The Promise of Rural Health Innovation in Djibouti

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This is the unlikely — and unfinished– story of a public-private partnership for development, linking the Gulf emirate of Dubai, the Red Sea State of Djibouti and the United States Agency for International Development (USAID).

In 1998 Ethiopia and Eritrea fought a brief but brutal war.  Ethiopia lost use of its former two main ports (Assab and Massawa) to Eritrea, and almost all of Ethiopia’s exports and imports (Ethiopia’s 2011 GDP was close to 40 billion dollars) shifted onto a thin road linking Ethiopia’s capital of Addis to the port of Djibouti. Dubai was at this time seeking a beachhead in Africa through which to export its combination of port management services, free trade zones, customs management and amenities.  Developments in Ethiopia, a precipitous drop in trade through neighboring Aden, Yemen due to the USS Cole Bombing in 2000, and Djibouti’s strategic location at the foot of the Red Sea, made Djibouti an inspired — and profitable–  bet.

A 2008 presentation in Djibouti by the late Gail Goodridge, then with Family Health International (FHI), converted me to the rather brilliant idea of using transport corridors as a vector for delivering social services to a number of disadvantaged populations.  Dr. Jeff Ashley, a veteran USAID hand, conceived several years before of the idea of using “augmented truck stops” along major transport corridors in Africa to get out the message about HIV/AIDS.

With Dubai catalyzing nearly $1.3 billion in investment in this state at the foot of the Red Sea — paying for the construction of the most technologically advanced port in East Africa, a luxury hotel, and roads, among other things–  both Dubai-led external investors and Djiboutian government were under pressure to show that this relationship was generating benefits for Djibouti’s urban and rural poor (Djibouti’s unemployment rate is over 50%, and the country’s population of 800,000 is under continued threat of famine and drought).

As the Corporate Social Responsibility point person for Dubai Ports (DP World) from 2008-2011, I oversaw a three-year campaign to broaden the ROADS remit to include the provision of primary healthcare services and small-scale commercial activities, enabled by advances in solar and satellite wireless technology.  We revamped the “truck stop” concept and persuaded Dubai Ports and its suppliers to invest in more permanent healthcare structures according to a “hub and spoke” model, which has since been successfully implemented in other countries in the Subcontinent.  After Djibouti, the next recipients were to be the Maputo Corridor in Mozambique, the port of Dakar, in Senegal (both of which were run by DP World).

The model, and the division of labor, looked robust:  Dubai Ports would pay for the hard infrastructure that USAID funding did not allow, and the contractors (in this case, FHI) would work with the Djiboutian government and local hospital to make sure local resources were trained to staff the facilities.

During stage I, the base camp at a truck stop called “PK12” (for its distance twelve kilometers from the city center), essentially two shipping containers welded one on top of the other and furnished, was outfitted with solar panels (electricity was prohibitively expensive, so the facility was dark 9 hours a day) and a VSAT internet connection, so visiting truckers could Skype their relatives, and pull up a variety of health-related information, some in the form of software donated by DP World suppliers. Planned small-scale commercial activities included mobile phone charging stations and a small canteen.

Meanwhile, we set about designing a prefab clinic (manufactured by Italy’s Edil Euganea)  which included exam rooms, a lab, a canteen, an audio-visual room, easily sanitizable surfaces and separate entrances for male and female visitors (in deference to the country’s conservative mores). Importantly, we thought hard about what would make the clinic more attractive to its users.  We designed the facility, within budget, to accommodate 30,000 individual visits a year.  With the ‘hub clinic’ was built, the existing, upgraded ‘SafeTStop’ was to be moved up the highway to Dikhil, closer to the northern border.  Connectivity between the two posts, and other posts over the border in Ethiopia, would serve as the skeleton of a widening network of services, where a mobile patient’s records would be available throughout the network.

Thus, a USAID “Global Development Alliance” (GDA) linking Dubai Ports, the Djiboutian government, and the United States was launched in 2009, formally, in a ceremony attended by the Djiboutian Minister of Health, Senior DP World executives, and representatives from USAID and FHI, and touted as the “First Ever U.S.-Djibouti Public-Private Partnership” (the USAID link has since been taken down).  A Dubai and Kenya based company, Intersat/ SPARC, installed the solar panels.

Here’s where things started to go awry:  Dubai’s increasing preoccupation with the fallout of the 2008 financial crisis, a tussle with Djibouti over an exiled ex-Djibouitan official, and an odd drop-off of interest by contractors employed by USAID, left the upgraded unit operating much as it had previously been, and the new clinic sitting unassembled for the better part of two years.

No longer working for Dubai Ports, I and a group of colleagues worked with Edil Euganea and other entities over the course of 18 months to assure the new prefab unit was not sold for scrap for delinquent payment (it came close), and lobbied with USAID and senior government officials to make sure programming and training was not suspended or abandoned.

Now, in mid 2013, a somewhat promising thaw in Dubai-Djibouti relations has brought the clinic concept back to life:  Dubai unsealed the containers and the 2000 sq ft unit — the one pictured above– was assembled in less than two weeks by, using a combination of Djiboutian, Italian and Dubai labor.

Certainly better late than never, but what of the original plan?  Will the new clinic be staffed by purpose-trained Djiboutians in a collaboration between American and Djiboutian medical personnel?  Will the original PK12 structure be moved up the corridor to the town of Dikhil to establish the second node?  Who will make sure the clinic and the outpost are working properly?

The success of this venture is all the more critical, as every one of the stakeholders– Dubai, Djibouti, the U.S. government, the Ethiopian transport workers– has a stake in the outcome.

–EDC