Climate-Related Hazards.................................................................................................................................... 14 Key Messages....................................................................................................................................................... 17 II. CLIMATE-RELATED HEALTH RISKS........................................................................................ 19 A. Nutrition risks..................................................................................................................................................20 B. Vector-borne disease (VBD) risks...............................................................................................................23 C. Waterborne disease (WBD) risks.................................................................................................................24 D. Heat-related mortality and morbidity.........................................................................................................25 E. Air quality risks................................................................................................................................................26 F. Direct injuries and mortality..........................................................................................................................28 G. Mental health and well-being risks.............................................................................................................29 III. ADAPTIVE CAPACITY OF THE HEALTH SYSTEM ...............................................................33 Health System Overview................................................................................................................................... 33 A. Leadership and Governance........................................................................................................................ 33 B. Health Financing............................................................................................................................................. 34 C. Health Workforce............................................................................................................................................36 D. Health Information Systems (HIS)...............................................................................................................36 E. Essential Medical Products & Technologies.............................................................................................. 37 F. Health Service Delivery................................................................................................................................. 38 Summary of Health System Adaptive Capacity Gaps for Djibouti............................................................40 iv | Climate and Health Vulnerability Assessment: Djibouti IV. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE..................................................................................................................43 Leadership and Governance............................................................................................................................. 44 Health Financing................................................................................................................................................. 44 Health Service Delivery..................................................................................................................................... 44 Essential Medical Products & Technologies.................................................................................................. 44 Health Workforce................................................................................................................................................45 Health Information Systems (HIS)....................................................................................................................45 ANNEXES........................................................................................................................................47 REFERENCES.................................................................................................................................57 INDEX OF TABLES Table 1. Extreme weather events, injuries, and mortality in Djibouti from 1980 to 2022...........................28 Table 2. Key Climate Change and Health-Related Policies............................................................................... 34 Table 3. Public Medical Facilities (2019).................................................................................................................39 Table 4. Categorization of recommendations.......................................................................................................45 INDEX OF FIGURES Figure 1. Operational framework for climate-resilient healthcare systems.......................................................7 Figure 2. Administrative boundaries of Djibouti..................................................................................................... 8 Figure 3. Elevation of Djibouti and major cities.....................................................................................................10 Figure 4. Monthly and seasonal climatology observed in Djibouti, 1991–2020.............................................11 Figure 5. Showing projected days with the heat index > 35°C anomaly.........................................................13 Figure 6. Risks of coastal, river, and urban flooding in Djibouti (left to right).................................................15 Figure 7. Projected water stress for Djibouti (2040)............................................................................................22 Figure 8. Tropospheric nitrogen dioxide (NO₂)..................................................................................................... 27 Figure 9. Rainfall-induced landslides in Djibouti..................................................................................................28 Figure 10. Operational framework for building climate-resilient health systems......................................... 43 Table of Contents | v ACKNOWLEDGMENTS This Climate and Health Vulnerability Assessment (CHVA) for Djibouti was produced by the Health, Climate, Environment, and Disasters (HCED) program in the Health, Nutrition, and Population (HNP) Global Practice of the World Bank led by Tamer Rabie. It is authored by Judith Namanya, Claire Bayntun, Ana Lucrecia Rivera-Rivera, Mikhael Iglesias, Muloongo Simuzingili, Stephen Dorey, and Tamer Rabie. The authors sincerely appreciate the valuable contributions provided by Ana Besarabic, Abdillahi Houssein Abdallah, and Jessica Flannery. The work also benefited from the administrative support of Fatima-Ezzahra Mansouri, the editorial work of Kah Ying Choo, and the production of Sarah Jene Hollis. The authors are also highly grateful to the HNP management for their strong support of the HCED program and this product and would like to extend their thanks to Juan Pablo Uribe and Monique Vledder. Finally, the authors are thankful to the Climate Investment Funds (CIF) and Climate Support Facility (CSF) for funding this work. vi | Climate and Health Vulnerability Assessment: Djibouti LIST OF ABBREVIATIONS AR6 IPCC Assessment Report 6 BAU Business-as-Usual (Scenario) CCKP Climate Change Knowledge Portal [World Bank] CHVA Climate and Health Vulnerability Assessment CHE Current Health Expenditure CME Continuing Medical Education CMIP6 Coupled Model Intercomparison Project Phase 6 NCCC National Climate Change Committee COPD Chronic Obstructive Pulmonary Disease COVID-19 Coronavirus disease 2019 CRU Climatic Research Unit [University of East Anglia, UK] CVD Cardiovascular Disease DALYs Disability Adjusted Life Years DHIS2 District Health Information System 2 DRM Disaster Risk Management ENSO El Niño Southern Oscillation EU European Union EWSS Early Warning Score System FDJ Djiboutian Franc GCF Green Climate Fund GDP Gross Domestic Product GHG Greenhouse Gas [emissions] GHS Global Health Security HIS Health Information Systems HMIS Health Management Information System HNA Health Needs Assessment HSS Health System Strengthening HVAC Heating, Ventilation, and Air Conditioning IGAD Intergovernmental Authority on Development ILO International Labour Organization INDC Intended Nationally Determined Contributions IOM International Organization for Migration IPC Integrated Food Security Phase Classification IPCC Intergovernmental Panel on Climate Change ITCZ Intertropical Convergence Zone MoH Ministry of Health List of Abbreviations | vii NAP National Adaptation Plan NAPA National Adaptation Programme of Action NCD Noncommunicable Disease NDC Nationally Determined Contributions NDP National Development Plan NEML National Essential Medicines List NTD Neglected Tropical Disease OOP Out of Pocket (spending on health) PHC Primary Healthcare (services) PM2.5 Fine Particulate Matter PNDS National Health Development Plan RCP Representative Concentration Pathway SAM Severe Acute Malnutrition SGRC Secretariat for Risk and Disaster Management SLR Sea-Level Rise SMS Short Message Service SNCC National Strategy on Climate Change SSA Sub-Saharan Africa UHC Universal Health Coverage UNFCCC United Nations Framework Convention on Climate Change VBD Vector-Borne Disease WASH Water, Sanitation, and Hygiene WBD Waterborne Disease WHO World Health Organization viii | Climate and Health Vulnerability Assessment: Djibouti EXECUTIVE SUMMARY Djibouti is highly vulnerable to climate change, which exerts immense impacts on human health, the environment, and the national economy. Climate change, combined with natural and human-induced health stressors, aggravates existing health burdens while simultaneously creating new health risks. Increasing temperatures, unpredict- able rainfall, and severe climate-related hazards (such as heavy rain-induced floods, rainfall variability, droughts, and heat waves), which influence the geographic range and burden of a variety of climate-sensitive health risks, are affecting human health in multiple ways. They include impacts on vector-borne diseases (VBDs), waterborne diseases (WBDs), health-related mortality and morbidity, air quality risks, direct injuries and mortalities, along with mental health and well-being risks. These climate-related health risks and hazards are putting more pressure on Djibouti’s already fragile health system, further undermining its adaptive capacity and resilience. Given Djibouti’s vulnerability to climate-related hazards and risks, the World Bank’s Health, Climate, Environment, and Disaster (HCED) Program has conducted a Climate and Health Vulnerability Assessment (CHVA). The objective of this CHVA is to assist decision-makers in Djibouti with planning effective adaptation measures to mitigate climate-related health risks. To do so, the climatology of Djibouti is first depicted by highlighting observed and future climate exposures relevant to health. Then climate-related health risks are examined based on projected climate variability, including identifying the vulnerable populations most at risk. The final step assesses the adaptive capacity of the health system to manage current and future climate-related health risks in order to inform a series of recom- mendations — at both the national and subnational levels — with the aim of reducing climate-related health vulnerability in Djibouti. Climatology: Djibouti has seen an increase in mean annual temperatures: July is the hottest month with an average temperature of 33.34°C (low of 27.87°C and high of 38.85°C). At the subnational level, the small port town of Obock has the highest mean temperatures while the city of Ali Sabieh has the lowest. In contrast, Djibouti’s mean annual precipitation has been decreasing, though this does vary by region, season, and year. During the 1971–2020 period, Djibouti’s mean annual precipitation decreased slightly with statistical significance (>95th percentile) at a rate of 2.25 millimeters (mm) per decade. Projected precipitation patterns under SSP (shared socioeconomic pathway) 3-7.01 indicate that the main summer rainy season would get wetter by the 2050s. During 2040–2059, Djibouti is expected to experience an August anomaly of 18.26 mm (-32.52, 116.50) nationwide. The capital city will experience an increase in the monthly cumulative precipitation averaging 219.01 mm. 1 Projected increases in temperatures and declining precipitation across Djibouti during the mid-century are likely to increase the occurrence, intensity, and prolonged droughts in the country. Increased frequency of erratic rainfall is also expected to increase the occurrences of rain-induced floods and associated mudslides. Climate-related health risks: Djibouti, as with other countries in the Horn of Africa, is highly vulnerable to climate change impacts, including the impacts on water and food security, heat risks, and climate-sen- sitive infectious diseases. Climate change, combined with natural and human-induced health stressors, aggravates existing health burdens while simultaneously creating new health risks. Increasing temperatures and unpredictable rainfall will affect the geographic range and burden of a variety of climate-sensitive vector-borne diseases (VBDs), such as malaria, dengue fever, yellow fever, and the chikungunya virus. Precipitation changes have also increased the burden of waterborne diseases (WBDs) significantly throughout Djibouti, as characterized by the high rates of morbidity and mortality across the country, especially among children under five years of age. Projected increases in the frequency of erratic rain-induced flooding will exacerbate the occurrences and spread of diarrheal diseases in Djibouti. The health risks of high temperatures are also a concern, with adverse wide-ranging effects on mortality, heat-related injuries, along with mental health and well-being. Increases in average seasonal temperatures and an increase in the frequency and intensity of heatwave events are projected to increase health risks among the population in Djibouti. From an occupational standpoint, extreme heat also presents a growing health risk in Djibouti. Average rising seasonal temperatures as well as the increased frequency and intensity of heatwave events by the 2050s are projected to elevate health-related morbidity and mortality levels across Djibouti, especially in the regions of Obock and Dikhil. High levels of poor air quality from harmful airborne particulates have also led to an increased incidence of illness and deaths, thus resulting in chronic lung diseases and acute respiratory infections among the Djibouti population. In 2019, air pollution was among the top five risk factors for mortality in the country, especially among children under five years of age. Food insecurity in the country — compounded by high poverty levels — has also worsened due to the increased frequency and intensity of extreme weather events, such as floods and droughts, in Djibouti. In 2021–2022, following three years of little to no rain, Djibouti experienced the worst drought it had ever seen in 40 years, which triggered significant food insecurity among the population in Djibouti. In 2022, 37.1 percent of rural households and 9.7 percent of urban households were affected by moderate to severe food insecurity. Food insecurity has also led to increased food prices and conflict. 2 | Climate and Health Vulnerability Assessment: Djibouti The adverse effects of floods and droughts on livelihoods, food security, living conditions, property damage and personal injury, or the deaths and injuries of family members have also exerted a toll on mental health. Climate change events are key risk factors for trauma, anxiety, depression, and intense negative emotions such as terror, anger, and shock, which are recognized as acute responses to natural disasters. The extent to which the health system in Djibouti is prepared for changes in hazards, exposures, and susceptibility, and has the capacity to manage them will determine its resilience in coming decades. In this CHVA, Djibouti’s adaptive capacity to prevent and manage climate-related health risks is examined according to the World Health Organization’s (WHO) six health system building blocks.  • Leadership and governance: Djibouti recognizes the impacts of climate change and, as such, has undertaken various adaptation and mitigation plans and programs. However, the country lacks guidance on the integration of climate change adaptation in key national policies. Cross-sectoral coordination, institutional arrangements, and stakeholder engagement mechanisms are currently weak. • Health financing: Although current health expenditure (CHE) per capita (current USD) has increased steadily over the year, health expenditure as a share of the country’s gross domestic product (GDP) has not kept pace with the rapidly expanding population. The Ministry of Health (MoH) lacks a budget line dedicated to climate and health strategies, and resource allocations for health services do not consider climate-related hazards as a criterion. • Health workforce: Despite an overall increase in its health workforce, Djibouti faces a critical shortage of skilled healthcare workers. In addition to the low availability, Djibouti also faces sig- nificant challenges in the uneven concentration and geographical distribution of health workers. Most of the skilled health workforce is found in urban areas, particularly Djibouti City. • Health information systems (HIS): Although Djibouti has made progress in improving disease surveillance, the country still faces challenges with non-functional surveillance systems and a lack of infrastructure, which affects the country’s preparedness and timely response to health impacts related to climate change. • Essential medical products and technologies: Djibouti has a national essential medicines list (NEML); however, the country still experiences limited access to essential medicines and other essential medical products. In addition, it has a critical lack of essential medical equipment — a situation that impacts the health system’s preparedness to tackle climate change impacts on health. • Health service delivery: Djibouti lacks adequate health facilities, especially in the rural areas, which are also highly vulnerable to climate change. There are geographical inequalities in the distribution of higher-level public health facilities between rural and urban areas. 3 Recommendations to reduce climate-related health risks include establishing a climate-smart health system to reduce climate-related health risks and improve overall health service delivery. More specifically, the following activities could be prioritized: • Include adaptation and mitigation strategies for the health sector in the next submission of the nationally determined contributions (NDCs) and the National Adaptation Plan (NAP). This would also include developing a policy strategy for the health sector that accounts for climate and health-related risks, strengthening the role of MoH in climate change adaptation. This Climate and Health Vulnerability Assessment (CHVA) can feed into specific activities to be developed in the forthcoming policy documents. • Establish a budget line in MoH for developing and implementing climate and health action plans and interventions. This would incentivize MoH to develop a Health National Adaptation Plan and integrate climate change as a cross-cutting challenge in other projects and programs, such as those related to surveillance systems or health facilities’ infrastructures. • Develop and implement national building codes and standards as well as climate-resilient certi- fication systems. This includes standards for building sustainable and climate-resilient healthcare infrastructures, such as the requirements for the location of new facilities; the expected charac- teristics of walls, roofs, and ceilings to ensure their capacity to withstand storms and high-speed winds; and contingency plans that account for climate hazards. • Establish a laboratory outreach system and laboratory facilities at the subnational level to improve the collection, transportation, storage, and processing of climate-sensitive disease tests, such as malaria, dengue, and diarrheal diseases. This may include the establishment of a reference laboratory per region to reduce delays in specimen processing as well as patient diagnosis and management. The government of Djibouti and MoH could engage development partners to support the establishment and stocking of regional reference laboratories. • Use climate and health vulnerability as a criterion for developing incentives and retention packages for health workforce in areas that are highly vulnerable to climate-related hazards. Health workforce retention packages should also be introduced in regions that face the highest risks of climate-related hazards (droughts), such as Arta, Ali Sabieh, Obock, and Tadjourah. • Develop tailored early warning alerts that account for subnational climate-related exposures to facilitate quick response and preparedness at the community levels. The Djibouti National Meteorological Agency should collaborate with MoH to create a such a system, which would be particularly important for the flood-prone regions of Djibouti City, Ali Sabieh, and Arta as well as the drought-susceptible regions of Dikhil, Obock, and Tadjourah. 4 | Climate and Health Vulnerability Assessment: Djibouti INTRODUCTION COUNTRY CONTEXT 1. Djibouti is a lower-middle-income country whose economy is largely dependent on its strategic location on the Bab el-Mandeb strait. Djibouti has been expe- riencing steady economic growth for many years: its gross domestic product (GDP) was USD3.37 billion in 2021 (compared with USD373.4 million in 1985).2 The country’s economy depends on trade at its busy ports and profits from container transshipments, transit taxes, as well as land lease and storage revenues.3 Other key contributors to the country’s economy include the airport, the banking sector, the Addis Ababa-Djibouti railroad, and the trading partnership with Ethiopia.4 However Djibouti’s economy has been threatened by the impacts of COVID-19 (Coronavirus disease 2019) pandemic, internal civil conflict, and external conflicts such as the Ethiopia Tigray conflict and the Ukraine war, which have affected food prices. For example, it is estimated that fiscal deficit would reach 3.7 percent of the country’s GDP in 2022 and 3. 6 percent in 2023 due to the adverse effects of the Ethiopia conflict on bilateral trade, the costs of border security and interior enforcement, and the increases in public expenditure on the refugee influx.5 2. Although Djibouti has attained a lower-mid- and North Africa region based on the Gini dle-income status, overall income inequalities index, which measures income inequality.8 remain high. The country’s economic growth The COVID-19 pandemic has further increased has not been equally reflected in the country’s inequality gaps and pushed many people in reduction in poverty rates. As of 2017, 17.1 Djibouti into extreme poverty. percent of the population lived below the poverty line according to the international 3. Djibouti has a steadily growing population reference of USD1.90 per day,6 while an that is predominantly young and urban. As estimated two-thirds of the population in of 2021, it had an estimated population of 1.1 Djibouti lived below USD3.20 per day — placing million people. Based on an annual growth rate this segment on the lower-middle-income of 1.4 percent, the population is projected to poverty line.7 In particular, rural areas had be 1.29 million in 2050. Djibouti’s population a very high extreme poverty rate of 62.6 is disproportionately young, with more than percent in 2017. In fact, with a Gini index of 50 percent below the age of 25 years.9 It is 41.6 in 2017, Djibouti had one of the highest one of the urbanized countries in Sub-Saharan levels of income inequality in the Middle East Africa (SSA): an estimated 78 percent of the 5 population (2021) is based in urban areas, by 40 percent in 2030 compared with the particularly Djibouti City.10 The rural population business-as-usual (BAU) scenario. Djibouti has consists primarily of nomadic pastoralists of a National Climate Change Committee (CNCC) cattle, goats, camels, and sheep. that is responsible for climate change-related policy, coordination, and action.14 4. Despite Djibouti’s steady economic growth and efforts to address unemployment, long-term unemployment persists especially AIMS OF THIS ASSESSMENT AND among young people. As of 2021, the CONCEPTUAL FRAMEWORK overall unemployment rate was 28.4 percent (percentage of the total labor force based 7. The objective of this Climate and Health on a modeled estimate of the International Vulnerability Assessment (CHVA) is to identify Labour Organization [ILO]). In addition, women climate vulnerabilities and risks as well experienced higher unemployment rates (39.4 as adaptation gaps, along with providing percent) than men (24.6 percent).11 recommendations to assist policy makers and practitioners with planning effective 5. Djibouti’s political stability in an unstable adaptation measures to deal with climate-re- region has attracted over 23,000 refugees lated health risks. Where available, the and 11,000 asylum seekers from the proposed measures are also offered at the neighboring countries of Somalia, Ethiopia, subnational level to assist regional health Yemen, and Eritrea.12 The refugees (mostly planners. Although the recommendations of Somalians and Yemenis) and asylum seekers this CHVA are primarily aimed at the health (mostly Ethiopians and Eritreans) are hosted sector, they are applicable to other sectors in the four refugee villages of Ali-Addeh (49 dealing with climatic hazards, such as disaster percent), Holl-Holl (23 percent), Djibouti City risk management (DRM) and the Djibouti (20 percent), and Markazi (8 percent).13 The Meteorological Department. refugee and asylum seeker influx comes with two health challenges including the unique 8. Adaptation priorities need to be accompanied health problems faced by refugees and the by fundamental and urgent action to mitigate additional burden of providing health services climate change. It is important to stress how to refugees on Djibouti health system. complex the climate challenge is and how hard it is to predict exactly how severe climate 6. Djibouti is committed to meeting the climate exposures facing populations will become. challenge through both adaptation and There are many factors that could slightly mitigation measures. It ratified the Paris slow or significantly speed up the rates of Agreement of the United Nations Framework change, including positive feedback effects Convention on Climate Change (UNFCCC) and cascading climatological tipping points, on November 11, 2016, which aims to limit which are the most worrisome. For this reason, the global mean temperature increase to mitigating existing GHG emissions as well well below 2°C compared with pre-industrial as developing and implementing measures levels. Moreover, the government submitted to protect human health from the changing the intended nationally determined contribu- climate is of paramount importance. tions (INDCs) in 2015, which set out a target of reducing greenhouse gas (GHG) emissions 6 | Climate and Health Vulnerability Assessment: Djibouti 9. Investing in adaptation strategies to governments and communities around the proactively address the effects of climate world act. Adaptation is now as critical a part change on health outcomes is critical. This of climate action as mitigation. As such, this assessment outlines climate risks to health report focuses on adaptation measures. and health systems, the adaptive capacities that are in place to deal with these risks, 10. An operational framework for building and the recommendations to meet identified climate-resilient health systems is adopted gaps. The primary focus of this assessment is, to analyze Djibouti’s adaptive capacity to therefore, on climate adaptation and resilience adequately deal with current and future measures. However, as the Assessment identified risks. Following this framework Report Six (AR6) of the Intergovernmental (Figure 1), this CHVA is structured around six Panel on Climate Change (IPCC) makes clear, health system strengthening (HSS) building “Global surface temperature will continue to blocks. These six categories encompass the increase until at least the mid-century under assessment of capacities and gaps — now all emissions scenarios considered.”15 Thus, and into the future. The CHVA then moves on mitigation alone is no longer a sufficient to consider the 10 components of the health strategy regardless of the pace at which system’s climate resilience. FIGURE 1: Operational framework for climate-resilient healthcare systems.16 ATE RESILIENCE CLIM hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li o r m e h Re ima & I n f e a lt m s Medical ma d C l a lt h se te Products & h H ra Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o Res le ir o n f C li m a t e b in a D et m ental & S u st a gies ri m e lo of H n ts Techno cture e a lt h f r a s tr u & In Source: World Health Organization. Operational framework for building climate resilient health systems. World Health Organization (WHO), 2015. Introduction | 7 11. This CHVA follows a step-wise linear and consultations with key counterparts in the approach. The first step characterizes the Djibouti government, including the Ministry climatology in Djibouti — highlighting the of Health (MoH) and development partners. observed and future climate exposures relevant to health. The second step examines 12. The CHVA incorporates subnational consid- climate-related health risks, including erations for health-related climate action. identifying the vulnerable populations most Djibouti is administered through five geograph- at risk. The final step assesses the adaptive ical regions and the capital city of Djibouti City; capacity of the health system to identify gaps they are further divided into 20 administra- in managing current and future climate-re- tive districts/subdivisions. The regions are Ali lated health risks. Together, these steps Sabieh in the south, Dikhil in the southwest, inform a series of recommendations to Arta in the south-central, Djibouti (the capital reduce climate-related health vulnerability city) in the east, Tadjourah in the north-cen- in Djibouti. The CHVA is based on a review tral, and Obock in the north (see Figure 2). of the published literature, national statistics, FIGURE 2: Administrative boundaries of Djibouti. Source: World Bank Cartography Unit 8 | Climate and Health Vulnerability Assessment: Djibouti SECTION I. CLIMATE CHANGE: OBSERVED TRENDS AND PROJECTIONS 13. This section describes the observed climatic changes and projected climate trends — highlighting the climate-related hazards as a priority in relation to human health risks in Djibouti. Climate information was taken from the World Bank Group’s Climate Change Knowledge Portal (CCKP), where historical, observed data is derived from the Climatic Research Unit (CRU) at the University of East Anglia. Observed changes in mean annual temperatures, mean maximum tem- peratures, and mean minimum temperatures, along with precipitation levels for the 1901–2021 period can be found on the CCKP website. Climate data used in the World Bank Group’s CCKP was obtained from the Coupled Model Intercom- parison Project, Phase 6 (CMIP6). The CMIP’s efforts are overseen by the World Climate Research Program: it supports the coordination of the production of the global and regional climate model compilations that advance the scientific under- standing of the multi-scale dynamic interactions between the natural and social systems affecting climate. CMIP6 provided the foundational data used observed climate conditions for the latest to present global climate change projections climatology, 1991–2020, this assessment presented in the Sixth Assessment Report projects climate conditions and changes under (AR6) of the Intergovernmental Panel on SSP3-7.017 for the near (2030s; 2020–2039) Climate Change (IPCC). It relies on the shared and medium terms (2050s; 2040–2059). socioeconomic pathways (SSPs), which represent potential societal development and policy scenarios for meeting the designated DJIBOUTI’S GEOGRAPHY radiative forcing (measured in watts per 14. The Republic of Djibouti is located in the square meter [W/m2]) by the end of the Horn of Africa along the Gulf of Aden at century. These scenarios — characterized by the southern entrance of the Red Sea. different plausible future societal development Covering a land area of more than 23,000 storylines (influencing future emissions and square kilometers (km2), with a coastline land use changes) and associated contrasting of 372 km, Djibouti is one of the smallest emission pathways — are used to gauge the countries in Africa and shares its borders with corresponding responses of the climate Eritrea, Ethiopia, and Somalia (see Figure 3).18 system. Based on an exploration of the 9 Djibouti is a highly arid country with limited resource-scarce and prone to natural disasters arable soil: nearly 90 percent of the country — a status quo that is further exacerbated is classified as desert, with approximately 9 by water scarcity, poor water management, percent considered as pasture and approxi- and poor land-use planning. mately 1 percent forest. The terrain comprises arid lands interspersed with shrubs scattered throughout the country’s plateaus, plains, OBSERVED AND PROJECTED volcanic formations, and mountain ranges CLIMATOLOGIES — some of which reach 2,000 meters (m) in height. Across the country, the altitude varies 15. Djibouti has a hot desert climate — charac- from 155 m below sea level at Lake Assal terized by high year-round temperatures and to over 2,000 m at Mount Moussa Ali. The evaporation rates as well as low and irregular eastern region is dominated by high ridges amounts of precipitation in the form of two and relatively deep ravines. Western zones or three rainy seasons per year.19 Average are made up of regularly deepening plains and seasonal temperatures observed during the depressions marked by fracturing. The coastal current climatology’s (1991–2020) mildest and plains in the north of the country include cliffs most humid months (November–February) falling directly to the sea as well as pebble and ranged from a minimum of 18.98°C in January sandy beaches. Djibouti is considered to be to a maximum of 31.36°C in November. As for FIGURE 3: Elevation of Djibouti and major cities. Source: Oak Ridge National Laboratory 10 | Climate and Health Vulnerability Assessment: Djibouti the hottest months from June to September, A southwesterly monsoon flow drives the average seasonal temperatures ranged Djibouti’s main rainy season between July from a minimum of 25.95°C in September to and September (amounting to a little less than a maximum of 38.85°C in the hottest month half of the yearly precipitation average for the of July. latest climatology).22 During this time, western Djibouti and the mountainous region north of Typically, northeasterly trade winds from the the Gulf of Tadjourah receive roughly twice as Arabian Sea and the Gulf of Aden result in much precipitation as eastern Djibouti’s arid variable rainfall between the cool months of Gulf of Aden coastline, where the majority of October and February, followed by a short but Djibouti’s population resides. more reliable rainy season between March and May.20 These spring rains account for Figure 4 illustrates these seasonal fluctua- roughly one-third of Djibouti’s average yearly tions, which are influenced annually by the precipitation (215 millimeters [mm] for the movement of the intertropical convergence latest climatology). The driest season, June, zone (ITCZ) and interannually by the strength receives less than 5 mm on average, during of a potential El Niño southern oscillation which southerly winds strengthen, often (ENSO). producing violent sandstorms (khamsin).21 FIGURE 4: Monthly and seasonal climatology observed in Djibouti, 1991–2020. Source: World Bank Climate Change Knowledge Portal Climate Change: Observed Trends and Projections | 11 TEMPERATURES 18. The number of hot days above 35°C will 16. Between 1971 and 2020, Djibouti’s mean, increase during the transition months maximum, and minimum annual temperatures between the warm and cool seasons (April increased by 0.2°C (0.1°C for the minimum and October) across regions by the 2050s annually) per decade.23 At the national level, due to the drastic impact of the changes in this increase has been significant during atmospheric moisture content (see Figure 5). the fall months for the climatology of the A comparison with the reference climatology 50-year period. July — the month that had (1995–2014) median of 57.51 hot days (>35°C the highest observed temperatures for the on the heat index) occurring during the summer climatology of the most recent 30 years — months (82.86 mean days annually) is illu- had a mean temperature of 33.34°C, with an minating. For example, the coastal city of average minimum of 27.87°C and a maximum Obock is expected to experience 80.25 hot of 38.85°C. January — the month with the days (-30.71 days, +2.67 days) in the summer lowest observed temperatures for the same months for the 2040–2059 period and 129.40 period — had a mean of 24.08°C, with an hot days (-22.02 days, + 28.49 days) annually. average minimum of 18.98°C and a maximum The capital and most populous city, Djibouti of 29.23°C. While the temperatures varied by City, will nearly match these values by the topography and distance from the coast, they mid-century. In contrast, the inland city of were not as pronounced as subnational-level Dikhil will likely see a drastic increase in precipitation patterns. hot, humid days by the mid-century to 51.07 days (-24.78 days, +9.12 days) during summer, 17. Under SSP3-7.0, Djibouti’s mean annual 65.39 days (-22.23 days, +48.19 days) annually, temperature will increase by the mid-century compared with its historical median of 2.49 while showing greater seasonal uncertainty hot days during the summer months (2.96 during summers. The national-level mean days annually). annual temperature is projected to increase from 28.33°C during the historical 1995–2014 19. Importantly, this shift will be accompanied by reference period to 29.74°C by the 2040s an increase not only in warm spells (where the and further to 30.50°C (-0.51°C, +0.76°) by the daily maximum temperature rises above the 2060s. Projected summer temperatures have 90th percentile based on five-day intervals) a much wider range of uncertainty. For the but also in tropical nights (nights where the 2040–2059 climatology, SSP3-7.0 projects a temperatures stay above >20°C). Warm spells mean temperature anomaly of 1.07°C for the will increase nationally from the historical month of August compared with the historical reference period (1995–2014) by an anomaly reference period (-2.48°C, +3.18°C). Similarly, the of 128.65 days (64.76 days, 234.17 days) for the maximum August temperature anomalies will projected 2040–2059 period. Furthermore, range from -3.61°C to +3.06°C, with a median the single-day monthly maximum temperatures of 1.07°C above that of the historical reference will increase by annual anomalies of 1.43°C period. Given the country’s homogeneity, (0.92°C, 2.29°C) and 1.58°C (0.82°C, 2.39°C) projected temperatures are expected to vary for Obock and Dikhil, respectively, based on minimally subnationally. the comparison of the two periods. These trends are of concern because warm spells are associated with increased risk of insomnia, 12 | Climate and Health Vulnerability Assessment: Djibouti FIGURE 5. Showing projected days with the heat index > 35°C anomaly.24 cardiovascular and respiratory morbidities. observed from 1991–2020 shows that Obock The increased frequency of tropical nights received roughly one-third of its annual total is also important because the temperature rainfall (148.72 mm) from the main rainy season, marks a biophysiological threshold where the one-quarter from the short rainy season in human body cannot adequately cool down spring, and one-quarter from the variable cool to achieve restorative sleep. and dry season (October to February). By comparison, inland Dikhil received half of a PRECIPITATION much larger annual total (259.35 mm) during 20. Historically, Djibouti’s mean annual precip- the main rainy season, one-third during the itation has decreased, though the trend spring short rainy season, and the remainder differs by region, season, and year. For the during the cool and dry season. 1971–2020 period, Djibouti’s mean annual Another climatology change is captured precipitation decreased slightly but with in the differences in the season with the statistical significance (>95th percentile) at highest variability in the rainfall. While Dikhil 2.25 mm per decade. During the winter months observed particularly high variability during the of this period, Obock on Djibouti’s east coast short spring rainy season during 1981–1990 experienced a significant decrease in mean compared with the current climatology trend precipitation. The average seasonal rainfall Climate Change: Observed Trends and Projections | 13 (1991–2020), Obock’s season with the greatest expected to have the greatest potential range variability was in the winter months such of precipitation percentage anomaly (median as December and February, characterized of 11.54 percent [-44.16 percent, 191.70 percent]) by tighter and less pronounced seasonal for 2020–2039. peaks that are linked to the short spring and summer main rainy seasons. By comparing the peaks and valleys of the interannual precip- CLIMATE-RELATED HAZARDS itation trends observed and how close they 22. Djibouti is vulnerable to several hazards adhered to the current climatology trend of associated with the ongoing climate change, the 1981–1990 and 2011–2020 periods, we which presents considerable impacts on can see that the trend varied widely by month population health. The country is highly and location. vulnerable to droughts, heat waves, floods, and sea-level rises (SLRs). As one of the most 21. Projected precipitation patterns under water-scarce countries in the world, Djibouti’s SSP3-7.0 do not signal a clear direction vulnerability will be further exacerbated by on a national scale in the coming decades, the anticipated declines in precipitation as though there are metrics indicating strong well as increases in its temperature and potential trends. The main summer rainy the frequency of extreme events, such as season is projected to get wetter by the droughts, soil erosion, and desertification, 2050s. For 2040–2059, Djibouti is expected among others. to experience a nationwide anomaly of 18.26 mm (-32.52, 116.50) in August. The largest At the same time, the region will also be monthly cumulative precipitation quantity for impacted by an increase in the frequency the same period is expected to increase to a and intensity of erratic rainfall, which will mean of 219.01 mm for the capital city. This lead to mudslides and flash floods. SLRs will will most likely occur during the main rainy also pose a significant threat to the country’s season: for example, the average largest coastline not only due to inundation but also five-day cumulative precipitation anomaly salinization, which increases risks to port will be an increase of 21.45 mm during the infrastructures and tourism along the coast. month of July (-31.67, 90.07) compared with They are projected to lead to the loss of a the 1995–2014 reference period. The precip- sizable proportion of the northern and eastern itation amount for the wettest days expected coastlines due to a combination of inundation by the end of the century (2080—2099) is and erosion, with consequential losses of agri- likewise projected to increase by an anomaly cultural land, infrastructures, and urban areas. of 27.37 mm in August (-1.16 mm, 88.98 mm) during the main rainy season compared with the historical reference period (1995–2014). DROUGHTS 23. Djibouti is highly vulnerable to severe However, significant uncertainties remain. droughts. The current drought that started The percentage changes in precipitation and in 2020 followed five consecutive failed rainy the annual drought index do not portend a seasons, which have affected more than clear signal by the 2030s or the 2050s. For 200,000 people in Djibouti. More generally, now, March (during the short rainy season) is the whole of Djibouti has seen an increase 14 | Climate and Health Vulnerability Assessment: Djibouti in the occurrences, duration, and intensity FLOODS of droughts in recent decades. In particular, 24. Floods are among the most significant the eastern coastal region of the country climate-related hazards in Djibouti (see has experienced more severe and extreme Figure 6). Increases in the frequency and droughts between 2007 and 2017, accounting intensity of heavy rains and related flash for approximately 80 percent of the drought floods and mudslides are already impacting events.25 human health and threatening livelihoods in Djibouti. Coastal urban towns are at the Projected increases in temperatures, as well as highest risk of flooding. Erratic rains on April declining precipitation levels, across Djibouti 20–21, 2020 caused flash floods that struck during the mid-century, are likely to increase Djibouti City and the neighboring suburb of the occurrence and intensity of prolonged Balbala, resulting in eight deaths and affecting droughts in the country. By the 2060s, the over 110,000 people.26 Under current climate mean annual temperature is projected to change projections, frequent intense rains in rise to 30.50 ° C compared with 28.33 ° C Djibouti will trigger more damaging floods, during the 1995–2014 reference period, with with severe impacts on health and health minimal differences at subnational levels. infrastructures. Potentially damaging waves Under projected climate change conditions, are expected to flood the coast at least once Djibouti is likely to experience more frequent over the next 10 years. and intense aridity, with potential for droughts and extreme heat, in addition to critical sea level rise (SLR) resulting in coastal inundation — all of which will adversely affect food and water security, sanitation, and heat-related risks in both coastal and inland areas. FIGURE 6: Risks of coastal, river, and urban flooding in Djibouti (left to right).27 Climate Change: Observed Trends and Projections | 15 SEA-LEVEL RISES (SLRS) Saltwater intrusion also presents a high risk, 25. SLRs significantly threaten coastal specifically for low-lying barriers and river communities along the Djibouti coastline mouths along the country’s coastline. The and the inhabitants’ livelihoods. Djibouti coastline of the estuaries located between has a coastline of 372 km with an exclusive the Eritrean border and the Gulf of Tadjoura is maritime area of 7,190 km2. Djibouti’s coastal at risk of coastal zone erosions, specifically the zone houses more than two-thirds of the northern part of the Gulf of Tadjoura. Moreover, population as well as socioeconomic activities. the vulnerability of Djibouti’s coastline is At the same time, the coastline and south already being exacerbated by human activities, of Djibouti City is considered to be at high which have degraded coastal areas and their risk of gradual inundation. Given the ongoing ecological habitats. These degradations are though gradual nature of this threat, it should predicted to increase in tandem with SLRs, be considered a relevant inclusion for the water warming, and rising water salinity, thus coastal planning processes. leading to water contamination and poor water quality increasing the risk of water-borne diseases particularly diarrheal diseases in the country. 16 | Climate and Health Vulnerability Assessment: Djibouti KEY MESSAGES: Temperature → Overall, the mean annual temperature in Djibouti has increased by 0.2°C per decade since 1970, with the highest observed temperatures in the month of July (mean of 33.34°C) and the lowest observed temperatures in January (mean of 24.08°C). → Under a high-emissions scenario (SSP3-7.0), mean annual temperature will increase by the mid-century though with greater seasonal uncertainty during the summer. A mean temperature anomaly of 1.07°C is projected for the month of August based on the comparison between the reference 1995–2014 and the 2040–2059 periods. Precipitation → Mean annual precipitation in Djibouti decreased at 2.25 mm per decade over the 1971–2020 period with variability by region, season, and year. → Future projections of precipitation under SSP3-7.0 do not signal a clear direction on a national scale for the coming decades, though the main summer rainy season is expected to get wetter by the 2050s. Djibouti is expected to experience an August anomaly nationwide of 18.26 mm during the 2040s. Climate-related hazards → Drought: Djibouti has seen an increase in the frequency, duration, and intensity of droughts in recent decades. In particular, the eastern coastal region of the country has experienced more extreme droughts triggering water and food insecurity. → Extreme heat: Djibouti’s mean annual temperature increased by 0.2°C between 1971 and 2020. At the national level, this increase has been significant during the fall months. The number of hot days above 35°C is projected to increase during the transition months between the warm and cool seasons (April and October) and across the regions by the 2050s. → Floods: Floods, especially coastal flooding, are a significant risk in Djibouti, especially in northern Djibouti, along with Djibouti City and the suburb of Balbala. They are expected to increase in frequency and intensity. → Sea-level rises (SLRs): SLRs significantly threaten coastal communities and livelihoods along the Djibouti coastline. Areas south of Djibouti City have the highest risks of gradual inundation. Climate Change: Observed Trends and Projections | 17 SECTION II. CLIMATE-RELATED HEALTH RISKS 26. Climate change influences human health outcomes and diseases in multiple ways. This section reviews the evidence for the burden of current climate-related health risks in Djibouti and projections of the future risks of health outcomes due to climate change, based on the expected changes in the country’s climate under the representative concentrative pathway (RCP) 8.5.28 Health risks are presented according to prioritization and examined according to historical, current, and projected risks, wherever information is available. Risks to the health system related to climate change are covered in Section III on Adaptive Capacity. 27. Climate change is worsening the emergence, exert a strain on the country’s health system re-emergence, and transmission of infectious and threaten its capacity to provide affordable diseases and increasing the burden of quality health services to all the population in noncommunicable diseases (NCDs). In Djibouti, thus emphasizing the importance of Djibouti, infectious diseases as well as child building a resilient health system. and maternal malnutrition are among the leading causes of mortality. Djibouti has one 28. Risks to health outcomes related to climate of the highest maternal mortality ratios — 248 change are not evenly distributed in the maternal deaths per 100,000 live births — population, with some groups at greater risk almost five times the regional average. In than others. Climate change may exacerbate Djibouti, an estimated 58 out of 1,000 children health inequalities, especially among certain die before turning five years old.29 vulnerable population groups including the poor, rural populations, those living in informal Neglected tropical diseases (NTDs) — likely urban settlements, women and young children, to be exacerbated by climate change — are the elderly, people living with pre-existing also a significant contributor to the burden conditions and disabilities, along with refugee of disease in Djibouti. In particular, there are / displaced populations. Therefore, investment currently sporadic cases of visceral leish- in adaptation and mitigation measures must maniasis, soil-transmitted helminths,30 and carefully consider groups who would directly trachoma (described by the World Health benefit from, or may be disadvantaged by, Organization [WHO]) as an ongoing public adopted measures. health problem in Djibouti.31 In 2020, as the world was struggling to control the spread of 29. Djibouti’s CHVA assesses seven climate-re- COVID-19 (Coronavirus disease 2019), Djibouti lated health risk categories. These include was also facing a resurgence of measles that risks to (a) nutrition and food security risks, further strained the health system.32,33 As such, (b) vector-borne diseases, (c) waterborne and climate-related health impacts would further water-related diseases, (d) heat-related risks, 19 (e) air quality, (f) direct injuries and mortality, and climate in a multitude of ways — from and (g) mental health. Risk categories were short-term shocks (for example, natural selected from the literature review on climate disasters) to longer-term changes in agroeco- and health risks to Djibouti. Each category logical conditions that can drastically reduce was assessed in terms of current and future yields or redefine spatio-temporal patterns of risks, with considerations for both national and crop suitability. Djibouti is already experiencing subnational peculiarities, wherever possible. limited agricultural productivity due to unpre- These risk categories represent only the most dictable rainfall and associated prolonged pressing climate-related health risks to the droughts and devasting floods. population of Djibouti, as indicated in national documents such as the National Development Rural poor communities, who are heavily reliant Plan (NDP 2020–2024), the National Adaptation on agricultural and pastoral activities, are more Programme of Action (NAPA 2006), and the vulnerable to water scarcity and related food Third National Communication to the United insecurity caused by climate events than Nations Framework Convention on Climate other groups.36 For example, in March 2022, Change (UNFCCC) (2021). Other climate-related 12 percent of the Djibouti population (approx- health risks may include but are not limited imately 122,000 people), particularly the rural to NCDs associated with climate change and communities of Tadjoura, Obock, Dhikil, Arta, direct injuries and mortalities related to floods. and Ali Sabieh, became food-insecure as a result of a drought that was induced by high temperatures and below-average rains.37 A. NUTRITION RISKS 31. High morbidity and mortality are the 30. The mechanisms by which climate change immediate consequences of undernutri- affects nutrition via the food system are tion, thereby resulting in a predisposition profound; they include the acute and chronic to infections, particularly those of the gastro- effects on agricultural production, storage, intestinal and respiratory systems.38 Globally, processing, distribution, and consumption. undernutrition caused an estimated 45 percent Nutritionally secure and stable diets not only of all deaths among children under five years depend on agricultural production but also the of age in 2020, with most of those being complex interactions of demand, economics, in low-income countries.39 A similar trend legislation, conflict, food waste, nutrient losses, was also identified in the 2011 data when food safety, and access.34 Climate variability aggregating fetal growth restriction, stunting, is already contributing to increases in global wasting, and deficiencies of vitamin A and hunger and malnutrition.35 While a compre- zinc, along with suboptimal breastfeeding.40 hensive analysis of climate change’s impact Children with severe acute malnutrition (SAM) on the food system is beyond the scope of face a risk of morbidity and mortality 9–11 times this assessment, this CHVA examines climate greater than their healthy counterparts.41 The and nutrition linkages through a food security projected burden of SAM in children under lens in Djibouti as it relates to weather and five is projected to increase in Sub-Saharan climate impacts on agricultural productivity. Africa (SSA) — from 8.1 million cases in 2014 to potentially 9.0 million cases by 2030.42 Agricultural productivity is a key determinant of food availability, and it is affected by weather 20 | Climate and Health Vulnerability Assessment: Djibouti 32. Although Djibouti has progressed in by international comparisons, mainly due to addressing malnutrition and hunger, child climate shocks such as droughts, with large and maternal malnutrition is one of the areas of the country unsuitable for agricul- leading causes of disability and death in tural activities. the country, with stunting and wasting also at high levels. Sixty-eight percent of children Food security is a significant growing risk due from Djibouti die before their fifth birthday. to the acute shocks and chronic changes of Malnutrition directly or indirectly accounts for climate projections. Compounding factors — about 35 percent of all deaths among children such as the Tigray conflict, desert locusts, under five years.43 In Djibouti, in 2022, malnu- food prices, and the COVID-19 pandemic — trition accounted for an estimated 83 deaths continue to drive up levels of chronic food per 1,000 children under five years of age.44 and nutrition insecurity as well as the prices of Djibouti has one of the highest levels of food staple foods in Djibouti. Poor communities in insecurity in the world, in which more than 30 the Obock region in the north, the livelihood percent of its population (aged 6–59 years) zones of Dikhil and Tadjourah in the northeast, is chronically malnourished.45,46 When the and the pastoral zones of Ali Sabieh and Dikhil country was hit by COVID-19, approximately in the south are already experiencing chronic 28,000 people needed food support from the food insecurity, which is largely attributed to World Bank and the World Food Program.47 poor rainfall with ramifications for nutritional In terms of stunting, rural communities face status among the rural poor households.50 higher rates than urban communities, with According to the Integrated Food Security the regions of Obock (45.9 percent), Dikhil Phase Classification’s  (IPC) country food (44.2 percent), and Tadjourah (40.8 percent) insecurity analysis for March–June 2022, an having the highest rates of stunting. Wasting estimated 5,000 people are in an emergency (weight-for-height) rates in Djibouti remain situation (IPC Phase 4), approximately 132,000 high at 17.8 percent — exceeding the WHO people are facing acute food insecurity (IPC severity threshold of 15 percent.48 Phases 3 and 4), while roughly 127,000 people are in crisis (IPC Phase 3) and 423,000 people 33. Climate change through erratic rains, are under stress (IPC Phase 2).51 In a changing prolonged droughts, and floods is worsening climate, prolonged droughts and flash floods food insecurity. Increased extreme rainfall will continue to worsen food insecurity and triggers soil erosion and reduces soil fertility, lead to associated health outcomes including which is further aggravated by prolonged anemia, cognitive disorders, birth defects, and drought periods. Moreover, droughts have mental health issues and related concerns. increased in frequency, duration, and intensity, which has and will likely continue to impact 34. Projected rainfall variability and increases Djibouti’s rainfed agricultural areas, potentially in the frequency and intensity of droughts leading to reduced crop yields for smallholder will significantly impact food security in farmers. This is particularly significant for Djibouti in the 2030s and the 2050s. Water Djibouti, as agriculture and related activities scarcity in Djibouti is pivotal for agriculture and are the main source of livelihood for the livestock (see Figure 7). Overall, there is a high rural communities (30% of the population).49 level of uncertainty regarding projections of However, yields are considered to be low precipitation under different climate scenarios Climate Change: Observed Trends and Projections | 21 in Djibouti, with key indicators such as the and a lack of development in the agricultural maximum number of dry days (in which the sector, will potentially increase the country’s daily accumulated precipitation is less than 1 vulnerability to food insecurity. mm) expected to vary by region and season. However, the shifts in precipitation and the threat of continued drought conditions, coupled with a limited water management infrastructure FIGURE 7: Projected water stress for Djibouti (2040). Source: Natural Earth, ASTER GDEM Version 3, World Resources Institute 22 | Climate and Health Vulnerability Assessment: Djibouti B. VECTOR-BORNE DISEASE (VBD) is distributed all year around, with a peak between March and October, in both urban and RISKS rural areas. Between January 2011 and May 35. Climate is a critical driver of VBD distribution 2014, 128 cases of dengue were confirmed and transmission dynamics. Climate variability at the Bouffard Military Hospital.56 A case of causes vector and host ranges to expand or the Eastern / Central / South African (ECSA) contract, thus shifting disease distribution and chikungunya virus was documented in Djibouti seasonality and/or facilitating the emergence in 2019.57 or re-emergence of VBDs. For instance, flooding results in the geospatial expansion Because of the overlapping epidemiological of breeding sites for vector-borne diseases, features of dengue fever and malaria, the such as malaria, chikungunya, and dengue, vectors of both diseases breed in habitats — which are transmitted through mosquitoes. On such as small water pools in discarded utensils a local scale, vector abundance is a product adjacent to households, canals often with of microclimates; the availability of larval sites, stagnant water, and wells which increasing shade for resting, sources of blood meals and the risk of concurrent dengue and malaria nectar; and predator density.52 Investigating infections in Djibouti.58 species distribution and seasonality of vectors is valuable for understanding plausible VBD 36. In Djibouti, temperature and precipitation distributions and planning efficient, spatially are important drivers of malaria epidemics, targeted methods of control. but their effects on malaria vary depending on the local climate and geography. Overall, This assessment focuses on malaria due to its evidence has shown temperature to be a more significant impact on morbidity and mortality important driver in cooler highland regions, in Djibouti. There are more than 40 species of with precipitation being a more significant Anopheles (An.); however, An. arabiensis and factor in drier areas. Although the occurrence the invasive An. stephensi are the principal of endemic malaria is known to be limited malaria vectors in urban Djibouti.53,54 Other to areas below 2,000 meters above sea vectors that transmit malaria in Djibouti are level, malaria cases were documented in An. funestus, An. pharoensis, and An. nili. In highland-fringe areas beyond the altitude Djibouti, malaria risk occurs all year around, threshold during non-epidemic periods. In though its peak period is between November fact, highland areas have seen a corresponding and May.55 Djibouti has seen an increase in the increase in the altitude at which malaria trans- incidence of malaria from 3.4 cases (per 1,000 mission is possible, thus exposing non-immune population at risk) in 2000 to a high of 97.6 populations in new highland areas to the risk cases (per 1,000 population at risk) in 2020. of the disease. The drastic increase occurred between 2013 and 2020 when malaria incidence leaped from Evidence from the Sixth Assessment Report 2.5 in 2013 to 97.6 in 2020. (AR6) of the Intergovernmental Panel on Climate Change (IPCC) on the observed The other main VBDs in Djibouti are dengue impacts of malaria and its projected risks fever ( Aedes [Ae.] aegypti ), chikungunya shows — with a high level of confidence — that (primarily Ae. aegypti and Ae. albopictus), higher temperatures and shifting patterns of and yellow fever (Ae. aegypti). Dengue risk Climate Change: Observed Trends and Projections | 23 rainfall influence the distribution and incidence sources; or person-to-person transmis- of malaria in SSA. Further, there is evidence of sion. Households with unimproved water the increasing incidence of infection caused and sanitation facilities are most at risk of by Plasmodium (P.) falciparum malaria at higher increases in diarrheal diseases,.62 Furthermore, temperatures, particularly in Djibouti. the water and sanitation systems in Djibouti have not received sufficient investment. Over 37. Climate change and associated increasing 15 percent of the population in Djibouti practice temperatures are already altering the distri- open defecation and an estimated 78 percent bution and transmission of vector-borne lack access to improved sanitation facilities.63 diseases and the VBD risk will likely worsen The population is thus vulnerable to the trans- in the 2030s and 2050s. Though rainfall mission of diseases such as cholera, diarrhea, patterns and drought conditions will vary dysentery, hepatitis A, and typhoid. by region and season, the numbers of heat index days >35°C are projected to increase 40. Rising temperatures speed up the life cycle slightly in the Obock region in the 2030s and survival of pathogens and vectors,64 (100.6 days) and further in the 2050s (129.4 making it ideal for the rapid proliferation days). This includes the approximately 67 dry and persistence of pathogens and the days projected between the months of June, concomitant increase in the episodes of July, and August — historically considered to diarrheal diseases.65 More intense droughts be the months of high malaria transmission are also associated with reduced water quality in Djibouti. and disease outbreaks. The lack of fresh rain during droughts prevents the opportunity to flush out stagnant waters. As sources become C. WATERBORNE DISEASE (WBD) overused, water quality will deteriorate, leading to increased person-to-person spread of RISKS diseases and the risks of outbreaks, even 38. In Djibouti, diarrheal diseases are responsible away from the direct source of contamination. for high levels of morbidity and mortality. Furthermore, warmer waters will contribute They cause 6.94 percent of disability adjusted to increases in toxic algae blooms in fresh life years (DALYS) among children under five waters, resulting in associated cases of food years, mainly due to the Salmonella serovars poisoning from affected aquatic foods and and the Shigella species, and 4.27 percent of resulting in outbreaks. total DALYS for all ages.59,60 In 2020, it was found that 364 deaths (5.44 percent of total 41. At the same time, shifting patterns of rainfall deaths) were attributed to diarrhea diseases and an increase in heavy precipitation events in Djibouti, which was an inevitable outcome in Djibouti will also play a major role in the of the country’s unsafe water, sanitation, and transmission of diseases66 by influencing hygiene (WASH) practices and infrastructure.61 the proliferation, and dissemination of infectious agents, particularly through the 39. The spread of enteric diseases can occur water and sanitation systems.67 Djibouti through the direct use of contaminated often experiences riverine and flash floods, water for swimming, bathing, and drinking; especially along the coastal areas and in the contamination of food that is farmed Dikhil, with groundwater and sewer flooding or washed using contaminated water 24 | Climate and Health Vulnerability Assessment: Djibouti presenting hazards to human health. The such as respiratory and cardiovascular diseases increased frequency of floods in Djibouti will (CVDs), with further risks of detrimental inter- exacerbate challenges with water pollution and actions for those on medications. Longer-term subsequently increase the risks of diarrheal mental health risks are also an important diseases.68 The inundation of agricultural lands, effect to consider. Apart from the impacts villages, towns, and cities contaminates fresh on individuals, the exposure of the whole water with human and animal sewage along population exposure to an extreme heat event with agricultural and other pollutants while should also be considered, as the significant increasing sediment loads in rivers, thus increases in hospitalizations can impose a undermining water quality. Furthermore, flies severe strain on health systems.75 and other pests tend to proliferate in flood waters, risking food contamination as bacterial Finally, several factors will also influence pathogens attach to leafy crops under flood mortality and morbidity in relation to extreme and drought conditions.69 heat events. The magnitude of the aforemen- tioned impacts will be influenced by the timing, 42. In low-income countries, changes in climate duration, and intensity of the temperature are expected to influence diarrhea rates,70 event, the levels of acclimatization (an individ- though the extent will vary depending on ual’s adaptive response to a hot environment), climate change scenarios and local factors.71 the built environment (for example, the urban While country-level projections of climate-at- heat island effect76), the adaptive capacity of tributable diarrheal disease are unavailable, the affected populations, and the resilience of projected increases in diarrheal deaths due to infrastructures and institutions, among others.77 climate change in the African region among children aged below 15 years are 48,000 and 44. Extreme heat also presents a growing occu- 33,000 by 2030 and 2050, respectively.72 pational health risk in Djibouti.78 Physical work The East African subregion is projected to capacity can decrease when high tempera- be impacted the worst by cholera, particu- tures and humidity exist for several months larly during and after El Niño events.73 It is each year, with some global assessments estimated that 20,000–30,000 additional estimating that the annual loss of healthy work cholera deaths among children aged below hours would be tripled (ranging from 3 percent 15 years old could be attributed to climate to 18 percent) by 2100.79 Although there is change.74 a lack of reporting on heat-related injuries, illnesses, and deaths amongst occupations in Djibouti, studies from other countries indicate D. HEAT-RELATED MORTALITY that workers in agriculture and construction are at particularly high risk of occupational AND MORBIDITY heat stress.80 Climate-based indices can be 43. The health risks of heat are wide-ranging, used to quantify workdays lost to extreme including effects on mortality, heat-related heat, reflecting recommended heat strain injuries, along with mental health and thresholds.81 well-being. Health effects caused by heat include the direct effect of heat stress, heat 45. Both the increases in the average seasonal rash, cramps, exhaustion, dehydration, and the temperatures and an increase in the acute exacerbation of pre-existing conditions Climate Change: Observed Trends and Projections | 25 frequency and intensity of heatwave to acute exacerbations of chronic respiratory events are projected to increase the health and cardiovascular conditions.86 For example, risks in Djibouti in a changing climate.82,83 extreme heat and high humidity can trigger Although there is no specific data on the asthma symptoms and can also increase impacts of heat on health in Djibouti, there overall respiratory infections in individuals is a potential threat of elevated mortality. with underlying chronic obstructive pulmonary Obock and Djibouti City have the highest diseases (COPDs).87 average temperatures with institutional working adjustments recommended for the Furthermore, changes in wind patterns and peak season / months (for example, July, increased desertification can increase the August, and September). Further, based on long-range transport of air pollutants. Under climate change projections, all the regions in certain atmospheric circulation conditions, the Djibouti will likely experience increases in the transport of pollutants — including aerosols, number of hot days (TMax>35°C) and tropical carbon monoxide, ozone, desert dust, mold nights (>20°C) by 2050 under a high-emissions spores, and pesticides — may occur over scenario. Moreover, projected increases in large distances and timescales typically of summer days (Tmax > 25°C) are expected to 4–6 days, which can lead to adverse health be pronounced for the entire country. This impacts.88 Other key contributors to poor air would expose more people to potentially quality in Djibouti include biomass, methane life-threatening temperatures with implications emissions, air pollutants from container ships, for the health of those populations, particularly power plants, diesel generators, waste burning vulnerable groups such as pregnant women, / garbage disposal, and vehicle emissions.89, 90 children under five years of age, people over 65 years, and people living with pre-existing 47. In Djibouti, in 2019, air pollution was among conditions. the top five risk factors of mortality, especially among children under five years old.91 In 2016, it was estimated that the mortality E. AIR QUALITY RISKS rate attributed to ambient and household air pollution was 156 per 100,000 population in 46. Climate change influences other sources of Djibouti, compared with 169.73 regionally and air pollution, with the annual global mortality 92.43 globally.92 In 2019 alone, in Djibouti, 453 rate driven by the fossil fuel’s contribution deaths were attributed to exposure to outdoor of fine particulate matter (PM2.5)84 estimated PM2.5, with a further 201 deaths attributed to to be 10.2 million per year.85 Changes in wind household air pollution and 6.52 to ozone.93 patterns and strength will lead to increased Air pollution also accounted for 11 percent of PM2.5, such as atmospheric dust, desertifi- all deaths among children under five years cation in some regions that promotes dust old in 2019.94 Moreover, air pollution was also formation, and increased risks of wildfires, responsible for deaths related to the following in tandem with the presence of heat and conditions: COPD (37 percent), stroke (29 droughts, thus resulting in severe health percent), ischemic heart disease (28 percent), impacts from widespread smoke inhalation. lung cancer (26 percent), lower respiratory The interaction of high temperatures with infection (26 percent), diabetes (23 percent), air quality can also affect levels of ozone, and neonatal (17 percent).95 Other possible pollutants, and aeroallergens, thus leading 26 | Climate and Health Vulnerability Assessment: Djibouti outcomes include exacerbations of asthma rose from 35 µg/m³ in 2019 to 39 µg/m³ in and the advancement of dementia. 2021.97,98 Available data indicates that smog areas of high pollution remain, with the coastal 48. The State of Global Air research group zone in Djibouti City showing the worst air estimated that the entire Djibouti population pollution of 46 µg/m³, making it the most lived in areas with PM2.5 concentration polluted part of the country (as indicated levels above the 2021 WHO Air Quality by the high levels of tropospheric nitrogen Guidelines for healthy air — 5 micrograms dioxide — see Figure 8), with the dry months per cubic meter (µg/m3).96 In fact, the popu- of December, January, and June having the lation-weighted average PM2.5 concentration highest concentrations of particulate matter. FIGURE 8: Tropospheric nitrogen dioxide (NO2). Source: Natural Earth, ASTER GDEM Version 3, Sentinel-SP OFFL No2 Climate Change: Observed Trends and Projections | 27 F. DIRECT INJURIES AND MORTALITY mm of rainfall, which was equivalent to two years of rainfall. The flash floods triggered 49. Mortality and direct injuries — associated by the heavy erratic rainfall caused 11 deaths with heavy rains-induced flash floods, and affected approximately 250,000 people, mudslides, and landslides — seriously risk mostly in Djibouti City (200,000 people).99 lives and human health in Djibouti (see Subsequently, heavy rains from April 20–21, Table 1 and Figure 9). An increase in the 2020 induced flash floods in Djibouti City and frequency and intensity of heavy rains are the suburb of Balbala, causing eight deaths triggering flooding, flash floods, landslides, and affecting approximately 110,000 people.100 and mudslides. Coastal urban towns are at the Projected increases in erratic rain-induced highest risk of flooding. Between November floods will likely result in more direct injuries 21 and 23, 2019, Djibouti received over 295 and deaths in Djibouti. TABLE 1: Extreme weather events, injuries, and mortality in Djibouti from 1980 to 2022.101 Extreme Events Events Count Total Deaths Total Affected Flood 17 250 852,300 Drought 10 0 1,380,176 Storm 2 2 25,775 FIGURE 9: Rainfall-induced landslides in Djibouti. Source: Natural Earth and ASTER GDEM Version 3 28 | Climate and Health Vulnerability Assessment: Djibouti G. MENTAL HEALTH as housing, water and income insecurities, as well as living in physically uncomfortable AND WELL-BEING RISKS drought or humid conditions. 50. The association between climate change-re- lated events and mental health can be direct 52. The increased frequency and intensity of or indirect, short-term, and long-term. In extreme weather events, such as floods 2019, mental health disorders accounted and droughts, are potentially leading to the for an estimated 970.1 million cases in the increased risk and prevalence of mental country — a 48.1 percent increase from 654.8 disorders. The impact of floods and droughts million cases in 1990.102 Acute events (such on livelihoods, food security, living conditions, as a flood) in the short term can precipitate a damage of property, personal injury, or the psychopathological pattern similar to experi- death and injury of a family member may encing traumatic stress. For example, mental trigger direct trauma, anxiety, depression, health impacts in children can be manifested and intense negative emotions such as terror, as behavioral disorders. Exposure to extreme anger, and shock, which are recognized as or prolonged weather-related impacts may acute responses to natural disasters. These also result in delayed mental impacts, such extreme events can also result in long-lasting as post-traumatic stress symptoms, in the psychological distress.104 future or psychological impacts on younger generations. Nonetheless, the impact of climate Extreme heat105 can also aggravate mental change and climate extreme events on mental health symptoms, increase the risk of suicide,106 health and well-being can be mediated by and conflict. 107 More generally, research individual and community resilience. has shown that hot nights are associated with insomnia, with consequences that 51. To assess mental health in the context of include susceptibility to disease and chronic climate change, the full spectrum from mental illness,108,109 along with psychological and illness to psychological and social well-being, cognitive functioning.110,111, 112 Research in other or “psychosocial health,” is considered. This countries has projected levels of heat-related allows for the incorporation of considerations excess mortality for mental disorders.113 of well-being and resilience, 103 which is partic- ularly relevant for Djibouti. They include the 53. The trends between increasing tempera- background strain on the resilience of the tures and associated mental disorders have population due to food and income insecurity; also been found concerning self-harm and the status of refugees and conditions arising suicide rates. Some findings suggest that from regional conflicts involving neighboring suicide rates increased by 0.7 percent and countries; long-term climate stresses; as well 3.1 percent, respectively, for a 1°C increase as limited opportunities for psychological or in the monthly average temperature.114 Two psychiatric assessments and diagnoses to likely mechanisms could account for such a inform an analysis. The concept of mental phenomenon. First, direct physiological effects health and well-being can thus be framed on the brain are hypothesized to influence as a spectrum of “psychosocial health” — emotional control, aggression, and violent encompassing the diverse psychological and behavior. Second, high temperatures generate social strains of climate change impacts such negative economic shocks, particularly in Climate Change: Observed Trends and Projections | 29 agriculturally dependent communities, which is on mental health disorders’ incidence and critical for the subsistence farming population prevalence in Djibouti, global figures show in Djibouti.115 These economic losses have that 14 percent of the global burden of disease been shown to translate into increased suicide can be attributed to mental health illnesses.117 risk.116 Although there is a lack of information CLIMATE CHANGE IMPACTS ON HEALTH OUTCOMES CURRENT RISK PROJECTED RISK Food Security & • Djibouti has one of the highest • In a changing climate, prolonged Nutrition levels of food insecurity in the droughts and flash floods will world, with more than 30 percent continue to worsen food insecurity of the population (aged 6-59 years) and associated health outcomes chronically malnourished. — including anemia, cognitive • In Djibouti, malnutrition accounted disorders, birth defects, mental for an estimated 83 deaths per health issues. 1,000 children under five years of • Increases in projected precipitation age and 248 maternal deaths per and prolonged drought conditions, 100,000 live births in 2022. coupled with the lack of develop- • Rural poor communities — such as ment in the agricultural sector, is those in Ali Sabieh, Arta, and Dikhil predicted to increase vulnerability —who rely heavily on agricultural to food insecurity in Djibouti. and pastoral activities are more vulnerable to water scarcity and related food insecurity. Vector-borne • Djibouti has seen an increase in • Climate change and associated diseases (VBDs) the incidence of malaria from 3.4 increasing temperatures are already cases (per 1,000 population at risk) altering the distribution and trans- in 2000 to a high of 97.6 cases (per mission of VBDs and the VBD risk 1,000 population at risk) in 2020. in Djibouti, and these rates are • In Djibouti, malaria risk occurs all projected to worsen in the 2050s. year around, peaking between November and May. Waterborne diseases • In Djibouti, diarrheal disease causes • Projected increases in warm (WBDs) 6.94 percent of DALYS among temperatures, shifting patterns of children under five years old, mainly rainfall, and an increase in erratic due to Salmonella serovars and heavy rainfall events will increase Shigella species, and causes 4.27 water contamination and related percent of total DALYS for all ages. WBDs. • The increased frequency of floods in Djibouti exacerbates challenges by causing water pollution. 30 | Climate and Health Vulnerability Assessment: Djibouti CLIMATE CHANGE IMPACTS ON HEALTH OUTCOMES CURRENT RISK PROJECTED RISK Heat-related • Extreme heat also presents a • Average rising seasonal tempera- mortality & morbidity growing occupational health risk in tures as well as the increased Djibouti. frequency and intensity of heatwave events by the 2050s are projected to elevate health-related morbidity and mortality levels across Djibouti, especially in the regions of Obock and Dikhil. Air quality & respira- • In 2019, air pollution was among • Rising temperatures are projected tory health the top five risk factors for mortality, to increase the occurrence and especially among children under spread of particulate matter and five years old. pollutants, increasing air pollution • In Djibouti, it was estimated that the and thus leading to increases mortality rate attributed to ambient in chronic and acute respiratory and household air pollution was 156 diseases. per 100,000 population in 2016. Direct injuries & • In 2019, flash floods triggered by • Projected increases in erratic mortality heavy erratic rainfall caused 11 rain-induced floods will likely cause deaths and affected about 250,000 more direct injuries and deaths in people, mostly in Djibouti City Djibouti. (200,000 people). Mental health & • Extreme weather events, such as • Increased temperatures will well-being floods and droughts, are becoming continue to affect agricultural pro- more frequent and intense in ductivity and water availability, live- Djibouti, potentially leading to the lihoods, and increased poverty, with increased risks and prevalence of implications for negative mental mental disorders. health outcomes. Climate Change: Observed Trends and Projections | 31 SECTION III. ADAPTATIVE CAPACITY OF THE HEALTH SYSTEM HEALTH SYSTEM OVERVIEW 54. Djibouti has a centralized healthcare system that is administratively managed by the central government. The Djibouti Ministry of Health (MoH) is mandated to develop and implement a national health policy, including planning, coordinating, and overseeing the implementation of healthcare policies and programs in all five regions of the country. Healthcare provision in Djibouti is dominated by government / public health facilities, followed by the private for-profit health sector and charity health facilities. Traditional healers and traditional medicine, along with traditional birth attendants, also play an integral role in the healthcare system of the country.118,119 A. LEADERSHIP AND GOVERNANCE 56. National climate adaptation plans and strategies in Djibouti have unclear and limited 55. The Republic of Djibouti recognizes the guidance on the integration of climate change impacts of climate change and, as such, impacts on health and health systems, which has undertaken various adaptation and has been hampered by weak cross-sectoral mitigation plans and programs. Key national coordination, institutional arrangements, adaptation plans and policies in Djibouti and stakeholder engagement mechanisms. include the Intended National Determined While the NAPA identifies agriculture and Contributions (INDCs, 2015), the Third National water and hygiene as priorities for furthering Communication (2021), the National Adaptation climate adaptation interventions, no framework Programme of Action (NAPA, 2006), and the is provided for collaborative action with MoH National Strategy on Climate Change (SNCC, for relevant health risks. 2017) (see Table 2 for additional climate and health policies). Nevertheless, these documents Furthermore, there is a lack of integration do not identify climate change impacts on of climate change and health across all health and the health system as a priority, national adaptation and health strategies, and MoH has limited available information thus weakening the efforts to address and guidelines on addressing climate-related the health impacts of climate change and health risks. For instance, there is a lack of building a climate resilient health system. climate change adaptation strategies in the For instance, MoH, under the National Health INDCs (2015). Development Plan (PNDS 2018–2022) does not outline adaptation and resiliency to climate change as one of the strategies of the PNDS. 33 In contrast, the National Development Plan B. HEALTH FINANCING (2020–2024) identifies key health recovery 57. Health expenditure as a percentage of financing measures that can contribute to Djibouti’s gross domestic product (GDP) building a climate-resilient health system, has remained at 3 percent on average over namely (a) ensuring a comprehensive upgrade the past two decades.128 Although Djibouti’s of health service delivery, (b) introducing digital current health expenditure (CHE) per capita technologies in healthcare delivery, and (c) (current USD) has increased steadily over the investing in renewable energy for health to year,129 its health expenditure as a share of ensure universal access in rural communities. the GDP has not kept pace with the rapidly TABLE 2: Key Climate Change and Health-Related Policies. DATE POLICY/ PLAN 2022 National Development Plan (2020–2024)120 2021 The Third National Communication superseded the Second National and the First National Communications to the United Nations Framework Convention on Climate Change (UNFCCC)121 2020 Djibouti Country Strategic Plan122 2019 National Adaptation Plan (NAP) 2018 National Strategy for the Prevention of Different Forms of Malnutrition in Djibouti123 2018 National Health Development Plan (PNDS — 2018–2022) supersedes the PNDS (2013–2017) 2017 National Strategy on Climate Change (SNCC)124 2015 Intended Nationally Determined Contributions (INDCs)125 2014 Vision Djibouti 2035 (2012–2035)126 2006 National Adaptation Programme of Action (NAPA)127 2006 Decree No. 2006-0192 / PR /MID establishing the National Risk and Disaster Management Framework 2004 National Risk and Disaster Management Strategy 34 | Climate and Health Vulnerability Assessment: Djibouti expanding population.130 Even though out-of- and public health problems. It also covers pocket (OOP) expenditure declined from 51 100 percent of basic care services such as percent of its CHE in 2000 to 24 percent in consultations (children and adults) by a general 2019,131 the level of OOP expenditure is still practitioner, a standard check-up, radiology high enough to push households into financial examinations, and the delivery of essential catastrophe and impoverishment.  drugs. Health financing in Djibouti is derived primarily The Compulsory Health Insurance Scheme from public resources, with taxes and grants covers formal workers, as well as retirees and being the main source. However, domestic their dependents, while the Social Assistance general government health expenditure Programme is reserved for vulnerable declined from approximately 62 percent in populations and their dependents. 136 2013 to 46 percent in 2017, though it increased Additionally, the country has established the to 54 percent in 2019.132 The government’s Universal Student Health Insurance Scheme health expenditure as a share of total health for the University of Djibouti students aged expenditure was only 4.4 percent in 2015.133 less than 35 years. Although Djibouti has in place various risk pools, these pools are External health expenditure constitutes an fragmented and do not consider climate-vul- important source of health financing, although nerable populations.   the amount has fluctuated since 2002, with a slight overall decrease. Specifically, the 59. MoH lacks a budget line dedicated to shares of external health expenditure out of climate and health strategies and resource the CHE were as follows: 25 percent in 2002, allocations for health services do not consider 15 percent in 2003,134 19 percent in 2012, 27 climate-related hazards as a criterion. The percent in 2016, and 20 percent in 2018.135  NDP 2020–2024 outlines three strategies for the health sector with limited integration 58. Since 2014, the country has set up health of climate change, estimating a total cost of insurance schemes that provide UHC to 4 billion Djiboutian franc (FDJ). It set out (a) its people. However, they do not take into FDJ1.7 billion for ensuring a comprehensive account climate-vulnerable populations. The upgrade of the health service delivery, (b) Universal Health Insurance Law was enacted in FDJ0.9 billion for digital technologies for 2014 to ensure the coverage of all individuals healthcare delivery, and (c) FDJ1.3 billion for in Djibouti through the Compulsory Health investing in renewable energy as a resiliency Insurance Scheme and the Social Assistance measure for ensuring health service delivery Programme. According to the law, every citizen in rural areas. is provided with complimentary fundamental medical coverage at the primary level of care. Most of the financing mechanisms for The insurance provides services on vaccines; developing climate action in Djibouti depend consultations for children under five; reproduc- on development partners such as the Green tive health (pre- / post-natal consultations) and Climate Fund (GCF), which is supporting five examinations including ultrasound and family projects at a total resource allocation amount planning; as well as treatments of diseases of USD38.1 million. However, the projects on such as tuberculosis, malaria, epidemics, energy, agriculture, water, and infrastructure Adaptative Capacity of the Health System | 35 financed by GCF have limited integration and professionals may not be able to respond in coordination with the health sector which a timely manner.140 hinders the advancement of climate and health action.137 61. Djibouti’s workforce is below the WHO minimum threshold of 4.45 per 1,000 population necessary for the achievement C. HEALTH WORKFORCE of UHC.141 The government of Djibouti has made improvements in child and maternal 60. Despite an overall increase in its health health through investments in training workforce, Djibouti faces a critical shortage medical service providers, improvements in of skilled healthcare workers. Although the the procurement of medicines, and general establishment of the faculty of medicine at health service delivery however the country the University of Djibouti in 2007 led to an still faces significant shortages of healthcare increase in the number of healthcare profes- workers.142 In 2014, Djibouti had a ratio of 0.2 sionals from 1,664 in 2008 to 3,381 in 2017,138 physicians as well as 0.7 nurses and midwives Djibouti still ranks the lowest in terms of the per 1,000 population.143 In general, there are density of skilled health workers (physicians, an estimated total of about 221 physicians in nurses, and midwives) per 10,000 population Djibouti.144 In 2014, Djibouti had 488 nursing in the Eastern Mediterranean region after personnel, 210 pharmacists, 19 dentists, and Somalia and Afghanistan.139 The capacity of 19 dental assistants.145 In 2017, there were the limited number of professional health an estimated 3,381 health workers146 in the workers is further strained by an increasing country, which was inadequate in meeting population, the influx of refugees from the health needs of an increasing population neighboring countries, emergencies, and with the addition of approximately 35,000 the resurgence of infectious diseases. refugees and asylum seekers.147 More detailed information and data on health professionals In addition to the low availability of its health — such as their numbers, cadres, and skill workforce, Djibouti faces significant challenges sets including their knowledge of climate and in the uneven concentration and geograph- health — are unavailable. ical distribution of health workers. Most of the skilled health workforce is in urban areas, particularly Djibouti City. As a result, healthcare services are inaccessible to the D. HEALTH INFORMATION SYSTEMS rural population and most of the urban poor. (HIS) 62. Although Djibouti has made progress in Climate change will further exacerbate the improving disease surveillance, the country adverse impact on the health workforce still faces challenges with non-functional through mechanisms related to changes surveillance systems and a lack of infrastruc- in the frequency and intensity of extreme ture, which affects the country’s preparedness weather events. Such events may affect a and timely response to health impacts related facility directly or its workers’ ability to reach to climate change. According to the 2021 the facility, as well as alter the patterns of Global Health Security (GHS) Index report climate-sensitive diseases to which health on Djibouti, the country does not have an accredited national facility to serve as a national 36 | Climate and Health Vulnerability Assessment: Djibouti reference laboratory.148 As of 2018, Djibouti Climate Prediction and Application Centre of did not have a secure system or national Intergovernmental Authority on Development guidelines for the collection, transportation, (IGAD) in East Africa, which is based in Nairobi. and storage of specimens.149 This leads to challenges with the reliability and accuracy of forecasts, integration with 63. While Djibouti has a Health Management key stakeholders for preparedness and Information System (HMIS), there are response in the face of climate hazards, and inadequate finances for its effective the integrated surveillance of climate-sensitive maintenance and an integrated surveillance diseases. of climate-sensitive diseases that accounts for seasonal outlooks and weather data does not exist. Furthermore, the country does E. ESSENTIAL MEDICAL PRODUCTS not yet have a District Health Information AND TECHNOLOGIES System 2 (DHIS2) to support evidence-based health policies and decisions to build climate 65. Health sector purchases are primarily placed resilience.150 Djibouti still largely depends under the budget allocated to MoH. In 2004, on paper-based health recording systems, the Central Purchasing Agency of Essential especially in rural areas, which are highly Medicines was established in Djibouti to vulnerable to damage by floods. ensure the sufficient supply and distribution of medicines and supplies. However, the limited 64. Djibouti faces challenges with the delayed resources allocated to the health sector are dissemination of early warning information, largely spent on wages at the expense of thus affecting early response in the face medical equipment, drugs, and materials.153 of floods and droughts. While there is a This has contributed to the decline in the monitoring network set along the Oued de quality and quantity of public health services Ambouli watershed that indicates the water provided. levels and provides text messages via the short message service (SMS) before flooding, 66. Although Djibouti has a national essential the communities are alerted only shortly medicines list (NEML), the country still before flooding, therefore undermining a experiences limited access to essential timely response.151 medicines and other essential medical products. Djibouti’s NEML was last updated Similarly, even though Djibouti’s Secretariat for in 2007, falling short of the WHO’s update Risk and Disaster Management (SGRC) has an in 2021.154 In addition, Djibouti’s NEML has information system database — Desinventar 218 medicines155 — far shorter than WHO’s — for collecting, storing, and sharing recommended 479 medicines. Djibouti’s climate-related disaster data (the numbers of NEML also has either a lack of essential deaths, injuries, people displaced, damaged medicines or a low supply for some conditions infrastructure and facilities), funding is limited. including oncology156 and cardiovascular The system’s last update was in 2012.152 diseases (CVDs).157 There are insufficient funds to purchase essential medical products Moreover, Djibouti does not have a national including gloves and gauze, personal protective weather and forecasting station; instead, equipment, and laboratory reagents, along it relies on the numerical portal run by the with equipment needed for the diagnosis Adaptative Capacity of the Health System | 37 and treatment of both communicable and health centers, and hospitals for a population non-communicable diseases.158 slightly above 1 million.161 Most of the health facilities are in the urban areas, especially As a result, health facilities are faced with drug Djibouti City (see Figure 3). Twenty three of stockouts of medicines for cancer, diabetes, the 66 public health facilities, including all high blood pressure, as well as cardiovascular eight tertiary hospitals, are in the capital — and chronic respiratory diseases — conditions Djibouti City, where about 600,000 people that will be worsened by climate change, live.162 Even so, the facilities are not enough making them likely to be key disease burdens to meet the health needs of 78 percent of among the population in Djibouti in the 2050s. the urban population. Vulnerable populations like children and mothers also experience the shortages of 69. Djibouti lacks adequate health facilities, essential medicines.159 Finally, the lack of a especially in the rural areas, which are highly harmonized price list of essential medicines vulnerable to climate change shocks. People and essential medical products, especially in living in remote rural areas frequently face the private sector, makes access to quality-as- significant challenges in accessing healthcare sured essential medicines a challenge.160 services, as laboratory, surgery, and specialized services provided at the district hospitals are 67. Djibouti has a critical lack of essential medical often too far away from rural populations, equipment — a situation that impacts the thus increasing their vulnerability and risk health system’s preparedness to tackle to climate-related hazards. This is largely climate change impacts on health. Inventory attributed to the lack of health facilities, with the data on the availability of essential medical few health facilities available facing constant equipment in health facilities in Djibouti drug and medical supply stockouts and under- collected in 2022 shows that the equipment staffing, thereby resulting in poor, inadequate, available is not enough to provide basic health and inaccessible services. With inaccessible services, such as maternal and child health healthcare services, the rural population — the care. With projected increases in severe flood majority who live in extreme poverty (62.6 occurrences, heat waves, and climate-re- percent) — are left to deal with high costs from lated health risks in Djibouti in the 2050s, private health facilities. Private clinics offer the demand for essential medical equipment services at a cost that is not affordable by the will increase while accessibility to the few majority of the poor population in Djibouti. health facilities with the medical equipment will be limited due to poor road conditions Limited health facilities and services, especially caused by flooding. for some illnesses (such as mental health) and for services (such as diagnostic imaging and radiology services along with maternity F. HEALTH SERVICE DELIVERY services), in rural areas force people to visit traditional health healers, herbalists, and 68. There are also geographical inequalities traditional birth attendants. These profes- in the distribution of higher-level public sionals are not trained to provide skilled health health facilities between rural and urban services and their interventions can lead to areas. In 2019, Djibouti had 66 public health complications and premature deaths.  facilities, including health posts, community 38 | Climate and Health Vulnerability Assessment: Djibouti TABLE 3: Public Medical Facilities (2019).163 FACILITY TYPE DISTRICT OWNERSHIP Tertiary Hospital 8 Govt. Hospital Medical Center 5 Govt. Health Post 41 MoH Community Health Center 12 MoH 70. Djibouti has made progress in improving to the urban population and neighboring accessibility to health and medical services suburbs.164 On April 11–14, 2004, Djibouti to the population in Djibouti living in rural received torrential rains that induced strong areas, though floods make access more flash floods, affecting many areas and causing challenging. Djibouti’s MoH developed the Ambouli River to burst its banks. The several initiatives between 2017 and 2018 flash floods destroyed four main health center to address healthcare needs in rural areas. structures serving the affected communities, Medical caravans were dispatched to the caused damage to the health equipment, and southern, Obock, and Tadjouran regions to washed away medicine and documents.165 assist the rural poor. With the assistance of the European Union (EU) and the International 72. Djibouti experiences a dire lack of accessible Organization for Migration (IOM), a program and affordable primary healthcare (PHC) was established in 2017 to provide medical services in most regions, most of which are aid to migrants and vulnerable populations needed for improved preparedness and along migratory routes. Additionally, in 2018, response mechanisms that can address a 20-bed medical center was built in Obock climate-related health impacts effectively. with IOM’s support, benefiting migrants and Moreover, there are big gaps in the provision locals. Despite these efforts, floods pose a of emergency services in all the regions of challenge, as they impact roads and bridges, Djibouti. For example, among the district thus hindering access to health facilities and hospitals and health posts in the different the delivery of supplies to facilities. regions, very few have emergency units: three out of 10 in Arta, one out of 10 in Dikhil, 71. Health infrastructures, including those one out of five in Obock, one out of six in constructed with a lack of building codes Tadjoura, and none out of seven in Ali Sabieh. that account for climate-related hazards, A similar trend applies to the lack of laborato- are unprepared to withstand acute climate ries, communal pharmacies, and Caesarean shocks, thus affecting healthcare service services even in Ali Sabieh and Obock — the delivery. In the aftermath of Cyclone Sagar, regions hosting a large number of refugees. a rapid assessment revealed that in Djibouti alone, 14 health facilities were damaged by the floods, thus affecting health service delivery Adaptative Capacity of the Health System | 39 SUMMARY OF HEALTH SYSTEM ADAPTIVE CAPACITY GAPS FOR DJIBOUTI BUILDING BLOCK GAPS • Climate change adaptation plans have limited to no integration of health as a key sector for furthering climate change action as well as lack health Leadership & Governance adaptation strategies for climate change. • Climate change impacts on health are not articulated in key health policies of relevance. • Fragmented risk pools do not consider climate-vulnerable populations. • The is no budget line for the development and implementation of climate Health Financing and health strategies. • The estimated costs of priority interventions on climate-related impacts on health and the health system are lacking. • Djibouti ranks lowest in terms of density of skilled health workers (phy- sicians, nurses, and midwives) per 10,000 population in the Eastern Health Workforce Mediterranean region, after Somalia and Afghanistan. Most of the health workforce is concentrated in urban areas (mainly Djibouti City). • There is no information on the level of technical capacities in the country and workforce knowledge on climate change and health. • There is a lack of infrastructure for surveillance systems, including the lack of a central reference laboratory, delays in publishing an updated version of the Demographic and Health Survey, and dependence on paper-based health recording systems. Health Information Systems • Djibouti does not have a national weather and forecasting station. It relies (HIS) on a numerical portal that is run by the Climate Prediction and Applica- tion Centre of the Intergovernmental Authority on Development (IGAD) based in Nairobi, thus undermining the timeliness of information needed. Integrated surveillance — accounting for seasonal outlooks and weather data — is non-existent. 40 | Climate and Health Vulnerability Assessment: Djibouti BUILDING BLOCK GAPS • The lack of a harmonized price list of essential medicines and essential medical products, especially in the private sector, hinders access to quali- ty-assured essential medicines. • Inventory data on the availability of essential medical equipment in health Essential Medical Products facilities in Djibouti collected in 2022 shows that the equipment available & Technologies is not enough for providing basic health services. • The limited availability of essential medicines hinders preparedness efforts in the face of climate hazards, such as floods, which are frequent in the country. • Djibouti faces a lack of health facilities, especially in the rural areas, which are highly vulnerable to climate hazards. • There is a lack of provision of crucial health services in most regions, most of which are needed for improved preparedness and response Health Service Delivery mechanisms to address climate-related health impacts. • Health infrastructures, including those constructed with a lack of building codes that account for climate-related hazards, are unprepared to withstand acute climate shocks. Adaptative Capacity of the Health System | 41 SECTION IV. RECOMMENDATIONS TO ENHANCE HEALTH SYSTEM RESILIENCE TO CLIMATE CHANGE 73. This section outlines a set of recommendations to enhance Djibouti’s health system resilience and adaptation to climate change, including potential health interventions and strategies that can be put in place. The recommended options are based on an assessment of both the magnitude of the current and projected climate-related health risks and the existing gaps in adaptive capacity for managing and / or preventing these risks. This section is organized, using the WHO operation framework for climate-resilient health systems (Figure 10). FIGURE 10: Operational framework for building climate-resilient health systems. ATE RESILIENCE CLIM hip & Heal ders Workf th Lea vernance orce Go V uln pac ation t Fin alth & A Ca apt men He ate era ity & Leadership As g d ess Clim cin bil & Governance Health s ity, an Workforce Financing Preparedness & Integrated Risk Early Warning Management Monitoring & Emergency Health BUILDING Information BLOCKS OF Systems HEALTH SYSTEMS Service Delivery Essential C li r m e h Re ima & I n f a lt s Medical ma d C l a lt h se te o Products & h He ra m Pro te a rc Technologies He - g Ma nt na ili e Env ge m ent o Res le ir o n f C li m a t e a b in D et m ental & S u st a gies ri m e lo of H n ts Techno cture e a lt h s tr u & Infra 43 LEADERSHIP AND GOVERNANCE allocations and support enforcement. Such a system may be integrated into existing health 74. Include adaptation and mitigation strategies facility quality assessments. for the health sector in the next submission of the Nationally Determined Contributions 77. Develop training modules in weather (NDCs) and the National Adaptation Plan forecasting and climate-related health risks (NAP). This should also include developing for personnel at MoH to improve its surveil- a policy strategy for the health sector that lance capacity. For example, climate change accounts for climate and health-related risks and seasonal outlooks should be factored and strengthening the role of the Ministry of into the newly launched program on digitizing Health (MoH) in climate change adaptation. This Djibouti’s disease surveillance and monitoring Climate and Health Vulnerability Assessment system. This should be done in collaboration (CHVA) can feed into specific activities to with MoH, the Djibouti National Meteorological be developed in the forthcoming policy Agency, and the Climate Prediction and documents. Application Centre of the Intergovernmental Authority on Development (IGAD), based in Nairobi. HEALTH FINANCING 75. Establish a budget line in MoH for developing 78. Develop a communication strategy for better and implementing climate and health practices on sanitation and hygiene at the action plans and interventions. This would household / community level, with the aim incentivize MoH to develop a Health National of decreasing open defecation rates and Adaptation Plan and integrate climate change improving practices for water use. This may as a cross-cutting challenge in other projects include the distribution of hygiene kits for and programs, such as surveillance systems diarrheal diseases control, especially in rural or health facilities’ infrastructure. communities. MoH and the Djibouti National and Sanitation Authority should collaborate to develop this strategy. HEALTH SERVICE DELIVERY 76. Develop and implement national building codes and standards as well as a climate-re- ESSENTIAL MEDICAL PRODUCTS AND silient certification system. This includes TECHNOLOGIES standards on building sustainable and 79. Establish a laboratory outreach system and climate-resilient healthcare infrastructure, laboratory facilities at the subnational level such as norms for the location of new facilities; for improving the collection, transportation, walls, roofs, and ceiling characteristics that storage, and processing of climate-sen- can withstand storms and high-speed winds; sitive disease tests such as for malaria, along with contingency plans that account dengue, and diarrheal diseases. This may for climate hazards. The certification system include the establishment of a reference would include an assessment of the facilities laboratory per region to reduce delays in vis-à-vis existing climate-resilient infrastruc- specimen processing and patient diagnosis ture codes and identify health facility needs, and management. The government and MoH hence facilitating the prioritization of resource could engage development partners to support 44 | Climate and Health Vulnerability Assessment: Djibouti the establishment and stocking of regional 82. Develop health workforce training packages reference laboratories. on climate change and health linkages. They should include modules on addressing the 80. Develop a public health supply chain resilience additional health burden caused by climate strategy for guiding the procurement of change impacts as well as preparedness and medical products and equipment during response to climate change. extreme weather events. This includes the development of contingency plans that pre-position medicines to account for seasonal HEALTH INFORMATION SYSTEMS (HIS) outlooks for floods and storms. 83. The Djibouti National Meteorological Agency, in collaboration with MoH, should develop tailored early warning alerts that account HEALTH WORKFORCE for subnational climate-related exposures 81. Use climate and health vulnerability as to facilitate quick response and prepared- a criterion for developing incentives and ness at the community level. For example, retention packages for health workforce in these alerts should take into account the fact highly vulnerable areas to climate-related that regions of Djibouti City, Ali Sabieh, and hazards. Health workforce retention packages Arta are more prone to flooding while the should also be introduced in regions facing regions of Dikhil, Obock and Tadjourah are the highest risk of climate-related hazards more prone to droughts. (droughts) such as Arta, Ali Sabieh, Obock, and Tadjourah. TABLE 4: Categorization of recommendations. Timeline: Short-term = less than two years, Medium-term = between two and five years, Long term = more than five years. COMPONENTS RECOMMENDATIONS CATEGORY Leadership & Include adaptation and mitigation strategies for the health sector Short Governance in the next submission of the Nationally Determined Contributions (NDCs) and the National Adaptation Plan (NAP). Health Financing Establish a budget line in the Ministry of Health (MoH) for Medium developing and implementing climate and health action plans and interventions. Health Service Develop and implement national building codes and standards that Medium Delivery complement a climate-resilient certification system. Develop training modules in weather forecasting and climate- Short related health risks for MoH personnel to improve surveillance capacity. Develop a communication strategy to improve practices on Short sanitation and hygiene at the household / community level, with the aim of decreasing open defecation rates and improving practices for water use. Recommendations to Enhance Health System Resilience to Climate Change | 45 COMPONENTS RECOMMENDATIONS CATEGORY Essential Medical Establish a laboratory outreach system and laboratory facilities Medium Products and at the subnational level to improve the collection, transportation, Technologies storage, and processing of climate-sensitive disease tests such as for malaria, dengue, and diarrheal diseases. Develop a public health supply chain resilience strategy that Short guides the procurement of medical products and equipment during extreme weather events. Health Workforce Use climate and health vulnerability as a criterion for developing Medium incentives and retention packages for the health workforce in areas that are highly vulnerable to climate-related hazards. Develop health workforce training packages on climate change and Short health linkages, with modules on addressing the additional health burden due to climate change impacts as well as preparedness and response to climate change. Health The Djibouti National Meteorological Agency should collaborate Medium Information with MoH to develop tailored early warning alerts that account for Systems (HIS) subnational climate-related exposures to facilitate quick response and preparedness at the community level. 46 | Climate and Health Vulnerability Assessment: Djibouti ANNEXES ANNEX A. ADAPTIVE CAPACITY RAPID ASSESSMENT LEADERSHIP AND GOVERNANCE Assessment Questions Yes No Partial N/A 1.1: Does the country have a national climate change and health plan / strategy? 1.2: Is health mentioned as a priority in the Nationally Determined Contributions (NDCs)? 1.3: Is there a designated focal point responsible for health and climate change in their ministry of health (MoH)? 1.4: Is there a multi-sectoral technical working group / committee focused on climate change and health? 1.5: Does the MoH actively participate in climate change coordination and /or working groups? 1.6: Is there a memorandum of understanding (MOU) between the MoH and key climate change-related ministries / departments (for example, Environment, Meteorological Services, Agriculture, and Water)? 1.7: Are decision-makers (both within the MoH and outside) aware of climate change and health risks and potential adaptation options? 1.8: Does relevant information related to climate change and health risks and adaptation reach key stakeholders across sectors? 1.9: Is climate change included in health plans at subnational levels? 47 HEALTH WORKFORCE Assessment Questions Yes No Partial N/A 2.1: Are there dedicated full-time staff devoted to climate change and health? 2.2: Are the number of healthcare workers above 4.5 per 1,000? 2.3: Are health workers adequately distributed between urban and rural areas? 2.4: Is the health workforce aware of the health risks of climate change? 2.5: Are there capacity-building programs focused on climate change and health within the MoH? 2.6: Have the MoH staff received training on climate change and health in the last two years? 2.7: Does the health workforce have the technical capacity to interpret and utilize climate change information (for example, scenarios, projections, and forecasts) to inform planning / decision-making? 2.8: Is climate change and health included in the educational curriculum (for example, schools of public health, medicine, and nursing)? 2.9: Are there context- or country-specific climate change and health training / educational materials available for the health workforce? HEALTH INFORMATION AND DISEASE SURVEILLANCE SYSTEM Assessment Questions Yes No Partial N/A 3.1: Has the country completed a climate change and health vulnerability and adaptation or risk assessment? 3.2: Do surveillance systems exist for climate-sensitive diseases (for example, heat related illnesses, vector-borne diseases [VBDs], and waterborne diseases [WBD])? 3.3: Does the country have a centralized monitoring system for climate-related diseases? 3.4: Do health surveillance systems integrate meteorological and/or environmental information? 3.5: Are there efforts from the MoH to utilize national climate / meteorological information? 3.6: Does the country have a climate-informed early warning system for any health risks? 3.7: Are there early warning systems in place for climate change-related extreme events / hazards? (for example, flooding, droughts, and storms)? 3.8: Does MoH coordinate with disaster / hazard-focused early warning systems? 48 | Climate and Health Vulnerability Assessment: Djibouti ESSENTIAL MEDICAL PRODUCTS, TECHNOLOGIES, AND INFRASTRUCTURE Assessment Questions Yes No Partial N/A 4.1: Have the country’s healthcare facilities been assessed for climate resilience? 4.2: Are health facilities accessible to rural communities? 4.3: Do healthcare facilities implement measures to remove mosquito-breeding sites? 4.4: Have healthcare facilities employed adaptive measures to protect against climate change-related hazards (for example, flood walls or drainage systems)? 4.5: Does the national laboratory have the capacity to conduct diagnostic tests for climate-sensitive diseases? 4.6: Are building codes for healthcare facilities to protect against climate change-related hazards in place and enforced? 4.7: Have healthcare facilities implemented “greening” activities (for example, tree planting and cooling designs)? 4.8: Are there efforts to incorporate long-term planning (for example, urban design) to reduce climate change and health impacts? 4.9: Are health facilities adequately equipped to prepare for and respond to climate change-related hazards (for example, stockpile of medical/emergency supplies)? HEALTH SERVICE DELIVERY Assessment Questions Yes No Partial N/A 5.1: Has the country enacted legislation mandating universal healthcare coverage (UHC)? 5.2: Are there climate change-specific health programs underway in the country? 5.3: Does health service delivery have contingency measures for extreme weather events (for example, floods, storms, and heatwaves)? 5.4: Does current public health planning consider climate change information (for example, scenarios, projections, and forecasts)? 5.5: Has the MoH implemented any climate-health awareness campaigns to increase public awareness? 5.6: Is there access to safe water, sanitation, and hygiene (WASH) in over 80 percent of the country? 5.7: Do over 80 percent of healthcare facilities have access to safe WASH and healthcare waste removal / storage? 5.8: Have multi-hazard risk assessments been conducted in the country? 5.9: If conducted, do multi-hazard risk assessments include potential health risks? Annexes | 49 FINANCING Assessment Questions Yes No Partial N/A 6.1: Is the MoH currently receiving international funds to support climate change and health work? 6.2: Is there dedicated funding within the MoH for climate change and health activities? 6.3: Is the health expenditure percentage of the country’s gross domestic product (GDP) above the recommendation of the World Health Organization (WHO)? 6.4: Is the national health budget dependent on donors or foreign aid? 6.5: Are there climate considerations in the national health budget? 50 | Climate and Health Vulnerability Assessment: Djibouti ANNEX B. LONG LIST OF RECOMMENDATIONS COMPONENT 1: LEADERSHIP AND GOVERNANCE • Develop strategic plans for climate-related health risks that account for subnational and geo- graphical differences in climate hazard exposures and related health risks. For example, the plans should account for the fact that the regions of Obock, Tadjourah, and Djibouti City are at high risk of coastal flooding while the regions of Tadjourah, Dikhil, and Ali Sabieh are prone to wildfires. • Incorporate climate health risks into national policies and strategies wherever possible and ensure their implementation at the subnational level. For example, there is a need to integrate climate- informed assessments that take into account geographical and subpopulation vulnerability into the health policy and decision-making to better support the resilience of the healthcare system and the equitability of health service delivery. • Establish a climate adaptation and resilience working group. COMPONENT 2: HEALTH WORKFORCE • Create and implement interventions to attract and retain a sufficiently skilled health workforce in order to provide adequate health services to populations, especially in remote rural areas such as those in the Tadjourah region. Health workforce retention packages should also be introduced in regions facing the highest risk of climate-related hazards (droughts), such as those of Arta, Ali Sabieh, Obock, and Tadjourah. Retention packages should also include risk reduction and emergency protocols, as well as proper housing, salary increments, bonuses, and basic services for health workers. • Conduct regular climate and health workforce knowledge and needs assessments to integrate climate change-related health impacts into workforce planning. • Introduce climate change and health education in medical and paramedical school curricula and physician training and continuing medical education (CME). • Introduce regular refresher courses for continued learning and provide on-the-job training oppor- tunities to increase the health workforce’s understanding of how climate change impacts health, including climate-related health risks / diseases and their diagnoses, as well as modules on pre- paredness and response to climate change. COMPONENT 3: VULNERABILITY, CAPACITY, AND ADAPTATION ASSESSMENT • Develop a toolkit for health needs assessments (HNAs) specific to climate-related health risks. • Conduct regular HNAs both at the national and subnational levels to guide equitable resource allocations and priority setting for improved health outcomes in communities more prone to climate hazards. Annexes | 51 • Develop guidance tools / toolkits to guide healthcare management to assess the resilience of different health facilities in urban, rural, and climate hazard-prone areas. COMPONENT 4: INTEGRATED RISK MONITORING AND EARLY WARNING • Set up functional early warning systems that can predict and alert communities to climate hazards and related health risks. This includes using effective and efficient communication methods to pass on information to communities and other stakeholders. Popular and quick methods that consider the context should be used. For example, alerts should be translated into languages commonly spoken in a community. Local / religious leaders and celebrities should be involved in the com- munication since they are respected and trusted by their community members. • Conduct campaigns to create awareness of the linkage between climate change and human health, including climate-related health risks and the first-aid responses to take, at an individual and household level. • Develop early warning score systems (EWSS) to guide the early and quick diagnosis of climate- related diseases, including acute diarrheal diseases (such as cholera) and vector-borne diseases (VBDs). • Strengthen early surveillance and response systems for climate-related health risks to enhance the preparedness and adaptive capacity of the health system and increase climate-related health risk incident monitoring to inform disease prevention efforts / interventions. • Develop heatwave alert systems for urban and rural populations and the action to be taken by communities and health facilities. COMPONENT 5: HEALTH AND CLIMATE RESEARCH • Advocate for the increased awareness of climate and health through conducting research. For example, advocacy messages should include climate hazards and the related health risks, popu- lation, the most-at-risk geographical areas, and the suggested course of action. • Increase institutional capacity and building centers for research to conduct more climate and health research in Djibouti, which can be financed through government investment and interna- tional collaborations. • Improve effective strategies and channels for climate and health research dissemination for different audiences including policy makers, the civil society, and the scientific audience. • Strengthen the effective communication of climate change and related health risks as well as the use of evidence to inform climate-health policies and interventions, both at the national and subnational levels. 52 | Climate and Health Vulnerability Assessment: Djibouti COMPONENT 6: CLIMATE-RESILIENT & SUSTAINABLE TECHNOLOGIES AND INFRASTRUCTURE • Invest in improving indoor ventilation and filtration in health facilities, for example, by using low-cost infrastructure modifications such as providing open skylights and extra windows, especially in waiting and consultation rooms. • Healthcare facilities should schedule and conduct regular preventive maintenance on the main heating, ventilation, and air conditioning system (HVAC) components to identify opportunities for energy-efficiency improvements and upgrades. • In addition, there is a need to invest in training skilled HVAC technicians. • Scaling up passive / natural space-cooling measures (renewable energy) in healthcare facilities to reduce energy costs and prevent the overheating and destruction of medical devices and labo- ratory equipment. For example, health facilities in Djibouti would benefit from the use of a hybrid solar system, especially in rural areas where access to hydroelectricity is low. • Promote smart lighting strategies and improve energy efficiency in health facilities by investing in energy-saving light bulbs and motion-sensor light bulbs. • Install rainwater harvesting systems and water storage tanks (underground or aboveground tanks) for household water security and constantly treat the water to provide potable water at health facilities and in communities.  • Invest in eHealth, telemedicine innovation, healthcare call centers, solar and rechargeable bat- tery-powered mobile clinics, laboratories, and pharmacies (training health workforce, technical capacity, and financial investment). These should be introduced and reinforced, especially in urban areas, to free resources, including the health workforce and finances, for rural areas. • Use white paint with a cooling effect or two-layer cooling paint, instead of commercial white paint, in health facilities. • Invest in waterproofing solutions for health facilities, medical equipment, devices, patient files such as antimicrobial cement sealers, and metallic storage cabinets in flood-prone areas. • Invest in solar-powered health facilities, especially in rural remote areas that are off the power grids. Health facilities in Djibouti would benefit from the use of hybrid energy systems to power equipment / essential medical devices as well as life-saving services and procedures — including deliveries, emergencies, surgeries, Caesarean deliveries, blood transfusions, sample storage, medicines, and vaccines.  • Invest in cost-effective and efficient solar-powered mobile health clinics in all regions of Djibouti, especially those in remote rural communities with no or limited health facilities. • Invest in acquiring essential medical equipment and supplies to deal with the additional burden due to climate sensitive diseases, including medicines and medical supplies for climate sensitive disease, ultrasound machines, standard X-ray machines, anesthesia machines, and oxygen cylinders. Annexes | 53 COMPONENT 7: MANAGEMENT OF ENVIRONMENTAL DETERMINANTS OF HEALTH • Utilize and support community-led approaches to promote hygiene and sanitation. For example, establish a community-led total sanitation model that encourages working together with commu- nities and supporting them to conduct their own appraisal and analysis of the sanitation situation — identifying the main problems, causes, and sustainable local targeted solutions. • Educate communities on the health risks of poor sanitation, such as open defecation, especially in a changing climate. It is recommended that educational materials and communication on the hazards of open defecation as it relates to water quality and waterborne disease risk are used, especially among rural communities, slum dwellers, and those residing in temporary disaster shelters after extreme weather events.   • Enlist medical colleges and schools to collaborate with district- and local-level community groups to support dialogues, promote awareness, and develop prospective climate and health programs, such as health promotion programs focused on climate-related health risks. Engagement could include the use of mainstream media or community-level climate and health training modules.   • Invest in planting trees on health facility / hospital premises and plants in health facility wards, waiting and consultation rooms for health promotion and wellness, improving air quality, and providing cooling in health facilities. COMPONENT 8: CLIMATE-INFORMED HEALTH PROGRAMS • Invest in awareness campaigns on climate-related health risks — using local and national radios, television, and push notifications. Involve and engage community leaders and civil society in order to ensure better communication in the most vulnerable and remote rural communities. Campaigns should cover preventive measures and the management of environmental determinants of health including water, sanitation, and hygiene (WASH) programs, boiling of drinking water, and the proper disposal of human waste. • Create a national multi-sectoral program on food security and nutrition, with implementation plans for different sectors and levels — including national, subnational, and local levels. The different sectors include health, education, and agriculture / livestock. • Institute community nutrition education programs that train women how to prepare nutritious and balanced meals for their households, especially concerning children, pregnant women, and the elderly. • Create a national emergency food bank to help those in drought- and flood-prone areas, especially the poor and vulnerable households. 54 | Climate and Health Vulnerability Assessment: Djibouti COMPONENT 9: EMERGENCY PREPAREDNESS AND MANAGEMENT • Invest in the construction of emergency units in district hospitals and health posts to facilitate quick response and management in the face of climate change-induced hazards and related health risks, including heat shocks, direct injuries, and other related conditions. • Develop climate adaptation and resilience plans to guide the evaluation of the most significant climate-related health risks and vulnerabilities. • Integrate the health impacts of climate change into emergency preparedness plans. • Conduct routine climate resilience assessments of health facilities and infrastructures, taking into account geographical differences in climate hazard vulnerabilities. • Conduct routine assessments of climate risks and vulnerabilities. • Invest in purchasing ambulances for health facilities, mobile team vehicles, and supplies, especially those in the remote and rural areas of Ali Sabieh, Arta, and Tadjoura. COMPONENT 10: CLIMATE AND HEALTH FINANCING • Advocate for investing sufficient funds in health care to build climate-resilient health systems, both in terms of climate-resilient health facilities / infrastructure and equipment but also in the recruitment and training of more skilled health workforce to attend to the extra health burden of climate-related health risks. • Advocate for including climate change and related health risks in national, subnational, and local budgets and programs. • Design a detailed resource mobilization plan for financial resources to support climate-resilient health systems. 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