Supporting Women's Empowerment in Djibouti.

The Horn of Africa has lately attracted a lot of international attention, much of which has been focused on the conflict between Ethiopia and Eritrea. Negligible mention has been made of Djibouti, a little island of tranquillity in the backdrop of an otherwise turbulent region. Made up of a multitude of nationalities, including Afars, Arabs, Somalis, Ethiopians, French, Italians and Asians, Djibouti boasts four national languages--Afar, Arabic, French and Somali.

The country has few resources and high levels of unemployment, poverty and malnutrition. Its economic asset is its strategic location and a modern port that provides large-scale docking facilities for all vessels. On the social side, a low literacy rate, especially for women, and a 100-per cent rate of female genital mutilation is prevalent. Medical services are scant, and those meant for pregnant mothers, family reproductive health care and the delivery of healthy babies are even fewer.

Djibouti's small population of 700,000 has been affected by regional conflicts. Increased cross-border road traffic--trailers carrying everything from essential foods and medicines to more nefarious cargo--meander through its desert terrain to Ethiopia and Eritrea. They bring with them increased risks of sexually transmitted diseases (STDs), HIV/AIDS, prostitution, other social ills and the increased dynamic of political destabilization. A potential crisis is currently developing due to the flow of 25,000 to 40,000 refugees from Ethiopia and Eritrea. Most of them have settled in the rural areas of northern and south-eastern Djibouti, with little access to sanitation, safe water or health services. The burden of catering for them falls mostly on provincial authorities, which lack the means to cope with their citizens' needs, let alone these newly emerging needs.

Access to basic maternity services is lacking in many areas, despite the collaboration of the United Nations Population Fund (UNFPA) with the Government to equip and upgrade maternal and child health care centres and reference medical facilities. Most urgent is the situation in provincial maternity centres, which lack working equipment to handle obstetric emergencies.

In a country with one of Africa's highest maternal mortality rates-842 per 100,000 live births-most mothers still lack access to basic reproductive health care. Meanwhile, in a new development on 12 August, the Office for the Coordination of Humanitarian Affairs (OCHA) recognized that Djibouti is suffering from near drought conditions, and that the number of refugees currently seeking refuge there has risen to 100,000. An emergency appeal has been set up to provide them with basic food, safe water and blankets. Although OCHA does not include a specific analysis of the needs of women, it can be concluded that as many as 60 per cent of this population are women who require emergency health care assistance, including reproductive health care.

UNFPA started working in Djibouti in 1983, funding family planning and later reproductive health projects aimed at assuring access to services for a majority of Djiboutian women. In 1992, the Fund started its first country programme of assistance to help the Government with health care for its population and to conduct a population census. Currently at its mid-point, the programme faces increasing challenges, partially due to war and insecurity in the region, but mostly due to the lack of resources to organize more comprehensive assistance.

In February 1999, I had the chance to visit a maternity clinic in the province-city of Ali-Seibeh. We found about 10 women suffering from pains caused by various reproductive health maladies, including still or premature births and various cases of birth complications. The conditions inside the clinic were unhygienic, and all the equipment in the dusty operating room had broken down long ago. If an obstetric emergency were to occur, the patient would have to be transported to Djiboutiville for treatment. According to the physician assigned to the maternity clinic, a lot of aid agencies had visited the facility and expressed concern, but UNEPA was the only agency which had actually sent help, in terms of equipment and training of midwives.

In other rural centres, the Fund has also paid for the training of doctors, midwives and traditional birth assistants servicing grassroots communities, and for the rehabilitation of maternity clinic and RH/STD information centres for families. It has also supplied essential basic and obstetrical equipment, such as examining tables, sterilization containers for surgical/examination equipment and safe baby-delivery kits.

Apart from helping with reproductive health, UNFPA helps Djibouti's Ministry of National Education carry out a radio project to educate children and adults who lack access to schools in many outlying areas. The radio messages are crafted by a skilled team and broadcast in the four national languages through Radio National Djibouti. They not only contain education programmes, but also information on STDs and HIV/AIDS; safe motherhood and reproductive health for men and women; and other key issues such as safe water, sanitation and child health. Although the project addresses a small portion of the requirements in child and adult education, it has successfully relayed health and education messages to grass-roots communities. Despite that, further action is necessary to create awareness of reproductive and child health and basic care to ensure that Djibouti can grant to more of its people access to health care.

In May, ongoing efforts by UNFPA and other United Nations agencies supported the formation of the Ministry of Women and the Family. Since then, the State has embarked on a process of internal information gathering on the Djiboutian woman, marked by a national consultative process, to formulate a National Strategy for Women. UNFPA is taking the lead in providing gender and legal expertise for finalizing the Strategy; the United Nations Development Programme has supported the entire project by providing essential seed money for gender projects. Meanwhile, the United Nations Children's Fund has acted as an informal secretariat for the nuts-and-bolts organization of this success story in inter-agency collaboration in Djibouti.

Miracles Happen

This year, UNFPA plans to initiate a safe motherhood project to assure at least minimum basic reproductive health care for mothers. In order to be able to expand this project to support reproductive health needs of women in rural areas and to extend services to include key vulnerable groups, such as adolescents, young women and street children at risk of prostitution, UNFPA is still looking for funds. However, donor interest has been slow in responding to the near-emergency conditions in Djibouti. It provides a fraction of the assistance required for minimum reproductive health coverage for women and men. Although Djibuti is on the "A" list of all development agencies as a priority assistance country, repeated attempts by the Fund to secure $1.5 million from various donors have been unsuccessful. As the world's attention is riveted on Europe's emergencies, most donors brush off the silent emergency in Djibouti, pushing to the background the plight of some of the poorest women and children in Africa. Despite all the attention to containing the HIV/AIDS epidemic in Africa, UNFPA in Djibouti has been unable to secure sufficient assistance to ensure access to contraception. A regular and free supply of condoms, for example, would empower women by protecting them against unwanted pregnancy and at the same time allow for increased barrier protection against the spread of STDs and HIV.

On the positive side, miracles happen: early this year, a three-month premature baby was born at the Dar El Hanan Central Maternity in Djiboutiville, where it survived against odds, with only very basic medical assistance.

Point a View: The World Bank should rely on social indicators--and not on economic criteria alone--when it establishes the regulations of the International Development Association to provide soft and easy loans and assistance to developing countries. In this way, the developing countries can achieve the required balance between economic and social development. We all need to review development indicators as the World Bank lays down criteria for human resources development on the basis of gross domestic product. Scientific studies have shown that there is no automatic or inherent relationship between an increase in a country's income and its development. It was on the basis of this concept that Amartya Sen was awarded the Nobel Prize for Economics.

Mervat Tallawy, Minister for Social Affairs of Egypt (General Assembly's Special Session, 30 June 1999)