Central African
Republic: abandoned
to its fate?

Central African Republic, 2013 © Corentin Fohlen / Divergence

July 2013
Edited by Médecins
Sans Frontières

Summary
Instability has returned to the Central African Republic, and its people are in evengreater need of assistance. Yet most humanitarian organisations have either left thecountry or reduced their presence due to both the general insecurity and the targeted
attacks on international non-governmental organisations.
The international community must assure the conditions that will enable the delivery of
emergency relief to the population in need. Humanitarian and development agencies
must maintain, indeed scale up, their commitments, and take adequate measures
to respond both to emergency and long-term needs.

Background
The Seleka, a coalition of armed opposition groups, began its offensive against the
government of the Central African Republic (CAR) in December 2012. An agreement
was signed by warring parties in January 2013, but on 24 March 2013 Seleka took
control of Bangui, the capital, in a coup d’état. Michel Djotodia, one of the leaders of
the Seleka coalition, proclaimed himself president. The former president François
Bozizé fled the country and the state security forces (armed forces and police) largely
disbanded.
One month later, on 18 April, an Economic Community of Central African States(ECCAS) conference in N’Djamena, Chad, recognised Djotodia as head of atransitional government, mandated to lead the country to elections within 18 months.
ECCAS also authorised the deployment of an additional contingent of 1,500 soldiers tostrengthen the existing Mission for the Consolidation of Peace in the Central African
Republic (MICOPAX), which has been under the responsibility of ECCAS since 2008.
Médecins Sans Frontières (MSF) has been working continuously in CAR since 1996,
and has scaled up its programmes to respond to the recent increase in need. Despite
general insecurity and specific incidents, such as robberies, which have at times forced
the temporary evacuation of staff, MSF has never suspended activities. Currently MSF
operates nine programmes: in Carnot, Paoua, Boguila, Bossangoa, Batangafo, Kabo,
Ndele, Bria and Zemio.

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1. A country in chaos
The coup plunged the Central African Republic into chaos. Looting and attacks havecontinued even in the capital. State buildings, ministries, schools, hospitals andprivate homes have been robbed and damaged. Most civil servants have fled.
Archives and databases have been destroyed. Reactions of the population to thecontinuous lootings have met strong retaliation in Bangui1 and there have been similarreports from elsewhere in the country. The identification, disarmament, demobilisation
and reintegration of the armed opposition has not yet been organised and hundreds ofarmed men, who have been promised pay but received none since the beginning of thefighting, are still circulating in the city.
Elsewhere in the country, uncontrolled elements of Seleka and unknown armed
groups have carried out robberies and attacks against the civilian population. In
areas of existing tension between settled and nomadic peoples, the coup has fuelled
this underlying conflict.
All the humanitarian organisations working in the country have been victims of
security incidents since the beginning of the crisis. In Bangui, offices and houses of1

On 14 April, in Boy-Rabe district, more than 20 people were killed. More recently, on 28 June, six people were
killed and at least 25 wounded in fighting between civilians and Seleka supporters.
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United Nations agencies2 and international non-governmental organisations (NGOs)
have been repeatedly looted.3 Staff who have been threatened have reported serious
physical and psychological effects. Almost all international personnel working outside
the capital were evacuated as soon as the crisis began, and national staff were brought
to Bangui. Bases outside the capital have been robbed, with most cars stolen for use
by the armed opposition groups.4

Evacuation from Batangafo
The Batangafo team (48 people, including 42 medical personnel) had to be evacuatedon 10 April after a serious security incident, which involved armed people violently
entering an MSF compound. As a result, activities in the main hospital in Batangafo
were reduced for four weeks. Activities at surrounding health centres were suspended.
As Seleka advanced through the region on their way to Bangui, the population fled tothe bush. At the same time, regular, annual clashes between nomadic herders arrivingin the area with their livestock and local farmers had dire consequences: more than 20
villages were burned down, displacing around 8,000 people.
Marie Noelle, a young mother, explained to MSF staff that she fled the village of
Gbadéné with her neighbours in mid-April, after receiving the threat that pastoralists
were going to set the village on fire. She spent the night in nearby fields, and hervillage went up in flames the following day. Everything was burned down, including thetools villagers needed to tend their crops. Some weeks later, an MSF team carrying out
a mobile clinic to help the displaced found that her one-year-old child is malnourished.
Displacement has made thousands of people all over the country more vulnerable tomalaria.

The health system has not been spared. Ministry of Health facilities5 have been
robbed and looted of drugs, diagnostic tools, patient records, even furniture. Most
medical staff have fled their posts, especially those working outside the capital.
These attacks have deprived an already vulnerable population – 4.4 million people
spread across a country bigger than France – of access to even basic medical
treatment. In a country which already had the second-lowest life expectancy in theworld, at just 48 years,6 the people are now even more at risk.

2

According to the OCHA Humanitarian Snapshot of April 2013, six UN offices in CAR have been looted.
Of the MSF bases in Bangui, one office and one house have been completely looted, three cars havebeen stolen and one house has been robbed.
4
To refer only to MSF bases, four cars have been stolen (Boguila, Ndele, Batangafo) and three offices andhouses have been robbed (Ndele, Batangafo, Boguila) on several occasions.
5
While the hospitals in Bossangoa and Mbaiki were completely looted during the Seleka offensive, other
health facilities around the country (Allindao, Bangassou, Gambo, Grimari, Kembe, Kongbo, Mala,
Mobaye, Ouango) were damaged during the weeks preceding and following the coup.
6
WHO, 2011, “Mortality and burden of disease: Life expectancy”, Global Health Observatory Data
Repository. accessed 7 October 2011, at: http://apps.who.int/ghodata/.
3

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2. A crisis on top of a crisis
Not considered to be in a sufficiently acute situation to attract emergency funds, norable to fulfill the requirements to receive structural funds for development, the country
is trapped between a state of ‘emergency’ and one of ‘development’. As a result, CAR
has been in a state of silent, chronic medical crisis for many years. A recent MSF
study on the country reported:7
Mortality rates above the emergency threshold. Four retrospective mortality
surveys carried out by MSF in the south and northwest of the country between
2010 and 2011 revealed extremely high mortality rates.8 One survey, in June
2011, revealed an extremely alarming situation in areas not affected by conflict(Carnot, Gadzi and Senkpa Mpaéré): the crude mortality rate was
3.3/10,000/day (95% CI, 2.3-4.8), while the under-five mortality rate (U5MR)
was 3.7/10,000/day (95% CI, 2.4-5.6).9 In the urban commune of Carnot, theCMR was 3.9/10,000/day (95% CI, 3.0-5.2) and the U5MR was 4.9/10,000/day(95% CI, 2.6-8.8).
The survey found the crude mortality rates in three rural communes to be atleast three times the emergency threshold, with an under-five mortality rate
three times as high as the one in Kenya’s Dadaab refugee camp, where people
who fled Somalia are living in dire conditions.

High mortality and morbidity caused by easily treatable and preventablediseases. CAR has a high burden of malaria,10 diseases preventable byvaccination (due to a malfunctioning expanded programme on immunisation),chronic diseases such as HIV/AIDS, and rising malnutrition.11



Phantom healthcare system. The country’s health system suffers a chroniclack of facilities, skilled medical staff, diagnostic and treatment tools, medicines
and supplies, and surveillance, making it to all intents and purposes a phantom
system, which cannot really be said to function.

The impact of the recent crisis has been tremendous. Fear of movement has further
reduced access to healthcare, loss of income has made it even more difficult to pay
medical fees, and unreliable drug supply systems have completely collapsed. Mortality
rates are only likely to worsen in the coming months.
7

MSF, 2011, Central African Republic: A State of Silent Crisis.
Caleo G et al., 2011, Sentinel site mortality surveillance of mortality and nutritional status: Boda,
Boganda, Boganangone and Gadzy sous-prefectures, Central African Republic, 2010, Epicentre, Paris.
Espié E, 2011, Enquête de mortalité rétrospective dans la ville de Carnot, préfecture de Mambéré-Kadéi,
République Centrafrique, Epicentre, Paris. Rasella D, 2011, Retrospective Mortality Survey: Axe
Maitikoulou-Kdajama Kota, [Unpublished.]. See as well the retrospective mortality survey published
University of California, Berkeley : Vinck P and P Pham, 2011, “Association of exposure to violence andpotential traumatic events with self-reported physical and mental health status in the Central African
Republic”, Journal of the American Medical Association. 304(5): 544-552.
9
Cohuet S, C Marquer, S Abdallah, 2011, Enquête de mortalité rétrospective et de couverture vaccinale
dans les sous-préfectures de Carnot et de Gadzi, République Centrafrique, Epicentre, Paris.
10
Malaria is by far the most common illness seen in MSF’s outpatient facilities: of a total of 582,253 people
treated as outpatients in 2010, 46 per cent (or 267,471 people) were diagnosed with and treated for
malaria. Malaria is the greatest single cause of inpatient death in CAR’s hospitals.
11
MSF and Epicentre conducted a community surveillance survey (Caleo G et al., op cit.) in the
subprefectures of Boda, Boganda, Boganangone and Gadzi between February and December 2010,
which found the prevalence of global acute malnutrition to be 11.9 per cent (95 per cent CI 9.1-15.5). The
prevalence of severe acute malnutrition (SAM) was 3 per cent (95 per cent CI 2.3-4.0), of which half theindividuals had signs of kwashiorkor. SAM prevalence appeared to peak in April–May 2010, and moremarkedly between June and October.
8

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Hôpital Communautaire
Jordan is 14 years old and lives in Miskine, Bangui. He hid at home on 24 March,when Seleka entered the capital, but still he was injured in the leg by a straybullet.
Jordan’s mother explains how “a father from our church helped us to get to thehospital. Now he’s getting better and I hope that he’ll be at home soon”. Most
hospitals in Bangui were not functioning, but Jordan was brought to the Hôpital
Communautaire, where MSF donated drugs, medical supplies, water and fuel tohelp get it working again. An MSF team also set up an operating theatre, wherearound 40 procedures were carried out in 10 days.
By the end of May, when MSF withdrew, MSF staff had treated more than athousand patients, 36 per cent of whom had been wounded by bullets. Threemonths after the coup, normal services have resumed at the hospital: staff havereturned and the operating theatre and sterilisation unit are properly equipped.
MSF has made sure drug supplies are available in case they are needed.

We cannot yet estimate the overall impact of the political crisis on the healthcare
system, but a notable increase in consultations has already been observed at MSF
projects.
The situation is extremely alarming especially for malaria, which is holoendemic in
CAR. Frequent displacement of people into the bush since December 2012 hascontributed to an increase in exposure to the disease, and prevention and treatment
measures have been largely absent since the political crisis began. The large-scalemosquito net distribution planned by the Ministry of Health for 201312 has beencancelled because of insecurity. The supply of malaria drugs to rural areas has been
disrupted: MSF has committed to assist the National Malaria Programme’s
implementation of the Global Fund’s Action Plan, and deliver malaria treatments to 166
FOSA (Formation Sanitaire, the name of CAR health facilities) around the country, butthat still leaves 75 per cent of FOSA without any drugs. 13
In the first quarter of 2013, health facilities supported by MSF treated 74,729
patients for malaria. This is an increase of 33 per cent over the same period in
2012, when 50,442 patients were treated for the disease. For children under five yearsof age, there has been an increase of 46 per cent, from 23,910 in 2012 to 44,469 in
2013. In Boguila, 61 per cent of outpatient consultations with under-fives were formalaria during the first quarter of the year, compared with 41 per cent a year ago.
These data indicate the likelihood of a further increase in consultations during the peakmalaria season, which begins in July, and potentially one of the most acute malaria
crises of recent years.

12

Audit des subventions du Fonds mondial accordées à la République centrafricaine, GF-OIG-13-002, 6
February 2013.
13
Source: Micro Plan Sous-Prefectures, Carte Sanitaire 2003.
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Hospital

2012

2013

Increase

Batangafo

12,067

15,85324%

Boguila9,643

18,661

48%

Paoua

6,651

11,41742%

Total

28,36145,931

38%

2012

2013

Chury Baysa, MSF medical coordinator, Bossangoa“We had a four-year-old boy come to us at the end of May suffering from severe
anaemia and malaria. He was so sick we had to transfer him by car, along very
bumpy roads, from Bossangoa to our hospital in Boguila, so that he could have ablood transfusion. We have seen a number of cases like this, with children fallingvery sick because of a lack of mosquito nets and malaria drugs.”

The instability has also aggravated pre-existing food security problems: a poor harvest,
poor food supplies and volatile food prices. 14 Recent exploratory activities by MSF in
the southwest of the country15 indicate a risk of increased levels of malnutrition.

14

WFP/FAO, Evaluation rapide de la sécurité alimentaire en RCA, June 2013.
It is difficult to draw an accurate picture of the malnutrition situation for the population, but MSF madedifferent visits to the areas of Nola, Boda, Berberati, Gamboula and Gadzi, where they carried out rapid
screening. The screening revealed increases in global acute malnutrition (GAM) ranging from 6 per cent to10 per cent,, and 1–5 per cent increases in rates of severe acute malnutrition. There were some alarming
figures in sites like Boda, Nola and Gadzi.
15

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Increased malnutrition will make children even more vulnerable during the peak malaria
season.
The drug supply system has been disrupted for months now. Widespread looting of
medical facilities since the coup has led the Global Fund to Fight AIDS, Tuberculosis
and Malaria to cease keeping stocks of drugs in the country.
The supply problems have had serious consequences for adherence to treatment andthe development of drug resistance. MSF estimates that approximately 11,000 HIVpositive people (73 per cent of all people who are on antiretroviral treatment inCAR)16 have had their treatment interrupted due to drug supply problems during thepolitical upheaval.

Interruption of antiretroviral and TB treatment
In Bossangoa, approximately 150,000 people have endured an acute lack ofhealthcare since the political upheaval, when health workers fled facilities. Ministryof Health officials estimate that approximately 310 HIV patients were registered at
Bossangoa hospital before the coup, 170 of whom were on antiretroviral treatment.
In June, MSF began a two-month emergency programme at the hospital, providing
antiretroviral and TB drugs to patients whose treatment had been disrupted.

As half of all children were not receiving routine vaccination before the crisis,17 it can besafely assumed that most newborns since December 2012 have not had access to theroutine vaccination package, or Expanded Programme on Immunisation (EPI). This has
increased the risk of outbreaks of diseases like measles, meningitis and pertussis(whooping cough) in coming two years, and created a cohort of children particularly
susceptible to such diseases.
The international community’s only response has been a measles vaccination
campaign organised in May by UNICEF18 and those of its partners remaining in the
country. Carried out in difficult circumstances, this campaign was only able to reach
122,869 children living in Bangui and the surrounding area, not even 20 per cent of thetarget population.19 Nothing has been proposed for the 1.5 million children living
outside the capital.
To add to the problems, the withdrawal of most international assistance organisations
means that the phantom health system in CAR is unable to carry out adequate
surveillance and therefore monitor the rural areas that are more at risk of outbreaks20.
16

UNAIDS, 2011, Central African Republic: HIV and AIDS Estimates (2009). Delaunay S, 2011, Etat deslieux de l’infection VIH en République Centrafricaine et pistes de réflexion pour MSF, MSF, New York.
17
According to the External Review of the National Immunization Programme in Central African Republic(31/01/2013 from Auguste Ambendet, AFRO Central Intercountry Support Team): “The main weaknesses
are a) the low rate of fully immunized children (31%) identified by the coverage survey, b) frequent
shortage of vaccines and finally c) weak vaccine management.”
18“Conflict Brings Measles Back to Central African Republic”, UN Dispatch, 17 June 2012,

http://www.undispatch.com/conflict-brings-measles-back-to-central-african-republic
19
UNICEF, Central African Republic Situation Report: 21 May–13 June.
20

As example of the inexistent surveillance system, WHO reports that there were 175,210 probable andconfirmed malaria cases in CAR nationwide in 2009. This is less than the total number of confirmed cases
treated (187,736) by MSF in the country alone. So CAR appears relatively low-burden, when it mostcertainly is not.
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3. Lack of response
Despite an increase in need, the humanitarian presence in the country has
drastically shrunk. Most humanitarian organisations have scaled down activities.
Some are still in Bangui, waiting for the security situation to allow them to return to theirrespective project locations. Others have moved their base to neighbouring Cameroon.
The United Nations agencies do not have any international staff outside Bangui,
due to strict security rules applied since December 2012. Very recently, there havebeen some exploratory activities outside the capital, but no organisation has moved
permanently to the regions.
The UN has not allocated sufficient resources to mobilise actors and attract the funds
that are needed in CAR. So far, 47 per cent of the Consolidated Appeal for CAR 201321
has been disbursed. However this appeal is based on plans made in 2012, and does
not take into account the increase in need both for humanitarian and more long-term
assistance since the coup. If we look at the revised funding request following the crisis,
only 31 per cent of financial needs have been met.22 More specifically, only US$ 2.8
million have been disbursed in the health sector, which represents just 13.2 per cent of
the US$ 21.2 million requested.23

Equally, the efforts invested in analysing the security situation have been inconsistent,
making it impossible for humanitarian organisations to plan their return. The lack of
information and lack of financing, together with ineffectual coordination of thehumanitarian response, make it difficult to find implementing partners among

21

OCHA, CAR Situation Report no. 21 (21 June 2013).
Financial Tracking Services, Consolidated Appeal: Central African Republic 2013, Table C:
Requirements, Commitments/Contributions and Pledges per Appealing Organization Report as of 04-July2013 (Appeal launched on 14-December-2012),
http://fts.unocha.org/reports/daily/ocha_R1_A979___1307021923.pdf
23
Financial Tracking Service, Central African Republic: Funding Received 2013, at
http://fts.unocha.org/pageloader.aspx?page=emerg-emergencyCountryDetails&cc=caf
22

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international organisations already present in CAR and others interested in opening
new programmes in the country.
As a result, there is a vacuum of humanitarian assistance outside the capital: theresponse is inadequate, and the population is not receiving the assistance it
desperately needs. This vacuum is also likely to lead to problems later on, asorganisations lose contact with armed actors in the regions, making the negotiation ofhumanitarian access more difficult in the future.

CAR, a country in critical needThree months after the coup, the situation in the Central African Republic is critical.
The transitional government is still struggling to establish an acceptable level of
security in the capital, while there is a complete absence of state authority in the rest of
the country, which is at the mercy of uncontrolled armed groups. Despite the drastic
increase in need, however, the humanitarian presence in the country is reachingan historic low.
MSF is calling for:-the international community (United Nations, European Union, African Union,
ECCAS) to keep the Central African Republic at the top of its agenda andsupport this fragile country during transition;-

the humanitarian community (United Nations agencies, international NGOs,
donors) to maintain its commitment, despite the current situation, and allocate
adequate resources to CAR in order to respond to:
o
o
o

-

the medical crisis, particularly with regard to malaria;
the humanitarian crisis, by meeting basic needs; andstructural needs, by providing long-term support to the health system.

the transitional government:o to guarantee security conditions that will allow humanitarianorganisations to provide assistance to the population; ando to immediately commit to meeting the urgent humanitarian and medical
needs of the population, with international support.

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