The Persistent Silent Health Crisis in Central African Republic

The Central African Republic is experiencing what may amount to a health crisis, but garners much less attention that its neighbors South Sudan and the Democratic Republic of the Congo. MSF called attention to the crisis in a report last November.

The Central African Republic (CAR) today finds itself in a state of chronic medical emergency. Five separate retrospective mortality surveys, carried out by MSF and other researchers, in prefectures accounting for the majority of the population, show excess mortality above what is considered to be the
“emergency threshold.”

And yet the commitment by the country’s government and by the international community is going in the wrong direction. The government has been decreasing its investments in health, as have international donors, while humanitarian assistance has failed to reduce the widespread medical crisis.

MSF said at the time that the long-term outlook was bleak for the CAR at its present course. The NGO recognized the challenges of providing humanitarian assistance and realizing development, but said that more resources needed to be allocated to support medical services in the country.

Nearly a year later, it appears little has changed. Andrew Green reports in the Lancet on the medical problems faced by the CAR in an article that’s warnings are disturbingly similar to those issued by MSF a year prior. One area of concern is care for mothers.

In 2006, Denise Patricia Nambogoina completed the only midwifery programme in the country, one of 30 graduates that year. The country has a severe shortage of midwives, contributing to a rate of 42 neonatal deaths per 1000 livebirths and 850 maternal deaths for every 100 000 livebirths every year.

“It’s not enough” midwives to meet the country’s needs, she said, “and they still have not been integrated into the ministry of health”. For 4 years after she graduated, Nambogoina could not find a full-time job with either an NGO or the government. She was finally hired 2 years ago to work in an MSF hospital in the northwest.

Though government officials declined requests for interviews, they are not oblivious to the problems. WHO’s Maïga said strong policies exist on paper and government representatives have been active in recent immunisation campaigns. Officials also participated in preparing a recent report on the state of the country’s health system. The current draft document acknowledges health conditions have “highly degraded over the last 15 years”.

To some extent, the government has been hamstrung by too many priorities competing for too few resources. CAR’s gross domestic product per head of $800 is one of the lowest in the world. And there is little active civil society in the country pressuring the government to devote the resources it does have to health.

Instead, Maïga said, “everybody at the ministry is waiting for partners to come. To give money.” But they are not showing up on a scale necessary to turn CAR’s health system around. While MSF tracked a $230 million increase in official development aid to the country from major bilateral and multilateral donors between 2005 and 2009, the organisation also found a $30 million decrease in health funding during the same period. In 2009, there was only $9·9 million released in health disbursements.

Green also points to a concerted effort needed to address the crisis. While MSF is a little less optimistic about the role of the government, he seems to look towards the CAR government as an avenue for making changes and working with groups like MSF. He concludes:

Tackling malaria—or any major health intervention—will require a massive effort from the government: repairing an often-disrupted drug pipeline, rebuilding structures, and positioning national staff members who might one day be able to take over the work the NGOs are doing. It also means developing schedules, recruiting commitments from all of the partners—donors, government representatives, and NGOs—and sticking to a timeline. But it is the kind of solution MSF and other NGOs are pushing for: a bold strategy that would address one of the country’s major health problems and begin shoring up some of the deficiencies in the health system. A clear way forward and proof that health care in CAR is not a forgotten crisis.