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

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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.

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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, barely qualified or entirely unqualified, have moved to satisfy, perhaps even stimulate, unfulfilled demand.

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Health Service Provision in the Central African Republic

Map: The Central African Republic, showing the sixteen administrative sub‐regions, or prefectures1.

Source: Office for the Coordination of Humanitarian Affairs

In common with other poor countries, many of CAR’s services are reportedly of low quality. Service oversight and delivery coordination compete with other priorities. The UN agencies are as constrained in their operations as they are by their state‐centric mandates. Required by their own internal regulations to solely support, or work through, the host governmental institution, their options are necessarily limited in the physical or professional space beyond the government’s writ. Donors with limited room for manoeuvre cannot but introduce projects likely to have equally limited applicability. In insecure areas – much of the country – few projects can be fully monitored, or can be monitored only with intensive input. Projects in more secure areas face challenges in scaling‐up elsewhere. Extensive data collection apparently produces superficial information of scanty reliability. The classifications applying to infrastructure and human resources are muddled by overlaps and ambiguities, another common feature of disrupted environments. Self‐medication is widespread. Villagers are skilled at making the fullest possible use of only those resources around them. Sick people will have always sought out locally‐available herbs, roots, bark and leaves, and the generations‐long tradition of self‐treatment by the use of folk remedies continues, even in urban settings. Nowadays, the practice seems to have morphed to one of seeking out off‐the‐shelf pills, capsules and injections from medicine vendors who may be hawkers, stall‐ holders or corner‐shop owners. First‐level health seeking behaviour appears to be located not in a health post, but rather in the individual’s home, according to personal resources. How health‐

1 The map predates the independence of South Sudan in August 2011, which lies adjacent to the prefecture of Haute Mbomou. ‘Sanha’ is more familiarly known as Sangha‐Mbaéré; ‘Haute Sangha’ as Mambéré‐Kadei; ‘Gribingui’ as Nana‐ Gribizi; and ‘Kémo‐Gribingui’ simply as Kémo.

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Health Service Provision in the Central African Republic

seeking behaviour differs between genders and generations, and between regions was not studied. Within health facilities care appears as varied as the territory. Hidden among the generally bleak landscape there are some decent facilities staffed by committed and diligent workers doing their best in a sorely testing environment, and where service utilization is respectable. However, there would appear to be at least as many dilapidated, poorly‐designed or abandoned (or never‐opened) buildings which are over‐staffed ‐ when they are present ‐ by dejected and unpaid health workers with below‐minimal equipment waiting for a handful of members of a long‐suffering population to attend. Everywhere, health promotion and disease prevention through active outreach seems eclipsed by passive facility‐based prescribing. Stuck on a route that leads nowhere, with few materials and service providers coming in, and limited chance of getting out, the putative Central African healthcare seeker seems also in a literal and metaphorical cul‐de‐sac.

Introduction The cast of actors in any country’s health arena may vary little. Public and private players – both for‐ profit and not‐for‐profit – fill the formal space, with an array of informal providers operating alongside. What varies in each country is the play itself with a different role for each actor, affecting their size, contribution, dynamics and development. The very words formal and informal may come to lose their meaning as do public and private. In severely disrupted contexts, where the state has either collapsed or never properly established itself and, consequently, the role of the strictly public health providers is diminished, the other providers may come to the fore in a way less apparent in more stable settings. This examination of the features and inter‐connectedness of the present‐day Central African health arena, one of six locations under investigation in a larger study, describes the amended configuration of the various players, their adaptations and evolution2. CAR was the last country case study to be completed. It was therefore greatly informed by the findings of the earlier studies, and of the insights gained over two years of work. The main focus of the investigation in the CAR, and the interpretation of its results, evolved significantly as it unfolded. This report reflects such evolution in style, contents and structure. The overall research programme sought to understand the provision of health services in countries subjected to severe, protracted stress, examining both the evidence of such disruption, as well as of resilience within these systems. The ways health systems react, adapt and evolve in response to total or partial state failure, and the responses developed by national and international stakeholders to such challenges, are covered by the study. Beyond the aid horizon, it includes grassroots responses to the absence of the state, on the usually overlooked informal mechanisms that allow for healthcare provision in such difficult environments. A summary of the Central African healthcare arena follows a rudimentary description of the country’s geography and history. A description of the physical, human and economic landscape of each of CAR’s seven administrative regions places the available health services in context, detailing the features of one signature health provider in each region. Human resources for health and the pharmaceutical sub‐sector are outlined. An attempt at describing the evolution of the health arena follows a collation of the available figures on health expenditure and financing. A dozen particularities are discussed. Comments on nomenclature and on transport appear in the appendices alongside a country chronology. The country study followed a six‐step trail, approaching CAR by degrees. From outside the continent,

2 The research project is entitled “Providing Health Care in Severely Disrupted Environments: a multi‐country study” undertaken by the School of Population Health at the University of Queensland, Australia and largely funded by Danida. The other countries under study are Afghanistan, DR Congo, Haïti, Palestine and Somalia.

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a prolonged web search first sought and collected existing published material on CAR in either English or French. Later, for three weeks in February 2011, a co‐researcher travelled to Bangui, CAR’s capital, to seek all available up‐to‐date or unpublished written material and, through the interview of 34 experienced informants from the health field, disentangle fact from fiction and assemble a preliminary picture of the known health provision. Whereas the picture obtained until that point was quite detailed, it mostly related to formal aspects. Given the patent atrophy of formal provision, a large portion of the healthcare arena appeared missing. From the capital, this image looked incomplete and misleading. In light of the findings of the other case studies (particularly the neighbouring DR Congo, where the informalisation of the healthcare market is very advanced), a deepening of the exploration of the Central‐African healthcare arena was in order. A third step identified the missing pieces in the jigsaw3. Then for seven weeks in early 2012, a second researcher, the author of this paper, travelled to five of the seven accessible prefectures outside Bangui, where the activities and contributions of forty individual health providers were investigated. Between journeys, still‐missing jigsaw pieces were sought in Bangui as leads were followed up, new informants sought and apparent contradictions studied. A further thirty individuals were interviewed4. The single most serious constraint facing the study was physical inaccessibility: land transport between towns is scarce and, when found, is both over‐crowded and risky. Without independent hired transport, interrupted journeys (for example, stopping off at a series of villages along the route) are not feasible. Land travel in areas specified as insecure was not contemplated5. There are no domestic air services. As a result, a considerable limitation of the study is that while one of its specific aims was to discover who fills the health space in neglected sites, only accessible ones could be visited. Even these could not be independently chosen6. An individual’s personal accessibility was also a constraint: senior managers based in Bangui have duties which often require travel abroad or within country; conscientious programme managers are often in the field. Committed practitioners tend to be busy. Therefore, only meeting people who could be met was also another serious study limitation. In these meetings, the second researcher’s (and some informants’) limited command of French was a further constraint. Straightforward responses were probably not always properly interpreted; nuanced ones certainly misunderstood. Biases may have been introduced. The researcher confesses to a heightened alertness to the unusual, itself a bias. In addition, many rural clients do not speak French. The preferential seeking out of English‐speakers also introduced some distortion for some topics. Finally, outside central offices, documents are rare and photocopiers rarer still7. Most regional informants were hands‐on practitioners, without published or unpublished information to hand. The second study round relied heavily on informants’ memories and opinions as the source of information, rather than verifiable data. In this way, it complemented the first study round, which had mostly drawn from the scanty available documentation.

3 Little information had turned up about health service provision outside the capital, especially in the areas of the country not served by NGOs, and there were few details on the scope and role of private providers. 4 A verbal explanation of the research was delivered to each informant, sometimes with an accompanying Letter of Introduction. Names and contact details were requested in all cases. 5 A visit to a destination in a conflict zone may have been possible through the UN Humanitarian Air Services. However only personnel formally attached to accredited humanitarian organizations were permitted. 6 In compensation, happenstance and a willingness to go with the flow opened unexpected doors. There is also some virtue in deliberately getting lost with a purpose. 7 Maps are particularly uncommon. Interestingly, ‘state systems without maps’ were also a feature of African pre‐colonial administration. See Herbst (2000), p 53.

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Health Service Provision in the Central African Republic

Country Background ‘Oh! Central Africa, cradle of the Bantu! Take up again your right to respect, to life! Long subjugated, long scorned by all, But, from today, breaking tyranny’s hold.’

When first sung in 1960, the year of independence, the opening lines of the Central African Republic’s national anthem probably struck most listeners as fair comment on the nation’s ethnography, history and international relations8. The flat‐to‐rolling plains of the central savannah plateau, neither as arid as the Sahelo‐Sudanese belt to the north nor as humid as the vast equatorial rain forest to the south, may well have been the prehistoric cradle of the Bantu, later to migrate throughout sub‐Saharan Africa. Its long subjugation was also not in question. The territory of the present‐day Republic had been settled, it is believed, from at least the 7th century. Always on the edges of someone’s control, it was ruled by overlapping local empires, then claimed by various sultanates from Egypt (US Department of State, 2012). ‘Arab’ slavers once raided from the north and east, while agents of European slavers later did the same from the south and west9. The vast, empty expanses of scrub in the middle – the heartlands of present‐day CAR – would have been a ‘flight zone’ for those wishing to escape or evade bondage, a feature of many inaccessible areas at the periphery of earlier states (Scott, 2009). One of the last expanses in the European scramble for African territory in the late 1880s, Central Africa was contested by French, German and Belgian colonizers. The population of today’s south‐ east region shared with their southern neighbours in King Leopold II’s Congo Free State a brutal history of forced labour for portering and rubbervine exploitation, slave chains and burned villages (Hochschild, 1999). Later, France consolidated its claim to the territories beyond the north western bank of the Congo River and, combined with their northern neighbours in present‐day Chad, the whole territory came under French control. Given the name Oubangui‐Chari, after two rivers, it became one of the four territories of French Equatorial Africa in 1910 (Brégeon, 1998). The Zande Kingdom, which included parts of modern‐day CAR, was only defeated by the British in the 1920s. Tyranny was still within living memory at the time of independence: within fifty years from 1889, when French military administrators established their outpost, an estimated ‘half of the population…had perished from a combination of microbial shock and colonial violence’ (Saulnier, 1998). In the 1900s, three thousand porters were required each month to transport supplies for the French troops: A whole range of sanctions was inflicted on chiefs incapable of supplying the required number of porters: they were arrested or flogged with a whip made from hippopotamus hide; the women and children of their village were taken prisoner and kept hostage until the porters returned. Finally, if this blackmail failed, punitive expeditions were organised against recalcitrant villages, which were burned down and their inhabitants killed as an example. (ICG, 2007)

8 The design of the national flag is deeply prescient. Horizontal blue, white, green and yellow bands mark sky & freedom, peace & dignity, hope & faith, and tolerance respectively. The central red column is intended to represent blood spilled for independence. It could just as well symbolize the blood spilled since independence, a deep slash slicing through and rupturing the above aspirations. The lone yellow star at the top left of the flag, signifying the country’s aspiration towards a vibrant future, twinkles ever‐distantly. 9 ‘Although the captives often ended up in the Arab world, the [slave] traders on the African mainland were largely Swahili‐ speaking Africans from territory that is today Kenya and Tanzania. Many had adopted Arab dress and Islam, but only some of them were of even partly Arab descent’. See Hochschild, 1999, p28.

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Later, ‘[t]housands of refugees who had fled across the Congo River to escape Leopold’s regime eventually fled back to escape the French (Hochschild, 1999). During the period covered by the two World Wars, the territory was brutally ‘administered’ by private concessionary companies. As with the DR Congo, CAR had been in crisis long before the recent conflicts of1997 and 2003. The five years following the achievement of nationhood in 1960 led to the continued construction of a now‐ independent predator state where civil servants with exorbitant privileges at every level of the state apparatus formed a parasitic caste living from development aid funds and on the back of the peasants’ (ICG, 2007). Mismanagement and corruption led to economic decline and contraction of public revenues with the predatory elite in power losing interest in administering the state and therefore in providing social services. The infamous Jean‐Badel Bokassa took power in 1965. Matching Zaïrean President Mobutu Sese Seko’s legendary corruption, the as‐legendary delusions of Emperor Bokassa the First propelled the development of a criminal state until his ousting by France in 197910. For the next fourteen years until the free democratic elections of 1993 France created what could be called a shadow state and ‘took control of the CAR. Independent in principle but in reality [it was] dependent on France for everything’ (ICG, 2007). The decade following 1993, despite France’s intimate involvement, was a period of chaos and mistrust punctuated by repeated army mutinies, rebellions and severe civic unrest. The current leadership, governing what has entirely aptly been called the phantom state, has been in power since 2003, winning elections in 2005 and again in 201111. CAR’s multiple natural challenges, namely the landlocked geography, isolation and vast distances, combined with its human geography (the difficult neighbours, inadequate communication even in the dry season, sparse distribution of settlements, low population densities) and the economic pressures (high transport costs, low development base, decayed infrastructure) mean that successfully managing and leading the country would be a tough call even without such a turbulent recent political history12. The remaining lines of the anthem’s first verse ‐ which herald work, order, dignity, rights and unity – may jar modern listeners for their painful irony even while acknowledging that national anthems are purposefully uplifting. Fifty years after independence, CAR: ‘…is classified as one of the world’s least developed countries. ..[It] has made slow progress towards economic development. Economic mismanagement, poor infrastructure, a limited tax base, scarce private investment and adverse external conditions have led to deficits in both its budget and external trade.’ (US Department of State, 2012)

With development stalled, work remains overwhelmingly agrarian with most citizens engaged in subsistence farming13. The national population is an estimated 4.4 million (MSF, 2011). Meanwhile,

10 If given the chance, it seems most Central Africans would vote Jean‐Badel Bokassa as their best president to date. Greeting the coup leader as a saviour, the ‘Builder of Bangui’ and strongman who stood up for CAR is well‐, if selectively, remembered. This is a fascinating inversion of how his memory in the West where the abiding image is the ‘tropical farce’ of a garish and expensive coronation. After all, it should instead perhaps be the indulgent French government of the day, which supported that extravaganza, that is the international laughing stock. 11 It seems the International Crisis Group first coined the phrase ‘phantom state’ (ICG, 2007). Similarly, MSF describes a ‘phantom health system’ (MSF, 2011) 12 Independent CAR has been repeatedly misruled. Perhaps deep structural factors impede its functioning as a viable state, and bar access to power to decent and competent people. As likely, however, is that the checks and balances which should stop excess are absent in CAR, as they are in many other troubled countries. 13 55% of 2009 GDP is derived from agriculture, including timber which accounted for 48% of exports during 2002‐07. Uncut diamonds, the only mineral currently being developed, accounted for the remainder of exports. However, the mining industry, centred in the south‐western area around Carnot collapsed in 2009 as the government sought to establish control over diamond production, and the international price for industrial diamonds fell. (MSF, 2011)

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the transport and communication network is severely limited, with 700 kms of paved road (a third of the average road density in sub‐Saharan Africa), limited international air service and no railroad14. Services accounted for 30% of GDP in 2009 because of an oversized government bureaucracy and increased transportation costs; desertification, deforestation and poaching have diminished CAR’s one‐time reputation as “one of the last great wildlife refuges” (CIA, 2012). In its level of development, CAR is evocative of its neighbour to the east, South Sudan. Sharing, too, a forested south and vast open spaces of scrub in its north, CAR is also one of the poorest countries in the world. Like South Sudan, its climate is harsh. Roads, communications and the basic economic infrastructure are primitive. Seasonal floods impede transports and restrain physical investment. Education levels are dismally low. Order is elusive: seven of the country’s sixteen prefectures are subject to a UK Government travel advisory because of military operations and banditry by at least three armed groups both domestic and foreign15. CAR’s conflict defies easy classification: on the one hand its protracted duration, low intensity and enormous excess mortality of civilians form a cluster suggesting one type of conflict, while the considerable involvement of foreign actors, the acute relief orientation of aid organizations and recurrent episodic nature of violence suggest another type of conflict. The impression is of a conflict itself showing conflicting aspects. It is perhaps now best characterized simply as a situation of endemic violence. The roles of aid organizations are both to provide acute relief and replace state functions; the support required involves both policy directions and skills; outside agencies might deliver both short‐term support to alleviate the effects of the crisis and long‐ term sustained interventions. While peace treaties may have decreased the intensity of the political conflict, security threats remain: Insecurity has worsened as armed bandits, called coupeurs de route or zaraguinas, have become more vicious. Violent attacks by criminal gangs now pose the fiercest threat to people in many parts of the north. These well‐organised and well‐armed bandits rob travellers and merchants, kidnap children, women, and men for ransom, beat up and torture their victims, and kill civilians at will. Whereas they used to attack passing vehicles on main roads, these gangs have since October 2007 begun to attack, loot, and burn down entire villages (HDPT, 2008).

The profile of a ‘roadcutter’ gang is itself diverse. Gang members, who reportedly favour black ninja‐ style clothing or military fatigues, may be criminals from Cameroon, Chad, Nigeria, even Niger; off‐ duty members of the security forces, or rebels; others who have borrowed the latter’s service weapons; so‐called ex‐‘liberators’, unpaid Chadian mercenaries from President Bozizé’s 2003 campaign; mercenaries who provide armed security for Chadian or Sudanese herders and merchants against, ironically, roadcutters; Chadian poachers; or Central African herders themselves (Spittaels and Hilgert, 2009). The current government ‐ in power since 2003, re‐elected in 2011 ‐ and in common with all regimes since independence, has seemed ineffective in broadcasting and consolidating its power to the periphery16. The 1200 kms of unmarked border with Chad are disregarded by fighters and others,

14 The nearest seaport is Douala in Cameroon, 1500 kms to the west, the transhipment point for almost all imports. Kinshasa and Brazzaville are 1000 kms to the south on the River Congo, impassable in the dry season from November to March. Most of CAR’s fuel came through Kinshasa until fighting in DR Congo paralysed supplies. For the last decade fuel has come through Cameroon. International carriers are from France, Ethiopia, Morocco, Chad, Angola and Kenya. 15 The US Government is more cautious. Its citizens are “recommended against all but essential travel outside the capital, Bangui.” (US Department of State, 2012) 16 Nevertheless, CAR is considered by Herbst (2000) to have a favourable political geography. ‘(T)he concentric rings of population density correspond to the current understanding of sovereignty; the largest concentrations of people are

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particularly within the north‐eastern prefecture of Vakaga, a vertex of the so‐called tormented triangle17. A third of CAR’s 5,203 kms of border is shared with DR Congo. Other neighbours are South Sudan, Cameroon, Congo‐Brazzaville and Sudan. There were at least 300,000 displaced Central Africans in 2008, an estimated half of whom are living in the less‐accessible scrubland exposed to the elements (HDPT, 2008)18. Sixty thousand Central Africans are refugees in southern Chad, 45,000 in Cameroon19. There are even 3,000 Central African refugees in Darfur. Similarly, the vaunted dignity and rights for all remain out of reach. Gender‐based violence is widespread with one in seven women reporting they had been raped within the last year (Mercy Corps, 2012). There is human trafficking, especially of children, and a flawed human rights record in general (US Department of State, 2012). CAR is placed at, or near, the very bottom in all manner of international league tables. It is 49th out of 53 in the index produced by the Mo Ibrahim Foundation. Only DR Congo, Zimbabwe, Chad and Somalia fared worse (EIU, 2011) Unity is yet to be ‘re‐conquered’, in the words of the national anthem. There are forty political parties representing CAR’s eighty ethnic groups (CIA, 2012). No longer ‘scorned by all’ however, CAR continues its “close ties with France, albeit considerably reduced from previous years” (CIA, 2012). Multilaterals, including the World Bank, the International Monetary Fund, UN agencies, the European Union and the African Development Bank have ties. Germany, Japan, EU, China and the US are significant development partners (US Department of State, 2012). The United Kingdom, Ireland, the Netherlands and Sweden contribute to the Common Humanitarian Fund (De Valensart and Collin, 2011). A nine‐nation peace keeping force from neighbouring states may strengthen the state more through its symbolism that by the 725 pairs of boots on the ground20. In its north/south divide, CAR is reminiscent of Uganda, where a generally peaceful south focused on development co‐exists with a conflict‐ridden north in emergency mode, and where much of the latter’s population is displaced, the local economy ruined, and the surviving infrastructure derelict. Only in CAR’s south‐east does the comparison collapse: an emergency is in place caused by, ironically, elements from the Ugandan north. Five decades after the penning of the ringing words of the national anthem, the vocabulary of markets has replaced that of rights. A recent document, bland in its universality, colourful in its ambition, intends that, in the long‐term, CAR is to: become an emerging economy, built on a diversified, sustainable economy, evenly spread out throughout the national territory, a modern state open to the world, underpinned by a system of ethics and technological innovation (Government of CAR, 2011). Future Central Africans may find that sentiment as unreal as the current one finds the national anthem.

closest to the capital, where it is easiest for the state to rule them, and population density conveniently declines as distance from the capital grows.’ Low population densities generally may be another factor: the total population is under four and a half million. Given the emptiness of the country, relative densities do not change the basic fact that there is no critical population mass to build and maintain the infrastructures needed by a state administration. 17 This is the general area where CAR meets both Chad and the Darfur region of Sudan. See Giroux et al. (2009). The country, the world’s 45th largest, is slightly larger than France. If Bangui were superimposed on Paris, Central Africa would extend from the Channel Islands to Vienna, taking in London, Berlin and Prague. 18 History is repeating itself. Escape into the bush was the survival mechanism for villagers a hundred years earlier. See Hochschild (1999). 19 Despite that, the CIA World Factbook states that migration in 2011 was 0 migrants per thousand population, a state of equilibrium where the number of arrivals matches the number of departures. 20 The contributing states include all the immediate neighbours except Sudan and South Sudan, some military lightweights such as Equatorial Guinea and São Tomé e Principe and some battle‐experienced heavyweights such as Angola and Burundi. Gabon is also represented.

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Health Service Provision in the Central African Republic

The Healthcare Arena in Brief At least in the health field, the reality of the here and now is somewhat more sobering. Fully‐aware commentators describe a population in a chronic medical emergency causing frighteningly high levels of mortality, where even in the three calmest prefectures (in and around Bangui) crude mortality rates are above those normally considered to be the emergency threshold (MSF, 2011). Médecins sans Frontières, with 15 years’ experience in CAR, believe “the health system has always been very weak; in many parts of the country, to all intents and purposes, it does not exist”. Aside from an underlying poverty regardless of any crisis, three significant contributing factors are identified by MSF: [M]assive prevalence, incidence and mortality of preventable and treatable diseases; crisis, conflict and displacement which disrupts people’s lives and livelihoods; a phantom healthcare system which has failed to make even minimum‐quality care available and accessible to the population (MSF, 2011).

Nationally, the recent mortality rates for infants and under‐fives are high, as is the maternal mortality ratio. Life expectancy is low. Despite broad confidence intervals, considerable variation across regions (including the complete inaccessibility of the north‐eastern region), marked variation between urban and rural populations, inconsistency between reports and a volatile, rapidly‐ changing situation in half the country, the estimated figures reflect accurately, if not precisely, a very poor and probably deteriorating health status21. As in South Sudan, most tropical diseases show record levels of transmission. Service delivery costs are high, due to logistic constraints and operational fragmentation. Access to health care is limited, particularly (again like South Sudan) in the northern areas. Progress is hampered by crushing capacity constraints. Management systems are absent, or in their infancy, and the available information is inadequate. The absorption of pledged donor funds in support of the recovery of the CAR health sector has also been poor. The Ministry of Health describes, in its own documents, a reasonably‐financed, three‐tiered health service managing 80% of the formal primary and secondary health care facilities and all tertiary‐level infrastructure (MSPP, 2007). Ostensibly the Ministry oversees the delivery of the normal full panoply of comprehensive care through a network of around 650 functioning health facilities supplied by a central medical store and staffed by a lean workforce of three and a half thousand civil servants (MSPPLS, 2010). In reality, only a tenth of the allotted finance was disbursed in 201022. Data are unreliable23. An unknown – but sizeable – percentage of the workforce is ‘off‐ledger’. A distracted Ministry of Health exerts little influence over a staff which delivers strikingly limited services, erratically supplied, with the concomitant dismal productivity (World Bank, 2011). CAR’s health sector today concentrates most features recognizable in countless poor, distressed countries: extremely low resource levels supplying a derelict, ill‐equipped or poorly‐maintained infrastructure; a workforce under‐skilled and unevenly distributed with severe urban and hospital biases concentrated in the capital and other urban centres; health services delivered by public,

21 The 2011 World Bank Development Report, the third Multiple Indicators Clusters Survey (MICS 3) of 2006, published in 2009, and other UN reports differ in their exact figures. The maternal mortality ratio (MMR) offers an instructive example. The MMR for 2009 is reported as 980/100,000 live births in a 2010 UNICEF strategy paper with no explanations or sources, and as 850 in the 2011 World Bank Development Report. The Ministry of Health, in its National Health Bulletin published in 2008, with data related to 2006, misquotes the MICS 3 MMR as 1,102 instead of the actual reported one of 596. The 2011 Consolidated Appeal Process document reports a 1,355 MMR from the 2003 census (1,355/100,000) but quotes it as being the MICS 3 figure. 22 Personal communication. 23 For an example, please see the multiple estimates for health facilities described in Appendix 2 Notes on Nomenclature.

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private not‐for‐profit and private for‐profit health units, in a policy and regulatory vacuum; with only a minority of the population having access to health services of questionable quality. The conspicuous private sub‐sector, mainly for‐profit, reaches a larger share of the population, especially with its smallest and unregulated outlets, like drug shops and solo practices. The biggest and most sophisticated private for‐profit health units, like the public ones, are concentrated in urban centres. With a weak legal framework and a still foggy decentralization, management is poor at all levels. Private not‐for‐profit health providers have a high profile. A few international non‐governmental organizations (INGOs) support a small set of government clinics; most others maintain their own. Faith‐based organizations (FBOs) manage and supply their own facilities24. In competition to public facilities, private for‐profit providers run at least thirty clinics, all in the capital. Vendors, ambulatory and static, sell medicines which may, or may not, be genuine wherever there is a market for them (thus satisfying a commercial need that would otherwise be un‐realizable by state supply agencies and mechanisms). The role of remittances in supplementing out‐of‐pocket expenditure is unknown but likely to be negligible for all but a few households25. An unusual feature of the CAR health space, perhaps, is the extent to which it is inhabited by providers offering treatment outside the biomedical sphere. In Disorder as a Political Instrument, Chabal and Daloz (1997) comment that: It is often overlooked… that one of the primary concerns of witchcraft has to do with what we in the West would call therapy. Although much work focuses on the more ‘medical’ aspects of this healing process, witchcraft has also been instrumental in providing ‘treatment’ for psychological or social disorders associated with the modern post‐colonial world.

The Lay of the Land: Health in the Seven Regions Geography – physical, human and political – has intimately shaped CAR and its health care provision, an obvious fact too often neglected by distracted actors. A compact description by one perceptive commentator sums up the main features: Geography has had an important impact on the evolution of the area that comprises today’s Central African Republic. Although the country is at the centre of the continent, straddling the boundary between the sub‐Saharan savanna and the rainforests of the Congo basin, it lies apart from many of the traditional trade routes. Right into the modern era, its history has been shaped by its landlocked location, far from easily accessible economic opportunities. Most of the territory enjoys good rainfall and ample cultivable land, but isolation or, in the modern era, high transport costs, have hampered its ability to take full advantage of these assets. This may partly explain why it is so thinly populated – many eastern regions are barely inhabited at all (Melly, 2002).

The country’s seven health regions coincide with its administrative ones26. The following review of the main features of each exposes a cultural and economic diversity that national averages would mask. Each region’s profile displays its own challenges in the area of health. All health providers are present in each region outside Bangui to a greater or lesser –sometimes much lesser ‐ degree, but the fortunes of each type seem to be a consequence of each region’s peculiarities: historical, geographical and political. Each region, it could be argued, has its own signature provider. This

24 The coordination body lists twenty organizations working in health. www.hdpt‐car.net. 25 Except for the elite, the Central African non‐refugee diaspora are probably largely confined to neighbouring States. 26 However, in 2011 an EU‐funded project engineered a formal change in the sub‐regional health boundaries in Region 6.

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report uses this largely fortuitous (and only slightly contrived) distribution to introduce health providers in their most appropriate context.

Region 1: Plateaux In the south of CAR lie two prefectures, Ombella Mpoko and Lobaye, which make up Region 1. This is CAR at its most bountiful and perhaps most beautiful. The area lies close enough to Bangui to provide rural necessities to sustain the million‐plus population of the capital. Importantly, the country’s three main paved routes run through it: the road south to Mbaiki; the highway north to Damara and Sibut (and from there all destinations north and east); and the principal highway ‐ in fact, the only international land trade route ‐ north‐west to Bouar (and from there to Cameroon). Across the Ubangi River, which marks much of the region’s eastern border, is DR Congo. In the southern part of this region, less than an hour’s drive from Bangui, starts the equatorial rain forest. Matching the forest’s biodiversity is a mix of different ethnic groups. The indigenous and migratory Ba’aka, or pygmy, continue to live through hunting‐gathering in the forest. They may live in a settlement of their own, or less usually, in a half‐dozen huts on the outskirts of a village. The settled Ngbaka people, (pronounced mbaka) are the majority group of this area who, in addition to hunting and gathering, cultivate swamp rice, pigeon peas, cassava and coffee in small clearings within the forest and may live in 50‐200 hut villages amply spread along the few side roads with dozens of miles of empty forest on either side27. There is little bush‐meat, which is more a feature of the scrublands. They raise pigs, goats and chickens; have abundant free‐growing produce and building materials on their doorstep; and easy access to water from a high water table. Newcomers to the area, often Bangala from northwestern DR Congo or Gbaya from north and northwestern CAR, have been pulled by the evident abundance of Region 1 or pushed by conflict in their own areas28. They are likely to build their own villages from scratch producing ethnically diverse communities. These more‐recent arrivals bring with them a tradition of more open‐ground cultivation and business and are more likely to have larger clearings of peanuts and take sawn timber or firewood to market in Bangui. This easy coexistence between peoples is held to be a particular cultural feature of CAR where, according to Dr Jean Louis Ndama, a senior academic at the University of Bangui, there is no tradition of discrimination or even awareness of another’s mara, or tribe29. Meanwhile, outsider businesses open tracks to extract timber, and absentee town‐dwellers may buy up land for growing produce to be tended by local boys. A handful of Chadian traders are to be found in all but the smallest villages. Along the margin of the Ubangui River, a tributary of the Congo River, which marks the eastern edge of the health region, are a number of smaller ethnic groups, such as the Boffi, with fishing‐based livelihoods (HDPT, 2008). The consequences for the field of health which derive from the special type of existence represented by this region are fourfold. Firstly, there continues to be an immense biodiversity in the pharmacopeia with an existing indigenous people familiar with natural herbal treatment. The Ba’aka, while marginalized in most areas, remain respected for their knowledge of the forest and may sometimes be consulted by others. Secondly, the extremely localized higher‐density communities

27 Coffee here is for local consumption. As a further aside, this region, indeed this ethnic group, has contributed disproportionately to CAR’s political history: its founding president, Rev Barthélémy Boganda, his cousin David Dacko (who was president twice) and his nephew, Jean‐Badel Bokassa, its one‐time emperor, all came from this forest area south of Bangui. 28 Personal communications. 29 This is plainly untrue in the case of the indigenous Ba’aka people, however, who continue to be marginalized. The Ba’aka are the beneficiaries of a number of human rights based projects, run principally by Mercy Corps.

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sited along a limited number of routes offers an opportunity for fixed health facilities than is not available in the otherwise sparsely‐populated CAR30. Thirdly, Bangui and the health facilities it offers are, at a push, physically accessible (even if the services are almost certainly financially inaccessible). Equally, with transport, Bangui‐based health workers and managers could satisfactorily staff, stock and supervise any health facilities. Finally, all manner of everyday conversations show that there is a vibrant and continuing tradition of belief in the invisible world and the impact of omnipresent ancestors in everyday affairs, perhaps influenced by the majesty, obscurity and teeming life of the forest itself. Region 1 does have its own Regional Hospital, the new 100‐bed Chinese‐built Elizabeth Damatien Hospital in Bimbo, but since its location is actually on the outskirts of Bangui, and to all intents and purposes in it, it fails to markedly alter the region’s health facility profile31.

The small‐sized state‐owned Health Facility The health provider most characteristic of Health Region 1 is the small‐sized state‐owned health facility. Such a facility (at least in Region 1) is likely to be acceptably‐stout, well‐ utilized by the population, adequately stocked with equipment and medicines, with reasonably competent staff who are present and supervised. While similar physical infrastructure is distributed throughout CAR, Region 1’s health facilities are unusual. For a start, these providers are not in an active conflict zone: a somewhat rare feature of the CAR health arena. Often slightly set back from the village or at some distance, the building is typically a breeze‐ block bungalow with low zinc roofing (but no eaves or guttering) with a large painted red or green first‐aid cross on the front wall. An acronym‐laden sign, as mysterious to the facility’s staff as it is to the wider community, usually points the way. Sometimes dating from the Kolingba era (late 1980s), most facilities are of more recent construction. A small open entrance hall is standard, off which lie four medium‐sized rooms each with a small window. Handwritten descriptions are scribbled above each door32. Possibly a blackboard price list of medicines is present. The only health messages seem to be advice to contact the facility in the case of leprosy or guinea worm and some promotion for the use of condoms. A pair of ‘improved’ latrines is often found to one side33. Health facilities in Region 1 have probably benefitted from their relative proximity to Bangui. According to one nursing assistant, the more‐qualified staff members continue to live principally in the capital, while keeping a small house and some garden plots in the village. The purchase of medicines or delivery of reports is achievable within a day. Region 1 facilities are supported by an EU‐funded initiative. A Netherlands‐based FBO is the designated purchaser of the services awarding a salary to the key staff on condition, among

30 While the major road arteries (and minor roads in plantation‐rich central CAR) date from the late colonial period, the secondary road network seems to have largely been constructed during the Kolingba era. 31 The hospital is named after a Prime Minister of the Bokassa era. 32 This invariably includes the initialism ‘SMI’ (for Santé Maternelle‐Infantile), which is presumably incomprehensible to the majority of rural mothers. 33 The output of a well‐intentioned project, still ongoing in other regions, the design of the latrines is nevertheless poorly considered. Despite ample space, the latrines are cramped leaving no room for a receptacle of water for hand‐washing. The doors face the road.

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other requirements, that reports and statistics are compiled and delivered regularly34. This region has the highest health worker to population ratio outside Bangui ‐ 2.19 per 10,000 ‐ double that of Region 3 (World Bank, 2011). The typical staffing profile comprises the lead nurse (usually a nursing assistant with two years’ formal training), one or two sage‐femmes, or birth attendants (usually a TBA but sometimes a midwifery assistant also with two years’ formal training) and a microscopist (who has had some on‐the‐job training). The night‐watchman and the person in charge of the pharmacy (who is usually also an individual with three months’ on‐the‐job training) are paid from the profit from the sale of medicines35. The Bangui‐based project managers, who may have guaranteed the presence of some minimum equipment, also visit each facility once a month and, quarterly, bring along a supervisor from the prefectural health office36. Centralised training events are also organized. Evidence of some learning in the area of planning can be seen on the walls of the main consultation room: there is usually a map, a list of target populations with their sizes, and decent records37. However, in the clinical realm, according to many sources, much confusion reigns. Basic Primary Health Care knowledge – simply recognizing the signs of alarm for a variety of emergency conditions, for example – appeared very weak, sometimes entirely absent, at all training levels38. A Ministry of Health‐approved World Bank investigation found profound and extensive weaknesses in knowledge across the country. Of those clinical health workers successfully questioned – one in four staff refused to answer questions – only around a tenth could correctly name the symptoms of malaria, a third the correct treatment (World Bank, 2011)39. This is while MSF convincingly describes malaria as ‘certainly the major threat to public health in CAR and the principal cause of morbidity and mortality among children’ (MSF, 2011). Quality control studies looking at the accuracy of diagnosis and prescribing, or at the reliability of the results of laboratory examinations, could not be traced. Outreach appears to mean vaccination campaigns only. A teacher lamented that staff from the nearby health facility had not once visited his primary school of 200 children (while admitting he also had never invited them). A traditional healer complained he has learnt health staff berate patients who have visited him first. The combination of a minimum presence of staff, equipment and medicines has enabled the better‐performing facilities to attain respectable utilization figures: twenty to thirty pregnant women may deliver in the ‘SMI’ each month, while 15 to 20 patients may seek consultations

34 As a consequence of the IMF’s decertification of CAR’s financial procedures in 2011 and the EU’s own internal regulations, some EU‐supported projects have found their funding suspended. For five months, this Performance‐Based Financing project was, paradoxically, unable to finance its fully‐performing health workers, a situation not markedly dissimilar from the position of the publicly‐employed staff. 35 In those regions without EU salary support, all the individuals working in a health facility – rather than just the two as for the project above ‐ will expect their monthly salaries to come from the profit derived from the sale of medicines. 36 Personal communication. 37 Despite representing a fairly major achievement in planning, their relevance and use were dubious: the maps were not relevant local ones, however, rather hand‐drawn copies of the prefecture or region; target group estimates were calculated from the 2003 population census. 38 In conversation with range of individual health workers, distinguishing between dehydration, diarrhoea and malnutrition seemed consistently troublesome. 39 Damningly for front‐line PHC workers, a mere 4% of health post staff were able to correctly describe the care of a child with diarrhoea.

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daily40. There may be 8 to 10 laboratory exams. This usage, together with a very basic minimum of free money in local households (from the sale of produce) has enabled the pharmacy to maintain a level of liquidity sufficient to allow an operational revolving drug fund for the repeat purchase of a set basic set of 25 or so essential medicines, thus promoting further usage. Of the health workers delivering services at this local level, few – indeed very few ‐ are ‘integrated’, in other words on the Ministry of Health payroll41. Of those, either they simply haven’t been paid or, if paid, have had their salary transferred to a bank account for which there are no, or few, accessible branches42. Clinical staff see four patients a day on average (World Bank, 2011)43. The Ministry of Health compounds this remarkably low productivity by requiring all facility staff, not just the maternity team, and irrespective of the absence of emergency equipment, to arrange shifts in order to offer an open‐all‐hours 24‐hour cover. Large numbers of health centres – in reality mere buildings devoid of staff, equipment and supplies ‐ have been constructed in under‐serviced villages over the last decade by a variety of FBOs44. It appears that while health facilities in CAR are easily born, they do not die. In one example, a vast 15‐room maternity wing of a health facility on the periphery of Bangui (a prestige project of the late Ivorian president Houphouet‐Boigny) is completely unused, but remains open.

Region 2: Equateur Continuing clockwise around the map of CAR, three prefectures make up Region 2. Sangha Mbaéré, the most southerly, is solid equatorial rain forest which acts as a natural buffer with Congo‐ Brazzaville45. Both equally remote and equally under‐populated, the rain forest territories of both countries share migrating Ba’aka family groups. There is no land route connection. Spectacularly, butterflies abound. Logging and sawmilling are the major economic activities. Mambéré‐Kadei and Nana‐Mambéré prefectures lie on a higher plateau, and are consequently cooler with a more open browner, scrubland landscape. Acting as a second natural barrier, there is an arid semi‐circular ring marking the border with Cameroon, also colonized by France. This geographical feature may have led to limited cross‐border contact: a Cameroonian aid worker now living in CAR is convinced villages on either side of the border are markedly different, though concedes this may be more due to

40 The very pronounced rejection of home deliveries by Central African mothers may stem from their typical one‐room household where space and privacy are lacking. The house itself is more of a place to store belongings; daily life takes place in the big room outside the front door. 41 It is not obvious that, beyond expected diversions to family and friends, clinical staff routinely run their own private pharmacy businesses as a means of livelihood, a common situation in neighbouring countries. Possibly, in an echo of the separation of duties between traditional healers, there is a greater distinction in CAR than elsewhere between providing a chargeable service (such as diagnosing and prescribing) and providing a chargeable product (such as selling the prescribed medicine). Providing a service may be the clinical individual’s market niche. 42 In any case, the salary is to some extent notional. In 2011, in a novel inversion of the standard approach for cancellation of debt, President Bozizé wrote off the government’s 9 month’s salary arrears (Personal communication). 43 Productivity levels per person are of course even direr if all staff in a given health facility are included in the calculation. 44 CARITAS have built seventeen in the last five years in one prefecture alone. In a particularly egregious example, a pristine seven‐year‐old four‐room building “built to help the pygmies” and funded by a French charity stands empty next to the encroaching forest and collapsing huts of its intended beneficiaries, 5kms from a state‐owned health centre. 45 CAR’s link with Congo‐Brazzaville is instead via the River Congo direct to the capital. In the February 2012 munitions depot explosion in a Brazzaville neighbourhood which killed 200, 109 of the deceased were in fact Central Africans. (CAR national radio, March 2012.)

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central government influence than local character. The majority ethnic group has always been the southern Gbaya who have a strong tradition of cultivation. In keeping with the dominant development thinking of the late 1960s, then‐President Bokassa decreed a campaign of villagization requiring all communities to move to the road, apparently to facilitate a census‐taking. A series of smallish towns at regular distances along a single main road, with very few side roads, continues as a striking aspect of the region. Cattle herders from the pastoralist Mbororo, or Fulani people, with their distinctive circular huts, may live on the outskirts of each town hawking dairy produce. Rougher igloo‐shaped huts are also evident and indicate settled Ba’aka residents. As with much of CAR, there are still vast tracts of open space. The main economic activity in Region 2 is the artisanal prospecting of CAR’s high‐quality diamonds with gold panning in some of the northern areas (ICG, 2010). This has attracted diggers, with or without their families, from across CAR and entrepreneurs from, most notably, Chad. Small‐scale, unregulated diamond merchants have occupied the market void left in the wake of an inept government attempt in 2010 to further tax the larger‐scale, often European, regulated businesses (MSF, 2011)46. Berberati, the regional capital, is now possibly CAR’s third biggest town (still only a moderate 60,000 population estimate) constructed on the back of services to diamond mining. Region 2’s uniqueness in respect of the health arena lies in its history: it is the probable location of the first modern health providers in present‐day CAR, and it appears to be the scene of the health system’s most dramatic collapse. Early health provision in CAR seems to have been exclusively faith‐ based. According to the history of the Grace Brethren Fellowship, a US conservative evangelical Baptist congregation, a triad of their missionaries trekked from present‐day Cameroon and, in 1921, opened a small hospital – believed to be CAR’s first – in 1921 in Boguila. By the mid 1980s, the congregation had a further hospital in Yaloké and a network of dispensaries and clinics throughout the region, according to its one‐time administrator. For similar reasons – the happenstance of the presence of a determined missionary ‐ the Swedish Lutherans opened up a network of clinics, as did a second Baptist congregation, Baptist Mid Missions. Catholic missionary sisters later either established their own clinics attached to their churches or ran the local French administration one, as in the case of the now Regional University Hospital of Berberati. Two Catholic dispensaries in the heavily‐forested far south of the region remain the only health providers for Ba’aka families. In 2002, in the so‐called North‐North wars, the health system in Region 2 (along with the rest of the civilian state) dramatically collapsed47. Mercenaries from DR Congo, recruited by the then‐president Ange‐Félix Patassé, fought mercenaries from Chad, recruited by the current president François Bozizé. In a nutshell, the fighting moved up and down the country (literally, from Bangui to Paoua) three times. Each time, infrastructure was looted and trashed ‐ not, it is said, always by the mercenaries48. After the conflict, and in common with missions all over Africa, the Grace Brethren Fellowship found itself unable to restore its support and has left the health arena altogether (though continues to work in water and sanitation). Some facilities have been incorporated by other organizations; some entirely abandoned. Other repercussions, such as severely‐damaged buildings, loss of equipment, permanent departure of expatriate staff, perceived insecurity affecting the choices of national staff, continue to reverberate throughout the remaining network today.

46 On a pretext of breach of contract by the companies (to build infrastructure for their host communities) officials ordered, at gun point, the whirlwind emptying of all safes, with the subsequent departure of the companies and the collapse of what little tax revenue was in place. In February 2012, a Chadian diamond trader was still claiming to prefer using a motorbike in the countryside because “people will wave for the bike to stop and offer to sell a handful of uncut diamonds, which they won’t do if you’re in a car”. 47 Both protagonists are from the north of CAR. The so‐called North‐South wars, five years earlier, had seen northern rebels fight Kolingba’s largely southerner army. 48 A vast market of looted goods grew up at a site in southern Chad over the border from CAR. Personal communication.

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The wholesale folding of formal health provision in the region was followed by the collapse of the formal diamond mining industry, triggered by the government’s intervention almost a decade later. A worsening of health indicators ensued as miners’ cash income disappeared and livelihoods suffered (MSF, 2011). MSF Holland and MSF Spain intervened and remain in the region. The state‐owned Hospital. The distinctive health provider of Health Region 2 is the state‐owned hospital. In Berberati, the regional capital, this is a well‐kept, unfenced, 70‐bed complex of six or seven bungalows in large grounds near the centre of town. Constructed in the early 1950s, the hospital was run by a series of French military doctors until the 1980s49. Its continued high reputation is popularly explained by the presence, until today, of a formidable Italian Catholic religious sister. The hospital can perform operations not requiring general anaesthesia, typically hernia repair and caesarean section. Its maternity unit is well‐appreciated. Staffing levels are vague. All regional hospitals seem to have only one doctor‐surgeon, supported by a handful of senior medical students. The Regional Health Officer, whose offices are usually off‐site, is also a doctor50. There may be a dozen diploma‐level staff or above, including four or five technicians (a four‐year course now discontinued), the same number of State Diploma Nurses, and two or three State Diploma Midwives. There will be around ten nursing assistants or midwifery assistants and twice that number of auxiliary staff some of whom will be unqualified microscopists. There may be at least 40 staff on the books; Berberati had 67. However, while formally‐employed civil service staff may be absent (since senior staff frequently attend meetings or training), so‐called ‘non‐integrated’ staff are certainly present. Perhaps upto an extra ten nursing assistants work formally – they are rostered for night duty, for example – and are given some money at the end of the month from the user‐fees collected formally, the so‐called prime. (Patients are routinely charged directly by each staff member caring for them. However, this category of ‘user‐fee’ is not collected formally and will not go through the accounts.) A half‐dozen First Aiders (who genuinely seem to be community‐minded citizens) may work voluntarily. In theory, a regional hospital is the referral facility for the subordinate prefectural hospitals which in turn are the referral hospitals for a half‐dozen health centres each. The regional hospital itself – again, in theory ‐ refers patients to the national‐level hospitals in Bangui. In practice, a regional hospital in CAR is a stand‐alone facility that acts as a mega‐health centre for the main town and its immediate surrounds51. The difficulties associated with local travel dramatically affect the calculations of patients and their families. Even for those with means, following the officially intended referral pathway means extra journeys – and are thus extremely unlikely52. Equally, once hospitalised, the patient’s day‐to‐day care is the responsibility of family members who will need their own local support base. Using a health facility outside one’s own locality appears to be an unwelcome and prohibitively expensive option. Similarly, nearby health facilities ‐ whether state‐ or church‐owned ‐ are comprehensively bypassed and so suffer from abysmally low utilization rates of one to five patients a day,

49 The main office contains a wall display showing the dates and name of each of the hospital’s medical directors. 50 In some regions, these individuals may represent the only qualified medical doctors in the entire region. Sub‐regional hospitals are reportedly run by technicians and nurses. 51 During the dry season, Bangui is an all‐day drive away even in a private 4x4. In the wet season, a hyper‐crowded lorry may take two full days just to get to the Bouar highway, and most of a further day to reach Bangui. 52 Most ordinary people, presumably, would have no inkling of what is the intended referral pathway, and instead go to the nearest, biggest hospital. This is an issue for health planners in Cardiff and Carlisle, as much as it is for those in CAR.

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according to the facility registers. They have responded in contrasting ways53. As with many crippled healthcare arenas, the regional hospital in CAR is not at all a referral hospital in the normally‐accepted sense. Berberati is an atypical regional hospital for four reasons: the long‐term presence of an expatriate (Catholic) nun, with considerable personal connections, both in Bangui and in Europe; unusual liquidity in the local economy derived from the diamond‐miners; the consequent large size of the local population; and Protestant support to the area over generations. The Regional Hospitals in Bossangoa, Bambari, Birao and Bangassou will not have all of these features. A second atypical facility is the compact Medical Centre in Ngoboko, supported by Sucaf, the national sugar parastatal company. Fully‐staffed, impressively‐equipped and well‐used by the community, it has a surgeon‐doctor, an ambulance and 24‐hour electricity supplied from the sugar mill 200m away (which allows for three functioning air‐conditioners). The staff receive housing, transport and regular salaries. Financed and supported as if by a wealthy private company, it is nevertheless state‐owned. The largest health facility in a prefecture, the administrative sub‐division of a region, is called a prefectoral hospital though it may be indistinguishable from a large health centre. Some may be as close in size and range of services as the ‘parent’ regional hospital (as in Bouar), some possibly bigger (as in Kaga‐Bandoro).

Region 3: Yadé Region 3, in the north‐west and mostly bordering Chad, is made up of Ouham‐Pendé and Ouham prefectures, with Bossangou, the hometown of the current president, as its regional capital. The northern Gbaya, the predominant ethnic group, are traditionally farmers. Smaller groups are the Mboum and the Sara. Mbororo herders and Chadian traders are well‐represented. There is a relatively dense population, supporting a number of largish towns. Crop destruction and animal theft has caused violent skirmishes between farmers and herders (Spittaels and Higert, 2009). Also the zone of operations for a Central African rebel group, the APRD54, the whole region has been insecure for over a decade. There is a fluidity of exiles and rebels from both CAR and Chad across their common border (ICG, 2007). Both US and UK travel advisories continue to recommend against any travel to this region. This region poses particular challenges in the health arena. Unlike its neighbour to the south, it has yet to recover from the conflicts of the Patassé era. While most church facilities have collapsed for good following the withdrawal of their sponsors from the health field, public ones remain closed awaiting staff and supplies, as insecurity continues. A lucid publication describes health indicators pointing to prolonged severe stress, at levels normally associated with emergencies (MSF, 2011). Despite a doubling of the health worker to population ratio between 2006 and 2011 as a result of the presence of NGOs, Region 3 remains underprivileged (World Bank, 2011), an indication of the very low pre‐existing levels of service. The task of health provision, in the effective absence of the state, has fallen to a major NGO player: the MSF family. The large‐scale International NGO.

53 The managers of the pretty Baptist Evangelical Church health centre have formally downsized from five staff to one, keeping only the centre’s most experienced staff member. The managers of the dreary state‐owned Nambona health centre, meanwhile, have watched their staff informally vote with their feet, leaving only the two least experienced staff members to cover. 54 Armée Populaire pour la Restauration de la République et la Démocratie, or Popular Army for the Restoration of the Republic and Democracy, formed in 2005.

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The type of health provider characterized by Health Region 3 is thus the large‐scale International NGO. Collectively, MSF France, MSF Holland and MSF Spain assemble and deliver unparalleled experience, expertise and resources. In Region 3 they have established a network of primary, secondary and tertiary facilities that reportedly provide high‐quality care in the five sub‐prefectures where they operate55. Nationwide, MSF supports nine hospitals and thirty‐six health centres or health posts, in 2010 admitting over 25,000 people for in‐patient treatment and delivering almost six hundred thousand out‐patient consultations at a cost of US$ 22.8 million, an increase of a quarter over 2009 (MSF, 2011). If government staff at the under‐resourced Regional Hospital in Bossangoa believe an emergency patient can at all survive the 3‐hour journey (and if transport is forthcoming), they will readily opt for transfer to the MSF hospital in Paoua, a UN clinician claims. Annual out‐patient consultations approach the equivalent of a seventh of the entire non‐Bangui population, With a free‐of‐charge service, an inflow of patients from areas not formally served by MSF can be predicted. There are other examples where an INGO has assumed an outsize formal health provision role in their particular region, though none quite to the same extent as MSF in Region 3. MERLIN, Medical & Emergency Relief International, a UK‐based INGO, is a dominant provider in Region 6, though it also works elsewhere. International Medical Corps (IMC) is the sole private not‐for‐profit provider in Region 5. The cordial geographical partitioning of CAR between the INGOs, sensible for many operational reasons, has parallels in the earlier division of the then Oubangui‐Chari by the Evangelical Baptist missions.

Region 4: Kagas While each region borders two different states, only Region 4 spans the country north to south. Touching arid Chad and forested DR Congo, it has the least uniform geography. The northernmost prefecture of Health Region 4 is Nana‐Gribizi , the capital of which is Kaga‐Bandoro, the old French outpost of Fort Crumpel, now CAR’s second biggest town. The main crops are peanuts and cotton. An aid worker who knows the area well reports that villages are made up of a handful of homesteads only and are many miles apart. Bangui is more accessible than Bambari, the official regional capital for Kaga‐Bandoro prefecture. The prefecture is the home territory of the Mandja people who are, like their northern cousins the Gbaya, traditionally cultivators. Nana Gribizi has a history of being without the banditry familiar elsewhere in northern CAR. Any zaraguina, literally road‐cutters, or highwaymen, are said to have been sought out by villagers and executed using home‐made weapons. This opposition was adequate until the arrival in 2011 of the heavily‐armed militia of the rebel Chadian warlord Baba Wade who, believing himself to have been cheated in some way by the CAR president, announced his intention to take the presidential palace. The prefecture is now a conflict zone as Baba Wade’s militia engages in guerrilla fighting against the national armies of Chad and CAR who seek them. A mere 300 kms from Bangui, and theoretically easily reachable and back in a day’s drive along the paved road, Kaga‐Bandoro is also now effectively cut off. A French NGO, Committee Aide Medicale, withdrew from the prefecture in late 2011 and International Rescue Committee (IRC), the remaining lead agency, has had to scale back. MSF Holland however continues to operate there. It is the site of one of Unicef’s three sub‐offices. The challenge this prefecture poses for health providers is how, in a more stable time, to offer services to a largish population spread over a wide area where there are no, or few, concentrations of people.

55 Paoua in Ouham‐Pendé and Boguila, Maitikoulou, Kabo and Batangafo in Ouham. MSF also runs projects in four sites across three other prefectures. (MSF, 2011)

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Perhaps for this reason, the bed per population ratio in this prefecture is CAR’s lowest at 0.2 per 10,000, a hundredth of that of the nation’s highest in Mbomou56. The southern part of Region 4 is considered the agricultural heartland of CAR. Comprised of Kemo and Ouaka prefectures, the regional capital is Bambari, thought to be CAR’s fifth largest town, the gateway to the northeast and southeast of the country. Almost all inhabitants are Banda – one of CAR’s three major ethnic groups along with the Gbaya and Mandja ‐ who are primarily farmers. They are considered less independent‐minded than their northern cousins. The Ngbanziri, who live around Kouango, rely more on fishing. Still on the country’s central plateau, it is the site of vast sugar plantations in Ngokobo dating from the Kolingba era. Cotton is grown in small household plots (the purchase of which by the national company only restarted in the 2012 season). Many heads of cattle are reared for transport by boat to Kinshasa and Brazzaville. There are all the usual subsistence crops, most notably cassava and, because of its extensive scrubland, this area is the source of most of Bangui’s dried bush meat and charcoal. Because of the need for accessibility to passing trade and easy access for the cotton dealers all villages, which may hold 100 to 200 single‐room huts, lie along the main roads. Indeed, there are few branch roads. Its flat, open landscape was favoured by the French plantation owners of the mid‐19th Century who contractually ruled the then‐Oubangui‐Chari for France. This combination of earlier development, cash crops providing income and, in the vaguest sense, a transport hub has led to a (relatively) high population density with a minimum of disposable income. Bambari is host to a sizeable and economically influential Chadian community with extensive links to Sudan. They export CAR’s robusta coffee beans and import, among other things, Coca‐Cola57. The private Mini‐Pharmacy. The archetypal and predominant health provider in the south of Health Region 4 is the private mini‐pharmacy. Known as a mini‐pharma, it is typically a single‐room roadside hut or shop usually crammed on all sides, from floor to ceiling, with medicines and medical supplies. The ‘pharmacist’ is usually also the sole owner; one owner may have two or even three outlets58. All manner of preparations and products are available at a price that suits: if a customer has only money enough for one antibiotic capsule, that is what is sold. In some cases, the pharmacien may be a qualified health worker. In one observed example, a qualified nursing assistant working from the counter of his hut – one of a number of mini‐ pharmas in a row in the centre of Bambari – was repeatedly able to provide a consultation, do a stool exam, suggest a diagnosis, recommend a treatment and, when appropriate, make a referral to the nearby regional hospital. Following a fully‐aseptic technique, he expertly administered IV fluids and gave intravenous and intramuscular injections. The first dose of other medicines were offered with water and taken on the spot. (This is a WHO best practice recommendation, very rarely seen in the field). Benches in the front of his hut act which as a waiting room testified to public demand. They are an eloquent comment on his utilization

56 Bed occupancy rates are extremely low across CAR, ranging from 7.5% in Region 5’s Vakaga to 37.7% in Region 3’s Ouham Pendé (MSPP, 2008).Few statistics are quoted in this report since, in CAR, both their reliability and usefulness are deeply questionable. In this example, the unit ‘bed’, which can be seen as shorthand for a cluster of associated services, is of limited usefulness since the services are unknown or incomparable; the 2003 population statistics can only be vague estimates given the administrative limitations of the state apparatus and migration; and the prefectural average is misleading given the stark differences in population densities between town and countryside. 57 The Coca‐Cola Company closed its licensing operation in 2011, allowing CAR to join North Korea and Somalia (excluding Somaliland) in the handful of the world’s countries without local production (EIU, 2011). 58 Personal communication.

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rates and productivity, running at 25‐35 patients per day59. At the other end of the capacity spectrum are entrepreneurs who have spotted a high‐value, high‐turnover, low‐risk business opportunity. Commonly they have, or claim to have had, three months’ first aid training with the Central African Red Cross, or once worked as a volunteer with an unspecified NGO. Others report they have been taught by their mother who is a nurse. One merrily admitted to having no training whatsoever but, in case of doubt, was able to phone a doctor friend in Bangui: an unorthodox example of telemedicine perhaps. At first glance these all seem risible claims to competence and just cause for outrage. On second glance however, as noted above, three months is also the training period for most pharmacy workers in state‐owned health facilities, and knowledge levels amongst even qualified staff are far from ensured. The proliferation of small pharmacies, which very often function as minor health posts, is a phenomenon practiced, too, by other populations abandoned by the official government, such as the Somalis. Community dispensaries, which sometimes call themselves community hospitals, occupy more marginal sites and are essentially private mini‐pharmas run by community associations60. They operate with identical rationale ‐ and identical professional standards – but may rely on a greater‐than‐expected market share because of their appeal as a neighbourhood enterprise. All providers have individuals who supply medicines with abandon, with spurious rationale61. The common features of the mini‐pharmas are their accessibility (in town centres or crossroads), convenience (often open seven days a week, and usually until late evening), more reliably complete stock, immediacy, customer service and probably anonymity. Though the medicines themselves usually cost more than their equivalent in the health facility (when accessible and available) the total cost is cheaper since the otherwise obligatory registration, consultation and laboratory charges are avoided.

Region 5: Fertit Region 5 makes up a third of the entire national territory in CAR’s north‐east, the site of three designated national parks in earlier times and has been under‐populated, even unpopulated, for centuries (O’Toole, 1986). From November to April, the landscape is reported to be essentially road‐ less desert; in the wet season, all communities become, literally, islands. Humanitarian agencies report only those communities with a landing strip are accessible. Traditionally pastoralists, the Gula, a tall people related to the Darfuris, are the predominant local group along the region’s border areas with Chad and Sudan. Smaller groups are the Kara and Runga. Elsewhere, away from the borders, the main people are the Banda (HDPT, 2008). After the rains, extensive pastures of free bourgou, a highly nutritious grass, (which they would otherwise pay for) encourage Chadian pastoralists to bring their large herds. Each week, in secretive and heavily‐armed operations, some fifty trucks cross from Sudan to extract free ‘Chinese bamboo’, a prized construction material (Spittaels and Hilgert, 2009)62. The corner prefecture is Vakaga, vertex of what has become known as the ‘tormented triangle’.

59 By contrast, the entire Nambona Health Centre in Berberati with, officially, seven staff on its books recorded an average 30 patients per month. 60 For a fuller review of health facility nomenclature please see Appendix 2, below. 61 Asked for advice on what home care to give a 2‐year‐old with mild fever, the first aider manning one smelly and dark three‐roomed ‘community hospital’ in Bambari was happy to recommend as his sole intervention an adult dosage of intramuscular steroid and a double dose of IM analgesia, with a quinine injection if there was no improvement. 62 Central Africans then buy it back, plus costs and taxes.

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Vakaga’s geography has made it a site where the armies, rebels and proxy rebels of N’Djamena and Khartoum group and regroup (Berg, 2008). Birao, the regional capital, saw fighting in 2006, 2007 and 2010 (ICG, 2010). As with Uganda, the conflict in the north has attracted and focused international attention on an otherwise neglected larger country. Meanwhile not the geography, but the geology of the southern prefecture, Haute Kotto, has made it a destination for an assortment of various rebels from CAR and abroad. The extensive alluvial deposits of CAR’s eastern diamond field have made the whole area a conflict zone (ICG, 2010). Notwithstanding a recent peace agreement, two Central African rebel groups, the Union des Forces Démocratiques pour le Rassemblement (UFDR) whose members are predominantly Gula and the Convention des Patriotes pour la Justice et la Paix (CPJP) whose members are predominantly Runga, have fought each other for control of these diamond fields. The messianic Lord’s Resistance Army has also reached the area (EIU, 2011). Haute Kotto’s capital is Bria, at the extreme edge of the scrubland near Ouaka Prefecture ‐ where IMC, the only NGO, supports a hospital intended for the internally displaced from these conflicts. Wealthier Chadian traders and their families sometimes travel outside the region to Ippy Medical Centre, on the edge of Region 4, for minor operations. To the west of Vakaga, lies Bamingui‐Bangoran prefecture, where MSF Spain has some operations in Ndélé. The Supernatural Because of the perpetual insecurity, both in the town and countryside, the defining feature of the health services in Region 5 is their virtuality. While the Supernatural is therefore the principal health provider in Health Region 5, since alternatives are negligible, health through prayer alone may still be the first choice elsewhere in CAR. Animistic beliefs and practices strongly influence the Christian majority (CIA, 2012). The Muslim Gula , and Chadian and Sudanese nationals, wear grigri as preventive charms: Koranic inscriptions sewn into leather pouches prepared by marabout, religious healers, which are worn around the neck, upper arm or wrist until they fall off63. Adherents of the African charismatic churches consider only the Holy Spirit will heal and that all traditional medicines, not just sorcery, are the work of Satan64. Reportedly, some African charismatic churches also consider even modern medicine to be Satanic. Others are more ecumenical: a well‐known Baptist pastor and healer in Bangassou combines traditional medicines and prayer. Non‐Muslim citizens of CAR may recognize perhaps three dozen separate conditions all of which would have once been treated traditionally65. The use of roots, bark, leaves and berries is but one aspect of traditional care performed by a zo ti soyengo ti zo, or sage. A 26‐ page booklet on natural remedies is on sale at roadside stalls and a second larger book with translations in Sango is in circulation (Ayissi)66. In the University of Bangui, there is an Office for Studies and Research on Traditional Pharmacopeia and Medicines in Africa, the output of which could not be determined. As more conditions come to be seen, at least by urbanized centrafricaines, as being

63 Grigri are not Islamic items, but rather generic amulets worn across the Sahara. 64 According to the Congolese pastor of the Nzamba Malamu church in Yombo all healing comes through Bon Dieu, awkwardly also the name of his countryman the traditional herbalist who lived right next door. 65 Personal communications. 66 The authenticity of some of the translations in the second book is dubious. It is claimed the Neme tree, the bark of which contains quinine, is called Kéké ti Nivaquine, hardly a traditional name. Both draw on globally familiar folk remedies – lemon, onions, garlic, for example – so may simply be local reproductions of other texts.

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Health Service Provision in the Central African Republic

biomedical in origin – and so renamed – there are fewer calls on traditional medicine as the first option. A number of the remaining conditions may indeed have a biomedical origin but continue to be viewed in a traditional light. Kota ngbo, or boa snake, for example, is a condition where a newborn baby (with, from a Western perspective, a low APGAR score) is seen to be limp, or crushed as it were. All mental health conditions, including epilepsy, are ascribed traditional causes. Psychotic conditions are seen as payback from a crossed nganga, not rewarded as agreed. Other conditions, while within the traditional pathologies, are outside the biomedical ones. Urukuzu, or transitory metamorphosis into animals, talimbi, the use by enemies of malevolent water spirits to drag into water, beat up, kill and then deposit the body elsewhere, and likundu, sorcery, are deeply‐held and openly‐accepted beliefs even among the Ngbaka living in Bangui. Yet another belief, still prevalent, is that of Mamiwata, which may only in part have a biomedical explanation67. The carnal desire of this water goblin, who may be either male or female, and who may also live in rocky outcrops and tall trees of the northern plains, is held to the reason for childlessness or repeated miscarriages. One of the parents of an albino child is thought to be a mamiwata (Laird, 1993).

Region 6: Haut‐Oubangui Region 6 is in the south‐eastern corner of CAR, over a thousand kilometres distant from the capital at its furthest point. The eastern border splits the Zandé people from their South Sudanese cousins, while the Mbomou river, a tributary of the Oubangui, marks the southern border with DR Congo. Two main ethnic groups, who have traditionally lived chiefly through fishing, line both banks of the river. They are the N’Zakara, the original inhabitants of Bangassou, the regional capital, and the Yakoma, from whom came the former president General André Kolingba68. The prefectures are Basse Kotto, Mbomou and Haute Mbomou, the northern part of which is semi‐arid. From the mid‐1920s, this area was the focus of intense protestant missionary work by Baptist Mid‐ Missions, a second conservative US evangelical congregation, who arrived at first via Uganda69. Together, or rather in competition, with the Catholic Church, missionaries collectively have been responsible for a legacy of a relatively well‐educated population throughout this region. A Cameroonian doctor found grandmothers in a local market speaking better French than their grandchildren. Long‐settled and peaceful, the eastern third of the region has since 2008 suffered from the depravations of the Lord’s Resistance Army (LRA), once a northern Uganda‐based messianic group now straddling also in DR Congo and South Sudan (MSF, 2011). An important health provider, Merlin, a UK‐based INGO, has tried to maintain services amongst the insecurity. Sick inhabitants have crossed the river to the MSF hospital in Dondo, northern DR Congo, made use of the Ugandan Army medical facilities around Obo which are open to the local population, and have travelled to health facilities in South Sudan, which has a large CAR refugee population. In contrast to Region 5 and elsewhere, the inhabitants of Region 6 fled to towns for

67 Extraordinarily, Mami Wata is also the name of a malevolent angel venerated by Mexican narco‐barons whose tattoo adorns many Hispanic inmates in US penitentiaries. Mami Wata is a water goddess known on both sides of the Atlantic, the name perhaps reaching CAR via Nigeria and Cameroon, the concept in the reverse direction. 68 Across the Ubangui river lies Gbodolite, the ancestral home of Zaire’s President Mobutu Sese Seko. 69 To avoid overlap, the early missions agreed in Brazzaville in 1921 that Grace Brethren Fellowship, led by Jim Gribble, should work to the west of a line north of Bangui, a third evangelical Baptist mission, African Inland Missions, should work to the east of a line north of Bangassou, and Baptist Mid‐Missions, led by William Haas, should work between the two. William Haas, based in Bangassou, has claim to be the father of written Sango, then a trading language once only used along the river. Extensively used and taught in his preaching, it later was adopted as the national language of CAR.

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safety. The health worker to head of population ratio declined by a quarter between 2006 and 2011 (World Bank, 2011). The EC‐funded project supporting the national health system found in Region 1 is also active in this region, particularly in CAR’s smallest prefecture, Basse Kotto.

The Church Region 6 is not the only region where the church is a major health provider and neither is the church the exclusive provider in Region 6. However, for historical reasons particularly the presence of the Catholic hospital in Bangassou, the church as health provider is closely identified with this region70. At first working from unregistered dispensaries ‐ illegal for foreigners under French colonial administration law until the 1950s ‐ American missionary doctors and nurse‐midwives established a network of hospitals (but not officially called such) of varying sizes particularly in the smaller rural towns in the southern and central prefectures (Laird, 1993). It was this preponderance in the rural areas that disproportionately affected them during later looting and unrest. They were funded, supplied and equipped from donations raised by the same missionaries in their furloughs in the US, one year in every four. Individual person‐driven dedication seems to have been the key factor in their success. Training of local staff was high‐quality and on‐the‐job (Laird, 1993). At the same time, the Catholic Church, supported by the French administration, set up hospitals in the bigger towns. While committed and trained individuals from Europe and the US were willing to volunteer to live and work in such hardship hospitals, perhaps for life, certainly for decades, the business model, as it were, remained viable. Now, the Catholic hospitals, no longer able to depend on a stream of qualified volunteers, accept less‐qualified and less‐experienced national staff and increased numbers of lay workers71. For different reasons, the Evangelical Baptist hospitals never recovered, even partially, from the loss of expatriate staff. Success in fund‐raising in the States, perhaps without the impact of hearing personal experience, nosedived72. The once‐illustrious 60‐bed Ippy Hospital was founded ‐ indeed built – by Margaret Nicholls Laird, who was nationally and international recognized for her medical work (Laird, 1993)73. It is now a shell of its former self. The two operating theatres and associated rooms are at least put to more use than the 1000‐title, English‐language, hardback medical textbooks gathering dust in the library. Its full staff complement is eighteen first aiders. While all staff have received further training, according to its current manager, individuals can only be officially recognized for their basic certificate for three‐months training. The network of smaller church‐run health facilities appear similarly dependant on circumstance and leadership. The Apostolic‐run health centre in Bambari remains viable only through its patronage by the town’s wealthy Chadian traders. A second health centre is well‐ respected and supported largely because of the presence of a dedicated nurse‐qualified nun.

70 The association between the church and Region 6 is somewhat artificial. The Protestant church is also historically linked with Regions 1 and 2 and there is a Catholic Cathedral in Bangui. However, the pre‐eminence of the health component of the mission in Bangassou is well‐recognised. 71 Personal communication.

72 In keeping with their evangelical doctrine of outreach to the non‐baptised, organizational support from the parent church for the already‐baptized has also collapsed. 73 In an example of early recognition of the importance of brand name in marketing, Mrs Laird is said to have persuaded the chief of the time to rename his village from Pipi, which she perceptively understood would be a difficult name to promote.

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Health Service Provision in the Central African Republic

As with their sister facilities in the state‐owned sector, however, income‐generation through the sale of medicines often appears the priority. Over‐prescription looks rife; all consultations automatically result in a prescription for four or more medicines –perhaps required for commercial rather than clinical imperative. This is routinely preceded by an instruction for laboratory examinations which, given the circumstances, seems unnecessarily, indeed uncharacteristically, punctilious. As with their state‐owned partners, the community health role of the health facility – namely health promotion, disease prevention, behaviour change through health education – is absent. The association overseeing church‐run medical care, ASSOMESCA, which originated in 1989 as a collective bargaining tool largely for the smoother import of medicines, has expanded its role to include a more administrative and supervisory stance, while at the same time – or perhaps because ‐ its raison d’être has largely collapsed: its one‐time biggest medicine consumer, Baptist Mid‐Missions, has left the health field entirely, while others can obtain their supplies quicker and easier through any one of the three increasingly powerful drug import companies. All nine Catholic dioceses continue to participate. ASSOMESCA claims that the facilities under its umbrella provide “40% of CAR’s health care” but this figure turns out to apparently refer to a 2006 estimate of its share of the total health facilities, irrespective of size74. However, the market share estimate of health care may have been derived from elsewhere: 40% is exactly the standard estimate given by faith associations throughout Africa (Olivier & Wodon, 2012). Faith‐based providers from non‐Christian communities seem under‐represented. Non‐ Western donors adopt different approaches and follow different channels everywhere, so may be present, simply unrecognized. Certainly no overseas Islamic healthcare charity participates in health cluster meetings. Only one national NGO, the African Islamic League, is formally registered with the lead humanitarian coordination group (hdptcar, 2012)75.

Region 7: Bangui The seventh region, actually a collection of urban arrondissements, is Bangui, the capital. In many ways so unlike the rest of the country, in other ways it is not so very different. At night it reveals its paradoxical nature: it is as quiet as a village and looks like one. With no street lamps (except for 03.00 till 06.00) in most neighbourhoods the only lights – just as in a village – are the occasional dots of paraffin lamps stretching into the distance. The glare of a fully‐lit UN building perimeter lights up some stretches of main road. Less than 10% of homes have an electricity supply (ICG, 2007). Household generators are extremely rare. Probably, few Bangui residents could afford either the generator or its fuel. The only thing notably oppressive about Bangui is the heat. Police officers can occasionally be seen in the very middle of town but almost never elsewhere; there appear to be no patrols. Overt abuse of power by uniformed agents of the state, such as that witnessed at road blocks on the outskirts of towns, seemed entirely absent within Bangui. Low‐level criminal activity by individuals is known and restrictions in night‐time movement are recommended by some (US Department of State, 2012). Given CAR’s notoriety, the author anticipated and was prepared for a markedly more hostile city environment, but found instead a situation not unlike that referred to by an earlier political researcher:

74 Personal communication. 75 Some conservative Muslim states do maintain a presence in CAR. The Kingdom of Saudi Arabia recently constructed Bangui’s Grand Mosque and Morocco’s King Mohammed IV underwrote the 2011 refurbishment of the National University Hospital.

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Health Service Provision in the Central African Republic

The violence of 1996‐1997 marked a new threshold in the CAR’s destabilization. Until this point, violence – other than persistent rural criminal banditry – was a rare phenomenon. The successive military coups d’état had used little direct force, while the democratization campaign of the early 1990s had been a peaceful civil protest, to which the authorities generally responded with moderation (Melly, 2002). While the offices and stores may observe European working hours, street life beats with two daily pulses, at dawn and at dusk. Local coffee, traditional doughnuts and French baguettes are on sale everywhere from pre‐dawn as mamans prepare to fry fish and plantain for sale during the day, along with the staple food gozo, or cassava porridge. When the ‘sun dies’, as it is said in the national language, away from the town centre and the handful of up‐market restaurants, the culture that CAR shares with its Congolese neighbours dominates for a few hours: food stalls, pavement bars, Congolese‐style music, bottled beer and an endless parade of hawkers. The private for‐profit Health Provider As befits the centre of an energetic, informal economy, Bangui is the home of the private for‐profit health provider, and all price brackets are catered for. At the top end, serving the wealthiest and most expatriates, including embassy and UN staff, is the 8‐bed Chouaib Clinic, opened in 1950 by a Lebanese doctor (and where, incidentally, onetime Emperor Bokassa died). Senior government officials may then fly to Cameroon for treatment, very senior ones to Paris. UN expatriate staff may be evacuated to Nairobi, French diplomats may go to Gabon and wealthier Lebanese businessmen may travel to Beirut76. International NGOs have their own arrangements for their expatriate staff, and often their own doctors. Two private insurance companies act as agents for international and national companies, such the telecoms companies and the petrol giant Total, and for a few family groups. The larger of the two, Ascoma, holds policies for five thousand individuals. The business climate is favourable and in a period of expansion, according to a manager. High‐ to middle‐income earners, or those with some money, say they will call a doctor they know personally who will charge for a consultation, recommend tests (which are available at the private Pasteur Institute and elsewhere) and make a prescription for medicines which can be bought at any of Bangui’s fourteen well‐stocked private pharmacies. Such doctors work out of a cabinet medical or clinique either in association with two or three colleagues or alone or, if they are more recent graduates not yet with the capital or connections to have a permanent base, they will make house calls77. Some employers may pay a monthly retainer to a doctor to provide such services. One private doctor could name sixteen such cliniques off the top of her head and believed there were around fifty in total, including some petites cliniques, all told occupying the time of perhaps 80‐150 doctors. Her own clinic included a recent graduate on the morning shift and a retired doctor on call. All cabinets also employ a qualified laboratory technician and qualified nurse. They only rarely have an in‐ house pharmacy, which doctors seem keen to disassociate themselves from. A Romanian doctor from one of the state‐owned hospitals runs a clinic at the large International Turkish School three mornings a week78. A nutritionist offers homecare for diabetics and others at $60 a month. Outside Bangui in Berberati, a lone Somali doctor serves the Arabic‐speaking Chadian community. Similarly, nurses and nurse assistants can be expected to provide services to their own list of acquaintances. The quality of care in the clinics seems a varied as its format. A private not‐for‐profit paediatric facility ‐ part‐clinic, part‐hospital (8 beds) – which offers first‐world standards of

76 Various personal communications. 77 Personal communication. 78 There is also a small Central African community in Bucharest, a relic of the Ceaucescu‐Bokassa fraternal period.

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Health Service Provision in the Central African Republic

care is run by the Italian NGO Emergency. Meanwhile, an apparently‐certified Chinese heart consultant fronts a sham clinic that, probably for licensing reasons, doubles as a pharmacy selling mostly injections. In impenetrable French, she will tout the need for an $18 ECG exam to every customer. Lurid gynaecological posters add to the general unsavoury atmosphere. The private pharmacies are owned or managed by a sole qualified pharmacist, according to one of their number. They each usually employ at least one (‘non‐integrated’) State Diploma Nurse. The pharmacy can offer, but will charge for, consultations, check‐ups, laboratory services (off the premises) and injections. Half the pharmacists, who are all known to each other, were trained either in Dakar or France. One is Russian. The market is very price‐ sensitive and the margins for these pharmacies are slight, given the ability of the mini‐ pharmas to undercut prices. Consultations with specialists (of whom the Ministry of Health reports there are sixty‐four) are available. Consultations take place within MoH facilities, use state‐subsidised utilities and involve notionally state‐salaried personnel, but they seem private practices in all but name. Particularly since the concentration of financial control in early 2012 – which took financial control away even from the Ministry of Finance and directly to the Office of the President – all governmental financial processes have reportedly been in disarray79. With their host hospitals not now being in receipt of any funds at all, individuals with leverage collect their own revenue where they can. Instead of being charged the official 2,000 CFA fee for a specialist consultation, with a receipt that goes through the books, a longtime resident foreign businessman was instead quite openly charged a 10,000 CFA fee, with no receipt, hence not accountable. Even before the change in procedures, hospital directors estimated 70% of fees were misappropriated80. Where hospital admission is unavoidable, patients and their families go to one of Bangui’s seven large state‐owned hospitals. (The small private cabinet medical may have no beds, or only one or two beds for day patients recovering from tests or minor operations). Hospital patients are charged a $2 flat rate for a bed and must pay for all tests, medicines, equipment and administration of treatment. The option of going straight to a state‐owned hospital is rarely considered by the wealthier economic bracket: during the day, they say, the sick will only have to wait and then have the same tests; during the night they will find only medical students on duty. The popularity of the renovated Paediatric Complex (on the site of the original one‐storey French administration hospital), re‐opened by Mme Mitterand in 1980, is confirmed by its reported 80% bed occupancy rate (MSPPLS, 2006). It lies adjacent to the National University Hospital where the bed occupancy rate, along with Bangui’s other hospitals, is half its neighbour’s. The large Chinese‐built Friendship Hospital, whose staff now includes eight Chinese physicians, was renovated in around 2006. There is also the emergency‐oriented Community Hospital. The Military Hospital, which includes a large maternity wing, is open to the general public, as is the Police Hospital. There may be a second military hospital. The lifted restricted access to facilities run by units of the Ministry of Interior – so fiercely respected in many other countries – may reflect commercial pressures to expand their market. The previously‐mentioned 100‐bed hospital in Bimbo, the constituency of the First Lady, is in reality an eighth Bangui hospital. MSF is also evaluating the possibility of a long‐ term hospital project in Bangui (MSF, 2012).

79 Personal communication. This drastic move appears to have been in response to donors’ concerns about high‐level misappropriation. 80 Personal communication.

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Health Service Provision in the Central African Republic

Human Resources for Health In the popular mind, every health worker is a nganga, or ‘doctor’ (and every health facility is a da nganga, or doctor house). When speaking with the general public, health workers themselves may be only slightly more specific, being either infirmier, sage‐femme or pharmacien. This pattern of agglomeration by professional type is followed too by the Africa Health Workforce Observatory (AHWO, 2010). The MoH meanwhile recognises sixteen ‘groups’ or categories81. Following the stratification proposed by Baker (1988) a different type of clustering is possible, according to training level, as below. Degree‐Level (Full basic education + 6‐11 years of professional training) Medical doctors have been trained in a seven‐year course at the University of Bangui since the 1980s. Twenty‐eight promotions of 35‐ 50 graduates each year have delivered perhaps a thousand medical doctors into the health labour market. However, Ministry of Health records show that only 205 are ‘integrated’ (i.e. admitted into the civil service) about a third of whom are specialists (AHWO, 2010). A further 64 doctors await integration, some since 2002. The MSF family in particular employs a good number of the latter. Others are full‐time staffers or perform consultancies in the UN Agencies, work in donor projects, or may be attached to other branches of the state. Perhaps 80‐150 work in private clinics. A number will have emigrated. Many might work in mission health facilities. Nevertheless, even if there were only half the number of graduates estimated, the whereabouts and work status of a majority of Central African doctors are unknown. There is a respected and active Association for Anciens Medicins82. Among the expatriates in the state sector there are eight Chinese doctors and at least a handful of Eastern Europeans. Doctors from Cameroon and eastern DR Congo dominate the Anglophone NGOs, while those from Kinshasa are well‐represented in the UN. In addition, clinical doctors work for the MSF family and Emergency, while some doctors in managerial positions work in the church organizations. Diploma‐level (9‐10 years of basic education + 3‐5 years of professional training) Higher‐level technicians were trained in a now‐discontinued four‐year course83. 104 are integrated. While 47% are recorded as working in Bangui, given the almost complete absence of doctors in the countryside this cadre makes up the backbone of skilled senior staff in regional hospitals. Some are tutors for the nursing assistant courses. A limited number of laboratory technicians may also graduate from the University. State Diploma Nurses (IDEs) continue to be trained at the University of Bangui also in a three‐year course. The same Ministry of Health records show 308 are formally‐employed, 27% of whom are recorded as working in Bangui. 224 are ‘non‐integrated’, some since 199584. Of these, many remain entirely unemployed85. Such is the dismay among the pool of unemployed or under‐employed nurses, an Association of Non‐Integrated Nurses has been created. As with doctors, qualified nurses work in clinics and with NGOs but also in

81 MoH document, Annex 3 (undated). The document first laments that reports from the seven regions refer to more than fifty ‘categories’ of health worker. 82 Personal communication. 83 The reasons for the closure of the course could not be ascertained. 84 This is held to be an under‐estimate. Personal communication. 85 A State Diploma Nurse believed only seventeen of his class of 35 were employed five years after graduation.

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Health Service Provision in the Central African Republic

pharmacies. There are four or five in each of the bigger regional hospitals and they manage the remaining larger health facilities. It seems they also run Bangui’s hospitals: a patient’s family believed that if the non‐integrated qualified nurses were to leave, Bangui’s hospitals would shut. State Diploma Nurse‐Midwives (IADEs) are similarly trained and number about five hundred, with thirty graduates each year. Half are civil servants, and about half of those work in Bangui. There is a reference to Sages‐Femmes Diplômés d’Etat (SFDE) in one document. A founding member of ASSOMESCA reports that the organization has advanced plans to start a 3‐year Registered Nurse course (an American‐recognized qualification) in Gamboula, in Region 2, in 2013. There is also an Association of Diploma Midwives without Work. Certificate‐Level (6‐9 years of basic education + 2 years of professional training) Three sites, under the Ministry of Education, provide two‐year courses for Assistant health workers: the Bouar site trains midwifery assistants; Bambari nursing assistants; and Bimbo hygiene assistants86. The training in Bambari, which has a good mix of practice and theory, seems serious. There may be some post‐basic specialization training. The 689 integrated staff in these categories account for almost half (45%) of MoH integrated staff heading most smaller facilities, filling half of qualified staff positions in regional hospitals. Non‐integrated nursing assistants are also employed directly by hospitals (receiving a monthly prime) and NGOs. ‘Environmental technician assistants’ are trained at the Damara site but the role, numbers and employment prospects of this category are unknown. A number of health workers were trained to certificate level at individual mission hospitals, such as the Ippy Medical Centre. The lack of professional recognition is a source of some grievance according to one competent and experienced but not formally trained health worker. Elementary‐level (6 years of basic education + 6 months – 1 year of health training) The category of community health worker (CHW), a highly prominent feature of the health arena in many disrupted contexts, appears almost wholly absent in CAR. Its putative membership seem to have been drawn into the ranks either of the assistant health workers, above, or the secouristes, below. Some INGOs may have once trained CHWs following their own 6‐9 month curricula. Their number is not known but likely to be negligible. Imprecise classification criteria, or mistranslation, make the situation unclear87.

Untrained (No, or less than 6 months’, health training) The elementary‐level health worker in CAR is the first‐aider. Training secouristes is a core mission of all national Red Cross societies and the Central African branch annually trains two batches of fifty at each of five sites in three‐month courses, or around 500 each year88. The organizers may intend that these individuals are ordinary citizens who assist in accidents. Each graduate, however, is ready to start a career as a health worker and indeed many do. Half of mini‐pharma informants claimed to have had Red Cross training and graduates make up most of the volunteers who staff village health posts89. The ‘pharmacien’ and sage‐

86 Personal communication with senior trainer, Bambari. 87 An English‐language health coordination group estimated NGOs and FBOs supported almost 1,500 CHWs in 2008. An almost identical number of secouristes appears in a French‐language MoH report for the same year. 88 Personal communication. 89 Candidates appear to be self‐selected and do not necessarily represent a village. Since the returning first aider is not always the person the village chief has chosen for the role this has caused tensions in some places.

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Health Service Provision in the Central African Republic

femme, or midwife, in most health facilities are also first‐aiders. In hospitals of all sizes, most cleaning and all portering, laundry, feeding and basic patient care is undertaken by family members, drastically cutting the size of the large auxiliary workforce familiar in other countries (Pavignani and Colombo, 2009). Security is light, night‐ watchmen are few. There will be no call for drivers and mechanics. There is normally no electricity or water supply, so no electricians, plumbers or other handymen are required. The state is so shrunken that there are no examples of the rampant job creation for family members that plague the public sector in many countries90. Away from the health facilities, each village may have a number of specialist healers91. Besides the familiar herbalist, a specialist in the use of plants, other healers are: the nganga, who divines the nature of the malevolent spirit (and its patron) from the flickers in flames, the images on a calabash of water or the patterns of thrown shells; the once‐common circumcisers, both male and female; the ‘psychotherapist’, who will perform rituals recommended by the nganga; the bone‐setter; the nganga wali, or traditional midwife; and the specialist traditional midwife who treats malnourished children through diet. The Central African Federation of Traditional Practitioners (FNTCA), recognized in 2005, claims 48,000 registrants92. If true, about one in fifty adults would be a tradipracticiens or fifteen times the workforce of the official Ministry of Health. The areas of training and post‐graduate recruitment offer a set of interesting examples in local applicability and adaptation. • The Faculty of Health Sciences conducts only one type of training in each of its four regional units. This is an uncommon finding: many countries run the same courses in different training institutions93. Specialization offers economies of scale, allows the development of training expertise, optimizes scarce resources, and guarantees consistency in content, examinations and certification. • Training and employment is de‐linked. On the completion of their course, graduates in CAR do not automatically walk straight into civil‐service jobs, as commonly seen elsewhere. Graduates must compete for posts. This pre‐empts a familiar problem of a relentlessly expanding, yet un‐fundable, public‐sector payroll. • Consolidated Health Education. The Central African Red Cross’ three‐month First Aider training, though not without its unintended consequences, is an important and sizeable public education tool in a society that lacks the normal avenues for health awareness, such as government advertising campaigns, articles in women’s magazines, TV programmes on health, biology lessons, exchanged positive experiences. • Staged Post‐Graduate Training. The forthcoming two‐year post‐graduate course in health facility administration, provided by the Red Cross, is promising. This sort of staged training,

90 In 2010, a single one‐storey building in the central‐level Ministry of Health in Juba, South Sudan had more than 200 salaried cleaners. 91 This folk predisposition towards specialization, reinforced by the bureaucratic organizational culture of the early French administration, may explain the equanimity with which modern‐day over‐staffing in all areas is accepted. 92 For its own reasons the Federation embraces all‐comers. ‘Charlatan’, or fraud, is even a listed category. Nationality requirements are not followed. While a percentage of self‐proclaimed registrants could legitimately be excluded, probably a greater number of tradipractiens remain outside the organisation. In one large village, only five of an estimated one hundred tradipractiens were members. As long as the criteria remain so loosely defined the actual numbers will be meaningless. 93 In 2005, in then‐Southern Sudan “thirty‐three pre‐service training courses [were] delivered in 27 institutions in fifteen towns.” (Unpublished WHO report, 2006)

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Health Service Provision in the Central African Republic

which intersperses periods of teaching with practice, is more likely to lead to effective learning. • There is a pool of unemployed, or under‐employed, graduates in the capital. The attraction, and retention, of human resources to rural postings is greater when an over‐supply of nursing and medical trainees creates a market pressure. Compulsory allocations work only in rare circumstances. The voluntary movement of skilled staff away from the capital is only really feasible when there is a pool of unemployed graduates in the urban areas (World Bank, 2010). This is indeed the case in CAR where unemployed nurses from Bangui do seek and accept posts in Regional and Prefectural Hospitals. • Remuneration is coupled to the individual’s attendance in the health facility. In CAR, an individual’s only pay may be the fees from consultations actually performed. By contrast, salaried civil‐servants, who are paid centrally and routinely irrespective of their attendance, have less financial commitment to attend and, at least anecdotally, exhibit higher‐than‐ justified absenteeism. In CAR, where day‐to‐day supervision of the many isolated health workers is unrealistic, automatic payments for all would result in an explosion of uncontrolled, and uncontrollable, absenteeism, as seen elsewhere, for example in Angola. Linking remuneration to attendance is a further long‐recognized strategy for retention (World Bank, 2010). • Rotation of staff at isolated facilities. Since 2010 at their isolated clinics in Region 2, the Catholic Mission has introduced a shift pattern of alternating fixed periods of ‘on’ and ‘off’, like oilrig workers. Three pairs of staff work two‐month stints each. This model could work elsewhere.

The Pharmaceutical Sub‐Sector Four private pharmaceutical wholesalers are active within CAR: Centrapharm, a local family business operating since 1992; Shalina, an Indian‐owned company; Roffe Pharma, an outlet for a further three Indian pharmaceutical suppliers; and Aspharca, owned by Chinese investors, which manufactures intravenous fluids only. The quality of Shalina’s products and the integrity of its business practices, which reportedly include the co‐opting of health workers formally employed elsewhere as company vendors, have been questioned, but tolerated94. A parastatal, the Unité de Cession du Médicament (UCM), charged with the purchasing and delivery of medicines and medical equipment to publicly‐owned health facilities, has been serially unable to perform throughout its eighteen‐year history. An initial sizeable 1994 grant of almost 900 million CFA Francs (50% from the Agence Française de Développement (AFD), 45% from the European Union (EU), and 5% from the CAR government) soon became depleted. Promised annual government replenishments never materialised. A further EU grant in 1996 distributed among government health facilities as a start‐up purchasing fund, was again depleted. A 2003 re‐financing initiative of both the UCM (acting as the central purchaser) and the peripheral health facilities (acting as customer) floundered despite an attempt at decentralising operations to sixteen sub‐regional Medical Stores. The AFD suspended additional planned support, unhappy at UCM’s opaque contracts with an Italian supplier, in 2005. The Global Fund to fight AIDS, Tuberculosis & Malaria (GFATM), a major customer of the UCM, suspended the disbursement of funds in 2009 due to ‘mismanagement’ and worries about double‐purchasing (GFATM, 2010). Despite government action, which included widespread sackings of senior officers, only one further disbursement has been forthcoming.

94 There is no in‐country facility for quality control. Tests are mainly conducted at Clermont Ferrand in France.

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Health Service Provision in the Central African Republic

A panoply of laws, which include a maximum 12% mark‐up by UCM, an obligatory 20% transfer of income from prefectural medical stores to UCM and then from the UCM to the MoH, and enforced loans (which await reimbursement) of money and stock to the MoH, unsustainable interest arrangements with banks and the collapse of the prefectural medical stores’ own finances have left the parastatal non‐functioning. A supply chain extended in both time and space passes from the overseas supplier to the 1,500 km distant Cameroonian port of Douala, through Cameroonian and Central African customs, to the central and then sub‐regional medical stores. It is exposed to pilferage at multiple points95. Judged as not‐fit‐for‐purpose by partners, UCM has been the architect of its own current irrelevance. Consequently, to avoid stock‐outs due to dependence on a generally unreliable and crippled system, some programs, namely the Expanded Program on Immunizations (PEV), and the leprosy and onchocercosis control programs, together with the UN Family & Population Agency (UNFPA), source or manage their vaccines, medicines and materials independently. Government health units within or near Bangui also buy medicines on the open market whenever possible. Outside the government, the MSF family, the International Committee of the Red Cross, and AFD regularly purchase their medicines and consumables from domestic or foreign private wholesalers. Many INGOs do so occasionally. Individual government health units are responsible for the collection of their ordered supplies from the prefectural medical store, delivered to them by the UCM. For these units, transport constraints represent a severe challenge. All payments are upfront, except for those health units within Bangui. No transport and no cash were thought to be the reasons behind so‐called ‘asymmetrical stock‐outs’ where medicines in stock in the prefectural medical stores were nevertheless unavailable at the health unit (MSPPLS, 2009)96. Catholic‐run health facilities are supplied by a network of diocesan medical stores, which purchase either through ASSOMESCA or, increasingly, directly. The EC‐funded project supporting Regions 1 & 6 gives intensive (yet unsustainable) logistical and technical support to the delivery of medicines. There exists a National List of Essential Drugs, revised bi‐annually, and diagnostic and treatment guidelines for the most common diseases and conditions. A WHO‐supported study reported that, even in the three‐quarters of health units where the latter guidelines were found, they were not referred to (MSPPLS, 2009). Private medicine sellers operate from numberless mini‐pharmas, similar to the ones described earlier. Whereas provincial private pharmacies are bigger, better‐stocked and occupy sites in town centres, Bangui mini‐pharmas are smaller, stock predominantly what in Europe would be called over‐the‐counter medicines (including numerous Viagra‐type preparations) and occupy peripheral sites. Pills and capsules, particularly against intestinal parasites, vastly outnumber injectable medicines which may nevertheless be administered on site. Knowledge seemed weak. Informants claim fifteen to twenty customers a day, amounting to a daily $10 turnover. Mini‐pharma owners cannot strictly be said to be operating informally, since each is almost certain to have formal permission to have their businesses where they do, at least a verbal one from the local neighbourhood authority – the urban equivalent of the Chef du Village. Neither can they strictly be separated as unregulated, because the bigger pharmacies are in practice unregulated also. All general stores on neighbourhood corners have a shelf of a similar‐range of medicines, perhaps with another top shelf for disposable syringes and IV giving sets. The smaller hut‐type shops, deeper into the backstreets and selling only the basic household items, will all have a drawer or basket of a

95 Personal communication. 96 A handful of medicines, which might be considered the bread‐and‐butter drugs of PHC curative care, namely albendazol, amoxicillin, cotrimoxazole, ibuprofen and some sulphonamides, were found to have been absent in many health units for at least one year.

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Health Service Provision in the Central African Republic

clutch of loose packets of pills, normally just paracetamol, diclofenac and ampicillin. Owners of mobile stalls will display this reduced number of medicines alongside the cigarettes, boiled sweets, candles and packets of soap powder. This range of availability is mimicked in CAR’s villages: the fair‐ sized villages will have a fixed general store; many villages will have only one mobile stall, no bigger than a suitcase, as their only kind of commercial outlet. Legions of hawkers, called buba ngéré (literally ‘low price’) roam every street and backstreet of Bangui all day and evening. The medicine buba ngéré will carry a large box on his shoulder brimming with the same type and range of medicines as the mini‐pharma, will each claim to have approximately the same turnover but, as a rule, their reduced understanding of illnesses and treatment is offset by their greater chutzpah97. The medicine buba ngéré is a purely Bangui phenomenon, not found even in the larger regional towns. The sellers may not even be the owners of their stock: some claim to be, but others are probably the agents of bigger outlets, perhaps one of the pharmaceutical depots. The suspiciously uniform range and their absence outside Bangui seem to support this suggestion. Health facility equipment is received from a plethora of sources, mostly donations. In the absence of a national standardised list of items, leading to the existence of many different types and makes, maintenance and repair is a major challenge. Even the Ministry of Health’s dedicated equipment maintenance service is itself not functioning98. There are examples of the acquisition of inappropriate technology: some highly sophisticated laboratory equipment at the Paediatric Complex remains unused due to insufficient power in the hospital generator, and absence of reagents.

Health Expenditure and Financing In CAR, the Total Health Expenditure (THE) in 2008 was estimated at 38,500 million CFA Francs (approximately 57 million Euros) or 4.4% of the Gross Domestic Product (WHO, 2010). Assuming a population of four and a half million, the Health Expenditure per capita in 2008 was in the order of US$ 15. Looking at the external contributions outlined below, this figure is clearly a gross under‐ estimate. The Central African government allocated 10.7% of its 2011 budget to health, ahead of the Ministry of Defence (9.9%) but just behind two other ministries (Ministère des Finances, 2011)99. However, a history of much‐reduced actual disbursement makes the budget allocation rather whimsical. The National Health Policy Draft of 2004 records that the budget execution rate for 2003 was 5.4% (MSSP, 2004). Reportedly, only a tenth of the allotted health budget was disbursed in 2010100. Possibly only US$ 9.9 million was released in health disbursements in 2009 (The Lancet, 2012). The 2011 budget allocation represents a steady, if notional, improvement over recent years: health was awarded approximately 7% in 2009 and 9% a year later. CAR received a total aid envelope of US$ 317 million in 2008, half of which was destined for project aid and a third for humanitarian aid (OECD, 2010). External aid accounts for slightly over half the

97 In the busy Cinque Kilo market, medicine buba ngéré carry a brasher‐looking, presumably more attractive, cardboard cylinder ringed with the prettiest and most colourful packets thus confirming what the pharmaceutical industry has always reasoned. 98 Personal communication. 99 Behind the Ministry for Equipment & ‘De‐landlocking (Ministère de l’Equipement et du Désenenclavement) (11.7%) and the Education Ministry (10.9%) 100 Personal communication.

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Health Service Provision in the Central African Republic

total government health budget. Contributions to the Consolidated Appeals Process (CAP), a funding pool mechanism, appear to be decreasing: 44% of the 2010 CAP requirements were funded, against 73% in 2009, and 90% a year earlier (OCHA, 2011). However, two major contributors ‐ the ICRC and the MSF family ‐ remain outside the process. The 2010 expenditure for the MSF family was US$ 23 million, an increase of a quarter over 2009 (MSF, 2011). No estimates for external assistance channelled directly through NGOs or FBOs were found. Unicef received almost US$ 6 million for its CAR operations in 2010, about a third of that requested (Unicef, 2011). UNFPA in CAR has a five‐year budget of US$ 14 million (UNFPA, 2010). GFATM disbursed US$ 60 million over a seven year period to 2009, half of which went to HIV/AIDS‐ related activities, a third to malaria treatment and control and a fifth to TB treatment and control (GFATM, 2010). Through the 9th European Development Fund, the European Commission supports a geographical‐ focussed project ‘Health Services Improvement in Regions 1 & 6’ (ASSB 1& 6). The French Development Agency (AFD) is implementing two projects: support to the National Medical Store; and limited Performance‐Based Financing in several Bangui health centres. In 2010, the Common Humanitarian Fund disbursed US$ 10 million for one hundred projects in health, education, protection and early recovery/ quick response. However, over a two‐year period the overseeing agency, the UN Office for the Coordination of Humanitarian Affairs, was able to evaluate only eighteen of them, and external evaluators found only four short related reports (De Valensart and Collin, 2011). The total amount of money unofficially entering the pockets of hospital staff is unknowable. Income generated from formally‐ extracted user fees would appear to be negligible. According to the director of the Paediatric Complex – which is the facility with Bangui’s and CAR’s highest reported utilization rates – user fee income is a measly 15,000 Euros per year, a third of which goes on staff incentives. Of course, there is both a formal and an informal method of payment. Officially a public service, the health care on offer is not free and has been ‘privatized from within’. Cordaid, a Dutch INGO, ran a Performance‐Based Financing (PBF) pilot project among 48 health units in Nana‐Mambéré Prefecture, in Region 2, in 2009‐10. The project spent 750,000 Euros over the two years, equivalent to an estimated 1.40 Euros per head of population each year. Project support costs were deemed high: auditors calculated that for every Euro spent in direct service delivery to a beneficiary slightly more was spent in management and project administration. (In the first start‐up year, the ratio was thought to be two Euros in support costs for every Euro servicing a beneficiary101.

Health Provision over time, presumably No historical archive of health provision in CAR exists102. However, most alternatives to traditional medicine occurred ‐ just about ‐ within living memory. The picture that emerges from the collation of memories is more sculpture than patchwork. Successive layers of intervention may have been added, but not uniformly across the whole country. Developments in certain regions did not occur elsewhere, so freezing those historical features. Until the early 20th Century, only the nganga could help. Ill‐health, one of the many misfortunes which could affect an individual, could be allayed within the village through the appeasement of the

101 An external evaluation found that although utilization and coverage had apparently increased for a few services, in general rates had not reached projected levels (Remme et al, 2011). Establishing the size of the population served seemed to have been a problem. Improvements in quality were patchy. Though the evaluation team considered the two‐year period too short to determine effectiveness, noted the limits to applicability nationally and lamented the absence of an exit strategy, a follow‐up phase was instigated and the project area expanded. 102 As mentioned earlier, neither is there a record of the current distribution and make‐up of facilities.

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spirit would had caused the illness. Throughout the territory of present‐day CAR, the situation then was perhaps similar to the one found now in Region 5. After the first known hospital, in 1921, a further three small hospitals (10‐20 bed facilities run by one to three missionaries) and perhaps ten dispensaries had started in peripheral towns by the end of WWII. In the latter part of the period, the Catholic Church also established health facilities in each of its nine dioceses. Only from around 1953 did the French colonial administration build and staff medium‐sized hospitals (60‐70 beds) in the biggest half‐dozen rural towns (later to become the Regional University Hospitals). A long‐serving health worker remembers that in each of the seventy‐ eight sub‐prefectures, or districts, there was also one dispensary run by the Department of Rural Affairs. In regards to the health sector during the 70‐year colonial era, all development seems to have taken place in the final years of the period. Indeed, according to a retired doctor, at independence in 1960, the nascent Ministry of Health inherited one hospital in Bangui, half‐a‐dozen hospitals in the bigger towns, and the network of dispensaries. Echoes from that period remain in the profile of the health providers of Regions 6 and 1, two of the four rural regions least disrupted by conflict. Over the next thirty years, Cold War courtship would deliver three more large publicly‐owned hospitals, a few state security ones and a handful of prestige health facilities in some towns. It was probably the promotion of Primary Health Care arising from the 1978 Alma Ata Declaration that started the construction of a network of facilities even in the smaller towns and larger villages. An experienced health manager considers the late 1980s to have been the heyday of the state‐owned and church‐owned health network, still evident in Region 1. The conflict and chaos of the 1990s emptied the state‐owned facilities of staff and equipment causing the implosion of the public sub‐sector and the corresponding explosion of humanitarian health provision, as still seen today in Region 3. NGOs may be the only, certainly the main, health provider in conflict zones. Private for‐profit provision, both the more‐ and less‐regulated kinds, has expanded in recent times as elsewhere in the global South. A full range is seen where a full range of professionals (and their clients) exist, such as in Bangui; a more limited range elsewhere, such as in the south of Region 4.

Discussion Two waves of concerned outsiders have helped fashion CAR’s health arena. How does the experience of yesterday’s Protestant missions compare with that of today’s International NGOs? The parallels in the make‐up of these independent groups, driven by conviction, a sense of duty and obligation (and varying degrees of paternalism) operating where the national administration does not are intriguing. The generous funding that the INGOs enjoy now was previously enjoyed by the churches. The two approaches have in common their alien presences sustained by Western voluntary generosity, miles above what local poverty levels can afford. There are some parallels in their modus operandi, too: the consensual demarcation of territory; coordination but not true cooperation; working within the system but at the same time at arm’s length from it; the use of health as one component in the overall development of the targeted community; a greater attention paid to the frontier over the hinterland103. Both the Protestant missions and the INGOs developed islands of excellence in health care. For one, expatriates raised funds from overseas; for the other, overseas funds recruited expats. Suiting both partners, the Catholic Church could be said to have operated as the health wing of an under‐funded and stretched French colonial administration. Over time, the churches’ health work moved towards a consolidation of management leading to increased

103 For the former, reaching the many unsaved souls was more valued than supporting existing congregations. For the latter, reaching under‐privileged groups is more valued than strengthening the existing systems for the many.

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efficiency through some economies of scale (through the formation of ASSOMESCA), and decreased human and other resources leading to an almost complete withdrawal of the expatriate workforce and the closure or downsizing of some facilities. As organizations, missions and NGOs share a number of interesting comparisons. At the level of the individual, they tend to contrast. An expatriate missionary was apparently on the whole rooted in the locality and dependant on local resources. Receiving from outside only a nominal stipend and an erratic supply of donations for their personal needs, they were largely self‐governing and living a generally parsimonious existence not greatly dissimilar from the neighbours. Not many features of the modern expatriate experience correspond to that. Early missionaries would devote a lifetime with few interruptions104. Posts for modern expatriates have a high turnover with regular and frequent interruptions. What explains CAR’s continuing low population densities in rural areas? First and foremost is the disease burden, as in South Sudan and northern DR Congo, which sport similar low densities. Frequently‐mooted suppositions are the activities ofs lavers (which ended at least five generations ago, however) and the persistent high child mortality ratio (which is at a level not unique to CAR)105. Further research is required. While health‐seeking behaviour is influenced by many factors, health provision in CAR seems firstly determined by location. Why exactly is location such a major factor in determining health provision in CAR? Options decrease dramatically as isolation increases. Residents of Bangui have the greatest range of options: there is access to self‐medication, secondary‐level and tertiary‐level providers. By contrast, self‐medication may be the sole option for villagers. No (or practically no) transport is available to reduce the degree of isolation. Access to health care is perhaps secondly determined by the amount of out‐of‐pocket money available. In CAR, even richer individuals finding themselves sick in a poor village, would only have the option of the purchase of a few sorry pills or folk remedies. Conversely, sick but poor town‐dwellers who live within sight of a health facility may as well be living in a village; they will still be unable to access the care. There is of course some correlation: the rich are unlikely to live in a remote village. Other questions, such as gender friendliness and perceptions of quality, may be subsumed under the starker options of location and cost. Schematically, if the availability of out‐of‐pocket money (financial accessibility) constituted one axis and the degree of isolation (physical accessibility) the other, the arena might be portrayed as below. Structured Private refers to those facilities which, in other contexts, might be labelled ‘Formal Private’. Unstructured Private is the equivalent of ‘Informal’, a term which loses its meaning in CAR since these enterprises are formally allowed to operate106. Using this option is the also the equivalent of self‐medication since the purchaser dictates the treatment. In between, lie all other facilities. FBOs and NGOs (which are private not‐for‐profit enterprises subsidized by donations or grants) join the so‐called ‘public‐sector’ (which are now in fact private for‐profit providers subsidized by the state) in a Subsidized Private grouping. Below a certain level of cash availability, it becomes no longer commercially viable to operate.

104 The Comboni Brothers, a Catholic order, were given a period of home leave once every fifteen years. Personal communication. 105 Estimated at 171 per 1000 live births (World Bank, 2011). 106 The greater distinction may be the degree to which regulations (i.e. taxes) are applied. Neither entity is structured in the sense of inspected.

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Health Service Provision in the Central African Republic

Diagram 1: The distribution of types of provision within CAR

Structured Private (Cabinets Medicals, Cliniques, Pharmacies)

Subsidised Private (All State‐owned facilities, NGOs, FBOs)

money

pocket ‐ of

‐ Unstructured Private/ Self‐Medication out (Mini‐pharma, stores, stalls, buba ngéré)

of Limit of Commercial Viability

Availability Personal/ Self‐Medication (Folk remedies)

Degree of Isolation

Isolation roughly corresponds to the distance from Bangui: residents in the capital are the least isolated; those in the wastes of Vakaga the most. But isolation is a function of a slew of other factors which include the distance to the road, local security, access to transport once on the road, the state of the highway and the season, the distance to town, the number and size of that town’s facilities, and cultural factors such as the need for females in some communities to be accompanied. Isolation, in turn, will affect what staff are present and from which level. Except for the south‐east, most internally displaced (IDPs) actively seek isolation in the bush, doubting the supposed safety of towns107. The dotted diagonal line marks the limit of each type of provider. Bangui residents, and those who can make it there, have the option of structured private facilities, amongst others. Well‐ to‐do Bangui residents (who are, of course, not obliged to use the most expensive option) may attend state‐owned health facilities, use traditional healers, or purchase medicines from mini‐ pharmas. Away from Bangui, access to private clinics drops off immediately. Outside the towns and large villages, subsidized private provision becomes unavailable. In villages and beyond, there is next to nothing. What explains the vigour of religion in the life of the village, and what are the lessons for health? One contribution is the unbundling of religion and health in a modernizing society. Previously, religion and health were bundled together in the person of the village nganga, an individual with a certain presence, charisma or natural authority who could explain, give meaning and show a way forward. In the modern era, the roles assumed by the old nganga seem to have become divided between the religious leader and the health worker (even if the much‐diminished nganga himself has not entirely disappeared). Religion now has that charismatic individual with explanations, meaning and solutions. Health is merely the distribution of pills. The psychotherapy has been

107 There were ‘197,000 internally displaced people scattered in the seven northern prefectures’ in 2008. Humanitarian Needs in Central African Republic hdpt‐CAR (2008)

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captured by religion. Uplifted congregations feel empowered having attended busy churches in the middle of the village. Uncomprehending patients are dispassionately sold pills from a sad, near‐ empty building at the village margins. The church looks like the future; the health facility looks like the past. Churches are one of the three power bases in a village (Bierschenk and Olivier de Sardan, 1997)108. One unremarkable village supported nine churches: one Catholic, three rival Evangelical Baptist congregations, the Apostolic and the neo‐Apostolic churches and three African churches brought across from DR Congo. Most of the pastors were young, something not previously seen. Pastor, not doctor or teacher, seems the smarter modern career option, delivering both livelihood and status. Traditional health care has been admitted into CAR’s formal health sector. To what extent was the admission of tradipracticiens genuine? Politically, it was a sensible move by an establishment that had seen the evisceration of the formal health sector firstly in the nationwide looting and destruction of ‘the events of 1997’ and later in the perpetual instability throughout the entire north and the south‐east. Not only had traditional healers occupied the health space left by the fleeing health workers, they had indeed accompanied the fleeing communities, as community members themselves. With no need for new infrastructure, equipment, stock or support the contribution of traditional healers was uninterrupted. The opportunity presented by the African Heads of State in their declaration of the ‘Decade of Traditional Medicine’ (2000‐2009) allowed the formal sector to reoccupy abandoned territory, so to speak, by claiming that traditional healers were now part of the formal sector. In the day‐to‐day work of the health facilities, however, traditional healers remain excluded. In CAR, the invisible spirit world is alive and well. Is traditional medicine simply a second‐best option, only applicable to the rural poor? Is the frequency and popularity of traditional medicine due to the inadequacy of biomedicine? Or is the unpopularity of biomedicine in part due to the resilience of belief in the invisible spirit world? Witchcraft is the bread‐and‐butter of the home‐grown film industry at least, perhaps a barometer of popular culture. Seeking out a recommended nganga is seen as a wise first choice also in urban areas, not only for the well‐to‐do including some medical doctors, even – it is said – the president (EIU, 2011). This is not at all seen as an inconsistency, much less as a contradiction. The federation for traditional practitioners reports 2,800 of their members live and work in Bangui though, as explained above, the working definition of ‘traditional healer’ is all‐encompassing. During Kinshasa’s rapid expansion, the similar Kongo medical system was held to be ‘the prevalent overall medical culture in terms of recourse to treatment’ (Kimpianga, 1981) The neglect of health care is a manifestation of low‐intensity government, and a norm in severely‐ distressed ones. In CAR, is the absence of the state in health provision a consequence of default or explicit decisions? Health joins state security, the state apparatus and education as the key demands on government revenue, which is itself derived essentially solely from business levies and import/export duties. The consequences of paying insufficient attention to health’s competitors for revenue are presumably vividly seared into the leadership’s psyche, especially in CAR. In living memory there are mutinies (the Armed Forces demonstrated their power to destabilize when they brought down the Patassé regime), coups (the thirty Ministries, each with multiple titles, are numerous and essential instruments of patronage necessary to secure loyalty) and disorder among its core urban constituency (when teachers strike, Bangui’s university students were long fond of roadblocks of flaming tyres and stoned cars109). Meanwhile, what is the worst that health workers can threaten? The regime will know that health workers can always return home at shift’s end with something in their pocket. In fact, worsening health indicators may serve to attract additional overseas funds. This strategy by a ruthless elite is examined by Chabol & Daloz (1999).

108 The other two are the village chief and the Farmers Agricultural Union (ICG, 2007). 109 It was Bokassa’s miscalculations regarding university students that precipitated the downfall of his own regime.

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Auto‐medication, or self‐medication, is considered a satisfactory and legitimate route to treatment. Why is this? This behaviour may be partly an echo or modern adaptation of self‐reliance and the widespread use of folk remedies, and partly a consequence of the absence of any influential medical lobby nationally110. It is not merely a question of education or status: a Bangui‐based South African with internet access also prefers to consult websites and then self‐medicate. Entrepreneurs who depend for their livelihood on the sale of their medicines at least allow affordable access to medicines, where the formal sector has failed to do so, as pointed out by Bloom et al (2011): The behavior of informal providers is strongly influenced by the institutional context within which they are embedded. They have established a niche because neither government health facilities nor private providers have adequately met the population’s needs. Although there is no doubt the population needs protection against opportunistic behavior this labeling of all informal providers [as quacks] can also be seen as boundary protection by licensed professionals and as unhelpful in the realities of the environment where there is a chronic scarcity of quality providers.

Unsafe practices are widespread in the informal sector, particularly in rural areas. Is this a consequence of under‐regulation and would greater regulation in CAR improve safety? However appropriate the regulation itself is, it is the implementation which decides its effectiveness. The circumstances allowing a consistent, non‐arbitrary, binding, transparent implementation of any regulatory system would appear absent. Bloom et al (2011) are also doubtful. They consider that: Africa has been particularly prey to an excess of legalism, with over a hundred years of colonial and postcolonial legislation designed to change moral beliefs and practices, but with a very mixed record of effectiveness. So many laws have lacked legitimacy that many Africans have been left with a distinct lack of respect for the law of the land they live in. [...] Effective interventions need to take into account the sources of knowledge and drugs of these providers, the livelihood strategies of providers, and the institutional arrangements with which these providers establish and maintain their reputation within their community.

Chabal and Daloz (1999) vividly used a metaphor of the air‐conditioner versus the veranda to describe opposing approaches to problem‐solving. How much do a brace of new health care interventions in CAR represent a triumph of the A/C? Two projects, one of them Performance‐Based Financing, depend on complex, expensive monitoring mechanisms. Their health management information systems demand the completion of four pages of highly detailed data fields per consultation111. Like A/Cs, they are hi‐tech, high input, high maintenance devices. It is not known if any ‘veranda‐type’ options were considered and tested; approaches less against the grain which sought out pre‐existing patterns and strengths and made maximum use of existing dynamics. Donors would be disingenuous to dismiss any conceptual hurdles: project staff in high‐tech, resource‐rich projects with timeframes measured in months are not the obvious champions of interventions appropriate to a low‐tech, resource‐poor environment in timeframes measured in decades. Furthermore, as seen in the DR Congo, in a highly‐informalised context a structured management approach, such as that of PBF, is unlikely to function as expected. It is likely to be manipulated in order to make gullible outsiders happy. Setting the metaphor aside, the air conditioner has literally

110 The harm posed to the population by the taking of improperly prescribed medicines is a commonly‐voiced argument against the expansion of the informal sector. In fact, despite some dire examples, as above, that harm may be overstated. A study among Bangladeshi villagers found 18% of informally‐supplied medicines were appropriate and relevant, 7% were harmful, and 75% were unnecessary yet not dangerous (Iqbal et al, 2007). Controlling the trans‐shipment of dud medicines and counterfeit medicines (drugs, sometimes sub‐standard, produced outside licensing agreements) is an issue for all states, even functioning ones. 111 Personal observation. Health Post, Togo Village, 21 kms from Bambari.

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triumphed over veranda in the design of the new hospital in Bimbo: each room has an AC unit, a hostage to fortune indeed.

Conclusion Enclave, cul‐de‐sac, backwater: these are synonyms which fully apply to the Central African Republic. This quality of separateness explains many things about the present‐day nation, particularly as it affects development and commerce. In an indication of the malign influence attributed to separation at home, the CAR government even includes a Ministry of ‘De‐Enclavement’, possibly the only one of its kind in the world, which receives a larger share of the government budget than the Ministry of Health. Paradoxically, however, the circumstance of isolation normally also carries with it a quality of relative calm and non‐interference not obvious features of Central African affairs. Understanding this somewhat sheltered condition helps explain some aspects of health provision in CAR today. Like the diverse species in a turbulent ecosystem, the components of CAR’s health provision have grown, expanded or shrunk according to local circumstances and conditions each adopting, then adapting to, its niche. Continuing to evolve, different types of health provision co‐exist within a given biota, with one model typically predominant. Different strains of the same variety have appeared. Cut off (but not sealed), successive waves of different models of health provision have landed in the nursery, some faring better in some corners than in others. The historically weak state is unable to enforce diktats nationwide, so obliging a monolithic conformism. In the absence of a dense, light‐ blocking canopy in the garden, mutations may stand a chance.

Traditional medicine is the ur‐provider, existing throughout CAR including the capital. The recourse to preparations of leaf, bark or root appears to be the sole option for health seekers living in much of the countryside (which accounts for much of CAR) particularly so in the less formally served regions of the north and east. Healing through the appeasement of malicious spirits, including the use of charms, via the intervention of a witchdoctor, is more widespread than prevalent. The model of provision through curative care delivered from a small‐ to medium‐sized local hospital was introduced by missionaries less than a century ago chiefly in the areas of the west, south‐central and south‐east. Faith‐based not‐for‐profit provision remains an important provider in a set of established localities, with the Catholic Church and different Protestant denominations offering various mixes of in‐patient and out‐patient care. A handful of large‐sized provincial hospitals were inherited from the French military at independence but their number and size has not expanded since. Instead, growth in the number of curative‐care, in‐patient beds has come through the construction of a similar number of large‐sized hospitals located in the capital. The primary health care model reliant on volunteers and minimally‐trained staff working from small health units was introduced later, in keeping with global trends. Its uneven uptake has waxed and waned, disrupted in some regions by acute multiple and regular conflicts and interrupted elsewhere by chronic maladministration, financial and otherwise, from a largely phantom state. In the south‐ central regions, while local NGOs continue to support the hard construction of village health posts, the lack of soft support for staffing, supplies and supervision limit their viability. Outreach has withered, now led by UN Agency disease‐prevention programs only. Most functioning medium‐sized health facilities offering secondary care are run by private not‐for‐ profit providers, either faith‐based organisations or a small number of international NGOs. The distribution of health‐based NGOs is patchy in space and time: most address humanitarian need in insecure areas, but not overtly unsafe ones, and locate and relocate according to stringent funding conditions. They are generally absent from the south‐west and the north‐east. Overlain on this hotchpotch of models are the private providers, found everywhere but the remotest villages. They are both inside the state‐owned institutions, and outside them. State‐owned facilities

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have been privatised from within by their own workforce, as individuals at all levels charge formal and informal fees for services. Practices differ from facility to facility. Qualified for‐profit practitioners run a network of clinics in the capital, alongside a score of private pharmacies. Everywhere private vendors, usually entirely untrained, sell medicines and give injections. As in a gigantic lost valley, across the country cross‐fertilisation is uncontrolled, hybridisation rampant, symbiotic entities intertwined. There are curious off‐spring. At night, while some ngangas see patients in mission hospital beds, some hospital doctors undergo traditional ceremonies in villages. The major users of some Evangelical Christian outfits are Muslim families from Chad. Unemployed nurses work openly in state‐owned hospitals starved of state funds. Bangui’s Police Hospital runs a major maternity wing open to the public. The quintessential humanitarian NGO, specialised in short‐term, intensive interventions, is establishing a twenty‐year development programme in its region. Low‐level, affordable community care is kept afloat in one region only because of high‐level, unsustainably expensive project management. In this disrupted country under study, diversity in health provision seems the rule rather than the exception, evolving spontaneously rather than crafted through design. The inability of the state to extend its reach has not left a vacuum beyond the capital’s outskirts; rather a multi‐faceted, busy space. In the fabled cradle of the Bantu, a semi‐functional private disorder competes with a dysfunctional public pretence of order.

London, December 2012

Appendices

1. Country Chronology 1889 Establishment, by two civilian brothers, of first outpost in Bangui 1896 French military’s Congo‐Nile mission 1899‐1910 Forty private companies granted ‘vacant and unowned land’ in French Equatorial Africa 1903 Oubangui‐Chari declared a French colony 1921 Baptist congregation open a small hospital in Boguila 1928‐30 ‘War of the Hoe‐handle’ uprising in north‐west 1946 Barthélemy Boganda becomes territory’s deputy at the French National Assembly, Paris 1959 Death of Boganda (in air accident). Replacement by David Dacko. 1960 Independence. Sovereign Central African Republic. 1965 Coup led by Chief‐of‐Staff Jean‐Bedel Bokassa 1977 Coronation of Emperor Bokassa I. 1979 Fall of Bokassa. Restoration of David Dacko. 1981 General André Kolingba forms Military Committee for National Recovery 1993 First government with popular legitimacy. Free election of Ange‐Félix Patassé 1996‐97 Three army mutinies. Evacuation of foreign residents. ‘North‐south’ wars. 1998 French military presence ends

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1999 Re‐election of Patassé in disputed election 2001 Attempted coup, with reprisals against civilians 2002 ‘North‐north’ wars 2003 François Bozizé brought to power by France and Chad 2005 Election of Bozizé in free and fair elections 2009 Collapse of formal mining industry 2011 Re‐election of Bozizé

2. Notes on Transport Since accessibility is a key factor in health provision in CAR, a brief description of the country’s transport is in order. Between towns, vehicles are overloaded and overcrowded to a breathtaking degree. For example, on the tarmacked Bangui‐Sibut road which has a dead‐level gradient, adapted saloon car ‘bush taxis’ are routinely loaded with over two‐dozen passengers112. Even within Bangui, shared taxis carry six passengers113. On unpaved roads, lorries prevail. With no overhead bridges or wires to consider, loaded trucks look three times as high as they are wide. A dozen passengers may then sit on top of the load or hang from the back. Packed coaches from Sonatur, a national bus company, depart from Bangui to major towns once a day. For all vehicles, getting off at a village may be possible; getting on is unlikely. Multiple toll‐collection barriers are a feature of the paved roads. Military barriers, or checkpoints, block all roads going to and from towns and at crossroads114. In conflict zones, there may be military or rebel activity, or banditry. The principal town‐to‐village transport is the taxi‐moto, a standard motorbike that, CAR‐style, will carry two sometimes three passengers. A villager going to town or between villages will use a bicycle, be a bicycle passenger, or walk. Produce is transported by push‐push, a two‐wheeled, hand‐ pushed metal cart. No oxen, donkeys, horses or mules were seen115. A flotilla of dug‐out pirogues operates between Kouango in Ouaka Prefecture and Bangui 200kms downriver, a journey of two days. Some pirogues reach Mobaye, a further 200 kms upriver. There are no larger passenger or cargo boats. There is no railroad or domestic air service except charter planes. The UN Humanitarian Air Services (UNHAS) supports UN staff and accredited aid workers.

112 This is a feature readily visible from the PK 12 starting point. Three passengers sit next to the driver, five in the back seat. A platform of benches, welded to the chassis of such vehicles, allows two rows of five passengers to sit over the roof. A further three sit in the boot with their legs hanging over the bumper and the boot roof propped open. Two more pairs perch on the sides standing between the boot and the benches. One extra passenger has even been seen sitting on the hood. When one such vehicle had broken down with the passengers sitting at the roadside, a curious US resident once had the opportunity to confirm there were 27 passengers. 113 Bangui’s 8000 yellow taxis ply three routes radiating out from the Bangui La Coquette roundabout, the centre of town. They almost seem to outnumber private vehicles. An expatriate said Bangui was ‘a city that had never seen a traffic jam’. 114 Businessmen note that at some checkpoints four sets of payment are necessary: there are representatives from FACA (the Armed Forces), the Gendarmarie, Customs, and the Water & Forestry Bureau. Muslim traders feel particularly penalised. One Muslim Central African plans to change his name to a Christian‐sounding one to avoid going out of business. Conversely, for those local traders with contacts the system offers a competitive advantage.

115 Tsetse fly, an animal parasite, is common countrywide. CAR also has four of sub‐Saharan Africa’s remaining pockets of sleeping sickness (Simarro, P. et al., 2010).

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3. Notes on Nomenclature In CAR, health facilities seem named according to some formula which involves the importance of their host location and the proximity of other facilities. They most emphatically are not named according to the Ministry of Health classification system which lays down the respective size, catchment area, range of services and staffing profile. Thus, a small building in an obscure village can be named a Poste Sanitaire, or Health Post, while a similar‐sized building in a more important small town is a Centre de Santé, or Health Centre. A large facility with ten staff may still be called a Health Post if it is in a regional centre. A privately owned building the size of a health post with one first aider present awarded itself the title Community Hospital. The blanket term FOSA, standing for Formation Sanitaire, is in use. On paper, according to an elaborated Ministry of Health classification, a health facility falls into one of nine categories: either central, regional or prefectural hospital; one of the three rural health centre categories (A, B or C) or an urban one (D or E); or a health post. A catch‐all ‘Other’ might usefully be added to include therapeutic feeding centres, centres for the disabled and dental clinics. The churches’ umbrella organization may refer only to hospitals, clinics, dispensaries and others but on the ground the facilities themselves may use some MoH categories116. There are also some Medical Centres. While a pharmaceutical depot is referred to as facility, other non‐clinical infrastructure is not mentioned. The pick ‘n mix labelling of infrastructure goes some way to explaining the variety of official figures. In the National Health Development Plan (2006‐15) the number of state‐owned health centres, for example, is reported to be 181, the Annual Health Information Bulletin (2006) reports 195, the Health Inventory (2006) reports 235 and the Health Policy Draft (2004) reports 301. All four documents emanate from the same Ministry of Health. Taking a lead from the population who refer to every health facility as a ‘hospital’ (and a little health facility as a ‘little hospital’), this report has described anything smaller than a regional hospital as a ‘health facility’. ‘State‐owned’ has been used to describe public facilities, which is a misnomer. Since 2008, the ministry’s full title is the ‘Ministry of Public Health, Population and the Fight against AIDS’ (MSPPLS) referred to throughout this document simply as the Ministry of Health (MoH).

116 For ASSOMESCA, a dispensary is larger than a clinic. In some comparative tables of the health network, dispensary has been misallocated and considered as health post, further muddying the waters.

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4. Bibliography Africa Health Workforce Observatory (AHWO). (2010) Profil pays en ressources humaines pour la santé: Centrafrique. Ayissi, B. Soigner 50 maladies par les plantes naturelles à zero francs (undated). Baker, T.D. (1988) Referred to in Pavignani, E. and Colombo, S. (2009) Analysing Disrupted Health Sectors. World Health Organisation. Berg, P. (2008) A crisis‐complex, not complex crises: conflict dynamics in the Sudan, Chad, and Central African Republic tri‐border area. Central African Conflict Dynamics. IPG 4/2008. Bierschenk, T. and Olivier de Sardan, J.‐P. (1997) Local powers and a distant state in rural Central African Republic. The Journal of Modern African Studies, Vol. 35, No. 3, pp. 441‐468. Bloom, G. et al. (2011) Making Health markets work better for poor people: the case of informal providers. Health Policy & Planning 26:i45‐i52. Brégeon, J.N. (1998) Un rêve d’Afrique : Administrateurs en Oubangui‐Chari, la Cendrillon de l’empire, p. 24. Quoted in International Crisis Group (2007) Central African Republic Anatomy of a Phantom State. Africa Report N°136. US Central Intelligence Agency. (2012) CIA World Factbook. The http://www.cia.gov. Chabal, P. and Daloz, J.P. (1999) Africa works. Disorder as political instrument. The International African Institute – James Currey – Indiana University Press. De Valensart, L. and Collin, C. (2011) Evaluation of the Common Humanitarian Fund. Central African Republic Country Report. OCHA. Economist Intelligence Unit. Central African Republic Country Report December 2011. http://www.eiu.com. Ellis, S. and ter Haar, G. (2004) Worlds of power: religious thought and political practice in Africa. Hurst and Company, London. Giroux, J. Lanz, D. Sguaitamatti, D. (2009) The tormented triangle: The regionalisation of conflict in Sudan, Chad and the Central African Republic. LSE Development Studies Institute. Global Fund to fight AIDS, Tuberculosis & Malaria. (2010) CAR Grant Portfolio. Government of the Central African Republic. (2011) Central Africa Poverty Reduction Strategy Paper (2011‐15). Humanitarian and Development Partnership Team. www.hdptcar.net, accessed 13 April 2012. Humanitarian and Development Partnership Team. (2008) Needs analysis framework: analysing humanitarian needs in the Central African Republic. www.hdptcar.net, accessed: December 2011. Herbst, J. (2000) States and power in Africa. Comparative lessons in authority and control. Princeton University Press. Hochschild, A. (1999) King Leopold’s Ghost: a story of greed, terror and heroism in colonial Africa. Houghton Mifflin. Iqbal, M. Hanifi, A. Wahed, T. (2009) Characteristics of village doctors. In: Health for the Rural masses. ICDDR. International Crisis Group (ICG) (2007). Central African Republic Anatomy of a phantom state. Africa Report N°136. International Crisis Group (ICG) (2010) Dangerous little stones: diamonds in the Central African Republic. Africa Report N°167. Kimpianga Mahaniah, J.M. (1981) La structure multidimensionnelle de guérison a Kinshasa, capitale du Zaire. Social Sciences and Medicine. Vol. 15B, pages 341‐349. Laird, M.N. (1993) They called me Mama. Baptist Mid‐Missions. The Lancet (2012). Volume 380, Issue 9846. Pages 964 ‐ 965, 15 September 2012.

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Mahmoud, S. et al. (2010) Are ‘village doctors’ in Bangladesh a curse or a blessing? BMC International Health & Human Rights, 10.8. Marchal, R. (2009) Aux marges du monde, en Afrique central… Centre d’études et de recherches internationals. N° 153 – 154. Medecins Sans Frontières (MSF). (2011) Central African Republic: a state of silent crisis. www.msf.org. Melly, P. (2002) Central African Republic – uncertain prospects. UNHCR Emergency & Security Service. WriteNet Paper N˚ 14/2001. Mercy Corps. Women’s Empowerment. http://www.mercycorps.org, accessed 24 January 2012. Ministère de la Santé Publique et de la Population (MSPP). (2004) Projet de politique nationale de santé. Ministère de la Santé Publique et de la Population (MSPP). (2006) Cartographie de l’offre des services de santé. Ministère de la Santé Publique et de la Population (MSPP). (2007) Plan stratégique de renforcement des systèmes de santé. Draft 1. Ministère de la Santé Publique et de la Population (MSPP). (2008) 2006 Bulletin Annuel d’Information sanitaire, Ministère de la Santé Publique, de la Population et de la Lutte contre le SIDA (MSPPLS). (2009) Rapport d’analyse du système d’approvisionnement en médicaments de la RCA. Ministère de la Santé Publique, de la Population et de la Lutte contre le SIDA (MSPPLS). (2010) Profil des ressources humaines pour la santé. Murru, M. (2011) Central African Republic: Not much beyond PK12…and little before it. Unpublished. Office for the Coordination of Humanitarian Affairs (OCHA). (2011) CAR Consolidated Appeal Process. Oladepo, O. Salami, K. Adeoye, B.W. et al. (2008) Malaria treatment and policy in three regions of Nigeria: The role of patent medicine vendors. Future Health Systems. Working paper N˚1. http://www.futurehealthsystems.org. Olivier, J. and Wodon, Q. (2012) Playing broken telephone: assessing faith‐inspired health care provision in Africa. Development in Practice. 22:5‐6, 819‐834. Organization for Economic Cooperation & Development (OECD). (2010) Country Report 2 Central African Republic. O’Toole, T. (1986) The Central African Republic: the continent’s hidden heart. Boulder CO: Westview Press. Pavignani, E. and Colombo, S. (2009) Analysing disrupted health sectors. Health Action in Crises. World Health Organization Remme, M. Douzima, J.P. Peerenboom, P. (2011) Évaluation des deux premières années d’achat de performance. Cordaid. Saulnier, P. Le Centrafrique: entre mythe et réalité (1998), pp. 81‐96. Referred to in: International Crisis Group (2007) Central African Republic Anatomy of a phantom state. Africa Report N°136. Scott, J.C. (2009) The art of not being governed: an anarchist history of upland Southeast Asia. Yale University Press. Simarro, P. et al. (2010) The atlas of human African trypanosomiasis: a contribution to global mapping of neglected tropical diseases. International Journal of Health Geographics 9:57. Spittaels, S. and Hilgert, F. (2009). Mapping conflict motives, Central African Republic. IPIS. Strong, P. (1984) Burning wicks: the story of Baptist mid‐missions. Baptist Mid‐Missions. Unicef. (2011) Humanitarian Action for Children/ West & Central Africa/ CAR. UNFPA. (2010) The sixth CAR‐UNFPA Cooperation Program. US Department of State. http://www.travel.state.gov, accessed 24 January 2012 World Health Organisation (WHO). (2006) HR situation analysis and recommendations, HR development plan

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for 2006‐2011. Office for Southern Sudan. World Health Organisation (WHO). (2010) Rapport mondiale de la santé : financement de la santé. Geneva. World Health Organisation (WHO). (2011) World health statistics. World Bank. (2010) Reducing geographical imbalances of health workers in Sub‐Saharan Africa: A labour market perspective on what works, what does not, and why. World Bank Working Paper Nº 209. World Bank. (2011) Service delivery in the Central African Republic: An analysis of facility data from 2006 & 2011.

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5. List of Informants

Based in Regions Dr Abdi ABOBAKAR ADOW, Clinic owner, Berberati (Region 2) Abdramane AMIT, State Diploma Nurse, Head of Elevage Health Centre, Bambari Jean‐Jacques AWODOHOU, First Aider, Bobéle Health Centre (Region 1) Dr Joseph Chamberlain BAMA, Director, Regional University Hospital, Bambari Guerric BARANOVSKY, Head of Sub‐mission, French Red Cross, Bambari

Dr Maurice BAWA, EPI Consultant, WHO Nina Yvette DEKEZANDJI, Midwifery Asst, Bobéle Health Centre (Region 1) Davy Emmanuel NGOAGOUNI, Pharmacist, Diocese Health Coordinator, Bambari Ernest GUEREKOPIAMO, Sub‐Prefect, Bambari Dr Ernest KALTHAN, Health Officer, Bambari Prefecture.

Dr Emmanuel KITEZE, National Administrator, Unicef Zonal Bureau, Kaga‐Bandoro. Juste LE, State Diploma Nurse, Notre Dame de Victoire Health Centre, Bambari Elise LE CARRER, Anthropologist/ WaSH coordinator, French Red Cross, Bambari Boniface LELE, Nursing Asst, Yombo Health Centre (Region 1) Remy LINGOUPOU‐NAYETA, State Diploma Nurse, Head, The Samaritan Health Centre, Bambari

Rafael MARAGO, Nightwatchman, ICDI, PK 22 (Region 1) Timothee MANANGA, Head, Baptist Evangelical Medical Centre, Ippy (Region 4) Jean MANDABA, First Aider, Community Hospital Quartier Betaz, Bambari Brother Anatole MBANGA, Community of Apostolic Churches. Bénoit MENKENG, State Diploma Nurse, Baptist Evangelical Health Centre, Berberati (Region 2)

Dr Christopher MFORNYAM, Health Coordinator Bouar, MERLIN Donacien MOKOTÉME, Traditional Healer, Yatimbo (Region 1) Dr Timothee MUTIMA SHELUBALE, Medical Director, IMC. Marcelain NAMSENE, Head of Base, ICDI, Berberati (Region 2) Dr Christophe NDOUA, Regional Health Officer, Health Region 4, Bambari

Salomon NEOUMAN, Ippy Health Centre (Region 4) Mauricette NGANAMOKOE, First Aider, Nambona Health Centre, Berberati (Region 2) Albert NIAKAMATCHI, Nursing Asst, Ippy Health Centre (Region 4) Hilaire PADOU, Sociologist, CARITAS, Bambari Dr Aurelien PEKEZOU, Reproduction Health Coordinator, MERLIN

Maximin POGUI‐BISSY, Nursing Asst, Mini‐Pharma owner, Bambari Corneille RAWAGO, Nursing Asst, Regional University Hospital, Bambari Dr Babou RUKENGEZA‐MAKANDA, Program manager Region 6, Mercy Corps Pastor David SAN OLOPA, Baptist Mid‐Missions Pierre SANA, State Diploma Nurse, Houphoet‐Boigny Health Centre, Liton (Region 1)

Rigobert SARALÉ, First Aider, Nambona Health Centre, Berberati (Region 2) Papa SINGUE, Traditional Healer, Yombo (Region 1) Dr Joachim Paterme TÉMBÉTI, Regional Health Officer, Health Region 2, Berberati (Region 2) Moise WOMBE, Laboratory Technician (Rtd), Yombo Health Centre (Region 1) Clement ZAIMARA, Higher Technician, Director, Health Sciences Institute Annex, Bambari

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Auguy, Mini‐Pharma owner, Mambéré (Region 1) Bondieu, Traditional Healer, Yombo (Region 1)

Based in Bangui Youssouf ALI SOULEYMANE, State Diploma Nurse, Pharmacie AWA, Quartier La Kouanga Dr Patrick BERCKMANS, First Counsellor, EU Delegation Jean Félix BISSAKONOU, Head of Mission, National Traditional Healers Association Dr Gilles CHAUMENTIN, Technical Advisor, MSPPLS Christian CHORLIET, Pharmacy Consultant

Dr Naomi DOUMA, Clinic owner/ Occupational Health Inspector. Bambard Lesbord ENZA, Mini‐Pharma owner Elizabeth GRAYBILL, Gender‐based Violence Program Manager, Mercy Corps Dr Awa HAMAT, Pharmacist, Pharmacie AWA, Quartier La Kouanga Lela HAOSSALA, Admin/Finance Director, IMC

Jim HOCKING, CEO, Integrated Community Development International Charlie JEWELL, Coordinator, Baptist Mid‐Missions. Dr Léon KAPENGA MUKONKOLE, EPI Specialist, Unicef Jean KONDO, roadside stallholder, Bangui Polycarpe LAGOS, Finance Asst, MSF‐Holland

Maurice LENGA, Head of Human Resources, MSPPLS Prof LLOYD‐DAVIES, University of Bangui Dr Demba LUBAMBO, Humanitarian Focal Point, WHO‐Central Africa Dr Marie MARCOS, Health Coordinator, IRC Roch M’BONDJI, Customer Services, Ascoma‐ Centrafrique

Dr Christian MULAMBU, Field Coordinator, IMC Dr Raphael MUZÉKESSABOU, anaethestist (retired) Dr Jean Louis NDAMA, Head of Languages Department, University of Bangui Curious NINGALAO, Buba ngéré. Marie‐Angélé OMOZE, State Diploma Nurse, Anthropologist

Adrien RENAUD, Health Economist Consultant Charles Anibal SETA, Logistician, Coheb NGO José de SOUZA, Portuguese Consul Maria WANGECHI, Head of Mission, MERLIN

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