Three-quarters of the population live below the poverty line in this country with the lowest life expectancy in the world (53 years). Ongoing conflict has forced thousands to leave their homes and their livelihoods, and most people have no access to healthcare because of financial, cultural and physical barriers.  

Disease outbreaks
In January, the Ministry of Health declared a nationwide measles epidemic. Our teams supported the health authorities with vaccination campaigns in seven health districts across the country. We also treated children for the disease, and for other illnesses such as malnutrition. The spread of COVID-19 affected the response capacity of governments, donors and other health organisations in many countries; however, in CAR, pervasive insecurity, logistical constraints and the cost of setting up a large-scale vaccination campaign in remote parts of the country made the measles outbreak more challenging to manage than the pandemic.  

Although COVID-19 did not have a notable impact on death rates in the facilities we support, it affected our activities because the restrictions on movement caused delays in the delivery of equipment and medicines, and the travel of staff. In response to the pandemic, our teams undertook activities around the country, including awareness-raising sessions on protection measures, and distributing masks and soap. 

Malaria remained a major issue in the country in 2020. Our teams launched preventive treatment campaigns in Batangafo and Bossangoa targeting pregnant women and children, especially during the rainy season between July and October. To reach the maximum number of people and make sure communities understood the importance of prevention measures, we held discussions with community leaders, and broadcasted radio spots before distributing the medication. Post-distribution visits to verify that people had taken the treatment and to identify any side effects were conducted. This survey showed that both coverage and adherence were high. The number of malaria cases in 2020 compared to 2019 was also lower, indicating the effectiveness of this method.    

Sexual violence
In the capital, Bangui, we expanded our maternal care services – a vital support in a country with one of the highest maternal death rates in the world – and opened a centre dedicated to the care of victims of sexual violence, to consolidate the activities that we had been running in different facilities in the city since 2017. Through the Tongolo project, we offer a complete programme of medical and psychological care that is free, accessible and inclusive, with specific adaptations for men, children and adolescents. At our facility, we collaborate with other organisations who can assist if victims wish to pursue legal action or are in need of protection or socio-economic support, thereby providing a holistic response to sexual violence.   

HIV care and internal medicine
HIV/AIDS is still one of the main causes of death in CAR. In Bangui, we implement an integrative and progressively decentralised model of care for people living with advanced HIV, whereby they follow the same patient circuit and are cared for in the same hospital wards as everybody else. Healthcare staff are trained to tackle stigma in order to ensure equal quality of care for all patients. HIV testing is available in all MSF-supported facilities in the country. Many of our HIV patients take part in community antiretroviral (ARV) groups, which help mitigate the challenge of adhering to treatment. Group members take it in turns to pick up each other’s ARV medication, thereby reducing transport costs and stigmatisation. 

Continued efforts were made in adult medicine with the development in 2020 of outpatient follow-up care clinics for chronic diseases, particularly in Paoua and Carnot, with a view to improving the long-term management of HIV/TB and non-communicable diseases, and integrating affected patients into a continuum of care.  

Protracted violence and instability
Initially planned for the whole country and finally restricted to the Ouaka prefecture due to the pandemic, we conducted a retrospective mortality survey due to a lack of reliable mortality estimates in the country. Results are alarming, with the crude mortality rate for adults above the emergency threshold and the under-five mortality rate just below the emergency threshold* – mostly due to malaria and violence. We also found a high maternal mortality rate and a high proportion of under-five deaths, suggesting a general malfunctioning of the health system, and particularly a lack of access to quality reproductive health care healthcare. The outcomes of this survey are a reminder that CAR is experiencing a longstanding and under-reported health crisis. 

As the year ended, there was a rapid deterioration in the security and humanitarian situation, linked to the presidential and legislative elections on 27 December. Violent clashes broke out across the country between the newly formed coalition of non-state armed groups (CPC), and government forces supported by foreign troops. These events took a severe toll on people already traumatised by years of civil war and caused further waves of displacement, both within CAR and into neighbouring countries.  

On 28 December, several people, including an MSF staff member, were injured in a shooting incident on a public transport truck in Grimari. They were all taken to a nearby hospital to receive urgent medical care. We immediately dispatched a medical team from Bambari to provide assistance and referred five seriously injured patients, including our colleague, to the hospital that we support in the town. Sadly, our colleague succumbed to his injuries.  

This incident is one of many examples demonstrating how CAR is entering a new cycle of violence. Our teams maintain their support to the health authorities by ensuring continuity of care in all our projects and launching emergency interventions to assist the wounded and displaced in conflict areas. These interventions include mobile clinics, donations of medicines, water and sanitation activities, distribution of relief items, and contingency and mass casualty training for health workers. Heath workers trained through the MSF Academy programme are key in providing transversal support across the country.

*Mortality rate above which an emergency is said to be occurring. Usually taken as a crude mortality rate of 1 per 10 000 per day, or as an under-five mortality rate of 2 per 10,000 per day (WHO).