Covid-19 in the CAR: Turning a crisis into opportunity for health system strengthening
By Dr Pierre Somse, Minister of Health and Population of the Central African Republic, and Laura Hoemeke, University of North Carolina Gillings School of Global Public Health
On 11 March 2020, concerned by the alarming levels of spread and the severity of the illness, the World Health Organization (WHO) declared Covid-19 a global pandemic. This blog post is part of a series to reflect on the past year of the COVID-19 pandemic.
By all measures, the COVID-19 pandemic and its global impact have been unprecedented. Even in many so-called high-income countries, the pandemic nearly overwhelmed health systems and continues to put serious strains on overworked healthcare workers.
One could thus only expect the worst in the Central African Republic (CAR) – one of the lowest-income countries in the world with a depleted health system, a consequence of decades of conflict and neglect. However, thanks to a combination of strong political leadership, evidence-informed deployment of existing health resources and bold governmental actions, the country has limited the impact of COVID-19. As of 1 March 2021, approximately 5010 individuals have tested positive for COVID-19, and a total of 63 deaths have been reported. Drawing lessons from its response, the CAR is now considering approaches for turning the pandemic into an opportunity for strengthening its health system.
COVID-19 hits a weak health system
Before COVID-19, the CAR’s health system had been compromised by decades of socio-political, security and humanitarian crises. More than 2.6 million Central Africans — about half of the population — needed humanitarian assistance and protection in 2020. About 13% of the 1,014 health care facilities are non-functional due to insecurity or the destruction of infrastructures by armed groups. The physician density per 1,000 people is only 0.047, and the country continues to suffer a high maternal mortality ratio of 829 deaths per 100,000 live births.
When the first COVID-19 case in the country was diagnosed on 14 March 2020, many had predicted a wildfire of infections that would consume the fragile health system. The vulnerability of the local population to disease due to rampant malnutrition, high prevalence of HIV and tuberculosis, and poor water and sanitation systems were great causes of concern. Yet, early preparedness and decisive public health actions would show the resilience of the country.
Facing Covid-19 with leadership, science and action
In the CAR, the response to the pandemic began in February 2020 through awareness-raising and careful monitoring of people arriving in the country. Systematic screening of incoming travelers and suspected cases was introduced starting in late February 2020 and led to detection of the first imported case.
The response to COVID-19 gave rise to unprecedented mobilization at the national level under the leadership of the Head of State, His Excellency Professor Faustin Archange Touadéra. A national crisis committee was established, comprising government departments, United Nations agencies and humanitarian actors. Response coordination mechanisms were set up around three pillars: public health, socio-economic issues, and security and legal issues. The public health pillar coordinated by the Ministry of Health (MoH) was the cornerstone of the response. It consisted in deploying limited health resources for maximum impact through evidence-informed interventions to test, track, isolate, and treat. The approach focused on the following:
- Intensified prevention and awareness-raising activities;
- Active testing of incoming travellers, suspected cases, and contacts;
- Strategic surveillance and monitoring of cases focused on locations, populations, and risks; and
- Capacity-building for treatment and care of confirmed cases.
The Pasteur Institute of Bangui, a non-profit institution collaborating with the MoH, is responsible for coordinating COVID-19 testing and surveillance along with the National Laboratory for Public Health and Clinical Biology. Active testing efforts helped identify COVID-19 clusters in some communities and among truck drivers and travellers from neighbouring Cameroon, leading to renewed test-track-isolate-treat interventions for these populations and at borders posts. With the support of humanitarian and development partners, two facilities were renovated and equipped in the Bangui to handle severe COVID-19 cases. Teams of health care workers were trained to provide care and treatment to COVID-19 patients based on nationally approved protocols.
Active engagement of communities was essential to an effective response, especially in a country with a limited health workforce. Community leaders were involved in sensitization efforts and a community-based surveillance system was established to report suspected cases and monitor the implementation of self-isolation measures.
Building a resilient health system post COVID-19
Despite its weak health system, the CAR has thus far controlled the impact of COVID-19. As a country prone to humanitarian crises and vulnerable to outbreaks of epidemic such as Ebola, the CAR had the experience of epidemic preparedness and coordination to face COVID-19 with the support of its partners. The pandemic was an opportunity to:
- reposition health coordination and elevate its political capital;
- affirm and operationalize the centrality of community-based responses;
- strengthen laboratory services around the centres of excellence such as the Pasteur Institute and the National Laboratory; and
- prioritize training, support and protection of health care workers.
These lessons of health system strengthening are already being capitalised in the national plan to roll out COVID-19 vaccines through the COVAX facility.
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Image: CAR Ministry of Health
Congratulations on the good work. CAR/RCA is due for some good luck.
I agree with Dr Webster. The CAR is due some good fortune!