In CAR, data is not enough

Out of 814 health facilities in the Central African Republic, 254 are not functioning, with many of them partially destroyed, looted and abandoned amid conflict in the country.

Among the worst hit are regions 3 and 5, which covers the area in Bossangua in the north-west, and Bria in the east. Most child-related services in both regions, such as immunization and services to address child malnutrition, are lacking or nonexistent. Services for victims of sexual violence like clinical management and provision of psychosocial services are not available. And in region 3, almost all services related to HIV and AIDS and other sexually transmitted diseases are limited or not available.

The unavailability of services is linked to a number of factors: lack of sufficiently trained staff, equipment or funding, according to the nationwide assessment made last year by the World Health Organization and its partner nongovernmental organizations.

The same issues remain to this day however: Many of these health facilities, particularly those outside the capital Bangui, are missing medical supplies and equipment, and do not have sufficient staff, mainly due to ongoing insecurity and a significant funding gap.

Médecins Sans Frontières, which is among the few NGOs providing health assistance in the country, suspended part of its activities in a hospital in Kabo, located north of the country, in April following an attack on its facilities.

“The government tried to pay the nurses, but in the facilities, most of the workers, like cleaners, are being paid from the pockets of the patient. [So now] we need to fill this gap [to get people back to work],” Dr. Michel Yao, WHO’s representative in CAR, told Devex.

Ensuring health worker salaries and that they have a decent place to stay are critical, especially in areas where there aren’t NGOs that can fill the gap. The yearslong conflict has driven away many organizations; others are overstretched from responding to the Ebola crisis in neighboring Sierra Leone and Guinea, or other emergencies.

Recruitment, even among U.N. agencies, has been tough because of insecurity, Yao said. But that’s where the problem lies: The health cluster’s budget for 2015 is significantly underfunded, receiving only 12 percent of the required $63.2 million, which, according to Yao, has mostly gone to the purchase of medical supplies. Only a portion of received funding was spent on health worker salaries and re-equipping hospitals and health centers.

Serious funding gap

This is not surprising if one looks at the country’s aid funding history. When the conflict erupted in 2013, the health cluster received only 49 percent of its $21.28 million requested budget. That requirement shot up to $71 million in 2014, which by the end of the year was only 58 percent filled.

And the funding shortfall may even get worse.

Yao said some of last year’s donors have yet to commit funding to CAR this year. Several of them have contributed to other crises WHO is responding to, “but not CAR.” This comes despite the availability of data that clearly sets out the different needs of health facilities across the country until the end of 2015.

Yao said this could very well be a sign of donor fatigue and low political interest in the country. In his years of experience as senior health adviser for humanitarian crises at WHO’s headquarters in Geneva, Yao said that while donors are quick to pour in resources to countries of interest, their assistance often slows down in protracted crises.

The current crisis in CAR may have started in 2013, but Yao explained that donors have been providing aid to the country for nearly a decade now.

At the international conference for CAR in Brussels, Belgium, the EU made 15 million euros ($16.6 million) available from its multidonor trust fund, to be allocated for several health activities carried out by NGOs like Save the Children and the French Red Cross in the country. Yao said the multilateral donor has also expressed interest in supporting WHO, although nothing has been finalized.

“We also shared the clear plan to other donors, but up to now, we don’t have any significant contribution,” he said. “It’s difficult. I’m struggling.”

WHO international staffers are paid every three months; the next payout is scheduled for the end of June. As Yao struggles to find enough resources to pay them this month, he is already worrying about where to find financing for the next period’s payout.

“So from end of June, it will be critical … I cannot afford to reduce the staff [else many of the field activities like disease surveillance and monitoring will be affected],” he said.

The grading dilemma

Hopes to mobilize more resources for the country’s health needs however may go further down the drain, after the Inter-Agency Standing Committee and WHO last week downgraded the CAR crisis to Level 2 and Grade 2, respectively.

Yao said the decision was made not because the crisis is over, but because some of the crisis’ acute phases have “cooled down a bit.” For example, the need for trauma care has now gone down compared with a year ago. Level 3 or Grade 3 crises are those that require quick mobilization of resources and response, which is “not the case in CAR right now.”

But he is well aware of the decision’s possible implications, as well as the current limitations of WHO’s emergency framework.

“What we are afraid of is if the country is totally forgotten, because things are improving in the capital city,” the WHO official said. The danger with that is CAR can easily fall back into the acute phase again.

Yao is part of the working group reviewing WHO’s emergency response framework. And he said the case of CAR is among those that the organization is looking into as it improves its grading system. They are now looking to adopt an all-hazards approach where they’d be able to take protracted situations into account when grading crises. And coming from the organization’s experience in Ebola, they are moving toward adopting a clearer chain of command in emergencies.

“Because in some of crises, like Sahel, a food insecurity crisis, things moved slowly up to the peak of the crisis … so we are learning from past experience … to improve the new one that will come out soon,” he said.

In her speech at the recently concluded 68th World Health Assembly, Director-General Margaret Chan promised to complete that commitments she made on WHO’s emergency response capacity by the end of the year.

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