In three of the most impoverished districts of the Central African Republic, Cordaid supported 56 health facilities for the past 5 years. What are the results so far of this long-term project, financed by the EU’s Bêkou Fund?
December 2019, Ngouwé health centre in Bossangoa. Midwife Hélène Béanre with a young mother and her newborn child. © Cordaid/Mickael Franci
“After 1,2 million curative consultations and over 50.000 assisted deliveries, I can say: maternal and child mortality are decreasing and the health system is stronger than before”, says health programme coordinator André Zra.
But before we expand on these and other significant results and outcomes of the Bêkou Fund project, we need to go back to 2008. That was the year Cordaid started its health programme in the Central African Republic, introducing results-based financing (RBF) of health facilities in the district of Bouar and soon expanding to other parts of the country.
Better infrastructure, better performance
This approach, which finances health providers directly by purchasing services that meet a set of previously agreed criteria, gives them the opportunity and the responsibility to invest in the improvement of their facilities and services. As a result, staff payment and performance increase, drug supply improves, facility infrastructure is better maintained, says doctor Peerenboom, who was closely involved in Cordaid’s RBF health programme in the Central African Republic.
The Bêkou Fund – meaning “hope” in the local language Sango – is a multi-donor trust fund from the European Union (EU) created in July 2014 with financial support from the governments of France, Germany, Italy, the Netherlands, and Switzerland. It allowed Cordaid to provide immediate relief after the humanitarian crisis in 2013 that displaced populations and destroyed a large proportion of the health infrastructure.
“Almost 50 people graduated in Bangui and are now running health facilities in rural health districts. They are the bedrock of the health system.”
During phases 1 and 2, health centres in the districts of Bossangoa, Bangassou, and Ouango-Gambo were renovated. The current third phase (July 2018-October 2021), focuses on structurally improving the utilization and quality of health service delivery.
“Even in lockdown, we managed to distribute medicines”
Health programme coordinator André Zra recalls the first years of the project: “The impact of the conflict was such that a lot of the health facilities outside the major towns were dysfunctional. A lot of them were abandoned, looted, destroyed. Our first task in the three mentioned districts was to rebuild them. Then we started to equip them, train existing staff, and attract new staff.”
The longer aim of the project was threefold: to improve the infrastructure of 56 health facilities, to improve staff performance, and to improve drug supply chains.
“For a long time, assuring a reliable drug supply was a big challenge”, Zra explains. “The Bangui-Bangassou road was too insecure during the years of conflict. We had to deliver drugs by air, which took a lot of effort and time. But the security situation improved, and nowadays the health facilities hardly ever run out of stock. In fact, our central stock of drugs in Bangui allowed us even to overcome delivery delays due to COVID-19. Even during the lockdown, with the laissez-passers we had, we managed to distribute medicines among the health facilities.”
Finding and keeping qualified staff
Staffing the facilities was even a bigger challenge. “Finding and keeping qualified staff – nurses, pharmacists, lab technicians – in the rural areas is extremely difficult”, Zra continues. “Don’t forget that aside from the big hospitals, most health facilities in the country were on their own, run by committed but unqualified staff with hardly any means. The government simply didn’t and still does not have the means to support them financially.”
Zra’s team started by training the existing staff and then started attracting new staff. “But who wants to venture into the interior of the country, if she or he has better opportunities in the big cities? Very few people. That’s why we started offering contracts that included the possibility to get a medical training and qualification in the capital Bangui and then be posted in a rural health zone. So far, almost 50 people graduated in Bangui and are now running health facilities in rural health districts. It seems like a small number of people, but their number will grow. And they are the bedrock of the health system”, Zra claims.
Some accumulated results
These are some of the accumulated results of the past 5 years, achieved by the rural health facilities supported with the Bêkou Fund (bearing in mind that many of them were hardly operational before 2015):
- 1,242,180 curative consultations
- 37,612 children received 5-in-1 vaccinations
- 52,824 medically assisted deliveries
- 135,437 pregnant women completed a series of 4 prenatal consultations
“Health coverage in Bossangoa has increased to 99%”, Zra elaborates, “meaning that almost every person in the health zones of the 27 facilities we assist in that district has access to medical services when needed. Maternal health has significantly improved in all 3 districts. The number of pregnant women who are being medically assisted is much higher than expected. As medical services are free of charge for pregnant women, even women from outside the health zones – even from neighbouring country DR Congo – find their way to the health facilities.”
“Today, I can proudly say that all 56 health centres are medically equipped for the primary healthcare services they have to perform.”
The assisted delivery coverage is such (94% in Bossangoa, 89% in Bangassou, and 115% in Ouango-Gambo), that the number of women dying in childbirth has drastically diminished. “The past 2 years, 3 women have died while giving birth in the whole district of Bangassou”, Zra says. “That is 3 too many, but it is also a lot less than what it used to be.”
Investing in transportation and medical equipment
As the health facilities are paid for their results – fixed amounts per vaccination, per assisted delivery, per prenatal consultation… – they also have funds to invest. “Most commonly, the first investment they make is in transportation”, says Zra. “Today, all of them have at least one motorbike. They use it for mobile vaccination campaigns and even, in case there are no alternatives, as an ambulance. Secondly, they invest in medical equipment. Today, I can proudly say, all 56 health centres are medically equipped for the primary healthcare services they have to perform.”
Increased state involvement and digitalization in health care
Zra mentions other valuable outcomes: “Once we had proven the effectivity of our results-based financing approach, the Central African government embraced it and has adopted it in its national health policy. Where a lot of the health facilities used to be disconnected from the state, today national health authorities are doing a great job supervising and regulating all results-based financing activities.”
Lastly, the Bêkou Fund project positively contributes to the badly needed digitalization of the health system. “Results-based financing centers very much around data collection and monitoring. every month, the declarations of the health centers were verified and validated. cross-checks reduce cases of fraud. All these data are fed into a secured online portal. This solid and accurate information is shared with the national health information system. Unfortunately, these systems are not yet integrated or digitally connected, but we are making steps in the right direction.”
Step by step towards universal health coverage
Overall, André Zra is a proud man. “It is motivating to know that 56 health centers that were sabotaged by a brutal conflict some years ago are all operational today and performing well. Together they serve three districts with a total population of almost half a million people. Even with severe COVID-19 restrictions, all of them continued working. None had to close its doors.”
He is committed to further improve the effectiveness of the project: “By completing the packages of activities for all health centers. And by improving our management of the subsidies we receive“.
“It is thanks to the medical staff of isolated health facilities like these, and to donors like the Bêkou Fund, that the reality of universal health coverage is coming closer, step by step”, Zra concludes.
The Bêkou Fund project is one part of Cordaid’s health program in the Central African Republic. In total Cordaid supports 124 health facilities.