© Pierre-Yves Bernard/MSF

Central African Republic

Renewed, full-blown conflict across much of the Central African Republic (CAR) produced scenes of extreme violence in 2018, directed at people still suffering the trauma of the civil war that tore the country apart.


MSF's work in CAR in 2021

Around 1.5 million Central Africans were internally displaced or refugees in neighbouring countries, following the resurgence of the hostilities in the country, marking the highest number since the peak of the conflict in 2013-14. Widespread violence has placed increased pressure on the fragile healthcare system, making it even harder for people with chronic diseases or in need of specialised care to obtain treatment.

Sallet's father, Amat Gia, accompanies his son on the way to Bangui.

The year started with clashes between government forces and a coalition of armed opposition groups formed in December 2020, ahead of the elections that ratified Faustin-Archange Touadéra as president. Rapidly, violence swept over the country and continued throughout the year. Civilians were frequently caught in the middle; injured, forced from their homes and cut off from healthcare. In the context of a state-of-emergency already affecting the provision of care, the high level of insecurity and the increasing presence of foreign armed groups made it extremely difficult for Médecins Sans Frontières (MSF) and other humanitarian organisations to deliver assistance where it was needed, particularly in remote rural areas where the situation remained volatile.

While this overall situation affected our capacity to provide care, we continued to run 13 basic and specialist healthcare projects, focusing on maternal and child health, surgery, sexual violence, treatment for HIV and tuberculosis (TB), and responded to outbreaks of disease. We also ran various emergency responses and assisted people affected by conflict, treating a total of 390 war-wounded patients between mid-December 2020 and mid-March 2021.

In Bangassou, where we support the Regional University Hospital, more than 1,000 people arrived in search of shelter following attacks by armed groups in January. Another 10,000 fled across the Mbomou river into Ndu, in the Democratic Republic of Congo, where we increased our support to the local health centre and installed water purification systems.

In the same month, 8,000 people were displaced when the densely populated town of Bouar became the scene of intense fighting. MSF provided basic healthcare, as well as water and sanitation services, to people who had taken refuge in a cathedral and five makeshift displacement camps.

The warring parties did not spare medical or humanitarian workers. Our teams witnessed dozens of health facilities being ransacked, damaged and occupied, and patients subjected to violence, physical abuse, interrogation and arrest during armed incursions into hospitals. Community health workers in rural areas were also threatened and assaulted.

In early June, a camp hosting around 8,500 internally displaced people on the outskirts of Bambari was burned to the ground and an MSF malaria treatment point in the camp was destroyed. Days later, a patient’s carer was killed and three other people wounded when an MSF motorbike referral on its way to Batangafo came under attack.

The increasing presence of landmines and improvised explosive devices further hampered access to health facilities, for both staff and patients, in areas such as Bocaranga. In the last quarter of 2021, our emergency team ran an intervention there, assisting victims of sexual violence, administering vaccinations for measles, diphtheria, tetanus, polio, yellow fever or hepatitis B, to address the low coverage, and improving the provision of water and sanitation services.

SICA, MSF’s trauma surgery hospital in the capital, Bangui, frequently received patients referred from other provinces requiring emergency and longer-term surgical care, including physiotherapy and mental health support.


Community-based care

While most of MSF’s activities in CAR continue to be based in hospitals, in recent years we have scaled up our community-based projects. In 2021, we continued to train volunteer health workers to diagnose and treat people for some of the most prevalent diseases, such as malaria and diarrhoea, in their own communities. These workers receive medicines, as well as financial and technical support, from MSF. In Kabo and Batangafo, our teams supported this network to carry out early detection and treatment for malaria at designated treatment points.

We also implemented a community-based model of care for patients requiring longer-term treatment, such as antiretroviral (ARV) medication for HIV. In places like Carnot, Bossangoa, Boguila, Bambari and Zémio, members of community patient groups take it in turns to pick up each other’s drugs, thereby providing peer support and helping each other to adhere to treatment. As CAR has the highest rate of HIV in West and Central Africa, and extremely limited access to ARV treatment, this initiative represents a lifeline to many people.

Reducing maternal deaths and treating victims of sexual violence

Family planning and maternal and obstetric care is another of MSF’s priorities in CAR. The country has one of the highest maternal mortality rates in the world, and outside of MSF supported facilities, few women have access to free, quality care during pregnancy and childbirth. While maintaining our maternal care services in Bangui, we worked all year long on the rehabilitation of the emergency obstetric and newborn care units of one of the capital’s main public health facilities.    

Sexual violence is a major health issue in CAR. While a substantial number of sexual assaults are linked to armed conflict, many are perpetrated within the community. Almost all of MSF’s projects in the country, including those in Bambari, Batangafo, Bangassou, Bossangoa, Bria, Carnot and Kabo, have incorporated treatment and mental health support for survivors of sexual violence into their medical services. Through our Tongolo project in Bangui, we offer a holistic programme of medical and psychological care for sexual violence that is accessible and inclusive, with specific adaptations for men, children and adolescents. 

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MSF's work in CAR in 2020

Despite the peace agreement signed by the government and armed groups in the Central African Republic (CAR), violence has continued unabated in many parts of the country.  Although there have been fewer large-scale attacks on civilians, thousands of people are still living in constant fear, exposed to beatings, rape and murder, with no access to healthcare or other basic services. By the end of 2019, over 687,000 people were internally displaced, while the number of refugees from CAR in neighbouring countries had risen to 592,000.

The pervasive insecurity repeatedly hampered the ability of Médecins Sans Frontières (MSF) to deliver medical care and respond to the urgent needs of vulnerable people. Nevertheless, we continued to run 12 projects for local and displaced communities in six prefectures and the capital, Bangui, providing general and emergency care, trauma surgery, maternal and paediatric services, assistance to victims of sexual violence and treatment for malaria, HIV and tuberculosis (TB).

In addition, we launched a number of emergency interventions during the year and maintained our assistance to Central African refugees living in Ndu, Democratic Republic of Congo, across the River Mbomou from CAR’s Bangassou. 




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.

MSF staff provide care to a woman and her firstborn child, delivered by caesarean section at a hospital in Bambari, Ouaka. Central African Republic, December 2020.

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.

An 18-year-old woman, a survivor of sexual violence, receives medical care and counselling at MSF’s Tongolo centre. Central African Republic, November 2020.

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 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 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

MSF’s work in CAR in 2019

Médecins Sans Frontières (MSF) continued to provide lifesaving care amid brutal attacks against civilians, including killings and sexual violence. Whole villages and displacement sites were burned down, exacerbating the already immense humanitarian needs. 

By the end of 2018, almost 650,000 people were internally displaced, while the number of refugees from CAR in neighbouring countries had risen to 575,000 (from 540,000 at the beginning of 2018).*

Access to medical care, food, water and shelter was severely restricted by the conflict, and our ability to respond was repeatedly hampered by insecurity and attacks on our facilities. Nevertheless, we continued to run projects for local and displaced communities in eight provinces and in the capital, Bangui, providing primary and emergency care, maternal and paediatric services, trauma surgery and treatment for malaria, HIV and tuberculosis (TB).

General healthcare and paediatric activities 

Malaria remains the main killer of children under five in CAR, and its effects are often exacerbated by the precarious conditions in which they live, exposed to malnutrition, infections, measles and other preventable diseases. Insecurity, drug stockouts, long distances to health facilities and transport costs are some of the barriers restricting access to effective and timely medical care for children.

Mothers and children in Mingala, an area that is difficult to access due to insecurity and bad road conditions, during a two-day MSF vaccination programme. Central African Republic, March 2019.

Our teams intervene at all levels to address these challenges in all our projects outside Bangui. Strategies to deliver care nearer to people’s homes included supporting community health workers to test and treat patients with simple forms of malaria and diarrhoea cases in their villages in Bambari, and deploying teams to hard-to-reach areas and displacement sites, such as PK3 camp in Bria and the Catholic parish in Bangassou. 

In 2019, our teams assisted more than 50,000 displaced people as well as local communities in remote locations, such as Nzako in Mbomou prefecture, where the inhabitants have been trapped by three years of relentless violence. MSF supplied health centres with medicines and equipment, staff and technical training and supported hospital emergency rooms and paediatric wards, enabling the most severely ill children to obtain free specialist care.

In total, 31,300 children were admitted to MSF-supported hospitals in 2019. Prevention is essential to saving lives, which is why our efforts were also directed towards supporting routine vaccination and mass vaccination campaigns. During the year, our teams carried out vaccinations against diphtheria, tetanus, hepatitis B, whooping cough, polio and measles for children in Vakaga prefecture and set up two multiantigen vaccination campaigns in Pombolo, Ouango district.

Trauma surgery and comprehensive support to victims of sexual violence

MSF is the main organisation delivering medical and psychosocial care for victims of sexual violence in CAR, and we have progressively integrated it into our programmes across the country. In Bangui, 3,230 victims of sexual violence received medical and psychological assistance in the outpatient department of SICA hospital, a surgical trauma facility we built in 2017.

The hospital has 80 beds, an emergency room and two operating theatres, and offers comprehensive treatment, including post-operative care and physiotherapy. Of the 9,810 trauma patients we treated at the hospital in 2019, 80 per cent were victims of road accidents, and around 20 per cent victims of violence, with bullet or stab wounds. We also launched a new project called Tongolo – meaning ‘star’ in the Sango language – offering comprehensive care for sexual violence, specifically adapted to male, child and adolescent patients, in four of Bangui’s health facilities. 

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Tackling HIV and TB 

Another focus of our activities in CAR is HIV/AIDS, a leading cause of death among adults, as the country has Central Africa’s highest HIV prevalence. Our teams work to make treatment as accessible as possible in our projects in Carnot, Paoua, Boguila, Kabo, Batangafo and Bossangoa. We started similar activities in Bria, and in October, we launched a new project in Bangui, which aims to reduce sickness and death related to HIV/AIDS and tuberculosis.

Our teams also offer care, treatment and training in the university hospital and support partner health structures. Despite available funding, less than half of the 110,000 people living with HIV in CAR receive care. In 2019, when the country experienced a major stockout of antiretroviral (ARV) medication, we responded by providing emergency supplies to the Ministry of Health and medical facilities, while also maintaining provision to our regular HIV programmes.

For example, in Carnot, where we follow a cohort of 1,850 patients, antiretroviral treatment was initiated for 414 patients, including 27 children. Six hundred and four adult patients were admitted into MSF-supported internal medicine hospital wards in Paoua, mainly due to advanced HIV and tuberculosis. In addition, we worked with the Ministry of Health to set up more community-based patient groups with the aim of mitigating the daily challenges faced by people living with HIV and making it easier for them to adhere to treatment. 

For example, group members take it in turns to pick up each other’s ARV medication, thereby reducing the number of times each person has to travel to a health facility. In the Carnot area alone, there are more than 60 patient groups. The groups also function as psychological support systems in which people can speak openly about their HIV status – in Zémio they hold their meetings outside under the mango trees. One group decided to jointly purchase chickens, not only to eat as a source of protein, but also to sell as a source of revenue to enable them to travel to health centres.

Responding to outbreaks of violence and disease Throughout the year, we supported health centres in Alindao and Mingala in BasseKotto, where violence between armed groups continued despite the peace agreement, forcing thousands to flee. Our teams treated thousands of people for malaria and administered vaccines to children and pregnant women. We also conducted nutritional needs assessments and donated medical supplies to facilities in Zémio and Djema

find out more in our international activity report >


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