Attachments
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, unpredictable 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 recommendations — 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.
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-sensitive 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.
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 significant 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.
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 certification systems. This includes standards for building sustainable and climate-resilient healthcare infrastructures, such as the requirements for the location of new facilities; the expected characteristics 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.