Djibouti: Score Justification Summary

1.1.1a National plan for AMR priority pathogens

Score: 50

Djibouti has a national antimicrobial resistance action plan, but there is insufficient publicly available evidence that it covers surveillance, detection, and reporting of priority antimicrobial resistance pathogens. The World Health Organization TrACSS country profile for 2022 records that Djibouti has developed a national action plan while simultaneously showing no established integrated antimicrobial resistance surveillance system and notable laboratory system gaps, and it provides no public text demonstrating nationwide surveillance, detection, and reporting provisions ^{1, pp. 1, 3}. In April 2025, the World Health Organization Evaluation Office stated that Djibouti was the only country in the Eastern Mediterranean Region yet to endorse an antimicrobial resistance national action plan, indicating the instrument was not formally endorsed and that operational content was not finalized or publicly available at that time ^{2, p. 6}. The World Health Organization Joint External Evaluation mission report for 2018 documented the absence of national systems for detection and surveillance of antimicrobial resistance and offered recommendations, and no subsequent public plan text is evidenced to supersede that baseline with the required coverage ^{3, pp. 11–12}.

1.1.1b Capacity of national lab/lab system to test for AMR priority pathogens

Score: 0

There is no publicly available evidence that Djibouti has a national laboratory system that tests the World Health Organization Global Antimicrobial Resistance Surveillance System priority pathogens. The World Health Organization Joint External Evaluation mission report for the Republic of Djibouti states that the country lacks a national plan for laboratory detection and surveillance of antimicrobial resistance and identifies foundational laboratory system gaps, establishing a baseline absence of a coordinated national system as of 2018 ^{4, pp. 18–19}. The World Health Organization “Antimicrobial resistance TrACSS Djibouti 2022 Country Report,” dated 31 October 2022, records that Djibouti has not established or started implementing an integrated antimicrobial resistance surveillance system and documents laboratory quality and standardization weaknesses, which together do not evidence a national laboratory system testing priority pathogens ^{5, pp. 1, 5}. A World Health Organization Regional Office for the Eastern Mediterranean technical paper dated September 2024 describes uneven regional reporting to the Global Antimicrobial Resistance Surveillance System without presenting Djibouti-specific proof of a national laboratory system, and it does not overturn the country-specific findings reported in 2022 ^{6, p. 3}.

1.1.1c National environmental surveillance for AMR residues/organisms

Score: 0

There is no publicly available evidence that Djibouti conducts government-run environmental detection or surveillance of antimicrobial residues or antimicrobial resistance organisms in soil or waterways. As of April 2025, the World Health Organization Evaluation Office describes priorities for WHO support in Djibouti but presents no government program for environmental antimicrobial resistance or residue surveillance ^{7, p. 6}. The World Health Organization Joint External Evaluation mission report establishes a July 2018 baseline without national arrangements for laboratory detection and surveillance of antimicrobial resistance and does not cite environmental detection or surveillance activities in soil or waterways ^{8, pp. 18–19}. The World Health Organization Tracking Antimicrobial Resistance Country Self-Assessment Survey country profile dated October 31, 2022 shows that an integrated antimicrobial resistance surveillance system is not established or initiating and provides no indication of government testing of environmental media for residues or resistant organisms ^{9, pp. 1–2}. The Environmental Code promulgated in January 2009 sets general environmental monitoring and water-police authorities but contains no mandate for detection or surveillance of antimicrobial residues or antimicrobial resistance organisms in environmental matrices ^{10, pp. 1, 3–4}.

1.1.2a National law(s) requiring prescription for antibiotic use (humans)

Score: 0

There is no publicly available evidence that Djibouti has national legislation or regulation requiring prescriptions for antibiotic use for humans. The Journal Officiel de la République de Djibouti issue “Official Journal No. 14 of July 31, 2025,” published by the Presidency of the Republic of Djibouti, lists enactments on public accounts, petty cash, and institutional matters without any instrument establishing a prescription requirement for human antibiotics ¹¹. The “Journaux Officiels” 2025 index maintained by the Presidency shows no entry adopting or clarifying an antibiotic-specific prescription mandate, indicating no such measure was promulgated through July 2025 ¹². The controlling statute, “Law No. 145/AN/91/2nd Legislature on the Conditions for Practicing Pharmacy” of February 1991, bars pharmacists from substituting for physicians in prescribing but does not itself classify antibiotics as prescription only, and it merely delegates to the Minister of Health the authority to restrict or prohibit operations involving toxic, narcotic, or dangerous substances by order ^{13, pp. 4, 8}. The Ministry of Economy and Finance describes community pharmacists as dispensing medicines with or without a medical prescription, which does not evidence a nationwide antibiotic-specific prescription obligation in practice ¹⁴.

1.1.2b National law(s) requiring prescription for antibiotic use (animals)

Score: 0

There is no publicly available evidence that Djibouti has national legislation or regulation requiring prescriptions for antibiotic use for animals. The “Official Journals — 2025 Index,” maintained by the Presidency of the Republic of Djibouti, lists ordinary and special issues through July 2025 and contains no promulgated law, decree, or ministerial order establishing a prescription requirement for veterinary antibiotics ¹⁵. The operative statute, “Law No. 145/AN/91/2nd Legislature on the Conditions for Practicing Pharmacy” of February 1991, sets professional boundaries by prohibiting pharmacists from substituting for physicians in prescribing, which concerns human prescribing practices rather than a veterinary antibiotic rule ^{16, p. 4}. The same law regulates veterinary medicines by limiting retail sale to community pharmacists and allowing licensed veterinarians to keep stocks for animals under their care, but it does not classify antibiotics as prescription only or impose an animal antibiotic prescription mandate ^{17, p. 8}.

1.2.1a Laws/plans on zoonotic disease

Score: 0

There is no publicly available evidence that Djibouti has a national law, plan, or equivalent strategy that prioritizes zoonotic diseases and prescribes national detection and reporting procedures. During the World Health Organization Joint External Evaluation mission of 1–5 July 2018, the Zoonoses section records the absence of national zoonoses surveillance plans and of a prioritized list of zoonoses; it also notes limited intersectoral exchange, no eradication program, and activity confined to specific contexts such as risk-period Rift Valley fever surveillance and systematic brucellosis testing at the Damerjog quarantine, which together do not constitute a national prioritization or reporting plan ^{18, pp. 13–14}. The same report states Djibouti’s list of 20 notifiable diseases includes four zoonotic conditions and that services know the obligation to notify, indicating general notification mechanisms rather than a zoonoses-specific framework ^{19, pp. 7, 13}. The July 1999 “Law No. 48/AN/99/4th L on the Orientation of Health Policy” establishes compulsory notification of designated diseases under regulatory conditions but does not adopt a national zoonoses prioritization or a zoonoses-specific reporting plan ^{20, p. 24}. In April 2025, the Presidency created the Public Health Emergency Operations Center with a One Health scope, which strengthens coordination across human, animal, and environmental health; however, the order does not adopt a prioritized zoonoses list or a national zoonoses detection and reporting plan ²¹.

1.2.1b Laws/plans on zoonotic disease spillover from animals to humans

Score: 100

Djibouti has national instruments that include measures for risk identification and reduction of zoonotic disease spillover from animals to humans. The January 2011 statute “Law No. 99/AN/10/6th Legislature creating the National Institute of Public Health of Djibouti,” published by the Presidency of the Republic of Djibouti, assigns the surveillance service to monitor zoonoses in cooperation with the competent department within the institute’s notifiable-disease surveillance functions, establishing an explicit mandate for zoonoses surveillance in the national public health architecture ²². The April 2025 “Order No. 2025-055/PR/MS creating a Public Health Emergency Operations Center,” issued by the Ministry of Health, establishes a multisector One Health mechanism within the institute to coordinate prevention, detection, risk analysis, surveillance follow up, and risk reduction for threats of human, animal, and environmental origin, thereby operationalizing spillover risk identification and reduction ²³. The December 2007 “Law No. 200/AN/07/5th Legislature organizing the administration of the Ministry of Agriculture, Livestock and the Sea in charge of Water Resources” assigns the veterinary and food-control services duties for epidemiological surveillance, slaughterhouse hygiene control, quarantine, and eradication of major animal diseases, all of which reduce spillover risk at the animal interface ²⁴. A January 2025 ministerial order cites the 2007 law as a controlling legal basis ²⁵.

1.2.1c Laws/plans for surveillance & control of multiple zoonotic pathogens

Score: 100

Djibouti has national instruments that account for the surveillance and control of multiple zoonotic pathogens of public health concern. The January 2011 statute “Law No. 99/AN/10/6th Legislature creating the National Institute of Public Health of Djibouti,” issued by the Presidency of the Republic of Djibouti, assigns the notifiable-disease surveillance service to monitor enteric, foodborne, and parasitic infections and zoonoses in cooperation with the competent department, thereby establishing multi-pathogen surveillance in the human health sector ²⁶. The July 2023 “Law No. 11/AN/23/9th Legislature reorganizing and functioning of the Ministry of Health,” published by the Presidency of the Republic of Djibouti, designates the ministry as competent for public health policy, epidemiological surveillance, and sanitary watch, and structures a health surveillance pole and laboratory pole to support these functions, which together maintain multi-pathogen oversight within the ministry’s mandate ²⁷. The December 2007 “Law No. 200/AN/07/5th Legislature organizing the administration of the Ministry of Agriculture, Livestock and the Sea in charge of Water Resources” assigns veterinary services epidemiological surveillance, quarantine, abattoir and food-chain hygiene inspection, and prevention and control of zoonoses, providing animal-health interface controls across pathogens ²⁸. The April 2025 “Order No. 2025-055/PR/MS creating a Public Health Emergency Operations Center” establishes a One Health mechanism that coordinates prevention, detection, risk analysis, surveillance follow up, and risk reduction for threats of human, animal, and environmental origin, ensuring current multisector control across zoonotic hazards ²⁹.

1.2.1d Cross-ministerial department/agency/unit for zoonotic disease

Score: 100

Djibouti has a national multi-sector coordinating mechanism dedicated to zoonotic disease that functions across ministries. In March 2025, the Ministry of Health issued “Order No. 2025-055/PR/MS creating a Public Health Emergency Operations Center,” which establishes the center within the National Institute of Public Health of Djibouti as an intersector coordination space for national mechanisms of prevention, detection, and response; Articles 1 to 3 and 6 apply a One Health approach across human, animal, and environmental health and assign prevention, detection, risk analysis, surveillance follow up, and risk reduction for threats of animal origin, while Articles 4 and 5 create a Steering Committee chaired by the Prime Minister with members from the Presidency and the ministries of Health, Interior, Defense, Budget, Higher Education and Research, Social Affairs, Labor, Communication, and either Agriculture and Livestock or Environment depending on the emergency’s origin, and Articles 7 to 13 establish multi-ministry technical commissions, demonstrating operation across ministries ³⁰. In January 2011, the Presidency promulgated “Law No. 99/AN/10/6th Legislature creating the National Institute of Public Health of Djibouti,” which assigns the notifiable-disease surveillance service to monitor zoonoses in cooperation with the competent department, anchoring a zoonoses mandate in the host institution ³¹. The July 2023 “Law No. 11/AN/23/9th Legislature reorganizing and functioning of the Ministry of Health” confirms the ministry’s responsibility for public health policy and epidemiological surveillance supporting this cross-government coordination architecture ³².

1.2.1e Presence of One Health strategic plan

Score: 0

There is no evidence of Djibouti having a One Health Strategic Plan in place. ³³

1.2.2a Surveillance/reporting mechanism for zoonotic disease for livestock owners

Score: 100

Djibouti has a national mechanism for livestock owners to contribute to animal-disease surveillance and transmit information to a central veterinary authority. In October 2001, the Presidency promulgated “Law No. 142/AN/01/4th Legislature organizing the Administration of the Ministry of Agriculture, Livestock and the Sea, responsible for Water Resources,” which establishes the Livestock and Veterinary Services with an epidemiological surveillance mandate and a Section for Support to Herders that trains zoosanitary auxiliaries identified among herders, creating the owner–auxiliary–Directorate reporting pathway at national level ^{34, pp. 14–15}. Government-led cross-border surveillance and control activities on priority animal diseases took place at Ali-Sabieh in August 2022 under ministerial supervision, consistent with field reporting flows to the Directorate of Livestock and Veterinary Services ³⁵. In December 2023, the government reported refresher training for auxiliary livestock agents in Ali-Sabieh to recognize, detect, and report priority transboundary diseases, demonstrating continued owner-linked reporting practice ³⁶. In April 2025, the government highlighted early warning and local capacity for pastoralists at the DRESS-EA regional steering committee, indicating ongoing integration of community reporting pathways into national systems during the period ³⁷.

1.2.2b Laws/regulations on data confidentiality to protect livestock owners

Score: 100

Djibouti has legal safeguards that protect the confidentiality of owner-identifiable information that may be collected and handled through animal-health surveillance activities. In October 2001, “Law No. 142/AN/01/4th Legislature organizing the Administration of the Ministry of Agriculture, Livestock and the Sea, responsible for Water Resources” assigns the Animal Health Subdivision responsibility for epidemiological surveillance of major animal diseases, including collecting, processing, analyzing, and disseminating information, and it specifies clinical follow-up of herds and structured supervision and training activities with herders, demonstrating that official animal-health surveillance functions operate in owner-facing livestock settings ^{38, pp. 14-15}. Confidentiality protections applicable to such information are provided by the Penal Code, Law No. 59/AN/94 of January 1995, which criminalizes breach of professional secrecy by persons holding secret information due to their function or mission, and penalizes unlawful handling and disclosure of nominative information, including disclosure without authorization to unqualified third parties ^{39, pp. 134-137}. In September 2025, “Law No. 019/AN/23/9th Legislature adopting the Digital Code” states that processing of personal data is confidential and must be performed only under the controller’s authority and instructions, and that persons with access must be bound by a legal, statutory, or contractual confidentiality obligation ^{40, p. 52}.

1.2.2c Wildlife zoonotic disease surveillance

Score: 0

There is no publicly available evidence that Djibouti conducts surveillance of zoonotic disease in wildlife, poultry, and livestock. The Ministry of Agriculture, Water, Fisheries and Livestock’s official portal, including the Directorate of Livestock and Veterinary Services, contains no national laws, plans, standard operating procedures, routine surveillance bulletins, or datasets describing operational wildlife, poultry, or livestock zoonoses surveillance ⁴¹. The Presidency’s Official Gazette institutional index for the ministry shows no legal instrument establishing nationwide wildlife, poultry, and livestock zoonotic surveillance during the timeframe ⁴². A 2024–2025 gazette item concerns the National Food Analysis Laboratory’s forecast budget, demonstrating administrative activity but not a surveillance mandate or system outputs ⁴³. A 2022 government news report describes a Djibouti–Ethiopia workshop on surveillance and control of priority animal diseases, which is capacity building rather than evidence of an operational surveillance system in wildlife, poultry, or livestock ⁴⁴. The World Organisation for Animal Health’s April 2025 technical overview details reporting modules and synthesizes persistent global gaps in wildlife-disease reporting, which are not Djibouti specific ^{45, pp. 6–7, 11–12, 28–30}.

1.2.3a Annual reporting to OIE on zoonotic disease incidence

Score: 100

Djibouti has a government mechanism to report notifiable animal diseases to the World Organisation for Animal Health through the World Animal Health Information System. The World Organisation for Animal Health Regional Commission for Africa “26th Conference … Final Report,” held in Addis Ababa in February 2025, lists Djibouti among the Members participating ^{46, p. 1}. The same report describes the World Animal Health Information System as the Organisation’s platform for transparency, early warning, and reliable animal health data presented to Delegates ^{47, p. 3}. A dedicated technical session titled “WAHIS: what has changed, and what is in it for you” explains reporting modalities and Member support, underscoring that timely, accurate, and complete reporting to the World Animal Health Information System is essential ^{48, p. 12}. The adopted Recommendation No. 2 further urges Members to improve their transparency obligations in disease notification and reporting through the World Animal Health Information System, confirming the formal mechanism used by governments ^{49, p. 22}.

1.2.4a Number of veterinarians per 100,000 people

Score: 100

1.2.4b Number of veterinary para-professionals per 100,000 people

Score: 13.84

1.2.5a Inclusion of private sector in national plan/law on zoonotic disease

Score: 100

Djibouti has formal mechanisms that engage private-sector actors in controlling and responding to zoonoses. The Standards and Trade Development Facility case report dated September 2021 details a government–private concession under which the Livestock and Veterinary Services Directorate accredits private veterinarians at the Djibouti Regional Quarantine and the private operator delivers vaccination and laboratory testing for diseases including foot-and-mouth disease and brucellosis, establishing a structured public–private mechanism directly targeting zoonotic risks ^{50, p. 2}. In February 2025, the World Organisation for Animal Health presented at the Regional Commission for Africa a session referencing Djibouti and “capacity building for quarantine stakeholders for animal inspection, certification, and welfare,” corroborating ongoing engagement of quarantine actors that include private stakeholders within the veterinary domain ^{51, p. 7}. In April 2025, the Official Gazette created the national Public Health Emergency Operations Center with a mandate to coordinate with all partners during health emergencies, enabling activation of these public–private interfaces for zoonotic response at national level ⁵².

1.3.1a Updated national records of especially dangerous pathogen/toxin inventories

Score: 0

There is no publicly available evidence that Djibouti maintains a national record, updated within the past five years, of facilities storing or processing especially dangerous pathogens and toxins that includes facility-level inventories and inventory management systems. The World Health Organization State Party Self-Assessment Annual Reporting country page for Djibouti, posted as “SPAR 2024 (submitted)” and updated on April 2, 2025, reports a biosafety and biosecurity capacity value of 20 and provides no instrument, link, or dataset establishing a national register or inventory system for dangerous-pathogen facilities ⁵³. The electronic Official Journal portal of the Presidency of the Republic of Djibouti's listings do not show a 2025 instrument that creates or updates a national record with inventory obligations for these facilities ⁵⁴. The most recent sectoral framework located, “Law No. 11/AN/23/9ème L reorganizing the Ministry of Health,” dated July 2023, establishes directorates and defers operational details to implementing decrees but does not create a registry of facilities handling especially dangerous pathogens or require facility-level inventories or inventory-management systems ^{55, pp. 21–24}.

1.3.1b Biosecurity laws on facility security for especially dangerous pathogens

Score: 50

Djibouti has legislation and an implementing decree that regulate activities involving biological materials, including dangerous pathogens and toxins, through a national authority; however, the texts do not codify prescriptive facility-level biosecurity requirements such as physical containment standards, operational practice obligations, incident or failure reporting systems for labs, or cybersecurity controls specific to facilities. In February 2021, the Official Journal published “Law No. 107/AN/20/8ème L creating the National Authority for Nuclear, Radiological, Chemical and Biological Security and Safety,” which places biological safety and security under state control (Article 4) and empowers the authority to authorize activities involving biological products, inspect installations, and issue regulations and guides for biological products and associated installations (Article 5, points 2, 3, 7) ^{56, pp. 1–2}. The law mandates a national register linked to the Organization for the Prohibition of Chemical Weapons schedules and the Biological and Toxin Weapons Convention, expressly covering toxins, and provides for import and export controls for biological products (Article 5, points 18, 21) ^{57, p. 2}. In June 2022, “Decree No. 2022-126/PRE” confirms state control across the biological domain and requires notification and authorization for import or export of biological materials (Article 2) ^{58, p. 1}. In September 2025, Djibouti’s “Digital Code” imposed cybersecurity incident-notification duties to national authorities, strengthening general cybersecurity obligations applicable to public institutions and laboratory networks ^{59, pp. 218–219, 324–325}.

1.3.1c Agency for enforcement of biosecurity laws/regulations

Score: 100

Djibouti has an established government agency responsible for enforcing biosecurity legislation and regulations. In February 2021, the Official Journal of the Republic of Djibouti published “Law No. 107/AN/20/8ème L creating the National Authority for Nuclear, Radiological, Chemical and Biological Security and Safety,” which establishes the National Authority as a regulator with legal personality under the Presidency and assigns it cross-cutting competence over the biological domain, including the power to issue, suspend, or revoke authorizations and to conduct controls and inspections of installations handling biological materials ⁶⁰. In May 2022, the Official Journal published “Decree No. 2022-126/PR fixing the organization and functioning of the National Authority,” which operationalizes enforcement by creating directorates for inspections and compliance, empowering inspectors to access sites, review documentation, verify adherence to safety and security requirements, and propose administrative sanctions when non-compliance is identified ⁶¹. The World Health Organization’s State Party Self-Assessment Annual Reporting page confirms Djibouti’s 2024 submission and the capacity area on “implementation of a laboratory biosafety and biosecurity regime,” demonstrating that the enforcement framework remains current as of April 2025 ⁶².

1.3.1d Consolidation of especially dangerous pathogens into minimum # of facilities

Score: 0

Djibouti has legal and enforcement mechanisms in place to consolidate control over especially dangerous pathogen inventories nationwide, however there is limited evidence of efforts to consolidate inventories. In June 2022, the Presidency of the Republic of Djibouti issued “Decree No. 2022-126/PRE fixing the organization and functioning of the National Authority for Nuclear, Radiological, Chemical and Biological Safety and Security,” which requires prior authorization from the National Authority for any nuclear, chemical, or biological activity and notification of relevant imports or exports, establishing a national licensing gate for facilities and practices ⁶³. In September 2024, the Presidency and the Ministry of Health published “Decree No. 2024-219/PR/MS regulating private-sector health structures,” placing private laboratories under an authorization regime with conformity inspections by the General Health Inspectorate and limiting cabinet laboratories to hematology, chemistry, and direct bacteriology, thereby narrowing where complex microbiology may lawfully occur ⁶⁴. In December 2024, “Decree No. 2024-297/PRE creating the Inspectors Corps of the National Authority” empowered inspectors to instruct and control licenses and authorizations, to inspect sites using biological products, and to authorize or stop activities, operationalizing enforcement against noncompliant facilities ⁶⁵.

1.3.1e Capacity to conduct tests for anthrax/Ebola without culturing live pathogens

Score: 0

There is no publicly available evidence that Djibouti has in-country capacity to conduct Polymerase Chain Reaction testing for anthrax or Ebola. The World Health Organization’s 2025 country executive summary for Djibouti is an evaluation output that describes scope, findings, and recommendations for WHO’s contribution over 2019–2023 and contains no laboratory test menu or statement that Ebola virus disease or Bacillus anthracis PCR is performed domestically ^{66, p. 3, 7–8}. The World Health Organization Country Office in Djibouti’s 2025 management response accepts the evaluation and sets actions on primary health care, information systems, preparedness, and other priorities, yet likewise includes no indication that in-country PCR for Ebola or anthrax is available or performed, and it provides no standard operating procedures or assay lists evidencing such capacity ^{67, p. 1, 7–8}.

1.3.2a Biosecurity training using a standardised, required approach

Score: 0

There is no publicly available evidence that Djibouti requires standardized, mandatory biosecurity training for personnel working with especially dangerous pathogens, toxins, or biological materials with pandemic potential. The World Health Organization’s country report “WHO contribution in Djibouti: Executive summary,” published April 2025, is an evaluation synthesis for 2019–2023 and contains no national requirement establishing a common biosecurity curriculum, a train-the-trainer scheme, or any re-certification cadence for high-risk laboratory personnel ^{68, p. 3, 7–8}. The World Health Organization Country Office in Djibouti’s “Management response: Evaluation of WHO contribution in Djibouti,” dated 14 April 2025, accepts the evaluation and sets actions on primary health care, information systems, preparedness, and governance, but it does not introduce or cite any binding instrument mandating standardized biosecurity training or re-certification for laboratory personnel ^{69, pp. 1, 7–8}. Djibouti’s “Decree No. 2022-126/PRE fixing the organization and functioning of the National Authority for Nuclear, Radiological, Chemical and Biological Safety and Security,” promulgated 1 June 2022, organizes the authority’s mandate but does not require a standardized national biosecurity training program or re-certification interval for personnel handling high-risk biological agents ⁷⁰.

1.3.3a Personnel checks for permission to access to especially dangerous pathogens

Score: 0

There is no publicly available evidence that Djibouti specifies in regulations or licensing conditions that security and other personnel with access to especially dangerous pathogens, toxins, or biological materials with pandemic potential must undergo drug testing, background checks, and psychological or mental fitness checks. The “Law No. 107/AN/20/8ème L establishing the National Authority for Nuclear, Radiological, Chemical and Biological Security and Safety,” dated February 2021, empowers the authority to issue and condition authorizations but does not codify any personnel vetting triad for biological-agent access ⁷¹. The “Decree No. 2022-126/PRE organizing and operating the National Authority,” issued June 2022, sets institutional structures and functions without prescribing drug testing, criminal-record screening, or psychological evaluations for individuals in facilities handling especially dangerous biological materials ⁷². The “Decree No. 2024-219/PR/MS regulating private-sector health facilities,” dated September 2024, governs private laboratories and leadership requirements yet contains no mandatory staff-screening triad ⁷³. The “Decree No. 2024-296/PRE on protection from ionizing-radiation hazards” and the companion “Decree No. 2024-297/PRE creating the inspector corps,” both dated November 2024, reinforce authorization and inspection regimes but do not add drug testing, background checks, or psychological fitness as licensing conditions for personnel with access to high-risk biological materials ⁷⁴⁷⁵.

1.3.4a National transport regulations for Category A and B infectious substances

Score: 100

Djibouti has publicly available national instruments and a current regulator implementation notice for the safe and secure transport of infectious substances, consistent with the Category A and Category B scheme for air transport. The “Decree No. 2020-149/PR/MET setting the framework for supervision of civil aviation safety in Djibouti,” issued in July 2020 by the Ministry of Equipment and Transport, establishes oversight of dangerous goods under the national civil aviation safety supervision system and anchors conformity with International Civil Aviation Organization requirements ⁷⁶. The “Decree No. 2021-045/PR/MET amending Decree No. 2016-072/PR/MET on the organization and functioning of the Civil Aviation Authority of Djibouti,” issued in March 2021, authorizes the Civil Aviation Authority to regulate, supervise, and issue or withdraw authorizations for the transport of dangerous goods, providing enforceability for operators and ground entities ⁷⁷. In 2025, the Civil Aviation Authority’s publicly accessible “Supervision Policy” page identifies all entities in the dangerous-goods transport chain as subject to oversight, demonstrating implementation and operational supervision applicable to infectious substances consignments ⁷⁸.

1.3.5a Laws/regulations on cross-border transfer and end-user screening

Score: 100

Djibouti has a legally binding authorization and screening framework that covers cross-border transfers of biological materials and embeds end-user controls through targeted financial sanctions. The “Law No. 107/AN/20/8ème L on the creation of the National Authority for Nuclear, Radiological, Chemical and Biological Safety and Security” establishes the national authority’s mandate over biological safety and security and empowers it to control activities in biological domains, promulgated by the Presidency of the Republic of Djibouti in February 2021 ⁷⁹. The “Decree No. 2022-126/PRE on the organization and functioning of the National Authority” requires ministries and entities to notify the national authority of any import or export of nuclear, chemical, or biological materials to obtain an authorization and charges the authority to deliver, suspend, or annul such authorizations, issued in June 2022 by the Presidency of the Republic of Djibouti ^{80, pp. 1–2, 5–6}. Enforcement capacity was strengthened by “Decree No. 2024-297/PRE” creating an inspectorate to conduct licensing controls and transport inspections in biological domains in December 2024 ⁸¹. End-user screening mechanisms are operationalized by “Decree No. 2024-314/PR/MI” implementing the 2024 anti-money-laundering, counter-terrorist-financing, and counter-proliferation financing law under the Ministry of the Interior in December 2024 ⁸². In June 2025, “Order No. 2025/071/PR/MI” appointed the Technical Committee members that execute these targeted-sanctions procedures, confirming live operation under the Presidency and the Ministry of the Interior ⁸³.

1.4.1a Biosafety laws/regulations

Score: 100

Djibouti has national biosafety legislation and implementing regulations that establish government authority over biological safety and security nationwide. In February 2021, the Presidency of the Republic of Djibouti promulgated “Law No. 107/AN/20/8ème L on the creation of the National Authority for Nuclear, Radiological, Chemical and Biological Safety and Security,” empowering the authority to control activities involving biological materials and to maintain authorizations and registers for biological domains, including a system to control imports and exports of biological products ⁸⁴. In June 2022, the Presidency issued “Decree No. 2022-126/PRE on the organization and functioning of the National Authority,” which requires authorization for relevant activities and notification to the authority for any import or export of nuclear, chemical, or biological materials, and assigns inspection and licensing-control functions including transport in the biological domain ^{85, pp. 2, 9}. In December 2024, the Presidency adopted “Decree No. 2024-297/PRE” creating an inspectorate to conduct controls and inspections under the biosafety mandate, strengthening enforcement ⁸⁶. In June 2025, the Ministry of the Interior issued “Order No. 2025/071/PR/MI” appointing the national technical committee responsible for targeted screening measures that operate alongside biosafety authorizations and inspections, confirming live national control machinery ⁸⁷.

1.4.1b Agency for enforcement of biosafety laws/regulations

Score: 100

Djibouti has an established national agency responsible for enforcing biosafety legislation and regulations. In February 2021, the Presidency of the Republic of Djibouti created the National Authority for Nuclear, Radiological, Chemical and Biological Safety and Security as the state body mandated to exercise control over biological safety and security nationwide, including the power to issue and manage authorizations and registers and to organize national control of imports and exports of biological products ⁸⁸. In June 2022, the Presidency issued “Decree No. 2022-126/PRE on the organization and functioning of the National Authority,” which operationalizes enforcement by requiring authorization for covered activities, mandating notification to the authority for any import or export of biological materials, and assigning inspection and licensing-control functions that include site and transport checks in biological domains ^{89, pp. 2, 8–9}. In December 2024, the Presidency adopted “Decree No. 2024-297/PRE” establishing the inspectorate corps of the authority to conduct inspections and controls in biological safety and security, providing a dedicated enforcement cadre ⁹⁰.

1.4.2a Biosafety training using a standardised, required approach

Score: 33.33

Djibouti has ad hoc biosafety-related training at national institutions, but does not maintain a standardized national requirement or any recertification regime. In June 2025, the National Institute of Public Health of Djibouti reported institute-run training activities and a preparatory meeting for the seventh Regional Training and Certification event in Djibouti City, which evidences site-level trainings rather than a nationwide mandated curriculum for personnel working with high-risk biological materials ⁹¹. The National Food Analysis Laboratory describes providing training and expertise for hazard analysis and critical control points and food hygiene, indicating institutional training capacity without a government-wide requirement for standardized biosafety training or a recertification interval applicable to laboratories handling especially dangerous pathogens ⁹². In April 2025, the Official Gazette published an order creating a Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti, which defines coordination functions for preparedness and response but does not establish a mandatory biosafety training program or recertification schedule for laboratory personnel ⁹³. A review of the 2025 Official Gazette issues index shows no decree that creates such a national requirement ⁹⁴.

1.5.1a Evidence of national assessment of dual-use research

Score: 0

There is no publicly available evidence that Djibouti conducted a government-led assessment to determine whether ongoing research is occurring on especially dangerous pathogens, toxins, pathogens with pandemic potential, or other dual-use research. In April 2025, the Official Gazette published “Order No. 2025-055/PR/MS creating a Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti,” which defines coordination functions under International Health Regulations but neither reports nor mandates a nationwide assessment of ongoing dual-use or high-risk pathogen research across institutions ⁹⁵. The March 13, 2025 Official Gazette issue list shows laws and an Interior Ministry order without any Ministry of Health instrument announcing such an assessment ⁹⁶. The Presidency’s electronic Official Gazette landing page describes access to laws, decrees, and orders but provides no item documenting a national research-mapping exercise ⁹⁷. The Official Gazette’s “Orders” category index for 2025 lists ministerial orders without any order establishing or reporting a dual-use or especially dangerous pathogen research assessment ⁹⁸. Council of Ministers communiqué listings in 2025 likewise do not record such an assessment ⁹⁹.

1.5.1b National law/regulation on oversight of dual-use research

Score: 0

There is no publicly available evidence that Djibouti has enacted legislation or regulation requiring oversight of research with especially dangerous pathogens, toxins, pathogens with pandemic potential, or other dual-use research. In April 2025, the Official Gazette published “Order No. 2025-055/PR/MS creating a Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti,” which establishes coordination functions under International Health Regulations and does not institute a requirement for research oversight or a dual-use research review system ¹⁰⁰. Across entries in the electronic Official Gazette “Orders” category, no ministerial order creates a nationwide oversight mandate for dual-use or pandemic-potential research applicable across institutions ¹⁰¹. The Presidency’s electronic Official Gazette portal provides access to laws, decrees, and orders and contains no instrument mandating such oversight ¹⁰². Council of Ministers communiqué listings for agendas and adoptions without announcing any legislation or regulation that requires oversight of research on especially dangerous pathogens, toxins, or pathogens with pandemic potential ¹⁰³.

1.5.1c Existence of agency responsible for oversight of dual-use research

Score: 100

Djibouti has a national authority with legal powers to oversee activities involving biological agents and toxins, including authorization and inspection of practices and installations that encompass research. In February 2021, the Presidency enacted “Law No. 107/AN/20/8th L creating the National Authority for Nuclear, Radiological, Chemical and Biological Security and Safety,” establishing the Authority as an independent regulator with statewide remit across the biological domain to protect the population and environment from risks linked to biological activities ¹⁰⁴. In June 2022, the Presidency issued “Decree No. 2022-126/PRE setting the organization and functioning of the National Authority,” which operationalizes this mandate by requiring entities to notify the Authority and obtain prior authorization for activities and movements of materials, and by empowering the Authority to regulate and inspect activities, practices, installations, and sites involving biological products, including issuing, suspending, or canceling authorizations ^{105, pp. 1–2, 6–8}. In December 2024, “Decree No. 2024-297/PRE creating the corps of inspectors of the National Authority” established a dedicated inspectorate to conduct inspections and controls in the biological domain nationwide ¹⁰⁶.

1.5.2a Requirement to screen synthesised DNA against list prior to sale

Score: 0

There is no publicly available evidence that Djibouti requires suppliers to screen synthesized deoxyribonucleic acid against lists of known pathogens and toxins before it is sold. In June 2022, the Presidency issued “Decree No. 2022-126/PRE setting the organization and functioning of the National Authority for Nuclear, Radiological, Chemical and Biological Security and Safety,” which establishes authorization and inspection over activities, practices, installations, sites, and movements of biological materials, including powers to deliver, modify, suspend, or cancel authorizations and to control sites using biological products, but it does not mandate vendor pre-sale sequence screening of synthesized deoxyribonucleic acid orders ^{107, pp. 5-6, 9}. In December 2024, the Presidency promulgated “Decree No. 2024-297/PRE creating the corps of inspectors of the National Authority,” which enumerates inspections and controls across radiological, chemical, and biological domains without creating any requirement for providers to screen synthesized deoxyribonucleic acid against controlled lists prior to sale ¹⁰⁸. The February 2021 “Law No. 107/AN/20/8th L creating the National Authority for Nuclear, Radiological, Chemical and Biological Security and Safety” provides cross-cutting regulatory remit in the biological domain but contains no clause on pre-sale DNA sequence screening ¹⁰⁹.

1.6.1a Immunization rate for humans (measles/MCV2)

Score: 0

1.6.1b Availability of vaccination figures for livestock (FMD) through OIE database

Score: 0

There is no publicly available evidence that Djibouti has official foot-and-mouth disease vaccination figures for livestock publicly available through the World Organisation for Animal Health World Animal Health Information System database. The World Organisation for Animal Health and the Food and Agriculture Organization of the United Nations “WOAH–FAO Foot-and-Mouth Disease Reference Laboratory Network: Quarterly Report, January–March 2025,” published in March 2025, lists Member States and reported vaccination totals where available and shows no foot-and-mouth disease vaccination figures for Djibouti in the Eastern Africa section, indicating that no official vaccination numbers were publicly reported for Djibouti for the assessed period ^{110, p. 28}. In February 2025, the World Organisation for Animal Health presented the public World Animal Health Information System dashboards as the authoritative interface for consulting country-level disease control data, including a dedicated control measure dashboard for foot-and-mouth disease ¹¹¹. That dashboard indicates that “official vaccination” is listed as a control measure for Djibouti, but it does not display any publicly accessible livestock vaccination figures or numeric totals for foot-and-mouth disease for Djibouti ¹¹².

1.6.1c Equitablenature of national immunization strategy/plan

Score: 0

Djibouti has a national immunization strategy and plan in force but it is not publicly available, so it cannot be reviewed for plans to ensure equitable distribution or strategies to overcome socioeconomic inequalities, geography, cultural/linguistic differences and/or gender barriers to vaccination. Third party sources do, however, explain that it includes provisions for equitable distribution and targeted equity strategies. In April 2025, the World Health Organization Evaluation Office reported that Djibouti had established a “national immunization strategy for 2022–2026,” extended the annual operational immunization plan through June 2025, and was using outreach to remote populations as well as risk communication and community engagement to boost uptake ^{113, pp. 3, 8}. In July 2025, the “Law No. 176/AN/24/9th L on the obligation of vaccination for children under 5 years and pregnant women” mandated vaccination, guaranteed free-of-charge services, and required availability across public, para-public, and private health facilities nationwide, establishing systemwide equitable access and distribution ¹¹⁴. In January 2025, the Council of Ministers described the bill’s objectives and the expansion of vaccines under the Ministry of Health’s Expanded Programme on Immunization, evidencing national policy intent and scope ¹¹⁵. In April 2025, the Djibouti News Agency and in May 2025 the United Nations in Djibouti documented nationwide polio rounds with mobile teams reaching remote villages and targeting zero-dose children, demonstrating operational equity strategies across all regions ¹¹⁶¹¹⁷.

1.6.1d Vaccine hesitancy and build public trust coverage in vaccines in national immunization strategy/plans

Score: 0

There is no publicly available evidence that Djibouti’s national immunization strategy or annual immunization plan includes measures to address vaccine hesitancy and build public trust in vaccines. The World Health Organization’s 2024 evaluation annex confirms the existence of the Ministry of Health’s “National Immunization Strategy of the Republic of Djibouti 2022–2026” and lists it among current national policies, but the strategy text is not publicly posted and the annex does not reproduce clause level content ^{118, pp. 15–16}. The United Nations in Djibouti reports a December 2021 results chain validation workshop for the strategy that discussed communicating vaccination benefits with community and religious leaders, yet the story does not host or quote the strategy ¹¹⁹. The United Nations Children’s Fund 2024 country brief documents facility level focal points for communication, social mobilization, and community engagement to support routine immunization services ^{120, pp. 4–5}. Gavi’s 2024 country case study and a 2025 gender grant final report show risk communication and community engagement activities implemented for routine immunization, which do not substitute for written plan provisions ^{121, p. 34122, pp. 4–6, 11–13, 15–16}.

1.6.1e National advisory group for immunization strategy/plan

Score: 100

Djibouti has a national immunization technical advisory group that provides technical guidance and advice on immunization policy and strategy to government. The official record of the Fifth Global National Immunization Technical Advisory Group Network meeting in June 2023 lists “Djibouti — Farhan Ali Mohamed, NITAG Chair,” establishing the body’s existence and leadership ^{123, p. 5}. In June 2025, the Eastern Mediterranean Public Health Network documented an Evidence-to-Recommendations training for National Immunization Technical Advisory Groups in Gavi-eligible countries and named Djibouti among the beneficiary countries with 3–4 participants, demonstrating contemporaneous participation of Djibouti’s advisory group in evidence-informed policy processes relevant to national immunization planning ^{124, p. 1}. The World Health Organization Regional Office for the Eastern Mediterranean’s 2025 regional framework explicitly places Djibouti among the Region’s Gavi-eligible countries and states that national immunization technical advisory groups conduct independent reviews at national level, confirming the advisory role that applies to Djibouti’s committee within the formal decision-making architecture ^{125, pp. xiii, 2}.

1.6.1f Presence of an immunization programme for influenza

Score: 0

There is no publicly available evidence that Djibouti has an immunization program for influenza. The World Health Organization Regional Office for the Eastern Mediterranean influenza weekly bulletin for Week 13 of 2025 states that 14 countries in the Region have a national seasonal influenza vaccination policy and does not identify Djibouti among policy adopters ^{126, p. 2}. A March 2024 country case study by Gavi, the Vaccine Alliance, emphasizes routine immunization recovery, measles mortality reduction, polio elimination, and Expanded Program on Immunization strengthening, with no reference to a seasonal influenza vaccination program or protocols in Djibouti ^{127, pp. 14–15}. A later World Health Organization Regional Office for the Eastern Mediterranean influenza weekly bulletin for Week 34 of 2025 reiterates the regional policy count without attributing a national seasonal influenza vaccination policy to Djibouti, and it presents the country only within surveillance outputs rather than policy tables ^{128, p. 1}. The World Health Organization “Vaccination schedule for Influenza for Djibouti” page displays no visible schedule entries in this view to confirm a national influenza program ¹²⁹.

1.7.1a Strategy/plan for resilience of health system

Score: 0

There is no publicly available evidence that Djibouti has a government-issued strategy or plan to develop a health system that is resilient to climate change and changing seasonal weather patterns. The World Bank’s “Djibouti – Climate and Health Vulnerability Assessment” of April 2024 documents the absence of a Ministry of Health budget line for climate and health and recommends developing a health-sector policy strategy and a Health National Adaptation Plan, showing that such instruments were not yet in force ^{130, pp. 10–11, 51}. The same assessment states that the National Health Development Plan in effect during the review period did not outline adaptation and resiliency to climate change, confirming a sectoral planning gap ^{131, pp. 40–41}. Signs of movement exist: the World Health Organization’s “Health and environment scorecard: Djibouti” of 2025 records a recent climate and health vulnerability and adaptation assessment since 2020, indicating foundational analytic work but not an adopted plan ^{132, pp. 1–2}. A Ministry of Health publication from January 2024 notes the elaboration of a new National Health Development Plan for 2025–2029, evidencing ongoing planning rather than promulgation ^{133, p. 45}. An April 2025 ministerial order establishes a Public Health Emergency Operations Center for multi-hazard events, which is operationally relevant but not a climate-resilient health system strategy ¹³⁴.

2.1.1a Capacity of national lab system to conduct 5 or more WHO core tests

Score: 100

Djibouti has national laboratory capacity to conduct at least five World Health Organization core diagnostic tests and shows routine public-sector laboratory activity. The World Health Organization's 2018 Joint External Evaluation mission report lists named assays performed nationally, including malaria rapid diagnostic tests, human immunodeficiency virus serology, tuberculosis microscopy, Salmonella enterica serotype Typhi culture, and enzyme-linked immunosorbent assays for measles and rubella; it also notes rapid tests for cholera, brucellosis, mycobacteria, and dengue under the national laboratory system ^{135, p. 23}. The Ministry of Health of the Republic of Djibouti “Health Statistics Yearbook,” issued in March 2023 by the Directorate of Health Information, provides facility-level outputs for calendar year 2022 and explicitly tabulates routine laboratory services, including CD4 counts, coagulation testing (TP–TCK), glucose, and urea, evidencing ongoing operations across public hospitals and health centers ^{136, p. 26}.

2.1.1b Plan to conduct testing during a public health emergency

Score: 0

Djibouti has a national plan for conducting testing during a public health emergency, but this is disease specific and there is insufficient evidence that it includes considerations for testing for novel pathogens, scaling capacity, and defining goals for testing. The Ministry of Health’s “National Directive for the Management of COVID-19, Version of 18 March 2020” sets surveillance case definitions, specimen collection and transport, and operational procedures at points of entry; it is disease specific to COVID-19 and contains no explicit provisions on testing for novel pathogens, no quantitative testing goals, and no national scaling strategy beyond noting additions of RT-PCR machines ^{137, pp. 6–13, 29–34; 1, pp. 8–10}. The World Bank’s “Djibouti COVID-19 Response (P173807) — Implementation Status & Results Report” dated 28 February 2023 records disbursements for medical equipment, supplies, and test kits and confirms monitoring and evaluation arrangements for the national preparedness and response plan, demonstrating operationalization under government leadership ^{138, pp. 1–2, 5}. In March 2025, the Official Gazette established a Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti to coordinate preparedness plans and multisectoral response, which does not add the missing testing provisions ¹³⁹.

2.1.2a Existence of an accredited national lab serving as a reference facility

Score: 0

There is no publicly available evidence that Djibouti has a national laboratory that serves as a reference facility accredited to International Organization for Standardization 15189 or to the U.S. Clinical Laboratory Improvement Amendments. The World Trade Organization’s “Trade Policy Review: Djibouti,” issued in September 2022, states that no national accreditation system has been established and describes testing support functions without identifying any ISO 15189 accredited medical reference laboratory, which confirms the absence of a domestic accreditation framework ^{140, pp. 36–37}. The College of American Pathologists CAP 15189 directory lists no Djibouti laboratories ¹⁴¹. The Strengthening Laboratory Management Toward Accreditation list of ISO 15189 accredited laboratories across Africa likewise contains no entries for Djibouti ¹⁴². The International Organization for Standardization member page shows the Djibouti Agency for Standardization and Quality as a correspondent member created in 2022, which is a standards body and not an accreditation body ¹⁴³. The International Laboratory Accreditation Cooperation signatory search shows no Djiboutian signatory capable of issuing internationally recognized medical laboratory accreditations ¹⁴⁴.

2.1.2b External quality assurance of a national lab serving as a reference facility

Score: 0

There is no publicly available evidence that Djibouti has a national laboratory that serves as a reference facility which is subject to external quality assurance review. The World Health Organization’s “Joint External Evaluation of IHR Core Capacities of the Republic of Djibouti,” issued in July 2018, states that the laboratory of Peltier General Hospital does not have access to external quality control and notes the absence of a national laboratory quality assurance system, establishing a negative baseline for external quality assurance participation ^{145, pp. 22–23}. The World Bank’s “Environmental and Social Impact Assessment: Djibouti COVID-19 Response,” published in October 2020, identifies the Peltier General Hospital laboratory as the national reference laboratory but provides no evidence of enrollment in an external proficiency testing program or scheme and attaches no certificate of participation ^{146, p. 29}. The World Health Organization’s 2024–2025 country results page for Djibouti summarizes support activities but does not furnish document-level confirmation that a national reference laboratory is under external quality assurance review ¹⁴⁷.

2.2.1a Nationwide specimen transport system

Score: 100

Djibouti has a nationwide specimen referral and transport system. The World Health Organization States Parties Self-Assessment Annual Reporting country page for Djibouti shows that under the Laboratory Capacity section, indicator “C.5.1 Specimen referral and transport system” is scored at 80 in the 2024 submission published on April 2, 2025, indicating that Djibouti self reports a high level of implementation for a national specimen referral and transport system during the timeframe ¹⁴⁸. Under the World Health Organization States Parties Self-Assessment Annual Reporting methodology, indicators are assessed on a five-level scale and expressed as percentages, and a score of 80 corresponds to level 4 out of 5, which denotes that the system is largely implemented according to government self assessment. This assessment is not isolated to a single year, as the World Health Organization’s Djibouti submission for 2022 likewise reports “C.5.1 Specimen referral and transport system” at 80, demonstrating continuity of the same reported nationwide system across reporting cycles ¹⁴⁹.

2.2.2a Plan to rapidly authorize/license laboratories to scale-up testing during an outbreak

Score: 0

There is no publicly available evidence that Djibouti has a plan to rapidly authorize or license laboratories to supplement the capacity of the national public health laboratory system to scale up testing during an outbreak. The Ministry of Health established the Public Health Emergency Operations Center by “Order No. 2025-055/PR/MS Establishing a Public Health Emergency Operations Center” on April 6, 2025, which defines coordination, activation, logistics, and communications functions, and contains no provision for expedited or emergency-use authorization of clinical laboratories ¹⁵⁰. The Presidency of the Republic of Djibouti issued “Decree No. 2024-219/PR/MS Regulating Private Health Sector Facilities” on September 19, 2024, which sets routine authorization, inspection, and operating conditions for private facilities including medical biology laboratories, and does not create any outbreak-specific fast-track licensing pathway ¹⁵¹. The Official Gazette’s ministerial orders index and the Official Gazette’s Ministry of Health corpus list applicable health instruments and contain no legal text establishing an emergency rapid laboratory authorization mechanism in this period ¹⁵²¹⁵³.

2.3.1a Evidence of ongoing event-based and indicator-based surveillance and analysis

Score: 50

Djibouti has ongoing event-based surveillance, but there is no publicly available evidence that surveillance data are analyzed on a daily basis. The World Health Organization Regional Office for the Eastern Mediterranean reported in September 2025 that Djibouti implemented event-based surveillance nationally and subnationally and strengthened public health intelligence, and also made significant progress in automating data analysis and report generation for surveillance, confirming routine EBS operations and analytics capacity ^{154, p. 2155}. In March 2025, the Official Gazette established the Public Health Emergency Operations Center at the National Institute of Public Health of Djibouti, assigning the planning commission to collect and analyze data and mandating the center’s daily functioning, which formalizes analytic responsibilities but does not specify a daily analysis cadence for surveillance datasets ¹⁵⁶. Indicator-based surveillance is evidenced by the Institute’s Weekly Epidemiological Bulletin for Week 32 of 2025, which reports 93 percent completeness, notifiable syndromes, and weekly trend analysis with publication on August 11, 2025 ^{157, p. 1}. A separate “Completeness and Promptness 2025” coverage matrix through Week 39 confirms national, ongoing reporting performance across sites ^{158, pp. 1–2}. The Institute’s publications index shows continuous 2025 bulletins and the coverage file ¹⁵⁹.

2.3.1b Evidence of a mechanism (such as IHR focal point) for reporting notifiable diseases to the WHO within the set timeline

Score: 100

Djibouti has a publicly available mechanism for reporting notifiable diseases to the World Health Organization within the set timeline. In July 2018, the World Health Organization “Joint External Evaluation of IHR Core Capacities of the Republic of Djibouti” records that the National Institute of Public Health of Djibouti serves as the International Health Regulations National Focal Point and communicates with the World Health Organization’s regional contact, establishing the formal notification channel ^{160, p. 16}. On April 6, 2025, the Official Gazette published Order No. 2025-055/PR/MS creating the Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti and stating that the center is a response to International Health Regulations requirements, confirming continuity of IHR-linked coordination ¹⁶¹. On May 24, 2024, the World Health Organization “SDG Indicator 3.d.1 Metadata” specifies that States Parties submit the International Health Regulations State Party Self-Assessment Annual Report via the e-SPAR platform each year by February 28, documenting the time-bound reporting pathway used by National Focal Points ^{162, pp. 2–3}.

2.3.2a Electronic national and sub-national reporting surveillance system

Score: 100

Djibouti has a government-operated electronic surveillance reporting system functioning at national and sub-national levels. In November 2019, the World Health Organization Regional Office for the Eastern Mediterranean reported that the Ministry of Health of Djibouti launched an electronic Early Warning Alert and Response Network with real-time data entry and defined user roles across reporting levels, establishing the nationwide electronic platform ¹⁶³. In August 2025, the National Institute of Public Health of Djibouti issued the “Weekly Epidemiological Bulletin No. 32, 2025,” which reports national completeness and timeliness and presents notifications disaggregated by regions and health structures for Epidemiological Week 32, evidencing routine national and regional reporting coverage in Djibouti City, Ali Sabieh, Arta, Dikhil, Obock, and Tadjourah ^{164, p. 1}. A separate 2025 “Data Coverage and Timeliness” table shows week-by-week submissions from named facilities across all regions through Week 39, confirming sustained sub-national reporting under government operation ^{165, pp. 1–2}.

2.3.2b Collection of ongoing/real-time lab data by electronic surveillance system

Score: 50

Djibouti has a real-time electronic reporting surveillance system in place. In November 2019, the World Health Organization Regional Office for the Eastern Mediterranean reported that the Ministry of Health launched an electronic Early Warning Alert and Response Network with mobile application immediate alerts, weekly reporting, and real-time reporting to strengthen early detection and response in Djibouti ^{166, p. 1}. In March 2023, the Ministry of Health published the “Health Statistics Yearbook 2021–2022,” stating that national health data are managed in the District Health Information Software 2 platform with the possibility for decision makers to generate analyses from data in real time and describing monthly reporting and data entry flows at facility and central levels during this period ^{167, pp. 1, 4}. In April 2025, the World Health Organization issued the “Evaluation of WHO contribution in Djibouti: Management response,” confirming continued efforts to enhance the national health information system and to review and enhance the District Health Information Software 2 system as implemented in primary health care, which evidences active operation and strengthening of the national electronic platform ¹⁶⁸.

2.3.3a National wastewater surveillance programme or initiative

Score: 50

There is some evidence of an ongoing national or sub-national wastewater surveillance programme in Djibouti.

Djibouti initiated environmental surveillance for poliovirus in August 2021 to complement acute flaccid paralysis (AFP) reporting, focusing on sewage testing in high-risk areas like Djibouti City and Arta.¹⁶⁹ In 2025, according to Statement of the Forty-fourth Meeting of the Polio IHR Emergency Committee, cVDPV1 outbreaks were reported in Djibouti based on environmental surveillance detections.¹⁷⁰ However, it is unclear whether this multi-site ES is still ongoing or ad-hoc.¹⁷¹

The WHO EMR Polio Bulletin from May 2026 documents positive environmental samples from the country in 2025.¹⁷²

In 2022, acting WHO Representative to Djibouti Mohamed Jameleddine Ben Slama said, “Over recent years Djibouti has made significant improvements to both surveillance for acute flaccid paralysis, and environmental surveillance for poliovirus in sewage outflow," although there is limited evidence that such progress has translated into ongoing national or sub-national ES programmes.¹⁷³

The United Nations University Institute for Water, Environment and Health (UNU-INWEH) and the United Nations Environment Programme (UNEP), in collaboration with the World Health Organization (WHO) and its Regional Office for the Eastern Mediterranean (WHO EMRO), hosted a regional workshop in Cairo, Egypt, from 19–21 October 2025, focused on strengthening wastewater surveillance systems across North Africa. This involved government leaders and key stakeholders from Algeria, Djibouti, Egypt, Eritrea, Libya, Morocco, and Tunisia. The workshop was aimed at exploring how wastewater surveillance can support public health, environmental protection, and ecosystem sustainability.¹⁷⁴

2.4.1a Common usage of electronic health records

Score: 50

Djibouti has electronic health records in use but they are not commonly used. In July 2023, the Official Gazette of the Republic of Djibouti enacted “Law No. 11/AN/23/9th L on the reorganization and functioning of the Ministry of Health,” which mandates, in collaboration with the ministry responsible for the digital economy, the digitalization of health services, establishing a legal basis for electronic records without demonstrating nationwide routine adoption ^{175, p. 2}. In February 2024, the Ministry of Health reported that a computerized medical record was already used at Dar El Hanan Maternity and stated an intention to generalize its use to all health facilities, evidencing operational use in at least one facility and a planned expansion rather than common use ^{176, p. 37}. In May 2025, the United Nations in Djibouti documented deployment of an electronic patient record for family planning using mSupply in 23 public health facilities, confirming current, targeted use across multiple sites rather than systemwide adoption ¹⁷⁷.

2.4.1b Public health system access to individual electronic health records

Score: 100

Djibouti has national public health system access to electronic health records. In January 2024, the Ministry of Health reported that a computerized medical record was already used at Dar El Hanan Maternity and stated an intention to generalize its use across all health structures, alongside a national digital stack that includes District Health Information Software 2, mSupply, and the Surveillance Outbreak Response Management and Analysis System, demonstrating government-led deployment within the public system ^{178, p. 38}. In April 2025, the World Health Organization issued the “Evaluation of WHO contribution in Djibouti: Management response,” committing with the Ministry of Health to enhance the national Health Information System, to review and strengthen District Health Information Software 2 at primary health care level, and to provide technical assistance on the design and use of disaggregated data, with milestones scheduled in 2025, which confirms national governance and access to digital health data ^{179, pp. 1–2, 7–8}. In May 2025, the United Nations in Djibouti documented deployment of an electronic patient record based on mSupply in 23 public facilities, integrated with the national information system and used via a monitoring dashboard by program managers, evidencing Ministry of Health access to patient-level records ¹⁸⁰.

2.4.1c Existence of data standards for health record data comparability

Score: 100

Djibouti has government-wide data standards that ensure data are comparable across public institutions and sectors. The National Agency for State Information Systems and the Presidency of the Republic of Djibouti issued the “Interoperability Framework of Djibouti” in 2022, which defines common models, principles, scope, and structure for standardized data exchange, including explicit Norms and Specifications and catalogues of norms and metadata that enable reuse and comparability across the administration ^{181, pp. 6–9, 24, 50–52}. The Ministry of Health of the Republic of Djibouti published the “Health Statistics Yearbook” in March 2023, which confirms use of District Health Information Software 2 as the national platform supporting standardized indicators for comparable datasets within the health sector ^{182, p. 4}. In September 2025, the Presidency of the Republic of Djibouti and the Official Gazette of the Republic of Djibouti published the “Digital Code,” which legally mandates a general interoperability and security reference that determines applicable data directories, norms, and standards for tele-services and establishes an analogous reference for the national health data system with a compliance attestation duty for administrations, thereby codifying government-wide data comparability requirements ^{183, pp. 314–315, 325}.

2.4.2a Data sharing mechanisms

Score: 100

Djibouti has an established interministerial mechanism for surveillance data sharing across human, animal, and environmental sectors. In July 2023, the Official Gazette enacted “Law No. 11/AN/23/9th L on the reorganization and functioning of the Ministry of Health,” designating the Directorate-General of Public Health as the International Health Regulations national focal point and mandating surveillance, sanitary vigilance, a National Public Health Laboratory with entomology and parasitology services, and a Health Information and e-Health directorate to collect, analyze, and disseminate epidemiological data ^{184, pp. 14–16}. In Quarter 1 of 2024 the African Leaders Malaria Alliance country quarterly documented active vector and malaria surveillance challenges, including Anopheles stephensi and diagnostics issues, evidencing operational streams that feed national data systems ^{185, pp. 1–2}. In April 2025, the Presidency published Order No. 2025-055/PR/MS establishing a Public Health Emergency Operations Center under the National Institute of Public Health with permanent commissions that include the ministries of health, agriculture and livestock, and environment, and that are mandated to collect, analyze, and disseminate information across sectors ¹⁸⁶. On August 29, 2025, the Intergovernmental Authority on Development communiqué, signed on-page by Djibouti’s Ministry of Health Secretary-General, committed to real-time, interoperable One Health surveillance data sharing and unified platforms ^{187, pp. 3–5}.

2.4.3a Availability of de-identified health surveillance data on disease outbreaks

Score: 100

Djibouti has publicly available, de-identified infectious-disease surveillance data posted on official government websites. In March 2023, the Ministry of Health’s Directorate of Health Information published the “Health Statistics Yearbook,” which reports aggregate, de-identified surveillance outputs for malaria, human immunodeficiency virus, and tuberculosis in dedicated program sections with tables of confirmed cases, testing, and service activity by level and location, alongside a narrative stating the yearbook’s official publication and data provenance from the national District Health Information Software 2 platform ^{188, pp. 3, 30–32}. The Ministry of Health’s Publications page lists the “Health Statistics Yearbook” series for 2024 and 2025 on the same government domain, confirming continued public release of these de-identified infectious-disease data ¹⁸⁹. In parallel, the Government of Djibouti maintains a national coronavirus disease 2019 statistics page on its official domain that provides public case information as an additional government-hosted channel of de-identified surveillance reporting ¹⁹⁰.

2.4.4a Confidentiality legislation/regulations for identifiable health information

Score: 100

Djibouti has legislation in force that safeguards the confidentiality of identifiable health information generated through surveillance. In April 2008, the Official Gazette of the Republic of Djibouti promulgated “Decree No. 2008-0098/PR/MS on the Medical Code of Ethics,” which imposes professional secrecy on physicians and requires confidential medical records, directly protecting patient-identifying information in clinical and surveillance contexts ^{191, pp. 2, 6}. In January 2024, the Official Gazette published “Law No. 18/AN/23/9th L Ratifying the African Union Convention on Cybersecurity and Personal Data Protection,” aligning national obligations with continental personal-data safeguards applicable to public authorities handling health data ¹⁹². In September 2025, the Official Gazette issued the “Digital Code Annex (Journal Officiel Special No. 04),” establishing a comprehensive personal-data regime that mandates confidentiality, security, and privacy by design and by default and requires breach notification to the national commission, with penal provisions that expressly cover unlawful processing of health data and breaches of confidentiality, ensuring enforceable protection across government health information systems ^{193, pp. 51-54, 96-104, 113-114}.

2.4.4b Inclusion of cyber protections in health data confidentiality law/regulation

Score: 100

Djibouti has legislation in force that safeguards the confidentiality of identifiable health information, including protections from cyber attacks, with enforceable oversight. In January 2024, the Official Gazette of the Republic of Djibouti published “Law No. 18/AN/23/9th L Ratifying the African Union Convention on Cybersecurity and Personal Data Protection,” aligning national obligations with continental personal data safeguards for public authorities handling health information ¹⁹⁴. In September 2025, the Official Gazette issued the “Digital Code Annex (Journal Officiel Special No. 04),” which mandates confidentiality, privacy by design and by default, and technical and organizational security controls, and requires breach notification to the National Commission for the Protection of Personal Data and to affected persons, establishing concrete procedures responsive to cyber incidents such as ransomware ^{195, pp. 51–54}. The same instrument creates the National Commission as an independent supervisory authority with investigative and enforcement powers, including publication of decisions and annual reporting, which ensures implementation across government health information systems ^{196, pp. 96–104}. Penal provisions expressly cover unlawful processing of health data and breaches of confidentiality and security, providing sanctions that make the protections operational ^{197, pp. 113–114}.

2.4.5a Cooperative commitments or agreements within regions

Score: 100

Djibouti has made a government-level public commitment to share surveillance data during public health emergencies with other countries for more than one disease. On August 29, 2025 the Intergovernmental Authority on Development published a ministerial communiqué naming Djibouti’s delegation by official title and office, “Mr. Mohamed Ali Mohamed, Secretary General, Ministry of Health, representing the Minister for Health, Republic of Djibouti,” thereby placing the Government of Djibouti on record as a party to the commitments therein ¹⁹⁸. The communiqué’s section on strengthening cross-border surveillance and early warning systems commits Member States to establish cross-border surveillance and monitoring mechanisms and to develop unified digital One Health surveillance data repository platforms for seamless coordination among One Health personnel across Member States, which constitutes an explicit, multi-disease, cross-border data-sharing commitment tied to pandemic preparedness and response ¹⁹⁹. The same communiqué further commits to cross-border laboratory networks with interoperable information management systems, reinforcing the intent to share surveillance information across national boundaries for multiple pathogens ²⁰⁰.

The country's adherence to the International Health Regulations (IHR 2005) serves as a primary legal and operational commitment. As a signatory, Djibouti is obligated to notify the World Health Organization (WHO) of public health events that may constitute a public health emergency of international concern. This legally binding framework necessitates the sharing of surveillance data with the WHO but does not specify provisions to share with other countries. ²⁰¹

2.5.1a National support to conduct contact tracing in the event of a public health emergency

Score: 100

Djibouti has a national system that provides ongoing support to sub-national levels to conduct contact tracing in preparation for public health emergencies. The Ministry of Health’s March 2020 “Action Plan for the Prevention and Response to COVID-19” explicitly requires active surveillance, early detection, isolation and case management, and contact tracing, establishing national procedures to be implemented across levels, including follow-up of contacts and management of traveler lists and databases for points of entry ^{202, p. 3}. In January 2024, the Ministry of Health recorded the national launch of the “Surveillance Outbreak Response Management and Analysis System” for epidemiological surveillance as part of health system digitalization, confirming institutionalized, ongoing infrastructure that supports tracing workflows below the center ^{203, p. 38}. In 2023, the Intergovernmental Authority on Development documented a Trainers of Trainers cohort for 24 health professionals in Djibouti and published a table showing distribution of information technology equipment to the health sector and cross-border sites, evidencing resource and implementation support at regional levels and points of entry ^{204, pp. 78–79}. In September 2025, the World Health Organization Regional Office for the Eastern Mediterranean reported standard operating procedures, training of trainers, and roll-out of event-based surveillance at national and sub-national levels in countries including Djibouti, sustaining workforce capacity that underpins contact tracing functions ^{205, pp. 2–3}.

2.5.1b Provision of wraparound services to enable self-isolation/quarantine as recommended

Score: 100

Djibouti has nationwide measures that provide medical attention and quarantine-enabling economic support for infected people and their contacts. In February 2014, the National Assembly adopted and the President promulgated “Law No. 24/AN/14/7ème L establishing a Universal Health Insurance System,” which includes coverage for epidemics and public-health problems and authorizes the National Social Security Fund to finance care by direct payment to providers or by reimbursement to beneficiaries, establishing insured access to consultations, diagnostics, and treatment during outbreaks ^{206, pp. 2–3}. On March 23, 2020, the Presidency issued Decree No. 2020-063/PR/MTRA requiring employees in quarantine or confinement to remain at home without loss of salary and creating wage-loss compensation and an employer allocation ²⁰⁷. On April 29, 2020, the President and the Minister of Labor set a compensatory allowance at 70 percent of gross wages with state and employer shares; on August 23, 2020, the scheme was prolonged for affected sectors ²⁰⁸²⁰⁹. In March 2020, the Ministry of Health’s national clinical directive mandated operational follow-up for cases and contacts, including preservation of contact lists for follow-up and isolation precautions, evidencing organized medical attention for individuals under isolation or quarantine ^{210, pp. 11, 17}.

2.5.2a Strategy for tracing and quarantining international travelers

Score: 50

Djibouti has documented traveler screening, contact follow up, and quarantine procedures that were issued in response to the COVID-19 emergency, but no publicly available standing interministerial plan with border control authorities is evident. The Ministry of Health’s “Action Plan for the Prevention and Response to COVID-19, Version of March 18, 2020” prescribes point-of-entry workflows before disembarkation, systematic passenger screening by thermal camera and infrared thermometer, and required retention of passenger location listings with development of a national database and health declaration controls, demonstrating emergency-specific screening and follow up at borders ^{211, pp. 14–15}; the same plan sets quarantine requirements under defined scenarios ^{212, p. 8}. The Presidency’s “Decree No. 2022-243/PR/MS easing mandatory measures to prevent the spread of COVID-19,” Article 5, confirms operational border-health controls for arriving and departing travelers during the emergency period, evidencing application of PoE measures in practice ²¹³. The Presidency’s “Order No. 2025-055/PR/MS establishing a Public Health Emergency Operations Center” embeds the Ministry of the Interior in COUSP governance and operations but does not establish a joint plan or cooperative agreement with border police or customs for traveler case-finding or contact tracing outside active emergencies, so the evidence aligns with emergency-response measures rather than a standing intersectoral PoE agreement ²¹⁴.

2.6.1a Access to field epidemiology training program in country and/or abroad

Score: 100

Djibouti has applied epidemiology training available in country. In February 2022, the state-owned national newspaper La Nation reported that the Ministry of Health and the National Institute of Public Health organized a graduation ceremony in Djibouti City for the first cohort of twenty-two field epidemiologists after three months of training, with participation from the United States Centers for Disease Control and Prevention, the African Field Epidemiology Network, the World Health Organization, and the Intergovernmental Authority on Development ²¹⁵. In May 2024, the African Field Epidemiology Network documented a Horn of Africa disaster preparedness and response Training of Trainers held in Arta Region, Djibouti, co-organized with the Ministry of Health of Djibouti and the United States Centers for Disease Control and Prevention from May 5 to May 9, confirming ongoing in-country applied epidemiology training activities under government auspices ²¹⁶. On January 15, 2025 the African Field Epidemiology Network updated the Djibouti Field Epidemiology Training Program page to show an established date of 2021, two Frontline cohorts, and the Federal Ministry of Health of Djibouti as a founding implementing partner, demonstrating current domestic availability ²¹⁷.

2.6.1b Existence of field epidemiology training for animal health professionals

Score: 0

There is no publicly available evidence that Djibouti’s field epidemiology training programs explicitly include animal health professionals or that a dedicated veterinary field epidemiology program is offered. In November 2022, EcoHealth Alliance's “One Health and Veterinary Systems in Africa” report's Djibouti country chapter does not document veterinary inclusion in the country's training program or the existence of a veterinary field epidemiology track ^{218, pp. 16, 134–141}. On May 9, 2024 the African Field Epidemiology Network reported a five-day Training of Trainers held May 5–9 in Arta Region, Djibouti, co-organized with the Ministry of Health of Djibouti and the United States Centers for Disease Control and Prevention; the post does not indicate participation by animal health professionals or an animal-health-specific curriculum ²¹⁹. On January 15, 2025 the African Field Epidemiology Network updated the “Djibouti Field Epidemiology Training Program” page to list a Frontline tier established in 2021 with the Federal Ministry of Health of Djibouti and partners, without any statement of veterinary enrollment or a veterinary track ²²⁰.

2.6.2a Evidence of at least 1 trained field epidemiologist per 200,000 people

Score: 100

Djibouti has at least 1 trained field epidemiologist per 200,000 people. The state daily newspaper reported that the Ministry of Health and the National Institute of Public Health graduated the first frontline cohort of 22 field epidemiologists on February 9, 2022, a government-led program delivered with the African Field Epidemiology Network and the World Health Organization ²²¹. The African Field Epidemiology Network’s “Annual Report 2022” documents the Djibouti Field Epidemiology Training Program graduation with the Minister of Health speaking at the ceremony and field activities in Tadjourah during February 2022, corroborating the cohort size consistent with the news report ^{222, p. 9}. The World Health Organization Regional Office for the Eastern Mediterranean states that as of September 2025 Djibouti is implementing Field Epidemiology Training Programs to build its surveillance workforce, confirming continuity into the current timeframe ^{223, p. 3}. The World Bank reports Djibouti’s 2024 population as 1,168,722, so the national threshold is at least 6 epidemiologists; the February 2022 cohort of 22 exceeds this requirement by a wide margin ²²⁴.

3.1.1a National emergency response plan for diseases with pandemic potential

Score: 33.33

Djibouti has disease-specific public health emergency response planning in place, but does not have a publicly available overarching national public health emergency response plan addressing multiple communicable diseases with epidemic or pandemic potential. The Ministry of Health issued the “Action Plan for the Prevention and Response to COVID-19” in March 2020, which establishes surveillance, laboratory testing, case management, points of entry measures, logistics, and staged response actions specific to coronavirus disease, but is explicitly framed as a single-disease response plan rather than a multi-disease emergency preparedness and response framework ^{225, pp. 6–10, 13–14}. Financing for implementation of this COVID-19 plan is documented through the International Development Association–financed “Djibouti COVID-19 Response Project,” approved in April 2020, which aligns project funding with the national COVID-19 preparedness and response plan but does not finance or reference an overarching multi-disease public health emergency response plan ^{226, pp. 6, 31}. Legal and institutional instruments exist, including the April 2025 order establishing a Public Health Emergency Operations Center and the July 2023 law reorganizing and governing the Ministry of Health, but these instruments establish governance structures and institutional mandates rather than publishing or legally adopting a national multi-disease public health emergency response plan ²²⁷²²⁸. A national disaster preparedness assessment published in 2023 further recommends updating the national all-hazards preparedness framework, indicating the absence of a current overarching public health emergency response plan in the public domain ^{229, p. 16}.

3.1.1b National public health emergency response plan published in past 3 years

Score: 0

There is no publicly available evidence that Djibouti updated an overarching national public health emergency response plan. The Ministry of Health’s public publications page lists statistical yearbooks, project environmental and social instruments, and other sector files, but no multi-disease national public health emergency response plan issued or updated within the last 3 years is posted by the Ministry of Health ²³⁰. An intergovernmental baseline assessment prepared with the Ministry of the Interior’s National Directorate of Civil Protection recommends updating the all-hazards national disaster plan known as ORSEC and adopting an incident management system, indicating that the national framework requires modernization rather than documenting a recent update to an overarching health emergency plan ^{231, pp. 16, 141–142}. The World Health Organization’s evaluation advises assisting the Government of Djibouti to develop a multisectoral health emergency preparedness plan, signaling that no updated overarching plan is publicly available as of 2023–2024 ^{232, p. 68}. A ministerial order in April 2025 establishes the Public Health Emergency Operations Center, but it does not publish or update an overarching multi-disease plan ²³³. The only located national plan remains the March 2020 coronavirus plan, which is disease-specific ^{234, pp. 6–10, 13–14}.

3.1.1c One health principles by covering multiple threat types

Score: 0

There is no publicly available evidence that Djibouti has an overarching national public health emergency response plan that follows One Health principles by covering antimicrobial resistance, zoonotic spillover, biological accidents, and deliberate acts. On April 6, 2025, the Official Gazette of the Republic of Djibouti established a Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti, which formalizes emergency operations but does not constitute a national multi-hazard public health emergency response plan with One Health multi-threat provisions ²³⁵. On April 14, 2025, the World Health Organization Evaluation Office issued a management response describing support to review the national emergency preparedness response plan and to develop a multisectoral operational plan, with Pandemic Fund resources to enhance that plan pending finalization; the document does not publish or link to any government-adopted national plan demonstrating explicit One Health, multi-hazard coverage in force ^{236, pp. 5–6}. As accessed in October 2025, the Ministry of Health publications page lists sector documents but does not host a national plan meeting the rubric’s multi-threat, multisector requirements ²³⁷.

3.1.1d Vulnerable populations in national public health emergency response plan

Score: 0

There is no publicly available evidence that Djibouti has an overarching national public health emergency response plan in which health equity considerations or mechanisms for identifying and addressing the needs of vulnerable populations can be evaluated. Djibouti’s National Health Development Plan 2020–2024 articulates equity-oriented objectives for health service delivery, including prioritization of underserved populations and geographic areas, but this document is a health sector development and service delivery plan rather than a public health emergency preparedness and response plan addressing multiple communicable diseases with epidemic or pandemic potential ^{238, p. 4}. Project-level instruments, including the Ministry of Health’s April 2022 “Strengthening the Health System of Djibouti” procedures, include targeting mechanisms for peripheral areas, refugees, and host communities, but these mechanisms operate within specific health system strengthening projects rather than within a national public health emergency response plan ^{239, pp. 1–3, 12}. Legal and institutional instruments, including the April 2025 order establishing a Public Health Emergency Operations Center and the July 2023 law governing the Ministry of Health, define organizational roles and authorities but do not publish or adopt an overarching public health emergency response plan containing equity provisions ²⁴⁰²⁴¹. In the absence of a publicly available overarching national public health emergency response plan, health equity considerations and vulnerable population mechanisms cannot be assessed for this indicator.

3.1.2a Mechanism to engage private sector in outbreak preparedness/response

Score: 100

Djibouti has a specific government mechanism that engages the private sector for outbreak emergency preparedness and response via national organization of relief plans known as ORSEC. The Official Gazette of the Republic of Djibouti published “Law No. 140/AN/06/5th L on the National Policy for Risk and Disaster Management” on March 11, 2006, which requires risk and disaster management by the State and regions with the participation of economic operators, and mandates ORSEC plans that list public and private means and set conditions for their use by the competent authority ^{242, pp. 1–2}. The World Bank issued the “Environmental and Social Management Plan for the Djibouti Contingent Emergency Response Project” on June 29, 2025, confirming that ORSEC remains the principal coordination tool and a constantly updated directory of human and material resources used during emergencies, operationalizing engagement of private providers in public health response ^{243, p. 17}. The Pacific Disaster Center released the “National Disaster Preparedness Baseline Assessment: Djibouti” on July 11, 2023, recommending ORSEC updates with hazard-specific scenarios, explicitly including infectious disease outbreaks and leveraging private-sector partners, confirming scope and continued use ^{244, pp. 141–142}.

3.1.3a Policy/plan/guidelines in place to implement non-pharmaceutical interventions (NPIs)

Score: 100

Djibouti has current, government-issued policy and guidelines to implement non-pharmaceutical interventions for more than one disease. The Ministry of Health’s June 2023 “Manual of Procedures for Infection Prevention and Medical Waste Management” addresses epidemic and pandemic contexts, including a COVID-19 emergency response with quarantine and isolation sites and surveillance-capacity training; it lists COVID-19 among transmissible diseases managed by the guidance and prescribes isolation, segregation, reinforced cleaning, and staff training for highly infectious patients during epidemics ^{245, pp. 6–7, 39, 51}. “Law No. 11/AN/23/9th Legislature on the reorganization and functioning of the Ministry of Health” of July 31, 2023, assigns the Ministry responsibilities for epidemiological surveillance, health emergencies, and defining response strategy, providing a cross-disease legal basis for non-pharmaceutical measures ^{246, pp. 1–2, 13–15}. “Order No. 2024-107/PR/MS establishing an institutional framework for managing the Mpox epidemic” creates national coordination and technical committees to validate prevention and response decisions and to develop preparedness and response plans for Mpox, supplying disease-specific policy for non-pharmaceutical interventions ²⁴⁷. “Order No. 2025-055/PR/MS creating a Public Health Emergency Operations Center” establishes a national hub at the National Institute of Public Health of Djibouti for multisectoral prevention, detection, and response to health threats, operationalizing activation of these interventions ²⁴⁸.

3.2.1a Completion of biological-focused IHR exercise with the WHO in past year

Score: 0

There is no publicly available evidence that Djibouti activated a national emergency response plan for an infectious disease outbreak in the past year or completed a national-level biological threat-focused exercise in the past year. In April 2025, the Official Gazette of the Republic of Djibouti published “Order No. 2025-055/PR/MS establishing a Public Health Emergency Operations Center,” which creates the center and describes coordination and simulation functions, but it does not include any ministerial activation circular for 2024–2025 ²⁴⁹. The Presidency of the Republic of Djibouti’s Council of Ministers readout dated February 4, 2025 references the establishment decision and governance intent, yet it records no activation of a national infectious-disease response plan or completion of a biological threat simulation within the assessed year ²⁵⁰. The World Health Organization Regional Office for the Eastern Mediterranean’s “EMR Polio Bulletin, Issue No. 1409, Week 40 (ending on 05/10/2025)” lists Djibouti among countries with circulating vaccine-derived poliovirus detections in 2025, but it contains no statement that a national plan was formally activated or that a national biological exercise was conducted ^{251, p. 1}. National news coverage describes a February 2025 sea-rescue simulation led by the Minister of Health, which was a maritime mass-casualty drill rather than a biological threat exercise ²⁵².

3.2.1b Evidence of bio-focused exercise to identify gaps/best practices

Score: 0

There is no publicly available evidence that Djibouti in the past year identified a list of gaps and best practices through an infectious disease response or exercise and developed and published a plan to improve response capabilities. The Presidency’s Official Gazette created the Public Health Emergency Operations Center by “Arrêté n° 2025-055/PR/MS” in April 2025 and defines roles within the National Institute of Public Health, but it does not publish an after action or intra action review or a resulting improvement plan ²⁵³. The state news agency reported a February 9, 2025 sea rescue simulation led by the Ministry of Health, yet the article does not provide a public after action findings document or a linked improvement plan ²⁵⁴. The World Health Organization Eastern Mediterranean Regional Office documented Djibouti’s 2025 poliovirus detections and April to May 2025 vaccination rounds, but the situation report contains no national after action review or government published improvement plan for 2024 to 2025 ^{255, p. 3}. A World Health Organization management response states a three year budgeted multisectoral health emergency preparedness plan was developed with government by the fourth quarter of 2024, but the plan is not publicly posted and is not presented as an after action improvement plan ^{256, pp. 6, 19}. The Ministry of Health publications index for 2025 lists reports and project documents but no such review or plan ²⁵⁷.

3.2.2a Evidence of national-level biological threat-focused exercise that includes private sector

Score: 0

There is no publicly available evidence that Djibouti in the past year has conducted a national-level biological threat-focused exercise that included private sector representatives. The World Health Organization’s 2024 regional appeal includes a Djibouti country section describing outbreaks, operations, and training priorities but does not report a national biological simulation or document private sector participation on the Djibouti page cited ^{258, p. 5}. On September 19, 2024 the Official Gazette issued “Decree No. 2024-219/PR/MS Regulating Private-Sector Health Structures,” which sets authorization and oversight requirements for private facilities but does not establish or record a national biological simulation with private sector involvement ²⁵⁹. On December 2, 2024 the United Nations Office for Disaster Risk Reduction reported a national consultation to revise the disaster risk reduction strategy, which was a planning workshop and not a biological simulation exercise ²⁶⁰. On February 9, 2025 the Agence Djiboutienne d’Information described a full-scale maritime mass-casualty rescue simulation titled “Coordination,” which addressed sea-rescue operations rather than a biological threat and did not document private sector representation ²⁶¹.

3.3.1a Existence of Emergency Operations Center (EOC)

Score: 100

Djibouti has an Emergency Operations Center in place. On February 4, 2025 the Presidency of the Republic of Djibouti issued a Council of Ministers communiqué confirming cabinet approval of a draft order to create a Public Health Emergency Operations Center under the Ministry of Health, describing watch, alert, and rapid response functions consistent with an emergency operations center ²⁶². On the same date the Ministry of Foreign Affairs and International Cooperation published the government spokesperson’s readout reiterating creation under the Ministry of Health and alignment with the International Health Regulations ²⁶³. The Official Journal issue index dated March 13, 2025 lists “Order No. 2025-055/PR/MS establishing a Public Health Emergency Operations Center” under the Ministry of Health, confirming inclusion in the state publication cycle for that date ²⁶⁴. The Official Gazette legal text then published the order, signed on March 13, 2025 and published on April 6, 2025, creating the center within the National Institute of Public Health of Djibouti as a national coordination space for prevention, detection, and response to health threats in line with the International Health Regulations ²⁶⁵.

3.3.1b Requirement for EOC to conduct/evidence EOC conducts at least annual drills

Score: 0

There is no publicly available evidence that Djibouti conducts, or is legally required to conduct, a public health emergency scenario drill via its Emergency Operations Center at least once per year. The World Health Organization weekly update for 4 November 2022 lists simulation exercises completed that year with WHO support but does not include Djibouti ^{266, p. 7}. The 2023 “National Disaster Preparedness Baseline Assessment – Djibouti” assigns the Executive Secretariat for Disaster Risk Management responsibility to test and evaluate emergency operations plans through simulation exercises, yet explicitly reports there is no national training and exercise program and recommends creating one with an annual schedule ^{267, pp. 120–122}. In May 2024, the African Field Epidemiology Network documented a regional disaster preparedness training of trainers in Djibouti that was not a national Emergency Operations Center drill or evidence of an annual program ²⁶⁸. In April 2025, the Official Gazette created the Public Health Emergency Operations Center within the National Institute of Public Health and described simulation exercises among preparatory activities but did not establish any annual drill requirement or document annual drills ²⁶⁹.

3.3.1c EOC activation within 120 minutes of identification of emergency/scenario

Score: 0

There is no publicly available evidence that Djibouti’s Public Health Emergency Operations Center conducted, within the last year, a coordinated emergency response or emergency response exercise that was activated within 120 minutes of identifying the emergency or scenario. On December 5, 2024, the Official Gazette of the Republic of Djibouti published “Decree No. 2024-296/PRE on protection against ionizing radiation,” a health sector regulation within the assessment window that contains no emergency operations activation record ²⁷⁰. On February 4, 2025, the Presidency of the Republic recorded the Council of Ministers’ consideration of an order to create the Public Health Emergency Operations Center under the Ministry of Health, describing rapid coordination aims but providing no activation timing from an exercise or event ²⁷¹. On April 6, 2025, the Official Gazette published “Order No. 2025-055/PR/MS Establishing a Public Health Emergency Operations Center,” locating the Center within the National Institute of Public Health of Djibouti and assigning simulation duties, without reporting a ≤120-minute activation ²⁷². On September 17, 2025, the Djiboutian News Agency documented a national anti-pollution exercise at Doraleh, which is not a public health activation and includes no timing evidence for the Center ²⁷³.

3.4.1a Joint exercise/procedures for potential deliberate biological events

Score: 100

Djibouti has publicly available, nationally binding instruments that establish documented cross-sector procedures for preparing for and responding to deliberate biological incidents. In June 2022, the Presidency issued “Decree No. 2022-126/PRE fixing the organization and functioning of the National Authority for Nuclear, Radiological, Chemical and Biological Safety and Security,” requiring ministries, public bodies, and private entities to notify imports or exports of biological materials for authorization, creating a Technical and Scientific Committee that includes the National Security Service, the Ministry of Health, and the Ministry of Agriculture, and mandating contributions to emergency plans, coordinated interventions for incidents involving biological products, public-information mechanisms, and an internal procedures manual, thereby formalizing interagency arrangements that include private operators ²⁷⁴. In December 2024, “Decree No. 2024-297/PRE creating the inspector corps of the National Authority” assigns inspectors to control sites using biological products, conduct inspections for protection against biological risks, and participate in interventions with competent authorities in biological emergencies, operationalizing these cross-sector procedures across security, public health, animal health, and regulated private entities ²⁷⁵. As of August 29, 2025, the International Atomic Energy Agency lists the National Authority as Djibouti’s contact point, evidencing continued implementation ^{276, p. 9}.

3.5.1a Risk communication plan for specific use during a public health emergency

Score: 100

Djibouti has a publicly available, binding instrument that sets out a dedicated risk communication section for use during public health emergencies. In April 2025, the Presidency and the Ministry of Health promulgated “Arrêté No. 2025-055/PR/MS creating a Public Health Emergency Operations Center,” which assigns the center responsibility for public communication during activated responses and establishes a communication commission tasked with media interface, risk awareness, social mobilization, and development of communication products, with membership drawn from the Prime Minister’s Office, the Ministry of Health, the Ministry of Communication, the Ministry of Agriculture, and the Ministry of the Environment, thereby detailing how emergency risk communication is organized and delivered across sectors ²⁷⁷. This operates on a standing legal foundation from July 2023 in “Law No. 11/AN/23/9ème L reorganizing and modernizing the Ministry of Health,” which mandates structured health-risk awareness and communication campaigns, mass-media mobilization, monitoring and evaluation of communication and social mobilization, and designates the International Health Regulations focal point to support information dissemination during alerts and responses ^{278, pp. 2–3, 15–16, 19–22}. A February 2025 Council of Ministers record confirms the policy decision and rationale immediately preceding the April 2025 promulgation ²⁷⁹.

3.5.1b Inclusion of different population & sector needs in risk communication plan

Score: 0

There is no publicly available evidence that Djibouti has a risk communication plan or other guiding instrument that explicitly outlines how messages will reach populations and sectors with different communications needs, including different languages, subnational locations, media reach, and vulnerable or hard-to-reach groups. The Ministry of Health publications portal lists sector documents and periodicals but does not post any national risk communication plan or updated audience-segmentation guidance ²⁸⁰. The national reorganization law for the Ministry of Health, promulgated in July 2023, embeds communication and public-relations functions and assigns directorates mandates to mobilize mass media and conduct awareness campaigns, but it does not set modalities by language, geography, media access, or named vulnerable groups as required by the rubric ^{281, pp. 2, 11–14}. The Ministry’s January 2024 sector review magazine documents outreach activities in interior regions, which confirms operations but does not constitute a government plan that prescribes differentiated message-delivery channels for diverse groups ^{282, p. 10}.

3.5.1c Designation of a specific government spokesperson during a public health emergency

Score: 100

Djibouti has designated a specific government position to serve as the primary spokesperson to the public during a public health emergency. In April 2025, the Presidency issued Decree No. 2025-082/PRE appointing Abdoulkader Houssein Omar as Minister of Foreign Affairs and International Cooperation and Government Spokesperson, thereby establishing a single, government-wide spokesperson position for official communications ²⁸³. In April 2025, the Official Journal published Order No. 2025-055/PR/MS creating the Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti; Article 16 establishes a Communication Commission for emergency risk communication whose members include the Prime Minister’s Office and the Ministry of Communication, and specifies that the chair is from the Prime Minister’s Office, centralizing public messaging during health emergencies under the center of government ^{284, Art. 16}. The Presidency’s current “Composition of the Government” page lists the Minister of Foreign Affairs and International Cooperation as Government Spokesperson, confirming the institutional home of the spokesperson function consistent with the decree ²⁸⁵. Presidency Council of Ministers communiqués in May 2025 and October 2025 show the Government Spokesperson delivering official briefings, evidencing operational practice aligned with the designated role ²⁸⁶.

3.5.2a Government use of media platforms to share info on public health emergencies

Score: 100

Djibouti has regularly used official, non-social government websites to inform the public about ongoing health concerns during the past year. On January 14, 2025, the Djibouti News Agency, the state news portal of the Government of Djibouti, published the Council of Ministers communiqué reporting the Ministry of Health communication on a draft law establishing mandatory vaccination for defined population groups, providing policy guidance to the public via an official website ²⁸⁷. On April 12, 2025, the same portal issued operational public guidance for a nationwide polio vaccination campaign specifying dates, target children under 5 years, and deployment through health centers, schools, and households, which constitutes proactive public messaging on a current health risk ²⁸⁸. On April 13, 2025, it reported the Minister of Health’s official launch of the campaign at the People’s Palace, reinforcing nationwide participation and mobilization instructions for families and providers ²⁸⁹. On April 15, 2025, the Council of Ministers coverage described implementation details and adoption of the novel type 2 oral polio vaccine, extending campaign information to the public in the same month ²⁹⁰. On May 27, 2025, the portal carried the Minister of Health’s communication on malaria trends and control measures through 2025, providing seasonal risk context and intervention updates to the population ²⁹¹.

3.5.2b Evidence that senior leaders have shared mis/disinformation on infectious diseases

Score: 100

There is no publicly available evidence that Djibouti’s president or cabinet ministers shared misinformation or disinformation on infectious diseases in the past two years. On August 21, 2024, the state news agency reported that the Ministry of Health formally denied false social-media rumors of a supposed mpox case and reassured the public that no case had been detected²⁹². On April 12, 2025, the state news agency reported the launch of a nationwide poliomyelitis vaccination campaign led by senior authorities with pro-vaccination messaging, which contained no inaccurate disease claims by the minister or the presidency ²⁹³. On April 22, 2025, the Presidency’s Council of Ministers communiqué recorded the government’s adoption and communication of measures supporting polio eradication efforts, including use of the novel oral polio vaccine type 2, again without false statements on infectious disease by senior leaders ²⁹⁴.

3.6.1a Percentage of households with Internet

Score: 70.07

3.6.2a Mobile-cellular telephone subscriptions per 100 inhabitants

Score: 26.2

3.6.3a Gender gap in access to a mobile phone (percentage points)

Score: 80

3.6.4a Gender gap in access to the Internet (percentage points)

Score: 75

3.7.1a Restrictions on export/import of medical goods due to an infectious disease outbreak

Score: 100

There is no publicly available evidence that Djibouti implemented export or import restrictions on medical goods in the past year due to an infectious disease outbreak, or that any such intervention was based on international recommendations or a structured decision mechanism involving specific scientific evidence, expert input, or guidelines. The World Health Organization Regional Committee report for October 2024 describes agenda items on access to medical products and contains a consolidated “Resolutions and Decisions” section; neither the thematic agenda nor the adopted decisions identify medical-goods trade restrictions ^{295, pp. 4–5, 29–37}. The Presidency of the Republic’s official summary of the Council of Ministers on February 4, 2025 lists adopted and deliberated measures without any decree, order, or circular imposing export or import controls on medicines, oxygen, personal protective equipment, or other medical supplies ²⁹⁶. The Official Gazette issues in the past year, including “JORD No. 03 of 13/02/2025” and “JORD No. 13 of 15/07/2025,” publish finance and institutional acts but no outbreak-driven restrictions on medical goods ²⁹⁷²⁹⁸.

3.7.1b Restrictions on movement and/or exports/imports due to disease outbreak

Score: 100

Djibouti has not implemented restrictions on the export or import of non-medical goods due to an infectious disease outbreak in the past year. The Official Gazette shows no decrees or orders imposing outbreak-triggered trade controls on food, textiles, or other non-medical commodities in the past year's issues, including JORD n°20 of October 31, 2024; JORD n°03 of February 13, 2025; JORD n°13 of July 15, 2025; and JORD n°14 of July 31, 2025 [1; 2; 3; 4]. Each issue lists enacted acts and decisions, such as accounts approvals, ratifications, defense or budget items, and bursary contributions, without any disease-based import or export restrictions on non-medical goods during the assessed period [1]; 2; 3; 4].

3.7.2a Evidence of travel ban due to an infectious disease outbreak

Score: 100

Djibouti has not implemented inbound or outbound travel restrictions due to an infectious disease outbreak in the past year. The Official Gazette index confirms continuous publication, establishing where such measures would be promulgated if adopted ²⁹⁹. The issue “JORD No. 01 of 15 January 2025” lists presidential, budgetary, and sectoral acts but contains no decree, order, or notice imposing entry or exit health measures ³⁰⁰. The issue “JORD No. 03 of 13 March 2025” records Ministry of Health actions without any border-health restrictions ³⁰¹; in the same period, the Ministry of Health order “Order No. 2025-055/PR/MS establishing a Public Health Emergency Operations Center” created the center within the National Institute of Public Health of Djibouti in April 2025, documenting governance arrangements and containing no provisions on testing, vaccination proof, quarantine, or denial of embarkation or entry ³⁰². The issue “JORD No. 13 of 15 July 2025” similarly records legislative ratifications but no disease-related travel rules ³⁰³.

3.7.2b Risk-based approach to international travel-related measures

Score: 100

Djibouti has a risk-based approach to international travel measures that differentiates entry requirements by travelers’ origin or transit exposure. The World Health Organization lists Djibouti among countries that require proof of yellow fever vaccination for travelers arriving from countries with risk for yellow fever transmission, applicable from age 1 year; the table explicitly names Djibouti and the footnote states that the requirement includes airport transits exceeding 12 hours through a yellow fever risk country, which makes the measure exposure based by route and origin; the annex was issued in November 2022 and revised in January 2023 and remains the intergovernmental standard ^{304, p. 2, 4}. The United States Centers for Disease Control and Prevention country page for Djibouti, updated on April 23, 2025, confirms that proof of yellow fever vaccination is required if arriving from a yellow fever risk country or after a transit exceeding 12 hours in such a country for travelers aged 1 year and older, which corroborates continued application ³⁰⁵.

4.1.1a Doctors per 100,000 people

Score: 2.64

4.1.1b Nurses and midwives per 100,000 people

Score: 7.68

4.1.1c Updated health workforce strategy to address human resource shortfalls

Score: 0

There is no publicly available evidence that Djibouti has a national health workforce strategy updated in the past five years that identifies shortage fields and sets strategies to address them. The World Health Organization’s 2021 “Health workforce snapshot: Djibouti” states there is no clear national vision such as a human resources for health development plan to address workforce challenges, and it cites no national strategy document thereafter ^{306, p. 1}. The Ministry of Health’s “Health Statistics Yearbook 2022,” issued in December 2023, enumerates staffing by cadre and facility in Section I.2 but does not present a sector-wide human resources for health strategy or a gap-analysis plan with remedial measures ^{307, pp. 6–12}. A 2024 country brief by the United Nations Children’s Fund and the Ministry of Health confirms a National Community Health Policy and a budgeted National Community Health Strategic Plan for 2024–2028, which are program-specific instruments and do not substitute for a comprehensive, government-wide health workforce strategy ^{308, pp. 2–4, 6–8}.

4.1.1d Health system capacity for essential health services

Score: 0

There is no publicly available evidence that Djibouti has sufficient capacity within the health system to deliver essential health services.

The JEE for Djibouti gives a score of 1 for this measure and says that the country lacks a plan and/or procedures for receiving or dispatching medical personnel, a specialized intersectoral structure for personnel deployment, and regional and international agreements for the deployment of medical personnel. ³⁰⁹

A World Health Organization executive summary published in July 2025 characterizes Djibouti’s health system as fragile and fragmented with high donor dependence, and explicitly identifies the need to ensure the availability of a package of essential services at the primary care level, demonstrating insufficient service delivery capacity at the foundation of the system as required under the R3.2 criteria. ^{310, pp. 4, 6}. With respect to workforce and facility inputs, the Ministry of Health, Republic of Djibouti, “Health Statistics Yearbook 2022,” issued in March 2023, provides the most recent consolidated national data on health facilities and staffing, and does not present updated systemwide results for 2023 to 2025 that would demonstrate adequate national capacity or recent performance across the health system during the scoring timeframe. ^{311, pp. 1, 3}. Regarding infrastructure and supply chain readiness, the World Bank Implementation Status and Results Report dated April 2025 documents that health facility and warehouse renovations remained in the design phase with works anticipated to begin in fall 2025, and reports that only a subset of health facilities were connected to the national electronic logistics management information system, indicating that core R3.2 capacity-building measures related to facility readiness and logistics functionality were still under implementation rather than fully operational. ^{312, pp. 2, 9}.

4.1.1e Essential health services continuity plan for public health emergencies

Score: 100

Djibouti has an in-force governmental framework that ensures emergency plans and procedures are established and maintained, and requires permanent, continuous delivery of core services in health facilities. In September 2024, “Decree No. 2024-219/PR/MS regulating private-sector health facilities” mandated that every hospital or polyclinic must ensure the permanent and continuous exercise of health activities, including admissions, hospitalization, operating theatre, intensive care, emergency, laboratory, imaging, delivery unit, ambulatory care, and an ambulance service ³¹³. In March 2025, “Order No. 2025-055/PR/MS establishing the Public Health Emergency Operations Center” created the Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti; its steering committee is tasked to ensure that plans and procedures are in place, and the center remains on standby in non-emergency periods to prepare, draft, and update procedure documents and plans ³¹⁴.

4.1.2a Hospital beds per 100,000 people

Score: 34.73

4.1.2b In-country capacity to isolate patients with highly communicable diseases

Score: 100

Djibouti has the capacity to isolate patients with highly communicable diseases through designated in-country patient isolation rooms and quarantine or isolation units located within public hospitals and state-operated facilities. The Ministry of Health of the Republic of Djibouti states that, beginning in April 2020, Hôpital Bouffard and Hôpital de Balbala were renovated and used for COVID-19 diagnosis and treatment, and that three rehabilitated structures located approximately 23 kilometers from Djibouti City at a government site identified using the national kilometer-marker system as PK23 were converted into treatment and quarantine facilities, with staff trained on COVID-19 protocols including treatment and isolation measures ^{315, pp. 3–4}. The same Ministry document lists Hôpital Bouffard, PK13, and PK23 as state quarantine sites and identifies multiple hospitals, medical centers, and polyclinics as COVID-19 quarantine or care sites within the country ^{316, p. 5}. A February 2021 Environmental and Social Management Plan issued by the Ministry of Health specifies transforming PK23 structures by installing rooms for treatment and isolation of suspected or confirmed cases ^{317, p. 3}. Later regulatory instruments on private health structures from September 2024 and on public polyclinics from January 2025 organize oversight and services but do not establish requirements negating these isolation arrangements ³¹⁸³¹⁹. The 2025 investment budget approval for the Centre Hospitalier Universitaire de Djibouti lists investments without superseding the already described isolation sites ³²⁰.

4.1.2c Demonstrated capacity / evidence of plan to expand isolation capacity

Score: 0

There is no publicly available evidence that Djibouti has developed, updated, tested, or otherwise demonstrated the capacity to expand isolation capacity for infectious disease outbreaks in the past two years. In February 2024, the Ministry of Health issued a January 2024 bulletin that is explicitly a 2022–2023 retrospective and, while listing 2025 “Perspectives” such as emergency department extensions and a new National Health Development Plan 2025–2029, it does not present an isolation-expansion plan or report any exercise testing isolation surge procedures ^{321, pp. 5, 46}. In May 2024, the World Health Organization published an evaluation covering contributions in Djibouti during 2019–2023; it does not document Djibouti isolation surge planning or tested expansion and provides no evidence for the past two years ^{322, p. 41, 45}. Government reporting on the December 15, 2024 inauguration of Tadjourah Regional Hospital lists service expansions without identifying isolation wards or temporary isolation facilities activated or tested for outbreaks ³²³. In April 2025, the Presidency’s Official Gazette established the Public Health Emergency Operations Center and emergency committees, defining coordination and exercises, but it does not set out isolation-surge procedures or tested isolation arrangements ³²⁴.

4.2.1a National procurement protocol for the acquisition of routine laboratory/medical supplies

Score: 100

Djibouti has a government-wide public procurement framework that the Ministry of Health and the Ministry of Agriculture, Water, Fisheries, Livestock and Marine Resources can utilize to procure laboratory and medical supplies for routine needs. The national “Law No. 53/AN/09/6th Legislature on the New Public Procurement Code,” adopted in the Council of Ministers session on March 17, 2009, establishes uniform rules for public contracts for works, supplies, and services and applies to all contracting authorities, including ministries ³²⁵. On February 14, 2023, the Presidency issued “Decree No. 2023-038/PRE instituting the electronic public procurement portal,” designating the National Commission for Public Procurement to manage the portal and the National Agency for State Information Systems to secure it, thereby operationalizing a single entry point for government tendering ³²⁶. On January 26, 2025, the Ministry of Health issued “Order No. 2024-154/PR/MS” approving and making executable the 2025 budget of the Central Purchasing of Medicines and Essential Materials, listing revenue lines for medicines, medical equipment, reagents, dialysis consumables, solutions, and vaccines, evidencing routine sector procurement capacity for medical and laboratory supplies ³²⁷. On March 19, 2025, the agriculture ministry ran an open national tender titled “Acquisition of seeds for MAEPE-RH,” confirming routine procurement use under the framework ³²⁸.

4.2.2a Stockpile of medical supplies for national use during a public health emergency

Score: 100

Djibouti has a government-mandated national stock of medical countermeasures with defined mechanisms to ensure equitable, last-mile distribution for use during public health emergencies. In February 2016, the Ministry of Health published the national Essential Medicines List specifying medicine categories by level of care that underpin stock composition and allocation nationally ^{329, pp. 6–13}. In October 2020, the Ministry documented concrete response stocks for COVID-19, including diagnostic test kits, personal protective equipment, medicines, intensive-care equipment, and three medical-waste incinerators, with the Central Purchasing of Medicines and Essential Materials acting as the state supplier, evidencing tangible inventories and stewardship ^{330, pp. 3–5}. In December 2020, a presidential decree established the vaccine introduction and deployment commission with strategy and operations sub-commissions to set eligibility and establish procedures for acquisition, storage, distribution, site validation, resupply, and waste management that reinforce equitable allocation ³³¹. In August 2024, the Ministry adopted the “Pharmaceutical Products Supply Strategy 2022–2025,” establishing institutional arrangements, central warehousing at the Central Purchasing of Medicines and Essential Materials, distribution to regional hospital medical centers, traceability of orders, and delivery to the last mile with performance indicators ^{332, pp. 11, 13, 25}. In April 2025, the Presidency created the Public Health Emergency Operations Center within the National Institute of Public Health and mandated preparedness through planning and the constitution of reserves, with a Logistics Commission responsible for acquisition, storage tracking, and availability, and national and regional branches to ensure coverage during emergencies ³³³.

4.2.2b Stockpile of laboratory supplies for national use during a public health emergency

Score: 0

There is no publicly available evidence that Djibouti maintains a national stockpile of laboratory supplies for public health emergency use. In October 2020, the Ministry of Health of the Republic of Djibouti issued the “Environmental and Social Management Framework for the COVID-19 Response Project,” which authorized project procurement of chemical or biological reagents for laboratories and identified risks in transport, storage, and conservation, demonstrating time-bound project purchasing rather than a standing national reserve ^{334, pp. 15, 21}. On August 27, 2020, the Ministry of Health described the Central Purchasing and Supply Office for Essential Medicines and Materials as mandated to purchase, store, and supply health products, without documenting any national laboratory stockpile or its contents ³³⁵. On August 4, 2024, the Official Gazette of the Republic of Djibouti promulgated “Law No. 14/AN/23/9th L” adopting the 2023–2027 national supply strategy, clarifying governance but not creating or describing a laboratory stockpile ³³⁶. On August 4, 2024, the Official Gazette published the annexed “Strategy for the Supply of Medicines and Pharmaceutical Products 2022–2025,” detailing warehousing constraints and insufficient capacity at the Central Purchasing Office for Essential Medicines and Materials, with no emergency reserve of laboratory reagents or media described ^{337, pp. 11, 15}.

4.2.2c Annual review of national stockpile to ensure sufficient supply

Score: 0

There is no publicly available evidence that Djibouti conducts or requires an annual review of a national medical stockpile to assure sufficiency for a public health emergency. A Presidency communiqué on December 26, 2023 records a one-time physical inventory at the Central Procurement of Essential Medicines and Materials to establish the opening balance as of January 1, 2023, which is not an annual national stockpile review ³³⁸. Law No. 14/AN/23/9ème L adopted the “National Strategy for the Supply of Medicines and Pharmaceutical Products 2023–2027” on August 4, 2024; the promulgated text creates multisector and technical committees but contains no mandate for an annual national stockpile sufficiency review ^{339, pp. 1–2}. The August 2024 annex to that law sets performance indicators on orders, deliveries, internal audits, and stock management at the Central Procurement, but it does not establish or document an annual national-level stockpile sufficiency review ^{340, pp. 9–10; 26–27}. Order No. 2025-055/PR/MS on March 13, 2025 created the Public Health Emergency Operations Center and defines coordination and logistics roles, yet it does not require a yearly national stockpile review ³⁴¹.

4.2.3a Plan/agreement to produce/procure medical supplies during a public health emergency

Score: 100

Djibouti has a national plan and an operative government mechanism to procure medical supplies for national use during a public health emergency. Operational use is evidenced first by a government contract award showing direct agreement with the Central Purchasing of Essential Medicines and Materials to acquire medical equipment for the Ministry of Health, mandated “in accordance with national legislation and on instruction of the Minister of Health,” dated June 4, 2023, confirming CAMME as the national procurement channel ^{342, p. 1}. Subsequently, the Official Gazette records adoption and promulgation of “Law No. 14/AN/23/9th L adopting the National Strategy for Supply of Medicines and Pharmaceutical Products 2023–2027,” designating the strategy as the national reference and creating multisector and national technical committees under the Ministry of Health, published August 4, 2024, with promulgation on March 10, 2024 ^{343, pp. 1–2}. The annexed strategy issued by the Ministry of Health, published with the law in August 2024, details strengthening of the purchasing process and identifies CAMME across the procurement cycle, including quality-system activities, demonstrating a functioning government procurement pathway for emergency medical supplies ^{344, pp. 11, 27}.

4.2.3b Plan/agreement to produce/procure lab supplies during a public health emergency

Score: 100

Djibouti maintains a government mechanism to procure laboratory reagents and other laboratory supplies for national use during public health emergencies. In October 2020, the Ministry of Health’s Environmental and Social Management Framework states that acquisitions are executed via the Central Procurement Agency for Essential Medicines and Materials and that emergency financing explicitly covers “chemical or biological reagents (laboratory reagents …)” and materials for sample conditioning and preservation, i.e., laboratory supplies beyond medicines ^{345, p. 15}. In 2021, the World Bank’s restructuring paper records Ministry of Health contracts with the Central Procurement Agency and disbursements for emergency procurement; the same document tracks designated laboratories by the availability of diagnostic equipment, test kits, and reagents, confirming that laboratory reagents were planned for, procured, and monitored during the public health emergency under government auspices ^{346, pp. 5, 7}. In December 2024, the Presidency’s Council of Ministers enumerated the agency’s portfolio to include reagents alongside medicines, medical materials, solutions, and vaccines, confirming reagents as an explicit category in routine national purchasing and distribution entering the current period ³⁴⁷.

4.2.3c Mechanism emergency logistics and supply chain management

Score: 100

Djibouti has a national emergency logistics and pharmaceutical supply mechanism that functions from the central to regional levels, incorporates vaccine cold-chain requirements, and engages both public and private sector actors. In August 2024, the Ministry of Health issued the “Strategy for the Supply of Medicines and Pharmaceutical Products 2023–2027,” establishing the Central Office for the Purchase of Medicines and Essential Medical Supplies as responsible for national procurement and distribution under the public procurement code, alongside regulated private pharmacies and pharmaceutical depots, confirming public–private coverage ^{348, p. 11}. The same strategy specifies storage and transport from central warehouses to regional hospital medical centers and maintenance of cold-chain conditions for temperature-sensitive products, demonstrating national-to-subnational operations and vaccine cold-chain procedures; its framework also mandates preparedness for emergency supply, stock management, and waste prevention ^{349, pp. 4, 13}. In April 2025, the World Health Organization reported continued collaboration with the Ministry of Health to strengthen enabling systems and integrate Expanded Programme on Immunization services under a 2022–2026 national immunization strategy ^{350, pp. 7–8}. In June 2025, the United Nations Children’s Fund recorded logistics assets for Djibouti, indicating ongoing operational distribution capacity; WHO/UNICEF 2024 notes cold-chain considerations affecting service delivery, providing programmatic context ^{351, pp. 9–10; 4, p. 9}.

4.3.1a Plan/program/guidelines for dispensing MCMs during a public health emergency

Score: 0

There is no publicly available evidence that Djibouti has a plan, program, or guidelines in place for dispensing medical countermeasures for national use during a public health emergency. The Ministry of Health of the Republic of Djibouti issued the “Pharmaceutical Products Supply Strategy 2022–2025” in 2022, which documents systemic weaknesses across the pharmaceutical supply chain, including the absence of a pharmacovigilance center or technical committee, the absence of a validated national essential medicines list, fragmented stock management across facilities, major logistics and delivery planning constraints contributing to stockouts, and dispensing through multiple points without assurance of staff training, but it does not establish emergency procedures for stockpiling, allocating, or dispensing antibiotics, vaccines, therapeutics, or diagnostics during a public health emergency ^{352, pp. 14–16}. The Ministry of Economy, Finance and Industry of the Republic of Djibouti and The World Bank published the “Environmental and Social Management Plan for the Djibouti Contingent Emergency Response Project” on 29 June 2025, which assigns responsibilities for procurement, transport, storage, and distribution of medical supplies when the project is activated, but this document is project-specific and does not constitute national medical countermeasure dispensing guidance applicable across the health system during emergencies ^{353, pp. 36, 68}.

4.3.2a Plan to receive foreign health personnel during a public health emergency

Score: 100

Djibouti has a public plan in place to facilitate workforce surge in an emergency. On February 4, 2025, the Presidency of the Republic of Djibouti published the proceedings of the Council of Ministers documenting formal government review of a draft order establishing a Public Health Emergency Operations Center under the authority of the Minister of Health, describing a national mechanism intended to ensure rapid detection, coordinated response, and immediate nationwide action during public health emergencies, including functions that require rapid mobilization of human resources when an emergency is declared ³⁵⁴. On April 6, 2025, the Official Gazette of the Republic of Djibouti published “Order No. 2025-055/PR/MS establishing a Public Health Emergency Operations Center (COUSP),” which legally defines emergency response to include mobilization of resources and personnel, establishes rapid response teams as an institutional capability, authorizes the national coordinator to recruit personnel for the center, and permits the center to call upon any necessary competencies during epidemics or public health emergencies, thereby constituting a publicly issued, government-wide framework that enables workforce surge during emergencies ³⁵⁵.

4.3.2b Plan to facilitate workforce surge in an emergency

Score: 0

There is no publicly available evidence that Djibouti has a government-approved public plan that defines how the country will receive health personnel from other countries to respond to a public health emergency. The “National Disaster Preparedness Baseline Assessment: Djibouti” by the Pacific Disaster Center in July 2023 describes the disaster management legal framework as fragmented and recommends updating instruments; it does not provide or cite a reception plan for foreign medical teams ^{356, pp. 64–65, 81–82}. In April 2025, the Official Journal published “Arrêté n° 2025-055/PR/MS” establishing a Public Health Emergency Operations Center within the National Institute of Public Health and detailing governance, commissions, regional centers, and rapid response teams, yet it does not publish procedures or standard operating procedures for the reception, credentialing, or integration of international health personnel ³⁵⁷. In July 2025, the World Bank announced approval of a Contingent Emergency Response Project to strengthen Djibouti’s emergency response capacity, but the press release does not include a government plan or operational protocol for receiving foreign health workers ³⁵⁸.

4.3.2c Plan to redeploy existing health personnel within the country

Score: 100

Djibouti has a public, government-issued framework in force that provides for redeploying existing health personnel geographically and by role across the country. In April 2022, the Ministry of Health issued the “Labor Management Procedures for the Health System Strengthening Project P178033,” which state national scope and use of existing Ministry departments, regional hospital workers, and health facility staff across all regions, demonstrating an operational mechanism to reassign clinical and support personnel as needed ^{359, pp. 7–8}. On March 13, 2025, the Secretariat General of the Government listed the Ministry of Health order “Arrêté n° 2025-055/PR/MS portant création d’un Centre des Opérations d’Urgence de Santé Publique” in Official Journal No. 05, confirming promulgation for national application in 2025 ³⁶⁰. In 2025, the full text on the e-Journal Officiel establishes a national Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti, creates regional centers and Rapid Response Teams, sets commissions including logistics and administration and finance that handle human resource cost management, and authorizes activation to call upon any necessary competence, enabling nationwide mobilization and redeployment by function and location, per Articles 2, 6 and 7, 10 to 16, 17, and 21 to 25 ³⁶¹.

4.4.1a Constitutional guarantee of citizens’ right to medical care

Score: 75

Djibouti has a constitutionally guaranteed right that encompasses access to medical care through the explicit incorporation of international human rights instruments into its Constitution. The Constitution of the Republic of Djibouti, adopted in September 1992 and operative as consolidated through the April 2010 constitutional revision, states in its Preamble that the principles of the Universal Declaration of Human Rights and the African Charter on Human and Peoples’ Rights form an integral part of the Constitution, thereby granting these instruments constitutional value within the domestic legal order ^{362, p. 3363, p. 1}. Both incorporated instruments explicitly recognize the right to health and access to medical care as fundamental human rights, and their constitutional incorporation establishes a guaranteed right rather than an aspirational policy objective. Within the constitutional text itself, Article 10 further affirms an enforceable medical entitlement by guaranteeing that persons deprived of liberty may be examined by a doctor of their choice, demonstrating that medical care rights are judicially cognizable under constitutional law ^{364, p. 5}. Subsequent statutory and regulatory instruments, including Law No. 48/AN/99/4ème L on the orientation of health policy and Decree No. 2024-219/PR/MS regulating private-sector health facilities, operationalize and implement this constitutionally grounded right to health by organizing service delivery and affirming state responsibility, but they do not alter its constitutional source ^{365, pp. 1–2; 4, Art. 2}.

4.4.1b Access to skilled birth attendants (% of population)

Score: 80.88

4.4.1c Out-of-pocket health expenditures per capita, PPP (current international $)

Score: 94.11

4.4.1d Coverage of essential health services through universal health coverage

Score: 35.42

4.4.1e Total population pushed below a relative poverty line by household health expenditure (60% of media daily per capita consumption or income)

Score: 100

4.4.1f Rate of mortality amenable to health care

Score: 68.76

4.4.2a Guaranteed paid sick leave

Score: 66.67

Djibouti has paid sick leave for workers, and mental-health sick leave is guaranteed for civil servants but not explicitly for private-sector workers. The legal basis for paid sick leave in the private sector is established by the Labour Code issued through “Law No. 133/AN/05/5ème L establishing the Labour Code,” published in January 2006 by the Official Gazette of the Republic of Djibouti, which provides that an employment contract is suspended during duly certified illness and grants paid sick leave at 50 percent of salary for medically certified illness, with duration determined by worker seniority and conditions set by regulation, thereby confirming the existence of paid sick leave for workers without distinction of illness type ^{366, pp. 7–9}. However, the Labour Code does not explicitly state that mental or psychological illnesses qualify as grounds for sick leave, and its reference to workers who are physically or mentally diminished concerns post-illness reclassification obligations rather than eligibility for sick leave itself ^{367, pp. 8–9}. Mental-health applicability is explicitly established only for civil servants through “Decree No. 2025-165/PR/MTFPS fixing the regime of leave and absences of civil servants,” published in September 2025 by the Official Gazette of the Republic of Djibouti, which guarantees full salary for the initial period of non-occupational illness, followed by half salary, and expressly defines eligible long-duration illnesses as including both physical and psychical conditions, with psychiatric and psychological illnesses explicitly listed ³⁶⁸.

4.4.3a Government prioritisation of care for healthcare workers during response

Score: 0

There is no publicly available evidence that Djibouti has issued legislation, a policy, or a public statement committing to provide prioritized healthcare services to healthcare workers who become sick as a result of responding to a public health emergency. In March 2025, the Presidency of the Republic of Djibouti and the Ministry of Health issued “Order No. 2025-055/PR/MS establishing a Public Health Emergency Operations Center,” published in April 2025, which establishes institutional coordination arrangements during public health emergencies and assigns a logistics commission responsibility for providing support services, including health services, to responders during activation, but the order contains no clause guaranteeing priority access, preferential treatment, or expedited clinical care for healthcare workers who fall ill due to emergency response activities ³⁶⁹. Djibouti’s “Law No. 133/AN/05/5th L of 26 January 2006 establishing the Labour Code,” enacted in January 2006 and in force as of December 31, 2025, provides for daily cash benefits paid by the Social Protection Organism when an employment contract is suspended due to occupational disease or work accident, and requires employers to report such events to the Labour Inspectorate and the Social Protection Organism within 48 hours, but these provisions relate to income protection and administrative reporting rather than prioritized healthcare services during public health emergencies ^{370, pp. 8, 26}. The Caisse Nationale de Sécurité Sociale guidance on occupational accidents likewise addresses recognition and compensation mechanisms without any commitment to prioritized clinical care for healthcare workers during public health emergency response ³⁷¹.

4.5.1a Existence of system for communication during a public health emergency

Score: 100

Djibouti has a formal, government-established system that defines how public health officials communicate with healthcare workers during public health emergencies. In April 2025, the Official Gazette established the Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti and mandated public communication and coordination with all response partners, designated a Communication Commission to interact with public bodies, partners, and media, and required the National Coordinator to ensure the timely dissemination of information, creating operational communication channels during activations ³⁷². The same instrument organizes national and regional Public Health Emergency Operations Centers and Rapid Response Teams as the operational units drawn from the Ministry of Health and the national level, which constitute the frontline responder cadres through which officials communicate with healthcare workers in emergencies ³⁷³. In February 2025, the Presidency recorded the Council of Ministers’ consideration of the draft establishing the Center, noting objectives to strengthen coordination among health structures and international partners and to ensure immediate and effective crisis reaction, corroborating governmental intent and scope prior to publication ³⁷⁴.

4.5.1b Inclusion of public and private sector in healthcare communication system

Score: 100

Djibouti has a formal, government-led system that enables public health officials to communicate during emergencies with healthcare workers across both the public and private sectors. In April 2025, the Ministry of Health established the Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti, with functions that include public communication and coordination with all response partners during health emergencies, activated by ministerial circulars, which provides the operational channel for official directives to reach healthcare workers nationwide ³⁷⁵. This system applies to private facilities because a September 2024 decree regulating private-sector health structures places all private, parapublic, and public actors under the coordination of the Minister of Health and requires private establishments to transmit medical data to the Ministry, thereby integrating private providers into official information flows during emergencies ³⁷⁶. The legal foundation for this whole-of-sector coordination is further affirmed by the July 1999 health policy framework law, which states that all health actors, including private entities, contribute to the public health service under ministerial coordination ³⁷⁷.

4.6.1a Evidence of national public health system monitoring and tracking of HCAIs

Score: 0

There is no publicly available evidence that Djibouti monitors and tracks the number of healthcare-associated infections occurring in healthcare facilities. In March 2023, the Ministry of Health described national data flows through District Health Information Software 2 and recorded that level 3 was not yet parameterized, which limits availability of hospital surveillance indicators; the published indicator tables contain no healthcare-associated infection measures ^{378, pp. 4, 13–14}. On April 6, 2025, the Official Gazette announced the creation of a Public Health Emergency Operations Center under the Ministry of Health to coordinate public health emergencies, which does not establish a nationwide mechanism that publishes counts of healthcare-associated infections from healthcare facilities ³⁷⁹. In April 2025, the World Health Organization Strategic Partnership for Health Security country page confirmed Djibouti’s State Party Self-Assessment submission for 2024 and provided no Djibouti dataset or figures for healthcare-associated infections in 2025 on that platform ³⁸⁰. On October 16, 2025 the Ministry of Health publications portal listed 2024 and 2025 items without any 2025 bulletin, report, or dashboard presenting facility-level or national numbers of healthcare-associated infections ³⁸¹.

4.6.1b Infection prevention and control programme

Score: 100

Djibouti has a national infection prevention and control program in place. In June 2023, the Ministry of Health of the Republic of Djibouti issued the “Manual of Procedures for Infection Control and Medical Waste Management,” which requires each hospital to establish or revitalize an infection prevention and control program and a facility hygiene and infection control committee with defined composition, missions, training, supervision, and monitoring functions, and presents national implementation and financing arrangements including a public-private mechanism ^{382, pp. 37–38, 45–49}. On April 2, 2025, the World Health Organization recorded Djibouti’s 2024 States Parties Self-Assessment Annual Reporting submission with an active entry for “Capacity for infection prevention and control,” demonstrating national-level maintenance and reporting of infection prevention and control capacity ³⁸³. On July 16, 2025, the United Nations in Djibouti reported Ministry-supported WASH-FIT training held on February 17–20, 2025 in Dikhil to improve hygiene, hand hygiene promotion, biomedical waste management, and prevention of infections in health facilities, evidencing operational implementation under ministerial auspices ³⁸⁴.

4.6.1c National plan to ensure a safe environment in health facilities

Score: 100

Djibouti has a national plan and regulatory framework to ensure a safe environment in health facilities. In June 2023, the Ministry of Health issued the “Manual of Procedures for Infection Control and Medical Waste Management,” which sets nationwide objectives for improving public health and environmental sanitation in health facilities and standardizes infection prevention procedures and waste classification for hospitals, polyclinics, and regional centers ^{385, p. 6, 9}. In August 2024, the Official Gazette of the Republic of Djibouti published “Decree No. 2024-219/PR/MS regulating private health structures,” mandating water and sanitation connections, medical waste handling, protected electrical installations, fire safety equipment, and annual inspections by the Health Inspectorate for all private facilities nationwide ³⁸⁶. In December 2024, the Official Gazette gazetted “Decree No. 2024-320/PR/MS on the organization and functioning of polyclinics,” which defines level-2 public polyclinics and includes promotion of hygiene and sanitation as a core function, with facilities required to conform to the decree after publication ³⁸⁷. In July 2025, the United Nations in Djibouti reported national training roll-out using the Water, Sanitation and Hygiene Facility Improvement Tool in health-care settings beginning in Dikhil, evidencing operational implementation in regions ³⁸⁸.

4.7.1a Requirement for ethical review before beginning a clinical trial

Score: 0

There is no publicly available evidence that Djibouti requires prior ethics committee approval before beginning any clinical trial. The National Institute of Public Health of Djibouti was established by “Law No. 99/AN/10/6ème L of 3 January 2011 establishing the National Institute of Public Health of Djibouti,” which lists the Ethics Committee as an organ of the institute and assigns it the mandate to give opinions on research projects, confirming the body’s existence but not a country-wide pre-trial requirement for all clinical trials ^{389, pp. 4, 6}. A later nationwide instrument, “Decree No. 2024-296/PRE on the protection of workers, patients, the public, and the environment from the hazards of ionizing radiation,” published in the Official Journal in December 2024, explicitly requires National Institute of Public Health of Djibouti Ethics Committee approval before any biomedical research medical exposure and sets committee-approved dose constraints, but its scope is limited to ionizing-radiation research rather than all clinical trials ^{390, pp. 8, 11}.

4.7.1b Expedited approval for clinical trials of unregistered MCMs during epidemics

Score: 0

There is no publicly available evidence that Djibouti has an expedited process for approving clinical trials for unregistered medical countermeasures or a formal mechanism to recognize clinical trial results from other jurisdictions during ongoing pandemics or epidemics. The National Assembly’s 2023 law reorganizing the Ministry of Health assigns the Directorate of Medicines, Pharmacy, Laboratories and the Pharmaceutical Industry regulatory functions, including issuing national marketing authorizations, but it does not create a fast-track clinical-trial authorization or a mutual-recognition pathway ^{391, p. 17}. The law adopting the National Pharmaceutical Policy 2023–2027 was issued in a special edition in March 2024 and published in August 2024; it sets governance, quality, selection, and supply objectives without establishing emergency clinical-trial procedures or recognition of external trial results ^{392, pp. 1–2}. The presidential decree published in December 2024 on protection against ionizing radiation imposes licensing and safety obligations and requires ethics committee approval at the National Institute of Public Health of Djibouti for biomedical research exposures, but it does not introduce an expedited clinical-trial authorization or any mutual-recognition mechanism ^{393, p. 8}. Regional documentation shows reliance and review-acceleration initiatives through African Medicines Regulatory Harmonization and the African Vaccine Regulatory Forum, which are not Djibouti-specific legal instruments establishing expedited or mutual-recognition processes ³⁹⁴³⁹⁵.

4.7.2a Existence of agency responsible for approving new human MCMs

Score: 100

Djibouti has a government agency responsible for approving new medical countermeasures for humans. In July 2023, the Presidency of the Republic of Djibouti published “Law No. 11/AN/23/9th L on the reorganization and functioning of the Ministry of Health,” which establishes the Directorate of Medicines, Pharmacy, Laboratories and the Pharmaceutical Industry as a regulatory authority empowered to issue authorizations for placing products on the Djiboutian market and to regulate pharmaceutical products, medical devices, reagents, vaccines, and blood-derived products, confirming national approval authority for human countermeasures ^{396, p. 17}. In 2024, the Ministry of Health released a strategy for the supply of pharmaceutical products, which sets actions to elaborate regulation for the registration of medicines and health products and to strengthen pharmacovigilance and quality systems, evidencing an operational roadmap aligned with regulatory approval and post-market oversight ^{397, pp. 15, 22, 28}. In July 2025, the Africa Centres for Disease Control and Prevention reported that Djibouti was establishing a dedicated national pharmacovigilance unit and implementing reporting tools, demonstrating active regulatory functions that complement approval with safety monitoring ³⁹⁸.

4.7.2b Expedited approval for human MCMs during public health emergencies

Score: 0

There is no publicly available evidence that Djibouti has an expedited process for approving medical countermeasures for human use or a recognition mechanism for foreign approval decisions during public health emergencies. The Ministry of Health’s “Strategy for the Supply of Pharmaceutical Products 2022–2025” details procurement and logistics and notes work to elaborate regulation for registration and authorization, but does not establish any emergency fast-track or foreign-decision recognition pathway ^{399, p. 12, 22}. In July 2023, “Law No. 11/AN/23/9ème L on the Reorganization and Functioning of the Ministry of Health” assigned the Directorate of Medicines, Pharmacy, Laboratories, and the Pharmaceutical Industry as regulator to issue national marketing authorizations, without creating an emergency use authorization or recognition mechanism ⁴⁰⁰. In March 2024, “Law No. 14/AN/23/9ème L Adopting the National Strategy for the Supply of Medicines and Pharmaceutical Products 2023–2027” adopted a supply framework, not a regulatory fast-track ^{401, p. 2}. In September 2024, “Decree No. 2024-219/PR/MS Regulating Private-Sector Health Structures” set provider rules without emergency authorization provisions ⁴⁰². In April 2025, “Order No. 2025-055/PR/MS Establishing a Public Health Emergency Operations Center” created coordination functions, not expedited authorization or recognition procedures ⁴⁰³.

5.1.1a Submission of IHR reports to the WHO in past year

Score: 100

Djibouti has submitted an IHR Self-Assessment Annual Report (SPAR) to the WHO for the last calendar year, with the latest submission in 2024.⁴⁰⁴

5.1.2a Existence of specific risk reduction strategies for epidemics and pandemics

Score: 0

There is no publicly available evidence that Djibouti has integrated epidemics and pandemics into a finalized national disaster risk reduction strategy or adopted a standalone national disaster risk reduction strategy for epidemics and pandemics. On May 30, 2024 the United Nations Resident Coordinator’s Office in Djibouti reported a restitution workshop to inform finalization and validation of the national disaster risk reduction strategy, confirming work in progress rather than promulgation ⁴⁰⁵. On January 31, 2025 the United Nations Office for Disaster Risk Reduction reported a writing workshop to finalize a national climate informed disaster risk reduction strategy and action plan, which evidences drafting rather than an adopted instrument that explicitly integrates biological hazards ⁴⁰⁶. In February 2025, the Climate Risk and Early Warning Systems initiative recorded that the National Disaster Risk Reduction platform and the National Coordination mechanism for the Early Warnings for All initiative will be developed in 2025, indicating core governance elements remain under development ^{407, pp. 3–4}. On April 6, 2025 the Official Gazette published an order establishing a Public Health Emergency Operations Center under the Ministry of Health, which strengthens emergency coordination but is not a national disaster risk reduction strategy ⁴⁰⁸. In April 2025, the Capacity for Disaster Reduction Initiative’s annual report documented Djibouti’s 2024 scoping and May 2024 capacity diagnosis missions, again showing process steps rather than a finalized national strategy ^{409, p. 7}.

5.2.1a Existence of public health emergency agreements with regional neighbors

Score: 50

Djibouti has regional cross border public health emergency coordination commitments through a regional organization, with evidence of participation but limited evidence of implementation. The Intergovernmental Authority on Development issued the “Communiqué Second IGAD Ministerial Meeting on Enhancing Preparedness for Pandemic Response Using a One Health Approach 29th August 2025 Kampala, Republic of Uganda” in August 2025, which records representation from the Ministry of Health of the Republic of Djibouti at a ministerial meeting convened to strengthen cross border surveillance, early warning systems, laboratory networks, and real time data sharing among Member States under a One Health approach ^{410, p. 1}. The communiqué outlines agreed regional protocols and political commitments relevant to public health emergencies, including cross border coordination mechanisms and pandemic preparedness planning, but does not document operational implementation actions undertaken within Djibouti itself as of the publication date ^{411, pp. 3–5}. On the same date, the Intergovernmental Authority on Development publicly announced the launch of the Preparedness for Pandemic Response Project as a regional initiative covering all Member States, including Djibouti, describing objectives related to surveillance, laboratory capacity, workforce development, and coordination, while the only concrete implementation example cited concerns equipment support provided to Uganda rather than activities executed in Djibouti ⁴¹².

5.2.1b Existence of animal health emergency agreements with regional neighbors

Score: 100

Djibouti has cross-border agreements and operational protocols with Ethiopia under the Intergovernmental Authority on Development framework that address animal health emergencies. In March 2024, the Intergovernmental Authority on Development’s “Annual Report 2023” documented the operationalization of signed cross-border animal-health Memoranda of Understanding across four clusters including the Ethiopia–Djibouti cluster, reported harmonized disease surveillance and vaccination calendars, and recorded adoption of an animal-disease information-sharing protocol along Ethiopia–Djibouti border areas ^{413, pp. 22–23, 25}. In May 2025, the Intergovernmental Authority on Development Center for Pastoral Areas and Livestock Development presented evidence that six bilateral cross-border animal-health Memoranda of Understanding had been facilitated and it explicitly listed Djibouti–Ethiopia, while also noting synchronized vaccination between Djibouti and Ethiopia during 2019–2023 that supports transboundary animal-disease control operations ^{414, pp. 7–8}.

5.3.1a Biological and Toxin Weapons Convention status

Score: 0

There is no publicly available evidence that Djibouti has signed or ratified the Biological Weapons Convention or taken an action with the same legal effect. The United Nations Office for Disarmament Affairs’ final document of the Ninth Review Conference in December 2022 records that four States, including Djibouti, neither parties nor signatories to the Convention, were granted observer status at the Conference, confirming non-membership at that time ^{415, pp. 6–7}. The Biological Weapons Convention Implementation Support Unit and the United Nations Office for Disarmament Affairs draft procedural report of the Working Group’s second session in August 2023 states that two States, including Djibouti, neither parties nor signatories, participated as observers, indicating no legal change through that date ^{416, p. 2}. A United Nations General Assembly background document issued by the Biological Weapons Convention Implementation Support Unit in November 2023 lists Djibouti among States that have neither signed nor ratified the Convention, reiterating its non-party status as of late 2023 ^{417, p. 5}.

5.3.1b Submission of CBMs to the Biological and Toxin Weapons Convention

Score: 0

There is no publicly available evidence that Djibouti has submitted Confidence-Building Measures for the Biological Weapons Convention in the past three years. The United Nations Office for Disarmament Affairs reported on February 19, 2025 that Djibouti is among the African States not yet party to the Biological Weapons Convention, listing Djibouti by name alongside other non-parties, which means it is not eligible to file national Confidence-Building Measures to the Implementation Support Unit ⁴¹⁸. The United Nations Office for Disarmament Affairs Confidence-Building Measures portal provides annual submission lists and statistics by State Party for 2023, 2024, and 2025; Djibouti does not appear among submitting States in those year-by-year lists, consistent with its non-party status during this period ⁴¹⁹.

5.3.1c Submission of UNSCR 1540 reports

Score: 100

Djibouti has provided the required national report to the Security Council Committee established pursuant to resolution 1540. The United Nations Security Council record dated March 22, 2005 shows Djibouti’s formal “Report of Djibouti to the Security Council Committee established pursuant to resolution 1540 (2004) on non-proliferation of weapons of mass destruction” ⁴²⁰. The record is issued through the United Nations documentation system under symbol S/AC.44/2004/(02)/108 by the United Nations Security Council, confirming transmission to the 1540 Committee Secretariat in New York in 2005 ⁴²¹.

5.3.1d Extent of UNSCR 1540 implementation on public health emergencies

Score: 25

5.3.2a Membership in global health security and/or biological weapons agreements

Score: 0

There is no publicly available evidence that Djibouti is a member of at least two of the following initiatives, the Global Partnership Against the Spread of Weapons and Materials of Mass Destruction, the Australia Group, and the Proliferation Security Initiative. The Federal Foreign Office of Germany’s official Proliferation Security Initiative “Endorsing States List,” dated November 19, 2024, lists Djibouti among states that have endorsed the Proliferation Security Initiative Statement of Interdiction Principles, establishing participation in the Proliferation Security Initiative only ⁴²². The Global Partnership Against the Spread of Weapons and Materials of Mass Destruction maintains an official “Members and Partners” page identifying 30 active member countries and the European Union, and Djibouti does not appear among the listed members or partners as of the most recent publicly available update ⁴²³. The Department of Foreign Affairs and Trade of Australia’s official “Participants — The Australia Group” page lists all participating states and adherents, and Djibouti is not included in either category ⁴²⁴.

5.4.1a Completion and publication of JEE (or GHSA pilot external assessment) report

Score: 0

There is no publicly available evidence that Djibouti completed a Joint External Evaluation or precursor external evaluation and published a full public report in the past five years. The World Health Organization Strategic Partnership for Health Security and Emergency Preparedness portal lists Djibouti’s Joint External Evaluation as “Conducted” from July 1–5, 2018 under Joint External Evaluation version 1, provides the official report link, and shows no later Djibouti Joint External Evaluation ⁴²⁵. The World Health Organization country report confirms the Joint External Evaluation mission and documents the assessment for the Republic of Djibouti in 2018, which places the only verified report outside the five-year window ^{426, p. 1}.

5.4.2a Completion and publication of PVS report (past five years)

Score: 0

There is no publicly available evidence that Djibouti completed and published a World Organisation for Animal Health Performance of Veterinary Services assessment in the past five years. The World Organisation for Animal Health Regional Representation for Africa’s official “Performance of veterinary services (PVS) Pathway missions: status of implementation in Africa” page lists Djibouti’s PVS activities as an initial PVS Evaluation in 2007, a PVS Gap-Analysis in 2009, and a PVS Legislation mission in 2016; it shows no PVS Evaluation or follow-up Evaluation within the last five years ⁴²⁷. The World Health Organization Strategic Partnership for Health Security portal similarly records a “Djibouti 2007 PVS Evaluation” entry and a “Djibouti PVS Legislation mission,” both posted in January 2020, with no subsequent PVS Evaluation report in the past five years available ⁴²⁸⁴²⁹.

5.4.2b Completion and publication of PVS gap analysis (past five years)

Score: 0

There is no publicly available evidence that Djibouti has completed and published a Performance of Veterinary Services Gap Analysis in the last five years. The World Organisation for Animal Health Africa “Performance of veterinary services (PVS) Pathway missions: status of implementation in Africa” registry lists Djibouti with a PVS Evaluation in 2007, a PVS Gap-Analysis in 2009, and PVS Legislation in 2016, with no entry indicating a later Gap-Analysis ⁴³⁰. The Republic of Djibouti Ministry of Agriculture’s Directorate of Livestock and Veterinary Services website contains no PVS Gap Analysis document from the past five years ⁴³¹. The Official Gazette’s institutional page for the agriculture ministry likewise shows no PVS Gap Analysis publication for the past five years ⁴³².

5.5.1a Evidence of allocated national funds to improve capacity to address epidemic threats

Score: 100

Djibouti has allocated national funds within the past three years to improve capacity to address pandemic and epidemic threats. In March 2025, the Ministry of Health established the Public Health Emergency Operations Center within the National Institute of Public Health of Djibouti and specified that the Center’s operating expenses are borne by the State budget, with external financing also permitted, and the instrument was published in the Official Gazette of the Republic of Djibouti, which confirms both creation and financing authority at the national level ⁴³³. The Presidency of the Republic of Djibouti promulgated the Initial State Budget Law for Fiscal Year 2025 in January 2025 and Article 1 governs execution of State receipts and expenditures for 2025, enabling the Ministry of Health to execute these allocations under the national budget framework during the current three-year window ⁴³⁴.

5.5.2a National budget to address gaps identified in JEE, NAPHS or GHSA roadmap

Score: 0

There is no publicly available evidence that Djibouti’s Joint External Evaluation report, National Action Plan for Health Security, or any national Global Health Security Agenda roadmap allocates or describes specific funding from Djibouti’s national budget to address identified gaps. The World Health Organization July 2018 “Joint External Evaluation of IHR Core Capacities of the Republic of Djibouti” describes legislative and financing requirements but does not present Djibouti national-budget lines or appropriations linked to JEE gaps ^{435, pp. 6–7}. The Global Health Security Costing tracker lists a Djibouti National Action Plan for Health Security process conducted in August 2019 but shows no publicly available plan document or costing that attributes national funds to JEE gaps ⁴³⁶. Subsequent assessments reinforce this absence of domestic allocation: the Gavi and Ipsos March 2024 Djibouti Zero-Dose Year-1 case study details donor reliance, co-financing constraints, and limited documentation, not national-budgeted JEE or NAPHS financing ^{437, p. 16, 22}; the World Health Organization April 2024 “WHO Contribution in Djibouti: Executive Summary” cites a lack of operational plans and budgets to implement the National Health Development Plan, providing no evidence of national-budget lines tied to JEE-identified gaps ^{438, pp. 4–6}.

5.5.2b National budget to address gaps identified in PVS assessment or gap analysis

Score: 0

There is no publicly available evidence that Djibouti’s Performance of Veterinary Services assessment or gap analysis allocates or describes specific funding from Djibouti’s national budget for addressing identified gaps within the past five years or for any future period. The World Organisation for Animal Health regional status page confirms that Djibouti undertook a Performance of Veterinary Services Evaluation in 2007 and a PVS Gap Analysis in 2009, but it does not provide any Djibouti government budget allocations tied to PVS remediation or a posted national costed plan ⁴³⁹. The Presidency of the Republic of Djibouti’s Council of Ministers communiqué of November 26, 2024 presents the 2025 Initial Finance Law and sets overall priorities, yet it contains no veterinary-services appropriations linked to addressing PVS-identified gaps ⁴⁴⁰. The Official Journal entry for “Law No. 150/AN/24/9ème L on the Initial Finance Law for Fiscal Year 2025,” published January 29, 2025, establishes the legal budget framework and refers expenditure details to annexed budget documents, but it provides no wording that links appropriations to Performance of Veterinary Services remediation activities ⁴⁴¹.

5.5.3a Emergency public financing during a public health emergency

Score: 100

Djibouti has publicly identified special emergency public financing mechanisms and funds that can be accessed during a public health emergency. In March 2020, the Official Gazette of the Republic of Djibouti published “Decree No. 2020-068/PR/MEFI of 31 March 2020 Establishing the Emergency and Solidarity Fund COVID-19,” which created a national emergency financing mechanism, deposited an initial endowment of approximately USD 5.63 million (DJF 1.00 billion) in an account at the Central Bank of Djibouti, defined eligible epidemic-response expenditures, and established governance arrangements under the Ministry of Economy and Finance with participation of the Ministry of Health and the Central Bank of Djibouti ^{442, pp. 1–2}. In May 2020, the International Monetary Fund approved emergency disbursement for Djibouti under the Rapid Credit Facility and debt relief under the Catastrophe Containment and Relief Trust, and the Staff Report specifies that funds were disbursed to the Central Bank of Djibouti and on-lent to the government under a memorandum of understanding between the Central Bank and the Ministry of Budget, with the Rapid Credit Facility disbursement amounting to approximately USD 43.4 million (DJF 7.71 billion) ^{443, pp. 1–2, 9–10}. In July 2025, the World Bank approved a “Contingent Emergency Response Project” for Djibouti under the Rapid Response Option, enabling rapid repurposing of active project funds for eligible crises, including public health emergencies ⁴⁴⁴. In addition, the World Bank’s International Development Association publicly lists Djibouti as an eligible borrowing country, confirming access to concessional emergency financing pathways during crises ⁴⁴⁵.

5.5.4a Commitments to improve domestic or foreign capacity for epidemic threats

Score: 100

Djibouti has made a public commitment by a senior minister to expand domestic capacity to address pandemic and epidemic threats through new financing. In July 2025, the World Bank announced approval of a Contingent Emergency Response Project for Djibouti; the Minister of Economy and Finance, Ilyas Moussa Dawaleh, publicly stated that Djibouti is “proud to be among the first countries to implement the Contingent Emergency Response Project, enhancing Djibouti’s capacity to swiftly address emergencies,” confirming a government pledge to strengthen national preparedness using this financing instrument ⁴⁴⁶. In February 2025, the Presidency’s Council of Ministers reported a draft decree establishing a Public Health Emergency Operations Center under the Minister of Health, evidencing concurrent institutional measures to operationalize emergency readiness within the health sector ⁴⁴⁷.

5.5.4b Investments to improve domestic or foreign capacity for epidemic threats

Score: 100

Djibouti has received donor-funded technical support from intergovernmental partners to strengthen national epidemic surveillance capacity over the past three years. On May 12, 2023 the Intergovernmental Authority on Development, financed by the European Union with co-financing by the Federal Ministry for Economic Cooperation and Development and implemented by the German Society for International Cooperation, launched the “IGAD and the Government of Djibouti (MOH) Kick-Off Strengthening Djiboutian Digital Disease Surveillance and Monitoring through SORMAS” sub-project with the Ministry of Health in Djibouti-Ville to digitize surveillance and improve outbreak prevention and control, as noted by the Ministry’s Secretary General and project partners ⁴⁴⁸. On December 2, 2024 the Intergovernmental Authority on Development, with European Union funding and German co-funding, handed over advanced digital health equipment to the Ministry of Health to strengthen cross-border surveillance and real-time health data sharing ⁴⁴⁹. In September 2025 the World Health Organization Regional Office for the Eastern Mediterranean reported that Djibouti had implemented event-based surveillance and, with technical support from the World Health Organization, had automated surveillance data analysis and report generation, improving public health response capacity ^{450, p. 2, 4}.

5.5.4c Evidence that the country has fulfilled its full WHO contribution within the past two years

Score: 0

There is no publicly available evidence that Djibouti has fulfilled its full assessed contribution to the World Health Organization within the past 2 years. The World Health Organization Director General report “Status of collection of assessed contributions, including Member States in arrears in the payment of their contributions to an extent that would justify invoking Article 7 of the Constitution,” dated April 2025, lists Djibouti in Annex 1 with an outstanding balance of USD 5,740 for the 2024 assessment as at 31 December 2024, demonstrating that the 2024 assessed contribution was not paid in full within the relevant period ^{451, p. 6}. The same report lists Member States whose voting rights continue to be suspended for arrears, and Djibouti is not among them, which does not constitute evidence of full payment but only confirms that arrears have not reached the Article 7 threshold ^{452, p. 2}. The World Health Organization financial table “Assessed contributions overview for all Member States as at 31 December 2024,” dated December 2024, independently corroborates this finding by listing Djibouti with USD 5,740 outstanding for 2024 as at year end ^{453, p. 2}. Further, the World Health Organization “Statement of Account, Djibouti, As at 31 January 2025” shows assessed contributions of USD 5,740 for 2024 and USD 5,740 for 2025 with receivables outstanding totaling USD 11,480, providing no evidence that Djibouti settled its full assessed contributions within the past 2 years ^{454, p. 1}.

5.6.1a Sharing of genetic/biological data and materials beyond influenza

Score: 0

There is no publicly available evidence that Djibouti maintains a government plan or policy for sharing genetic data, clinical specimens, or isolated specimens with international organizations or other countries beyond influenza. The World Health Organization “Joint External Evaluation of IHR Core Capacities: Djibouti” from 2018 reports the absence of official documentation for notifications to the World Health Organization and the World Organisation for Animal Health, indicating unresolved governance gaps for cross-border reporting and sharing as of that date ^{455, p. 52}. The Ministry of Health Environmental and Social Management Framework for the coronavirus disease response issued in October 2020 sets operational procedures for sample collection, packaging, and transport and requires compliance with national or international rules for dangerous goods transport, but it does not establish a national cross-pathogen policy for international transfer of specimens or the associated epidemiological data, and it is limited to the project context of coronavirus disease activities ^{456, pp. 72–73}.

5.6.1b Evidence of non-compliance with sample sharing element of PIP framework

Score: 100

Djibouti maintains no publicly reported instance of non-sharing of influenza samples under the Pandemic Influenza Preparedness Framework during the past two years. Weekly respiratory virus updates from the World Health Organization Regional Office for the Eastern Mediterranean in September 2024 and October 2025 state that regional analyses are based on data reported to FluNet and EMFLU 2.0 and present country maps and panels that include Djibouti, evidencing continued participation in the World Health Organization Global Influenza Surveillance and Response System within the assessment window ^{457, pp. 1-2458, pp. 1-2}.

5.6.1c Evidence of non-sharing of pandemic pathogen samples during an outbreak

Score: 100

Djibouti has no publicly available notice, decree, bulletin, or intergovernmental report indicating refusal to share pandemic-pathogen samples during any outbreak in the past two years. The World Health Organization Regional Office for the Eastern Mediterranean’s “Influenza weekly bulletin, Week 35-2025” lists Djibouti by name in the country panels used for its regional respiratory-virus analysis, which explicitly draws on data reported by ministries of health to World Health Organization platforms during this period, and contains no indication of country-level refusal to share influenza or coronavirus disease specimens or associated data ^{459, p. 2}. The World Health Organization Eastern Mediterranean Region “Influenza and other respiratory viruses updates” index for 2024–2025 provides the continuously updated official repository for these weekly reports and contains no Djibouti-specific notices of non-sharing within the timeframe ⁴⁶⁰. Concurrently, the Republic of Djibouti’s Official Gazette portal and Ministry of Health website contain no legal acts, circulars, or advisories announcing a refusal to share pandemic-pathogen samples in 2024–2025, and no outbreak communications contradict this absence ⁴⁶¹⁴⁶².

6.1.1a Policy formation

Score: 25

6.1.1b Quality of bureaucracy

Score: 25

6.1.1c Excessive bureaucracy/red tape

Score: 25

6.1.1d Vested interests/cronyism

Score: 0

6.1.1e Corruption

Score: 31

6.1.1f Accountability of public officials

Score: 25

6.1.1g Human rights risk

Score: 0

6.1.2a Orderly transfers of power

Score: 0

6.1.3a Risk of social unrest

Score: 50

6.1.4a Risk of terrorism

Score: 50

6.1.4b Level of illicit arms flows within the country

Score: 50

6.1.4c Risk of organized criminal activity

Score: 75

6.1.5a Presence or risk of armed conflict

Score: 50

6.1.6a Government territorial control

Score: 0

6.1.7a International tensions

Score: 25

6.2.1a Adult literacy rate (15+ years old, both sexes)

Score: 0

6.2.2a UNDP Gender Inequality Index score

Score: 44.65

6.2.3a Poverty gap at $1.90 a day (2011 PPP) (%)

Score: 71.08

6.2.3b Share of employment in the informal sector

Score: 0

6.2.3c Coverage of social insurance programs (% of population)

Score: 0

6.2.4a Public confidence in government

Score: 0

6.2.5a Robust, open, diverse local media and reporting

Score: 0

6.2.6a Gini coefficient

Score: 58.4

6.3.1a Adequacy of road network

Score: 25

6.3.2a Adequacy of airports

Score: 50

6.3.3a Adequacy of power network

Score: 25

6.4.1a Urban population (% of total population)

Score: 16.51

6.4.2a Change in forest area (percentage points)

Score: 76.52

6.4.3a Natural disaster risk

Score: 50

6.5.1a Total life expectancy (years)

Score: 52.28

6.5.1b NCD mortality rate

Score: 67.45

6.5.1c Population aged 65+

Score: 74.92

6.5.1d Tobacco use (% of adults)

Score: 98.62

6.5.1e Level of adult obesity (%)

Score: 59.76

6.5.1f Age-standardised prevalence of mental health disorders (per 100 000 people)

Score: 75.47

6.5.2a Access to potable water

Score: 79.97

6.5.2b Access to at least basic sanitation facilities

Score: 60.95

6.5.2c Percentage of health-care facilities with no access to any electricity supply

Score: 72.92

6.5.3a Domestic general government health expenditure per capita (PPP)

Score: 5.27

6.5.4a Trust medical and health advice from the government

Score: 50

6.5.4b Trust medical and health advice from medical workers

Score: 50