CAR: Health progress remains fragile
Over one million people - a quarter of CAR's population - have been affected by violence. As the country fell apart, so too did its health service. As campaigns Manager for Merlin, the medical aid agency, I recently visited CAR to find out how the country, and its health service, is recovering.
Save for "bits here and there", Jean Preside Saya has not been paid since 1989. He runs the health clinic in Grevai, a remote village 65km from the nearest hospital.
Six months ago, the clinic had no drugs, no equipment, and often no patients. "People stopped coming," he said. "It was frustrating - as health workers, we feel we can treat most complaints but what are we meant to do without drugs? Even a traditional healer has drugs."
"Expect insecurity, instability, no electricity, no running water. Desperation, basically," said my Ghanaian passenger, as our plane bounced into Bangui, the capital of CAR.
I won't lie - I was already a little nervous about this trip, despite having lived in rural Tanzania for two years, working with isolated Maasai communities. The few articles I could find on CAR were dominated by its conflict-mired neighbours; Chad, Sudan and the Democratic Republic of Congo. The hard facts I gleaned were no less daunting: twice as many women die in childbirth now than a decade ago; life expectancy is a heart-stopping 43 years old. Yet when I asked around, virtually no one had heard of CAR. How can a country of over four million people have been so forgotten?
Within minutes of arriving, CAR handed me my first surprise: a homage to Hollywood. High in the hills surrounding the capital stands a 30ft sign, lit by 150 naked bulbs, proudly declaring "Bangui, La Coquette". I expected many things of Bangui, but being 'flirty' wasn't one of them. Neither was having electricity. Surprise number two: No one considers CAR a crisis, so few will truly commit to funding its recovery.
I had heard about the only qualified midwife in the Kaga Bandoro district and how she is responsible for nearly 50,000 women. Then I met her, and her patients - and the true meaning of a totally neglected health service was played out before my eyes.
It was there: in the uncomfortably swollen bellies of babies; the scalpel-sharp shoulder blades of toddlers; the birth attendants telling me of pregnant women who had died from routine complications. And it was there in the exhausted but triumphant face of a health worker who had just brought a child back from the brink.
Bruno Fugah, Merlin's country director in CAR, explains: "Proper analysis is sketchy, but it is estimated that CAR's health system needs six times as many qualified health workers to function properly. "In reality, the figure is probably far higher."
High child mortality
Currently, three times as many women die in childbirth in CAR than in Sudan. More than 10% of babies will not survive birth, and almost 20% of children will die before their fifth birthday. Such statistics sit uncomfortably with the looming 2015 Millennium Development Goals.
A three-quarter reduction in maternal mortality, for example, is impossible for CAR. Bruno's wonder is obvious: "How is this not a humanitarian crisis? What exactly needs to happen before the donor community meaningfully invests in CAR's shattered health services?" he asks, as yet another swollen-bellied infant is brought in for treatment.
Surprise number three: Change is tangible, and it is already happening. Merlin has been working with the Ministry of Health in CAR for just shy of 12 months. In that time, we have employed people from local communities to rebuild and renovate health facilities. A drug management and supply chain has been established, so health workers have the drugs they need to save lives.
We have introduced free health care to encourage people to use the clinics again, rather than relying on local healers, and provided equipment which can effectively test for malaria so health workers no longer have to guess.
The charity has also started on-the-job and classroom training for over 100 health workers, some of whom, like Jean from Grevai, have not had any learning for over 25 years. We have helped, in the words of one nurse, "to breathe life back into the lungs" of the primary health care system. The trained health workers so desperately needed are also coming up through the ranks, slowly.
I met a class of 2nd year medical students at the country's medical school; every one of them passionate and ready to stay in their country "to ease the suffering of our people". Bruno Fugah is in no doubt: "CAR isn't - or it needn't be - yet another story of desperate Africa."
Surprise number four: Investment is happening. It is written plainly on the only billboard in Kaga Bandoro town: Orange, the mobile phone giant, has arrived. Donors might not consider CAR ripe for investment, but big business clearly does.
There is a palpable sense of opportunity in CAR. And that was perhaps the biggest surprise of all. I arrived expecting to find a country where the need to survive today made a bonus of tomorrow. I left sharing the hope and conviction of a bright, young medical student I interviewed: "Now is our chance to do what those who came before us couldn't".
My optimism was dented on my first day back in the office. A key international donor has decided that CAR is "no longer a priority". They will not fund health care there beyond December. Merlin's concern is when one leaves, others follow. CAR simply can't fall off the international agenda. And for those who say it never made it on there, just you wait.
For more information on Merlin's activities in CAR contact: