Central African Republic Last update: 27 July 2004

The present context

• The Central African Republic, 3 millions habitants is among the poorest countries in the world (67% of the population living under the poverty line). In 2003 GDP growth is estimated at no more than 1.3%.Foreign direct investment, net inflows in 7.7 M US dollars in 2001; aid per capita decreased, from 33.3 US dollars in 1998 to 20.2 US dollars in 2001.

• Over the last 10 years, CAR has experienced at least four mutinies. In March 2003 General Francois Bozize took power and established a new government after a war which lasted almost six months. This war generated internal displaced people, destruction and looting of the public infrastructure. Armed groups are still harassing people all along the main roads and in the countryside looting their goods and even taking children as hostage against payment. The national consensus for holding peaceful general elections scheduled for January 2005 remains fragile as civil servants are irregularly paid.

• There has been no response to a UN flash appeal, issued in May 2003, from international donors and CAR remains one of the least funded countries of the world as well as one of the least developed countries. The UN has described this situation as “the world’s most silent crisis.”

Main public health issues and Concerns

Health status

• The deterioration of living conditions and notably the prolonged exposure to determinants of ill health has increased the vulnerability of the population to the most frequent diseases (diarrhoea, acute respiratory infections, parasitic diseases). The lack of access by the population to sources of drinking water, either due to displacements towards areas where boreholes do not exist or due to failure to repair the existing manual pumps, is another factor that has contributed significantly to the deterioration of the health conditions of the population. The available indicators confirm the severity of the crisis: from 1995 to 2000 the life expectancy went from 49 years to 43, the maternal mortality ratio increased from 680 to 1100 per 100,000 and the infant mortality from 97 to 120/1 000.

• The epidemiological profile is predominantly marked by communicable diseases:

• HIV/AIDS: At the end of 2001 the adult prevalence rate was 12.9%; the estimated number of people living with HIV/AIDS were approximately 250,000, 25,000 of which 0-14 years old. 107,000 children (0-14 year) were orphaned by HIV/AIDS at the same time. More recent data show that the situation is quickly deteriorating.

• Malaria1: There were 2,210 malaria cases per 100,000 people in 2000; malaria- related mortality for all ages was 132 per 100,000 people; the malaria-related mortality of 0-4-year-olds was much higher, at 777 per 100,000 people. • TB: In 2001 there were 255 Tuberculosis cases per 100,000 people, ranked the 100th. Yet the TB-related mortality rate ranks much higher, the 10th, 57.0 per 100,000 people. NB UNCLEAR THE MEANING OF THE RANKING! • Sleeping sickness: A recent survey (May 2004) showed very high prevalence in the three affected areas (Ouham, Nola and Haut Mbomou). • Two case of paralytic poliomyelitis (type 1 poliovirus), with onset of paralysis on 16 December 2003 and May 2004, have been confirmed approximately 200 km north of Bangui. The virus detected is linked to viruses circulating in northern Nigeria in 2003, where polio immunization campaigns have been suspended since August 2003.The Central African Republic had not reported polio cases since July 2000.

Health system performance

• The health infrastructure is insufficient (1 medical center/ 6 000 habitants, 1 bed/ 1 095 habitants), obsolete and for its most part destroyed or looted (including the cold chain). Only about one third of the infrastructure in the most affected zone has been rehabilitated. • Human resources : the overall indicators (1 physicien /6 000 habitants and 1 nurse /17 000 habitants) hide substantial inequalities in the distribution of the workforce. • Only 30% of the population has access to drinkable water. • The financing of the health sector relies heavily on external aid (which covers a share of 85%, while the Government contributes with10% and the private sector with 5%). • The sanitary (DO YOU MEAN HEALTH SERVICES??) coverage and the sanitary??? access are very low because of the poor quality of the services combined to the system of cost sharing limiting access to the poor people (67 % of the population live under the poverty line) • The surveillance system is disrupted and only 38% of the health centers are regularly reporting. • Outbreaks are recurrent: in 2004 there were epidemics of Meningitis, Poliomyelitis (the transmission of wild poliovirus was stopped since 2001), Measles, and Shigellosis.

Main sector Priorities

In this context the priority needs are: • Assessment of the impact of crises on population health • The setting up of a system of surveillance and response to epidemics • The reduction of the HIV transmission • Reduction of the diseases preventable by immunization by national campaigns and the rehabilitation of the routine vaccination • The reduction of the maternal and newborn mortality • Therapeutic and supplementary nutrition for children aged under five • Psychological assistance to the victims of violence particulary rapped women

The priority interventions should be directed towards the most affected zone : The districts of Ouham, Ouham-Pendé, Nana-Gribizi, Ombella-Mpoko, Kémo and Bangui. This zone covers about 70% of the central African Republic population.

Other Priority humanitarian needs

• Access to potable water • Security

1 UNDP, 2000

• The introduction of cost recovery system for health and other services: the overwhelming majority of the population cannot afford paying fees

Sector actors (NGOs, UN, Donors, MOH)

ƒ European Union through on Italian ONG called COOPI ƒ FRANCE: French Cooperation Agency ƒ NGO,s active in the sector ƒ COOPI ƒ MSF ƒ ASSOMESCA ƒ CARITAS ƒ AMI D’AFRIQUE

Disclaimer The emergency country profiles are not a formal publication of WHO and do not necessarily represent the decisions or the stated policy of the Organization. The presentation of maps contained herein does not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or areas or its authorities, or concerning the delineation of its frontiers or boundaries.

Contact details

Minister of Health Pr Nestor NALI Ministre de la Santé Publique et de la Population Boite postale 883 Bangui République centrafricaine

Minister of Social Affairs Mme Léa DOUMTA Ministre de la Famille, des Affaires Sociales et de la Solidarité Bangui – CENTRAL AFRICAN REPUBLIC Tél.:

WHO Representative Dr Léodégal BAZIRA WHO Representative BP 1416 Bangui – CENTRAL AFRICAN REPUBLIC Tél.: 236 05 99 99 E-mail: [email protected]

UN Resident Coordinator Mr. Stanislas Nkwain UN Resident Representative & UNDP Resident Coordinator Bangui Tel:+236 102 51 11 Fax +236 611 732 E-Mail: [email protected]

Key documents

WHO Mission report, 8-16 May 2004: www.who.int/disasters WHO-CCS, 2004 UN-CAP2004: www.reliefweb.org

Annexes

Annex 1: Health profile2

General Indicators Population (2004) 3,912,000 Refugees Internally Displaced Persons3 0-300,000 Healthy life expectancy at birth m/f (years) (2002) 42/44 GNI (Gross National Income) per capita (US $, 2002)4 260 Infant Mortality rate (deaths/1000 live births) (2000) 120 Under-five mortality rate (deaths/1000 live births) 179 Total adult literacy by % m/f (2000) 60/35 Population using improved drinking water sources (2000) 70% Population using adequate sanitation facilities (2000) 25% UNDP's Human Development Index ranking5 169/177

Health Systems Profile Total expenditure on health as % of GDP (2001) 4.5 Total per capita health expenditure (US $) (2001) 12 Nurses rate per 100,000 population 8.8 Physicians rate per 100,000 population 3.5 Hospital Beds per 1000 population 0.9

Tuberculosis Prevalence per 100,000 461 Mortality rate per 100,000 51

HIV/AIDS6 Adult prevalence of HIV/AIDS (15-49 years) (2003) 13.5 Estimated number of adults living with HIV/AIDS (2003) 240,000 Reported number of people receiving antiretroviral therapy 100 (15-49 years) (June 2004) Orphans due to AIDS 110,000

Malaria Mortality rate per 100,000 132

Immunization (2002)7 BCG 70% DPT3 40% Measles 35% Polio 40% Pregnant women receiving tetanus vaccine 63%

Women's Health Total fertility rate (2002) 5.0 % of antenatal care coverage 62 %of skilled attendant at delivery (2000) 44 Maternal mortality ratio (2000) 1100

2 WHO/CDS baseline statistics unless otherwise indicated 3 http://www.db.idpproject.org/Sites/idpSurvey.nsf/wCountries/Central+African+Republic 4 The World Bank Annual Report, 2003 5 UNDP Human Development Report 2004 6 UNAIDS 2004 Report on the global AIDS epidemic 7 http://www.unicef.org/infobycountry/car_statistics.html

Annex 2: Security8, accessibility and Essential for Logistics

Security phase Location II Sector Three: Mbaiki and Lobaye III Sector One: Bangui(capital); Sector Two: Bouar, Berberati, Bocaranga and Poua; Sector Seven: Mboki IV Sector Four: Bossangoua, Bouca and Ouham; Sector Five: Kaga Bandoro and Ndele; Sector Six: Bambari.

Accessibility and Essentials for Logistics9

• Landlocked and almost the precise centre of Africa; Border countries: Cameroon 797 km, Chad 1,197 km, Democratic Republic of the Congo 1,577 km, Republic of the Congo 467 km and Sudan 1,165 km • Railways: 0 km; highways: total 23,810 km with 643 km paved and 23,617 km unpaved; waterways 900 km (traditional trade carried on by means of shallow-draft dugouts; Oubangui navigable all year to craft drawing 0.6 m approximately; 282 km navigable to craft drawing 1.8 m approximately) • Ports and harbors: Bangui, Nola, Salo and Nzinga • 50 airports, 3 with paved runways and 47 with unpaved runways10 • Tropical climate with dry winters and wet summers; northern areas affected by hot, dry harmattan winds • Rainy season: mostly May to October; occasional floods; higher risk of malaria and extreme difficulty in access to logistics (extremely poor transportation) during this period.11

8 UNSECOORD, 2004 9 map from UN, 2002 10 CIA, 2003 11 Northstar Travel Media LLC, 2004

Annex 3: Affected population

• 2,2 million people ( 60% of the population) live in the most affected zone • Hospitals, health centres, public administration buildings, businesses and religious missions almost stopped functioning during the fighting; civilian public servants and staffs left their work places.1 • In May 2003 UN OCHA reported that approximately half of the 650,000 people in Ouham and Ouham Pende are still in hiding after the six-month fighting; in July 2003 ICRC reported that displaces people are gradually returning and any more new displacements seemed unlikely at the current situation. • Food production, particularly cereals, was severely disrupted during the six-month fighting; infant deaths due to hunger were reported considerably increased during the year 2003, and the UN has warned of famine in 2004. • On the other hand, CAR hosted nearly 50,000 refugees at the end of 2001; some 35,000 from Sudan, some 10,000 from Congo-Kinshasa, nearly 2,000 from Chad and approximately 2,000 from 19 other African countries.1