The Central African Republic (CAR) is grappling with a decades-long health crisis in the shadow of conflict. Here, in a country of 5.5 million people, access to healthcare is impossible, and life expectancy is little more than 54 years. Doctors Without Borders (MSF) has repeatedly called for more action from governments and humanitarian actors for years. Yet, the situation worsens, and our teams and the communities we serve are left wondering: Where is everyone?
"When I arrived here, I felt like I was falling into a void," said Dr Louis-Marie Sabio while standing in the courtyard of the Bakouma secondary hospital. At the beginning of 2023, Dr Sabio — a former MSF doctor in Bangassou — took over the hospital's management. It is meant to handle surgical complications in a volatile area near Nzacko, in the northwestern part of the Mbomou prefecture.
"For 12 years, not a single doctor was present here," he explains. "The hospital was run by a health assistant. Well, when I say 'hospital,' that's a big word. There is no electricity, no ambulance, and beds without mattresses. When I arrived, there wasn't even a thermometer, blood pressure monitor, pulse oximeter, or glucometer. The pharmacy was empty, too."
Although secondary hospitals like Bakouma Hospital should provide more advanced care than health posts, health centres, and district hospitals, Dr Louis-Marie Sabio needs help to provide even primary care. The hospital is empty and eerily silent. Despite the hospital's size, there are only ten patients. Chickens roam the corridors and wards, weaving between broken scales and rusty tables. The facility receives no other support except for the vaccinations and referrals provided by MSF. Patients know that despite Dr Sabio's goodwill, lacking human and material resources means they are unlikely to find the medical help they need.
"There are 18 of us running the hospital, but I'm the only one with medical training," said the young doctor. "Due to our limited technical resources, we can't meet the basic requirements of a hospital. We have no electricity, preventing us from performing ultrasounds or X-rays. The operating theater is virtually bare, equipped only with a small solar panel to power two light bulbs. When patients need medicines, we have to send them to the local market and hope they find something."
A critical health situation
This picture of no supplies, staff, or support is replicated in health facilities across the Central African Republic. According to a recent report from the World Health Organization (WHO) and the Ministry of Health, less than half of the country's healthcare facilities are fully operational, and the ratio of doctors to people is alarmingly low, with only 0.6 doctors for every ten thousand people – one of the weakest in the world.
Decades of political unrest and violence among armed groups fueled a massive crisis, leaving more than half of the country's six million citizens in need of humanitarian aid. The country's life expectancy is a mere 54 years. Pregnant women face a substantial risk of death or severe illness due to the scarcity of gynaecologists. And child mortality rates rank among the highest globally.
"We often feel alone"
MSF has nearly 2,800 staff members in the country—it's one of our largest programs across the 75 countries we work in. Most hired locally, they work tirelessly to support health authorities and communities to improve access to healthcare in some of the most neglected areas. In the Mbomou prefecture, MSF supports fifteen health facilities, from small remote health posts to the Bangassou Regional University Hospital (HRUB)—the only specialized reference facility serving a region the size of Greece.
Initially launched as an emergency response to the massive violence that shook the country in 2013-2014, MSF's programs in this area now service a significant portion of the prefecture. MSF sends mobile teams to local health facilities to provide essential equipment, vaccines, and vital medicines to help treat common childhood diseases in the region, such as malaria, diarrhoea, and respiratory infections. MSF also provides training to health workers. Our teams also arrange referrals for patients in critical condition to Bangassou's hospital, where we support most lifesaving services.
"[Our] objective is to bolster healthcare provision at all levels to reduce mortality in the area," explains Pelé Kotho-Gawe, MSF's nurse supervisor for mobile activities in Bangassou.
However, the needs remain grossly neglected as MSF is not—and cannot be—everywhere. Humanitarian organizations are scarce in this region, even though violence has calmed somewhat in recent years. The lack of access to water and electricity in health facilities, on top of economic difficulties, exacerbates the massive health crisis, which MSF cannot address alone.
"We are confronted with realities that make this work seem endless," said Kotho-Gawe. "We can treat children suffering from diarrhoea, but without anyone drilling boreholes, the problem persists as [people] continue to drink untreated water. The same goes for malaria: We visit health centres where 90 per cent of the tests are positive for malaria, and we provide free care for the children. Still, no one in the area is engaged in preventive measures or distributing mosquito nets. Sometimes other organisations come through, but they are not frequently seen, and we often feel alone in tackling these challenges. MSF clearly cannot handle everything on its own."
Bangassou Hospital, a mirror of the ongoing crisis
This feeling deepens as MSF's team travels further into the region, from health post to healthcentre. MSF's assistance is necessary for pharmacy stocks to be depleted, parents would struggle to afford treatment for their children, and women would give birth without the supervision of trained professionals.
However, this support is insufficient, and Bangassou Hospital is a stark reminder. The hospital is the last hope for all complications that cannot be treated elsewhere. In other words, patients flock to this facility day and night, sometimes travelling hundreds of kilometres by motorbike over rough terrain because treatment or medications are not available elsewhere.
Four-year-old Guy arrived in a coma. He has type 1 diabetes—a disease requiring lifelong insulin injections. His parents brought him to Bangassou from Bao, more than 100 kilometres away, because the hospitals near his home did not have insulin.
Newborn René* was admitted for the third time to intensive care due to severe malnutrition, as the malnutrition prevention programs in Bangassou, formerly run by an international nongovernmental organization (NGO), were discontinued.
Twenty-year-old Fanny was transferred from Bakouma, 130 kilometres away, because Dr Louis-Marie Sabio and his team lacked the medicines and equipment to treat the wound on her back.
"In a normal situation, patients like Fanny should be treated at my hospital," said Dr Louis-Marie Sabio, who was visiting Bangassou Hospital for an MSF training session. "But you've seen the state of the facility I run. I still send patients to Bangassou who shouldn't need to be referred. Sometimes, I even have to refer patients without being able to stabilize them beforehand, unsure if they will survive. The other day, I had to make an emergency transfer of a baby to Bangassou by motorbike, as we don't have an ambulance. We couldn't stabilize him, and he died on the motorbike a few kilometers from here."
Where is everyone?
"The health situation in the CAR is shocking, but I'm almost as shocked by the lack of international attention paid to it," said René Colgo, MSF's head of mission in the Central African Republic.
"Despite the scale of the crisis and the staggering statistics, the plight of [people] remains largely unknown to the outside world, and humanitarian funding for the country falls far short of the scale of the needs. For reasons linked to insecurity or logistical constraints, NGOs are not always present in the areas where the needs are greatest. Much more must be done to support people. Where is everyone? We cannot and must not get used to seeing CAR at the top of the worst humanitarian league tables."
To bring about change, it's high time to see the situation in the CAR for what it really is: a severe and lasting humanitarian crisis that requires the mobilisation of everyone.
Population: 6.1 million people, 3.4 million of those are in need of humanitarian relief and protection
Maternal and infants mortality rates are the fifth highest in the world
- Only 14% of CAR citizens have a connection to the electricity grid, most of them in urban areas. Only 1.5% of people living in rural areas have access to electricity.
- Only 30% of the population has access to clean water
- Only 2.5% of the roads are paved (600km out of 25 000 kilometres of roads)
- There are only 0.6 doctors per 10.000 inhabitants, much lower than the regional average of 1.5. If you wish to compare this figure with other geographies, please consult this page from WHO.
About Doctors Without Borders (MSF)
Doctors Without Borders (MSF) is a global network of principled medical and other professionals who specialise in medical humanitarian work, driven by our common humanity and guided by medical ethics. We strive to bring emergency medical care to people caught in conflicts, crises, and disasters in more than 70 countries worldwide.
In South Africa, the organisation is recognised as one of the pioneers of providing Antiretroviral Treatment (ART) in the public sector and started the first HIV programmes in South Africa in 1999. Until today, the focus of MSF’s interventions in the country has primarily been on developing new testing and treatment strategies for HIV/AIDS and TB in Eshowe (Kwa-Zulu Natal) and Khayelitsha (Western Cape).
In Tshwane, we run a migration project, and we offer medical and psychosocial care to migrants, refugees, and asylum seekers, who struggle to access public health services under South Africa’s increasingly restrictive.
Previously we offered free, high-quality, confidential medical care to survivors of SGBV in Rustenburg.
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