Health Service Provision in the Central African Republic The Bottom of the Sack: Health Service Provision in the Central African Republic. Mark Beesley Table of Contents Overview 2 Introduction 6 Country Background 8 The Healthcare Arena in Brief 13 The Lay of the Land: Health in the Seven Regions 15 1. Plateaux and the small‐sized state‐owned health facility 2. Equateur and the state‐owned hospital 3. Yadé and the large‐scale International NGO 4. Kagas and the private mini‐pharmacy 5. Fertit and the supernatural 6. Haut‐Oubangui and the church 7. Bangui and the private for‐profit health provider Human Resources for Health 35 The Pharmaceutical Sub‐Sector 39 Health Expenditure and Financing 40 Health provision over Time, presumably 43 Discussion 44 Conclusion 49 Appendices 51 1. Country Chronology 2. Notes on Transport 3. Notes on Nomenclature 4. Bibliography 5. List of Informants 1 Health Service Provision in the Central African Republic Overview The Central African Republic (CAR), created by an accident of colonial history, is an enclave geographically, commercially, linguistically, surrounded by turbulent neighbours. Perversely yet quite appropriately, it is perhaps best known in the Anglophone world for this same obscurity: the place few people have ever even heard of. To a large degree, it is this very environment, with perhaps some unusually extreme historical and geographical characteristics, that has moulded the health provision in present‐day CAR. While the nation has all the paraphernalia of statehood, such as fixed international boundaries, a national anthem, a flag, a recognized government and so on, what is rather striking to the observer is CAR’s apparent statelessness. It has been plausibly described as the Phantom State (ICG, 2007). Even its name lacks any historical or cultural resonance. In the middle of Africa, it is also at its margins (Marchal, 2009). It is both at the edge of the Sahel and at the edge of the equatorial rain forest. Some of its peoples straddle both sides of its borders. Christianity meets Islam. State structures, whether pre‐colonial, colonial and post‐colonial, have forever been at a physical and metaphorical distance from the population. Empty spaces throughout the country (whether dense rain forest in the southwest or vast open spaces elsewhere) would have allowed family groups to keep that distance, hiding or moving as necessary. About 80 years of French under‐administration and over‐exploitation set the tone of what independence, achieved in 1960, would bring: inept and predatory rulers, unable to govern the whole territory. A peripheral colony of negligible importance and marginal returns, the Oubangui‐ Chari was ruthlessly pillaged. By one estimate, half its population perished between 1890 and 1940. The countryside, perceived as not worth vital infrastructural investment, such as roads, was consistently neglected. Raided by slavers coming from the Sudan and the south during earlier times, the north‐east savannah remains empty to this day. Most of the Central African population lives along the Oubangui River and in the north‐west, where some economic activity (cotton farming and cattle breeding) is concentrated. The north‐east is cut off from the capital, and historically linked to south‐eastern Chad and Darfur. It has become embroiled in the conflict complex affecting the ‘tormented triangle’. Nomadic communities move across this tri‐border region, as do rebel groups. None of the three states concerned manages to broadcast its power to the respective portion of the triangle. Five decades of independence with constant and more or less heavy‐handed French tutelage have seen coups d’état (real or suspected, successful and failed), army mutinies, incursions by foreign armed forces dispatched by France, Libya, Chad and Uganda, as well as rebel groups emanating from Chad, the DR Congo, Sudan and Uganda. Widespread social unrest, stalled development and progressive impoverishment have been the unavoidable outcomes of such tribulations. The absence of the state, or its token presence, appears as a structural feature, maintained over time as nominal rulers succeed each other. Health governance follows such a pattern, with a hapless Ministry of Health routinely issuing policies, plans and guidelines while failing to make an impact on actual health services. With a Gross National Income per capita estimated at US$ 450 in 2009, the CAR is one of the poorest countries in the world. The CAR has been described as an “aid orphan”. In reality, the aid per person received by country, estimated at US$ 59 in 2011, was higher than the Sub‐Saharan Africa average. Aid in 2011 constitutes about 47% of the entire government budget. Public healthcare provision depended on external contributions for 54% of its budget. About forty national and international humanitarian agencies and NGOs operate in various parts of the country affected by insecurity (about twenty of them in the healthcare arena). Humanitarian flows have increased from the very low levels of 2002, thanks to debt forgiveness and also to the extraordinary visibility of the Darfur crisis. 2 Health Service Provision in the Central African Republic Health provision is almost exclusively local, with a health landscape resembling an archipelago of disconnected deliverers, some islands taller than others. In CAR, as in many other countries, the familiar pyramid of connected layers of increasing service complexity described by policy documents is, in fact, absent. Obliged through circumstance, Central Africans appear to access whichever health resources are nearest to them, separated from the alternatives by a severe lack of transport, over long distances, along roads which may be impassable or insecure, or both. The limited mobility of many people means in practice that they have no access to health care at all. Elsewhere, even local facilities may be inaccessible financially. Traditional healers constitute the most accessible segment of the healthcare market, though the set of conditions for which their intervention is popularly sought may be shrinking. The absence of the state as uniforming agent has compounded physical and financial inaccessibility, to preclude the development of an inter‐connected health system, leaving a constellation of atypical facilities delivering a fragmented service. Country‐wide, health provision appears strikingly diverse, too, though with that diversity distributed across regions rather than within them. In the north‐east, for example, there is no health provision to speak of, with flat, inaccessible, barely‐populated vastnesses of open plain affected by recurrent instability. Meanwhile, in the grasslands of the north‐ west, episodic violence over the last fifteen years, with the looting and destruction of health facilities and the flight of national health workers, has left health provision largely in the hands of a large international agency. Faith‐based and secular not‐for‐profit providers maintain health services in the under‐populated scrubland and bush of the south‐east. The extreme south‐east is also affected by insecurity. In the heavily‐forested south‐west, almost all large villages and small towns along the sparse network of dirt roads have either state‐owned health centres or health posts. A number of larger health centres and hospitals (both regional and sub‐regional) serve the relatively richer and more populated timber and diamond areas of the west. CAR’s heartland exhibits features from all its neighbouring regions: part‐arid, part‐scrub and part‐forest with insecurity in most areas yet relatively populated, it has health providers from the state, the church and the NGOs. Privately‐ owned, one‐man pharmacies‐cum‐health posts and general purpose village stores are important providers. Bangui, the capital with a fifth of the national population, stands apart. It is home to the Ministry of Health, seven large hospitals, all of fourteen formal pharmacies existing in the country, all of its thirty‐odd private medical clinics, umpteen large well‐used urban health centres and uncountable numbers of mini‐pharmas and medicine hawkers. Very advanced care is available only outside the country. Arguably, all domestic health financing in CAR is private, even if services may be delivered from state‐owned premises ostensibly in the public domain. Except where there are externally‐funded providers, money seems to deeply determine the type, quantity and quality of treatment. The state has, by default if not by design, apparently withdrawn from the public provision of health care, leaving health workers in state facilities at all levels to function as stand‐alone businesses in order to survive. Many such facilities are evidently commercially non‐viable, an outcome of extremely low utilization rates made worse by multiple charges levied to support, often, an often bloated facility team. Professionals with skills in demand, such as specialists and qualified midwives, fare best and run essentially private clinics within public hospitals. It is public knowledge that the formal employees supplement their salaries (often in arrears) as they can. Qualified health workers not on the state payroll openly work within public facilities charging for services. Colleagues – both formal employees within the civil service and those outside it but still at work ‐ share the fees which have been formally collected at the end of each month. Not‐for‐profit private providers follow a similar business model. Entrepreneurs, whether qualified,