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Djibouti’s Presidential Election 2026: A vote of confidence in three decades of transformation

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Djibouti City, Djibouti

On Friday, April 10, 2026, voters in Djibouti, a small nation in the Horn of Africa, participated in a presidential election that many observers consider a referendum on nearly thirty years of rapid economic and infrastructural change under the long-standing leadership of Ismail Omar Guelleh.

With around 250,000 registered voters out of a population exceeding one million, this election represents another milestone for a country that has largely defied the turbulent reputation of its region, establishing itself as a beacon of stability, strategic diplomacy, and growing economic influence.

A Legacy of Peace in a Restive Region

Since gaining independence from France on June 27, 1977, Djibouti has charted a unique course in the Horn of Africa, a region often marked by conflict, instability, and political turmoil.

In this context, Djibouti has maintained relatively peaceful democratic practices throughout its nearly fifty years of sovereignty. While critics have occasionally voiced concerns regarding political freedoms and the competitiveness of elections, the country has consistently held regular assembly and presidential elections since its independence.

Djibouti’s increasing soft power and regional significance are largely due to its strategic location at the southern entrance to the Red Sea and the Gulf of Aden, key shipping lanes in global trade.

The modern port facilities, the presence of foreign military bases from various global powers, and the active participation of its citizens on the international stage have all elevated Djibouti’s global profile, especially under President Guelleh, who has been in power since 1999.

Transforming an Economy: From a Single Old Port to a Maritime Powerhouse

When Ismail Omar Guelleh took office, Djibouti’s economic infrastructure was basic at best. The nation had only one small, aging port in its capital, which served as the main maritime entry point for landlocked Ethiopia—a burgeoning market of over 130 million people. This single facility suffered from congestion, inadequate oil handling capabilities, and serious environmental hazards due to oil company operations in the densely populated urban area.

However, over the past two decades, the Guelleh administration has overseen a remarkable infrastructure transformation. The construction of the Horizon Oil Port marked a pivotal moment, ending the era of insufficient oil handling and eliminating the hazardous environmental conditions associated with the old city-center port.

Subsequently, an exclusive deep-sea container terminal underwent a major expansion last year, now capable of accommodating the world’s largest vessels.

The transformation continued with the operationalization of ports in Tadjoura and Gobet, along with the state-of-the-art multipurpose Doraleh facility, which has enhanced capacity since 2017. Collectively, these projects have repositioned Djibouti as a dominant maritime hub for East Africa and beyond.

Free Trade, Industry, and the Great Horn Investment Holding

In addition to port infrastructure, Djibouti has made significant advancements in trade and industrial development. The opening of the Djibouti International Free Trade Zone (DIFTZ) stands out as one of the most notable successes of the Guelleh era. Today, the zone is home to over 500 companies from more than 56 countries, producing high-end export goods for Ethiopia, the region, and markets as distant as North America.

The expansion of marine businesses in Djibouti, including vessel refueling services, the establishment of a national shipping company, and the revival of Air Djibouti, has complemented the country’s economic growth. Among the most strategically significant achievements of the current administration is the formation of the Great Horn Investment Holding (GHIH), a sovereign entity aimed at transforming Djibouti into a major economic hub for East Africa.

Another visionary initiative is the Damerjog Industrial Development Free Trade Zone (DDID FTZ), which focuses on heavy industries such as oil, gas, ship repair, and livestock processing. This industrial free zone highlights the forward-thinking approach of the president and his economic team.

Djibouti’s leadership has also prioritized enhancing physical and social connectivity with its large neighbor, Ethiopia. The construction of two modern asphalt roads through Dewale and Belho, along with the ambitious Galafi network connecting to Ethiopia, has significantly strengthened the economic and social ties between the two nations. These road projects complement the electric railway line that became operational around eight years ago, marking the first modern rail link in the region in decades.

A notable example of cross-border cooperation is Djibouti’s access to tap water sourced from Adi Gala in Ethiopia, facilitated by a water pipeline agreement. Additionally, the electric interconnection between the two countries exemplifies the pragmatic, results-oriented diplomacy that has defined Guelleh’s foreign policy. Collectively, these projects symbolize social and diplomatic successes that have improved the daily lives of ordinary Djiboutians while deepening interdependence with Ethiopia.

International financial institutions have recognized Djibouti’s progress. The International Monetary Fund (IMF) and the World Bank have acknowledged the development achievements of the Red Sea nation over the past two decades, particularly the government’s efforts to combat poverty and unemployment through key social and economic development programs.

According to various official documents and international reports, Djibouti’s gross domestic product has reached approximately $4.5 billion, representing nearly a tenfold increase over the past thirty years.

This remarkable growth trajectory has set the stage for even larger projects on the horizon, including the nearly completed Damerjog Oil Terminal and other major initiatives slated for inauguration soon.

The 2026 Presidential Election: Candidates and Stakes

Against this backdrop of rapid transformation, Djibouti held its latest presidential election on Friday, April 10, 2026. In the lead-up to election day, Capital conducted extensive interviews with a diverse group of citizens, from first-time young voters to the elderly who have witnessed the nation’s entire post-independence history. While some expressed concerns about the limited number of candidates and the absence of certain opposition figures, nearly all acknowledged the tangible successes the country has achieved over the past two decades.

The incumbent president, 78-year-old Ismail Omar Guelleh, ran under the banner of the ruling Union for the Presidential Majority (UPM). His sole challenger was Mohamed Farah Samatar of the Unified Democratic Centre (UDC), who actively campaigned in the Tadjourah and Obock regions, rallying support with the slogan “another Djibouti is possible.”

It is important to note that several opposition groups chose to boycott the election, a decision that has garnered both domestic and international attention. Despite the boycott, the National Independent Electoral Commission (CENI) confirmed that approximately 250,000 citizens had registered to vote—a significant figure for a nation of one million people.

In a bid to enhance the credibility of its electoral process, the Djiboutian government has invited a significant number of international observers to monitor the upcoming presidential election. Earlier this week, the Ministry of Foreign Affairs and International Cooperation announced the deployment of 67 observers across the country.

These observer missions have been invited from four prominent international organizations: the African Union (AU), the Intergovernmental Authority on Development (IGAD), the League of Arab States, and the Organization of Islamic Cooperation (OIC).

The African Union mission, consisting of 47 observers, is led by former Rwandan Prime Minister Bernard Makuza. This team includes members from sixteen AU member states, such as ambassadors accredited to the African Union in Addis Ababa, representatives from African election management bodies, civil society organizations, and youth groups. The AU stated that its mission will engage with key national stakeholders, including government authorities, election management bodies, political parties, candidates, civil society organizations, and other relevant actors. The AU observation team is scheduled to release its preliminary statement on Sunday, April 12, 2026, at 10:30 a.m. at the Djibouti Palace Kempinski Hotel, where it will present initial findings and recommendations aimed at enhancing democratic governance, transparency, and the rule of law in electoral processes across the continent.

Meanwhile, the IGAD Election Observation Mission (IGAD EOM), led by former Ethiopian President Mulatu Teshome, consists of 17 short-term observers from Ethiopia, Kenya, Somalia, South Sudan, and Uganda. These observers represent national election management bodies, civil society organizations, and youth groups, and have been deployed across all regions of Djibouti to monitor election-day procedures, including the opening and closing of polls, voting, and the counting of ballots at polling stations.

The IGAD mission has indicated that its assessment will be based on Djibouti’s domestic legal framework governing elections, the IGAD Draft Protocol on Democracy, Governance and Elections, the African Charter on Democracy, Elections and Governance (ACDEG), and the International Declaration of Principles for International Election Observation. The team is actively engaging with Djiboutian state authorities, including the Ministry of Interior, CENI, political parties, media, civil society organizations, diplomatic representatives in Djibouti, and other election observation missions.

Looking Ahead

As Djibouti awaits the official results of the April 10 election, the nation finds itself at a pivotal moment. Supporters of President Guelleh view the past 27 years as a time of remarkable progress—transforming a decrepit port into a network of world-class maritime facilities, transitioning from economic isolation to a thriving free trade zone with hundreds of international companies, and achieving nearly tenfold GDP growth from a state of poverty. In contrast, critics and opposition figures see this election as an opportunity to advocate for greater political pluralism and a more democratic environment.

Regardless of the outcome, Djibouti’s peaceful conduct of yet another presidential election, observed by numerous international monitors, strengthens its reputation as a rare bastion of stability in the often tumultuous Horn of Africa. The future trajectory of the country now lies in the hands of its quarter-million registered voters and the integrity of the electoral process they have just completed.

Results of the election had not been announced at the time of print.

The age of AI-Powered combat: The need for global control

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Modern warfare has evolved into a multi-domain contest that integrates advanced technologies and innovative strategies. These changes extend conflict beyond traditional battlefields, merging physical, digital, and psychological elements. Technological domains such as autonomous systems, cyber capabilities, space assets, and AI-led targeting, along with concepts like hybrid warfare and cognitive systems, are transforming the dynamics of warfare. This emerging era is characterized by the collaboration of human operators and lethal autonomous weapon systems (LAWS) to achieve strategic impacts using hypersonic and space-based assets.

Predicting the future of war is a formidable challenge. However, the rapid pace of technological advancement—encompassing artificial intelligence, autonomous systems, hypersonic weapons, space-based assets, and cyber capabilities—indicates that the nature of conflict is evolving even as we attempt to comprehend it. The current trajectory reveals both the capabilities and limitations of remote precision warfare and highlights the future roles of human forces in an increasingly automated battlefield.

Advanced technology now enables warfare to be conducted with precision without the need for ground troops. Innovations such as drones, precision missiles, and cyber operations facilitate remote precision warfare like never before.

Drones such as the U.S. MQ-9 Reaper and Iran’s Shahed series are capable of executing targeted strikes over long distances without pilots. Precision missiles, including the U.S. PrSM (with a range of up to 500 km) and Iran’s Qiam, can hit high-value targets from afar. Enhanced by AI, electronic warfare, and cyber tools, real-time targeting and disruption have never been more effective. The drone-centric warfare observed in the 2026 U.S.-Israel-Iran conflict, along with patterns in Sudan and Ukraine, signifies a paradigm shift toward remote precision strikes that significantly reduce human casualties while intensifying strategic attrition and psychological pressure.

This reliance on drone and missile warfare minimizes the need for large-scale ground deployments, prioritizing personnel safety while delivering strategic impacts through precision and attrition. Nevertheless, human elements such as willpower, legitimacy, and territorial control remain critical factors.

The Enduring Role of Ground Forces

While remote warfare is efficient for strikes, it struggles to maintain territory and counter resilient underground networks. The depletion of interceptors and electronic countermeasures can strain resources in the absence of ground forces. Although remote precision warfare is a powerful tool, it has not yet reached a point where it can completely replace ground troops. The strategic functions of ground forces, though diminished, remain compelling.

The future of warfare may feature fewer ground force deployments, but a persistent need for specialized ground troops operating alongside autonomous systems will likely remain. This is largely due to the fact that while remote precision warfare excels in delivering strikes, it has not proven capable of fully replacing ground forces’ roles in securing territory and political administration. Therefore, tailored ground troops integrated with drones are still essential for achieving comprehensive control and endgame objectives.

A new paradigm is emerging—one where the traditional distinctions between peace and war, kinetic and non-kinetic operations, and human and machine involvement are increasingly blurred and often irrelevant. We are entering an era defined by human-machine collaboration and the deployment of lethal autonomous weapon systems (LAWS). The shift is moving from remotely piloted platforms to swarming drones and coordinated missile barrages that can adapt and select targets based on AI-driven parameters. A swarm of AI-coordinated drones does not merely target a tank; it can simultaneously disrupt a battalion’s command structure, logistics, and morale.

Cyber and Space as Operational Domains

Cyber warfare has evolved beyond mere espionage or website disruptions; it now represents a persistent, low-grade form of conflict that operates below the threshold of armed confrontation. Pre-positioned malware can serve as a strategic deterrent, poised to disrupt a nation’s financial system, power grid, or water supply at a moment’s notice. As technology advances, cyber operations have become ideal for gray-zone tactics, enabling aggressors to inflict damage without provoking a conventional military response. In an era where precision-guided munitions, real-time intelligence, and global communications rely on satellites, targeting an adversary’s space infrastructure has become a priority for first-strike operations.

Today, integrated AI-led targeting represents a significant enhancement of the “kill chain.” AI facilitates algorithmic warfare by synthesizing data from thousands of sensors—including satellites, drones, social media, and signals intelligence—to identify patterns and generate targeting solutions at speeds unattainable by human operators. The sensor-to-shooter loop is collapsing from hours or minutes to mere seconds, with the aim of predictive targeting—striking a target before it moves, based on AI’s prediction of its next action. This technological advantage can be applied effectively in military operations.

The Utility of Cluster Munitions

Cluster munitions, or any combination of missile launches, are increasingly utilized for targeting airfields, troop concentrations, and dispersed infrastructure due to their ability to release dozens to hundreds of sub-munitions. These smaller sub-munitions are more challenging to intercept than a single large missile, making cluster munitions particularly effective at bypassing defenses.

The Future of War

While predicting the future of technology is inherently uncertain, the current battlefield—characterized by “push-button” conflicts conducted from armchairs via missiles, robots, and drones—has not entirely eliminated the need for ground troops. Although modern warfare increasingly incorporates drones, missiles, and robots, ground forces remain crucial for seizing and holding territory or managing critical conflict areas. Although robotic warfare is still in the experimental phase, it is likely that these technologies will be deployed in real combat situations in the near future.

The deployment of humanoid robots could significantly reduce the need for ground troops, provided ethical and international concerns are addressed. However, this may also lead to unpredictable AI decisions and consequences.

Advancements in digital military hardware are accelerating, with technologies like AI-driven drones and hypersonic weapons emerging as potential counterbalances to traditional nuclear dominance. These innovations could shift power dynamics without relying on nuclear arsenals.

AI-enhanced drones and autonomous systems offer precision strikes, real-time intelligence, and defense evasion, rivaling nuclear deterrence by enabling targeted operations with minimal collateral damage. Hypersonic weapons and quantum computing further enhance speed and targeting capabilities, complicating enemy defenses and reshaping conventional-nuclear dynamics. Hypersonic weapons, which can travel at least five times the speed of sound (Mach 5 or roughly 6,100 km/h), are poised to be the next impactful features of warfare.

Hypersonic weapons significantly reduce decision-making time for adversaries and challenge existing early-warning and air-defense systems. Their ability to maneuver within the atmosphere complicates defense strategies. This represents a major shift in strategic dynamics, as these weapons combine high speed, long range, and unpredictable flight paths. The future of warfare remains uncertain as these technologies evolve, potentially leading to unimaginable, confusing, and unpredictable consequences that may extend beyond human control.

Conclusion and Recommendations

It is essential to establish an international regulatory system to manage the unpredictable effects of high-tech military hardware before we encounter the disastrous consequences of decisions made by irresponsible leaders. These leaders may misuse fast, opaque, and difficult-to-defend hypersonic and AI-enabled weapons, miscalculating their catastrophic impact on the future of the world.

Many cutting-edge technologies, such as AI, drones, and quantum computing, first emerge in the civilian sector, making their military applications often unpredictable until they are deployed in new ways. Each technological advance by one side prompts countermeasures from others, resulting in constant shifts in effectiveness. International norms, treaties, and public opinion can influence the use of certain technologies, such as autonomous weapons, by delaying or shaping their deployment.

The evolution of warfare reflects an ongoing tension between technological capability and human necessity. While remote precision warfare offers a lower-risk alternative, its limitations in achieving political objectives ensure that ground forces remain a crucial element in military operations. Consequently, the future of conflict is likely to be characterized by the integration of specialized ground troops with advanced autonomous systems.

To navigate this complex and dangerous landscape, the international community must act swiftly. This is a call for world leaders to come together and establish appropriate rules to address these challenges. Proactive diplomatic engagement is necessary to create clear norms and regulations governing autonomous weapons, hypersonic armaments, and the use of cyber and space assets, thereby preventing the uncontrolled catastrophic escalation that these powerful technologies could unleash.

The need to avoid the double-edged sword of economic sanctions

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The strategic use of economic tools—such as sanctions, trade policies, aid, and investment—has become a key component of modern statecraft, allowing nations to pursue security, geopolitical, and ideological objectives without resorting to direct military force. However, this power is not without consequences. While economic statecraft can promote development and cooperation, its harsh application often results in significant ethical and legal dilemmas.

The intention behind these tools is sometimes to inflict pain and instigate regime change in certain states. This tension is particularly evident in the use of unilateral economic sanctions, which, despite claims of precision, often lead to widespread civilian suffering. They restrict access to food, medicine, and livelihoods while leaving political elites relatively unaffected.

The use of economic means—such as trade, aid, investment, sanctions, currency policy, and infrastructure finance—to achieve strategic national goals can sometimes devastate other countries’ economies. The application of economic statecraft can seem deeply cynical, especially when powerful nations use it to cripple a nation’s economy, fully aware that ordinary citizens will bear the brunt of the resulting hardships.

The unfortunate reality of economic sanctions, even when aimed at specific targets, is that they frequently impose severe hardships on innocent civilians. It is not difficult to understand the challenges of escaping poverty, nor is it hard to imagine how the straightforward deployment of sanctions leads to suffering, increased infant and child mortality, unemployment, decreased life expectancy, and more. Although some sanctions are intended as a non-violent alternative to war, their broad effects can disrupt entire economies, limiting access to food, medicine, clean water, and electricity, and rendering populations vulnerable. The poor, sick, elderly, and children typically suffer the most, despite not being the intended targets.

This creates a stark moral and practical contradiction. While economic sanctions may be framed as a humane alternative to war, they can precipitate humanitarian crises, violate principles of sovereign equality under international law, and cause long-term socio-economic damage.

The disconnect between the intended strategic logic of economic coercion and its real-world consequences on vulnerable populations remains legally contentious. Additionally, unilateral measures and the persistent failure of even “targeted” sanctions to protect innocent lives from the effects of economic warfare diminish their effectiveness.

Sanctions can restrict access to food, medicine, and basic goods, leading to humanitarian crises while often sparing the political leaders they target. Countries that impose sanctions may claim to champion human rights or democracy, yet critics argue that they also seek to undermine economic rivals or gain strategic advantages. Even after sanctions are lifted, the damage to infrastructure, employment, and public health can take decades to repair.

Proponents argue that carefully targeted and multilaterally enforced sanctions can sometimes compel change more ethically than war. The crucial question is whether these tools are used as a last resort with clear, achievable goals or as blunt instruments of economic warfare. Economic statecraft often obscures underlying power dynamics, and vulnerable populations pay the price for decisions made far from their borders.

This form of economic statecraft involves using tools like sanctions, aid, trade policies, and financial measures to achieve foreign policy goals, including influencing the politics of other nations. While these tools can promote productivity and prosperity when applied positively—such as through development aid or trade agreements—their coercive use to disrupt economies, meddle in the politics of independent countries, or force regime change raises serious ethical and legal concerns.

UN General Assembly and Human Rights Council resolutions consistently condemn unilateral economic measures as violations of the UN Charter, international law, and principles of sovereign equality, particularly when these measures have extraterritorial effects that obstruct development rights. While UN Security Council sanctions under Chapter VII are generally deemed legal in response to threats to peace, unilateral sanctions often exist in a “grey area” without clear authorization unless they are deemed proportionate countermeasures to a wrongful act.

Broad economic sanctions tend to harm civilian populations by causing shortages, repression, and violations of socio-economic rights. However, attributing direct responsibility to states remains contentious due to a lack of exemptions and the challenge of preventing humanitarian crises. Targeted sanctions aim to mitigate these effects but can still lead to political disruption without achieving the intended policy changes or protecting innocent and vulnerable lives.

There is also a critical tension between the ethical implications and the effectiveness of sanctions. Even targeted measures, such as asset freezes on political elites or arms embargoes, can produce unintended ripple effects. For instance, restricting access to foreign currency can lead to currency devaluation, inflation, and reduced imports of essential medicines or food, even if these goods are formally exempt. Humanitarian exemptions often fail in practice because banks over-comply to avoid penalties, or because logistical infrastructures, such as fuel or medical supply chains, are indirectly affected.

Thus, the central dilemma of modern economic statecraft lies not in its intent but in its execution and accountability. On one hand, sanctions and similar tools provide a seemingly bloodless alternative to military intervention—allowing states to signal opposition, raise the costs of aggression, or uphold international norms without deploying troops. On the other hand, the gap between this non-violent ideal and the lived reality of targeted societies is often alarmingly wide.

The mechanisms designed to isolate elites, such as asset freezes, banking restrictions, and trade embargoes, frequently lead to widespread economic collapse, resulting in food insecurity, medicine shortages, and infrastructure decay that disproportionately affect innocent victims.

This contradiction is further exacerbated by legal ambiguity. While multilateral sanctions authorized by the UN Security Council possess a degree of legitimacy, unilateral measures exist in a contested space. They are condemned by many UN General Assembly resolutions as violations of sovereign equality and the right to development, yet are defended by imposing states as lawful countermeasures or acts of foreign policy discretion.

Even “smart” targeted sanctions often fail to protect civilians—not due to malicious intent, but because modern economies are deeply interconnected, making it impossible for humanitarian exemptions to shield the masses or exclude vital supply chains, currency markets, or public health systems from secondary shocks.

Ultimately, the ethical implications of economic statecraft hinge on a series of unresolved questions: When do sanctions cross into collective punishment, causing harm to the vulnerable for no fault of their own? How should the international community attribute responsibility for indirect but predictable civilian harm? And can any sanctions regime be deemed “humane” if it inflicts widespread suffering on the vulnerable while political elites remain insulated? These questions do not render economic statecraft illegitimate.

Thus, economic statecraft requires a more rigorous framework that prioritizes proportionality, transparency, and enforceable safeguards against humanitarian fallout. Without such a well-designed framework, the strategic logic of economic coercion will remain overshadowed by its tragic reality, where the powerless bear the brunt of power struggles.

Economic sanctions serve as a crucial diplomatic tool to restrict trade, finance, or assets to influence foreign policy, such as curbing nuclear programs or human rights abuses. Targeted measures, like asset freezes, minimize collateral damage compared to full embargoes and can deter aggression when supported by international coalitions.

Sanctions aim to isolate and pressure nations into changing their behavior without resorting to military action. However, their broad impact often backfires, causing greater harm to civilians than to leaders, making sanctions a double-edged sword.

Targeted “smart” sanctions are generally more effective than blanket sanctions, but their success relies on considering alternatives for vulnerable populations. Sanctions and embargoes rarely bring down regimes on their own; instead, they often prolong suffering if evasion continues. Targeted sanctions can succeed when they are applied to specific individuals, entities, or sectors, aiming to reduce the broader impact on the general population. Their effectiveness often depends on the collective agreement and enforcement among international partners to protect innocent civilians.

AI can strengthen Ethiopia’s frontline care

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Capital interviewed Dr. Ruth Diriba of Last Mile Health on how digital technology and artificial intelligence could reshape Ethiopia’s Health Extension Program, improve supervision and training, and help frontline workers deliver better care.

Dr. Ruth said the country’s next health-policy shift should move beyond expanding access and focus more on quality, with AI designed to give health extension workers stronger clinical support, faster guidance and greater confidence in handling complicated cases at the community level. She said the goal is to preserve the gains of the past two decades while adapting the system for a more complex disease environment.

A major concern around AI reliability was also addressed in the interview. Dr. Ruth said Last Mile Health has built several safeguards into its “Last Mile” project, including ministry-approved medical content, expert validation, model testing, and human review before any answer reaches a health worker. She added that the system is being rolled out in phases to reduce the risk of medical errors and ensure the technology is used as an aid, not a replacement, for professional judgment.

The conversation also covered patient privacy, offline functionality in areas with poor connectivity, and the long-term sustainability of the project. Dr. Ruth said the program uses secure infrastructure, encrypted systems and supervised workflows, while efforts are underway to build offline capability and local ownership so the system can be scaled sustainably across Ethiopia’s health network. Excerpts;

Capital: How will the application of digital technology and Artificial Intelligence (AI) fundamentally shift Ethiopia’s health policy to ensure the achievements of the Health Extension Program over the past 20 years are transferred to the next generation?

Dr. Ruth Diriba: To grasp this strategic shift, we must first reflect on the significant accomplishments of the Health Extension Program over the last two decades. This government-funded initiative has reliably provided essential healthcare services to remote communities through a workforce of over 40,000 professionals, predominantly women.

These dedicated workers, many of whom began their service at a young age, have devoted their lives to improving their communities. They act as vital links to the formal healthcare system. Our current fundamental transition focuses on passing this success to the next generation by shifting our emphasis from “access” to “quality.”

The Ministry of Health’s integration of digital technology and AI aims not only to streamline workflows but also to fundamentally enhance the capabilities of our health professionals. In an age where diseases are increasingly complex, we want our health extension workers to go beyond routine tasks and simple referrals to higher-level facilities.

By equipping them with AI-driven tools, we empower them with the confidence, knowledge, and clinical skills needed to manage intricate medical cases on-site. This technology allows our workers to make a direct, meaningful impact on the lives of those they serve, helping to restore the deep community trust established at the program’s inception while enhancing their professional motivation.

We acknowledge that the tech world faces challenges like “AI hallucination,” where unverified information may be generated. However, adhering to a “safety-first” principle, we have implemented stringent quality control systems in projects such as the “Last Mile.” This ensures that the AI support each professional receives is devoid of medical errors, enabling Ethiopia’s health policy to utilize modern technology to save and improve lives on an unprecedented scale.

Capital: Given that AI can sometimes exhibit hallucination, what does the quality control system look like in the Last Mile Project, currently being implemented in seven regions, to ensure health extension workers receive error-free answers?

Ruth: We prioritized the safety of our AI system from its initial development through to its full implementation. We have meticulously managed this project, fully aware that “hallucination,” or the generation of false information, poses a significant challenge that is unacceptable in the medical field.

To combat this, we have established several critical safety measures. First, we employed a Retrieval-Augmented Generation (RAG) system that limits the AI to retrieving answers exclusively from a database of ministry-approved documents, clinical guidelines, and protocols designed specifically for health extension workers.

Second, we conducted a comprehensive selection and validation process for the tools involved. This included a landscape analysis focused on safety, functionality, language support, offline capabilities, and multimodal features. An expert group from the ministry, regional health authorities, and health colleges that train health extension workers validated these tools using a blinded comparison matrix.

Third, we implemented a “model-as-a-judge” approach, complemented by rigorous human validation. Experts from the Ministry of Health and Saint Paul’s Hospital developed a standardized set of questions and answers. The model regularly self-evaluates its generated responses against these expert-validated benchmarks to identify any deviations or hallucinations. Any discrepancies are reported, and necessary adjustments are made immediately.

Finally, we implemented a human-in-the-loop strategy and a phased rollout to create a safe platform for health extension workers. During the initial 18-month testing period, call agents—recruited from health worker catchment areas and possessing advanced medical qualifications (such as health officers, nurses, and midwives)—personally evaluate the AI’s responses before providing guidance to the health extension workers (HEWs). HEWs can access these validated answers via a toll-free line.

This process is supported by supervisors and implementation protocols developed by the Ministry of Health and regional bureaus, ensuring that users have a guideline for personal evaluation and do not follow the AI’s suggestions blindly.

Capital: When health extension workers share patient data with the AI system, what technological safeguards and legal frameworks have been established to prevent patient privacy from being disclosed to third parties or exposed to cyber-attacks?

Ruth: To protect all data, we utilize high-security paid servers. Specifically, we leverage Amazon Web Services (AWS) along with encrypted API keys to reduce the risk of cyberattacks. While chat logs are not stored within the AI model, they are kept on a server in a secure, encrypted database; however, external LLM histories are not retained. For translation services, we avoid open-source systems in favor of purchased, secure platforms that align with our organization’s data security protocols.

Additionally, we have established an implementation protocol to guide the training and deployment for health extension workers. This includes systematic follow-ups on prompts and the provision of constructive feedback during routine supervision to ensure personal identification information is not used improperly.

Capital: In the rural districts where the project is implemented, internet and power outages are common challenges. What alternative solutions (e.g., offline capability) have been designed to ensure this AI technology provides uninterrupted service under these difficult conditions?

Ruth: During the model selection phase, we prioritized offline capabilities to address potential connectivity issues. We are currently developing this feature and will initiate formal testing once the necessary technical enhancements are complete.

By embedding offline functionality directly into the models, we aim to ensure that the tool remains functional even in low-bandwidth or no-internet environments.

In the event of a system interruption, our contingency plan includes a supervisor-led call center service. This allows health extension workers to directly contact supervisors, who can then provide the necessary AI-driven guidance over the phone. Beyond these immediate technical and operational workarounds, we are actively advocating with the Ministry of Health and other key stakeholders to secure more sustainable, long-term infrastructure solutions.

Capital: What is the significance of this technology in reducing the workload of health extension workers? Specifically, what awareness-building efforts have been made to ensure it doesn’t create extra pressure on workers with digital literacy gaps, and that they view the technology as an assistant rather than a replacement?

Ruth: The design follows a human-centered approach, ensuring that all solutions are tailored to address specific problems while remaining acceptable, relevant, and usable for the end-user. To achieve this, we thoroughly studied the existing workflows of health extension workers, allowing us to identify and prioritize key areas for support. We are currently monitoring and evaluating worker attitudes, specifically assessing whether the system is perceived as an additional burden or “extra work.” These insights will ultimately guide improvements in both service delivery and system presentation. Furthermore, comprehensive training has been provided to health extension workers to ensure they fully understand the system’s operation and practical benefits.

Capital: What was the reason for Last Mile’s strategic entry into this health sector? Furthermore, what is the long-term sustainability of these projects?

Ruth: The program employs an iterative methodology that enables us to tackle complex challenges by creating targeted solutions. As we implement each prototype, we identify new needs and adapt our approach accordingly.

At Last Mile Health, we are dedicated to achieving outstanding results through initiatives such as digitization, which is a fundamental principle of our organization. To fully empower and support community health workers, we work diligently to strengthen the healthcare system. We remain committed to advocating for this essential work, securing the resources needed for ongoing implementation, scaling up efforts, and providing steadfast support to the Ministry.

Capital: How will health supervisors’ access to real-time data on their staff’s learning progress and knowledge gaps transform the longstanding culture of reporting and monitoring within the Ethiopian health system?

Ruth: Health extension worker supervisors receive continuous data analysis to better support their staff within their catchment areas. This system facilitates easy tracking and completion of referrals, enabling health workers to be well-prepared for consultations, as decisions and outcomes are shared with the support team. Ultimately, this AI system integrates clinical support with proactive supervision and mentorship.

In addition to immediate clinical decision-making, this data is used to analyze questions and answers from health extension workers, helping to identify knowledge gaps and community needs. These insights inform the design of localized guidelines and the redesign of training programs to address specific skill shortages.

Furthermore, the system improves reporting and monitoring by identifying common regional illnesses, which can be cross-checked against submitted reports to drive continuous improvement in healthcare delivery.

Capital: Given that the majority of health extension workers are women, what positive impacts are expected from these digital tools and flexible training conditions on their professional competence, decision-making authority, and work-life balance?

Ruth: I am excited that women are now digitally empowered to use tools like AI in their work. This shift presents a significant opportunity to enhance digital literacy while improving their knowledge and skills. As a result, this strengthens their leadership roles and fosters greater community acceptance.

Capital: Beyond the initial pilot phase, how is the long-term economic benefit of scaling this AI and blended learning model to all 40,000+ health extension workers evaluated in terms of the national health budget and human resource development?

Ruth: By integrating blended learning and digital systems into the healthcare framework, we achieve a 40% reduction in costs along with a 20% increase in skill acquisition. These digital platforms not only enhance clinical knowledge but also create a ripple effect of financial benefits that extend from institutions to individual patients. With the integration of AI support and improved provider expertise at local health posts, the need for referrals is minimized, allowing proper treatment to be delivered at the primary point of care.

This transition significantly reduces direct patient expenses, such as transportation, redundant tests, and out-of-pocket costs, while alleviating the overall logistical burden on families. Consequently, higher-level facilities can focus on providing more targeted, high-quality care for complex medical conditions.

Capital: How is the collaboration between the government and international organizations like Last Mile Health facilitated to ensure that technology is sustainably led by local experts, allowing Ethiopia to manage its own digital health platforms independently?

Ruth: To ensure long-term sustainability, Last Mile Health emphasizes local ownership throughout the development process by empowering the local workforce. We work closely with the Ministry of Health to facilitate knowledge transfer and build regional capacity. Our multidisciplinary team, composed of local software engineers, digital health specialists, and technical experts, leads the design, development, and implementation of the system, ensuring it meets the highest standards of impact and efficiency.