Keeping the health system alive in times of war

In Mobaye, on the southern border with DR Congo, Cordaid staff coordinates and implements the results based financing support of 3 hospitals and 57 health centers  of Basse Kotto préfecture. The project, financed by the World Bank, is the main source of support for many health facilities, as the state is too weak to deliver. But what if war forces 80% of the people to flee, including health staff?

Mobaye, a small town on the Ubangi river, is one of Cordaid’s outposts in the Central African Republic. As the crow flies it’s a mere 250 km east of the capital Bangui. But due to armed conflict and bad roads it takes more than 2 days to get there. If you get there at all.

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Geografical location of Mobaye (© Google maps)

From May onwards, brutal attacks against civilians – including rape and murder – surged in Basse Kotto and its main town Mobaye. UN MINUSCA protection proved ineffective. Anti-Balaka militias attacked Mobaye, challenging the rule of Seleka rebels and their off shoots, who control Mobaye since the start of the armed conflict in 2013. Most people fled their homes and ran to the bush, to Bangui, or crossed the river to DR Congo. Schools, hospitals and other institutions were abandoned. Even the mayor left Mobaye.

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Transport on the Ubangi river, goods arriving from Mobaye to Bangui (This picture was taken before the crisis that started in May) (© Cordaid)

During the crisis our staff lived and worked in Mobaye, which was de facto an open air prison, a town closed off by violence – and practically forgotten by the outside world. They did whatever they could to prevent a total collapse of the health system in the whole of Basse Kotto. And they succeeded.

“When hell broke loose, we ran to the hospitals and health centers, providing what assistance we could and convincing them to stay.”

Dr. Côme Kamalo

Doctor Côme Gervais Kamalo, Cordaid’s health manager in Mobaye – now temporarily based in Bangui for safety reasons – shares his experiences.

When did you start working there for Cordaid?

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Dr. Côme Kamalo

“One year ago I started coordinating our health program in Basse Kotto. We cover 3 health districts, totalling a population of 320.000 people. We’re the main source of financial and technical support for 60 health facilities – 3 district hospitals and 57 primary health centers. Before the crisis, thanks to our efforts, these health facilities were able to recruit and train dozens of local medical staff. Our support allows health facilities, who operate on a shoestring, to invest in what is needed most: equipment, medicines, infrastructure. This is a country with on average 2 doctors and 5 nurses per 100.000 people. So we were slowly bridging a huge gap. Contracts were signed with the hospitals and centers, staff was being trained, facilities were being equipped and village communities were involved in monitoring the quality and accessibility of health services. We were rolling. Then violence flared up in Basse Kotto.”

What happened?

“The apex of the crisis was in May. Armed Seleka groups and their off shoots, most of them Arab speaking and coming from Chad and other countries, clashed with autochthonous anti-Balaka self-defence militias, mostly unorganized bunches of criminals. Violence and mayhem displaced 80% of the population. People, including health staff, ran away to seek safety. Even the mayor and his staff fled. In fact, he was one of the first to leave. People fled to Bangui or crossed the border to DR Congo. Or they hide in the bush. Of the 60 health facilities in our program, 45 are now abandoned.”

“Doctors had fled, the nurses couldn’t handle the delivery. So I jumped in. All went well, no c-section was needed.”

“When hell broke loose, we ran to the hospitals and health centers, providing what assistance we could and convincing them to stay. We managed to convince – and pay – staff to stay and run the 3 hospitals and some 12 health centers. Staff from our project, mainly local nurses and paramedics from Basse Kotto, are practically running the few health facilities still open. They depend on the salaries we provide, they have their families nearby, sometimes hiding in the bush. They are the ones now providing health care to the thousands of people trapped in Basse Kotto, many of them wounded, ill and traumatized. A lot of the higher medical staff, who are payed a – meagre – state salary, defected to hospitals in the capital Bangui. We were badly hit, but we never stopped program activities.”

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Displaced families waiting for medicines in front of the pharmacie of Poudjio health center, Basse Kotto (© Cordaid)

Does the conflict have financial implications for the program?

“Absolutely. In crises like these, given the volatility and insecurity it’s not only very difficult to continue a health program like ours, but also very costly, given the shortages of staff, medicines and equipment. For example, before the crisis the costs for a delivery with c-section – covered by our project – were about 20 USD. Today it’s 60 USD. A consultation would be 0,4 USD, now it’s 1,2 USD. Costs tripled. On top of that we decided that as long as the crisis is acute, patients do not have to pay. Usually they cover part of the expenses, for example 10 USD for a delivery with c-section. For the past 6 months Cordaid paid the patients’ part. This is a humanitarian measure. People can’t pay. They can barely survive with what little they have left.”

“Trigger happy men, high on drugs or alcohol, point their guns at you, try to intimidate you.”

What are the biggest health needs at the moment?

“It’s the provision of medicines. We’re lacking antibiotics, anti-parasitics, medicines and medical equipment for emergency surgery, for obstetrics and the care of malnourished children. Farming families cannot access their fields, food production has collapsed and market prices flare up. This is why malnourishment has severely increased. Before the crisis 1 in 10 children were malnourished, now it’s 2 in 5. Mobaye itself is an open air prison, people can go nowhere to produce or fetch food, armed groups are everywhere. For 6 months now the roads to Mobaye have been shut off by militias. The UN have suspended their humanitarian flights, meaning that Basse Kotto is practically closed off from the outside world. Luckily the border with DR Congo – which is the Ubangi river – can still be crossed now and then. What food there is comes from Congo.”

You lived and worked in this open air prison for four months. What was it like?

“Throughout these months we never stopped working, visiting and assisting the health facilities. But there are check points everywhere. Trigger happy men, high on drugs or alcohol, point their guns at you, try to intimidate you.”

“We were cut off from the world. We felt abandoned, forgotten.”

“There were moments we despaired, especially when aid workers like ourselves were targeted and killed. In July armed men attacked and plundered 2 of our health facilities. Health staff was killed. When insecurity was high, we hibernated in the Cordaid office, sometimes for more than a week. We had a small food stock of tin cans and rice. But just like everybody else, we had a hard time resupplying.”

“We were cut off from the world. There was hardly any international media attention, let alone political attention. We felt abandoned. This crisis in my country is a forgotten crisis, and during these months Mobaye, we felt forgotten ourselves.”

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Monitoring essential drug deliveries in Nzélété health center (taken before the crisis erupted in May) (© Cordaid)

“Every day came with new surprises, new crises to deal with. For example, at one point, I visited one of the hospitals. All doctors had fled. But this young women was in the hospital, about to give birth. Nurses couldn’t handle the delivery as there were complications. So, as I am a medical doctor, I jumped in. All went well, no c-section was needed.”

“First I thought the situation would calm down, but it got worse every week, with new houses being burned down and people killed by the dozens. It was hard to keep hope alive, also because state representatives, like the mayor and others, were the first to leave. Cordaid was one of the very few service providers that stayed in Mobaye. Our presence was a sign of hope for many. Together with community and religious leaders who had not fled, we set up a committee of peace. In June, together with Cordaid staff in Bangui, we called upon UNOCHA, UNICEF, the WHO and other international organisations to address the acute health, food, shelter and protection needs of the population. Unfortunately, at the time nothing much happened.”

You left Mobaye in August. Why?

“In August, we had to reduce our staff in Mobaye, as we were running out of resources  – remember it was not possible to access Mobaye, so there were no cash transfers. 10 of our staff, including me, left for DR Congo, making a detour of many days before we were able to reach Bangui. 6 persons stayed behind. They are the ones who continue the struggle to keep health services alive in Basse Kotto. From Bangui we provide whatever support we can, seeking funds and organizing transport of much needed medicines and equipment towards Mobaye.”

“Armed militias suffer from the food shortages and lack of services they have caused themselves. They cannot feed their own children and wives.”

“We managed to get 3 tonnes of essential medicines of the World Health Organisation and UNOCHA. Last week, we finally managed to transport them to Mobaye, which was a logistical nightmare. Now the big challenge is to deliver them to the isolated health facilities in Basse Kotto, as armed groups are still blocking the roads and controlling the bush. That means we have to negotiate under high pressure and use our diplomatic skills. Most of all, what we need now, is that UN MINUSCA convoys create a humanitarian corridor, allowing us to transport the medicines to the health facilities.”

What is the current situation in Mobaye?

“Humanitarian presence is not enough. The state should return as fast as possible.”

“The fighting continues. But I have the impression that the armed parties have exhausted one another. They suffer themselves, as there’s no more food, no more resources to plunder and less and less citizens to brutalize or to kill. Actually, they are asking for help themselves. So many people fled that the armed anti-Balaka militias and their families are now the majority of the population in some villages. And as they have blocked and destroyed so many roads and bridges, while fighting the Seleka mercenaries, they now suffer from the food shortages and lack of services they have caused themselves. They cannot feed their own children and wives.”

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Mobaye. Displaced families in the church of Elim. (© Cordaid)

What needs to be done in the short term, to help the people of Mobaye and Basse Kotto?

“As I said before, first of all there should be a humanitarian corridor, allowing aid workers to supply food, medicines and protection to the displaced population and citizens who stayed behind. The MINUSCA blue helmets never seriously tried to create this corridor on the ground, which is deplorable to say the least.”

“Health needs are big enough as they are, even without crazy armed men causing mayhem, death and destruction.”

“But humanitarian presence is not enough. The state should return as fast as possible. The return of prefecture authorities like the mayor and the judiciary is a first and crucial step in restoring the rule of law –  I am not even talking about the police as they weren’t there before. Our presence, as a service providing international NGO, certainly contributes to the restoration of hope and perspective. But we cannot properly function if we’re not seconded by state authorities. So we plead authorities to come back to Mobaye and we ask the UN to act and protect. The state has to come back, however weak. It has to be present, restore a minimum of administration, listen to the people, and come up with plans and means to rebuild a society that is torn to pieces by war.”

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Ambulance of the district hospital of Alindao (Basse Kotto), brought there with Cordaid support. The UK development agency DFID is the main source of funding for Cordaid in the Alindao area. (© Cordaid)

What are your plans for the immediate future?

“Cordaid’s health program in Mobaye and other areas in Central Africa – funded by the World Bank – lasts until August next year. So we still have 9 months to strengthen, revitalize the almost knocked down health system in Basse Kotto and serve the population. As soon as I can, I want to go back there. We prevented it’s total collapse in the hardest circumstances you can imagine. Now I pray for the fighting to stop, so that we can properly address the health needs of the population and get on track with all of our 60 health facilities. The Central African Republic is one of the poorest countries in the world, struggling with a structural lack of everything. Health needs are big enough as they are, even without crazy armed men causing mayhem, death and destruction.”

Apart from the World Bank, Cordaid’s work in Basse Kotto is also funded by the UK development agency DFID. DFID is our main source of funding in the Alindao area. Cordaid took over emergency health activities which were initiated by Save the Children in a DFID consortium project. This consortium project funds health staff, community health workers, supplies medicines and medical equipment, ambulance, vehicles and fuel, training and supervision and badly needed renovation and re-equipment.

Read more about Cordaid in the Central African Republic. 

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