The South-West and North-West regions of Cameroon, which host 16% of the nation’s total population, have been experiencing political and social instability since October 2016. Starting in November 2017, the levels of insecurity and violence have progressively increased in these regions. Since then, the escalation of tensions and hostilities between the government’s armed forces and non-state armed groups (NSAGs) have led to significant internal displacement, causing a rapid increase in the humanitarian needs of the two regions. The number of households forced to flee their villages in search of safer areas has rapidly and steadily increased since November 2017, with more than 25,000 Cameroonians registered as refugees in the Cross River, Benue, and Akwa Ibom States in Nigeria. In early 2018, the epicenter of the crisis moved from Bamenda, the capital of the North-West, to the Meme and Manyu divisions in the South-West. This region, which hosts more than 1.5 million inhabitants, is currently registering an internal displacement of 246,000 people.
Since the security and political context in these regions have challenged the flow of information, International Medical Corps (IMC) decided to conduct an integrated multi-sector needs assessment on July 12-25, 2018 to evaluate the Health, Nutrition, Water, Hygiene and Sanitation (WASH), Food Security, and Protection needs of the most affected areas in order to inform an adequate and efficient response. IMC partnered with United Action for Children (UAC), a local NGO with extensive experience implementing education and poverty alleviation projects in the region, to conduct a multi-sectoral needs assessment in the Fontem, Kumba, and Mamfe health districts of the South-West region.
The methodology used by IMC to conduct this evaluation combined various tools and techniques. First, a desk review of existing needs assessment reports, publications, and secondary data available on the humanitarian situation in the South-West was used to gather relevant background information and to avoid duplication. A health facility assessment and direct observations made it possible to assess the status of each health facility visited and the living conditions of the people affected by the crisis. In addition, the indepth interviews with heads of households and community leaders, in addition to a Lot Quality Assurance Sampling (LQAS) survey identified the priority needs of displaced people and host communities. Finally, the use of key informant interviews with the main representatives of the various ministries and with the community leaders permitted IMC to identify the humanitarian response gaps in the assessed health districts.
The assessment showed that IDPs and host communities living in the Fontem, Kumba, and Mamfe health districts are facing increasing protection challenges arising from the violence and insecurity as a result of the armed conflict between the government’s forces and the NSAGs. The implementation of the “Ghost Town” days (when the population is not allowed to engage in any commercial activities), the daily nighttime curfew, and the closing and burning of schools, health centers, and other public services have severely disrupted the social stability of the region. Many people have lost their identity cards and birth certificates during their displacement or after the burning of their homes, and the replacement of these documents is now even more challenging than ever. Likewise, as many women are now giving birth in the bush, children are being left without proper registration.
The number of children exhibiting distress and/or turning to drug consumption and theft has increased since the beginning of the crisis. Many adolescents are no longer able to attend school (most of the schools are closed due to the crisis) and some have abandoned their previous livelihood activities, leading many of them to join the armed groups actively engaged in the conflict.
The destruction of the infrastructure has increased the levels of insecurity and placed women and children at a greater risk. Access to water has decreased (as explained in the WASH needs section), and there are areas with little to no electricity forcing women and children to cover greater distances to collect firewood and water. People are now reporting being scared of walking alone, especially at night when they are more vulnerable to rape, assault, and abduction. Women, many of whom are widows, are particularly at risk of gender-based violence, especially sexual exploitation and abuse. Girls are particularly at risk of sexual exploitation and forced marriage. The assessment showed very few available services for GBV survivors, and no referral and coordination mechanisms exist.
The evaluation of the health and nutrition needs showed a gap of 122 staff in the 11 health facilities assessed, with the Menji District Hospital being the most affected. Only 1 out of the 11 assessed health facilities has a health protocol in place for the clinical management of rape and treatment of survivors, and only the Mary Health of Africa Hospital in Fontem has a mental health specialist (1 psychologist). Furthermore, all assessed facilities were suffering from shortages of essential medicines and supplies.
Currently, there is no referral pathway between the OTP in Ntam and the stabilization center in Kumba to ensure the proper treatment for children with severe acute malnutrition with medical complications. The degradation of the health system has also severely affected the outpatient therapeutic program (OTP) services in Fotabong, which are no longer able to deliver treatment to severely acutely malnourished children. The gaps in the management and prevention of severe acute malnutrition have been mainly observed in four OTPs: Fotabong, Bukemwe, Ntam and Mamfe urban.
The interviews with community members and officials showed that people are now less able to seek treatment as the insecurity levels make it more difficult to reach the health facilities, and only 3 of the 11 assessed health facilities have an ambulance for the transportation of critical cases to other health facilities. In fact, only 6% of women are now giving birth at a health facility, compared to 93% before the crisis. A second factor affecting people’s access to health care is their increased inability to afford the required services, supplies, and other related costs. As transportation becomes more challenging, the availability of medicine and supplies decreases and most people are no longer able to afford the increased prices. As a result, many people have reported an increase in the use of traditional medicine as an alternative.
Outreach activities and disease surveillance have also been severely affected by the conflict. The last Infant and Young Child Feeding sensitization sessions took place more than six months ago, and only 22% of people surveyed have been sensitized on preventable diseases since the beginning of the crisis.
The evaluation of the water, sanitation, and hygiene (WASH) needs showed that only 37% of the assessed households are now collecting water from an improved water source for daily use, compared to 83% before the crisis, and only 35% of people with access to potable water can access it within 30 minutes compared to 78% before the crisis. Most of the improved water sources cannot be used or are damaged, and the lack of personnel impedes their rehabilitation. A number of households have wells, but these are not treated or sufficient to satisfy the demand. As a result, women and children, who traditionally collect firewood and water, are now forced to travel greater distances to reach rivers and other natural sources placing them at a greater risk of assault and abduction. Children are especially at risk of being affected by water-borne diseases such as cholera and diarrhea, as open defecation is becoming more common, and the water from natural springs and most wells are not properly treated and maintained.
Meeting food security needs and restoring livelihoods were among the top priorities for the people (IDPs and host community) living in the assessed areas. Only 39% of the households interviewed had food in stock, but people are concern these may not be sufficient to provide for their families and increasing numbers of IDPs. Only 29% reported consuming more than one meal per day compared to 99% before the beginning of the crisis. The insecurity levels continue to undermine the livelihoods of vulnerable people. This conflict has reduced the agro-pastoral production, and women engaged in small businesses, like the sale of vegetables and other foods, have been forced to abandon their activities due to the widespread insecurity. The “ghost town” days, nighttime curfews, and the insecurity on the roads have disrupted the movement of goods and supplies including agricultural inputs.