Aspiring to a resilient health system in the Central African Republic

Awa Prisca had a sleepless night. Her three-month-old daughter, Maléyombo Mariana, hasn't stopped crying and is burning up with a fever. Her mother hurries to take her to the Sibut District Hospital located near her house.

It's 8:00 a.m. and the pediatric ward is already filled with patients. They had all heard the announcement made the day before on the community radio by Dr. Alain Doté, chief doctor at the Sibut District Hospital, informing residents of the arrival of medicines from the capital Bangui and inviting all those in need of care to avail themselves of the hospital's services.

When it's her turn, Awa Prisca is seen by a female medical assistant who asks her about her baby's health before examining her carefully and recommending that she be admitted for observation. The next day, she is diagnosed with early-stage meningitis. Awa Prisca is given the green light to go home but has to take her baby to the hospital every morning to receive the appropriate treatment. With that reassurance, the young mother returns home, secure in the knowledge that everything will be done to cure her daughter.

Targeted free health care welcomed by all

Awa Prisca and her baby in the waiting room of the Sibut District Hospital pediatric ward. Credit: Christelle Chapoy/World Bank.

For all the chronic fragility the Central African Republic is grappling with, the story of Awa Prisca is all the more compelling. A few years ago, she might have chosen an alternative to hospital care because her family's meager income would not have been able to cover their health needs.

The reform of targeted free health care is one of the key strategies in the fight against maternal and child mortality in the Central African Republic, where rates are among the highest in the world.

Awa Prisca has two other children, ages 4 and 6, who were both delivered at the Sibut District Hospital by the capable hands of Ndoumba Louise, a 59-year-old midwife who is a household name in Sibut. For this State-registered midwife with 20 years of service, targeted free health care is a welcome relief. "I used to pay for treatment and care for the poorest patients out of my own pocket," she admitted.

Strengthening the national health system

Modern incubators in the new maternity ward built at the Sibut District Hospital. Credit: Abdoulaye Ndao-Layepro Photos / World Bank.

Sibut, the capital of Kemo prefecture, is more than a four-hour drive from the capital city and plays a vital role in regional connectivity. But Sibut is also a city scarred by waves of violence that have punctuated the history of the Central African Republic for the past two decades.

Ndoumba Louise has witnessed firsthand the major changes in Sibut over the past decade. The hospital ward was rehabilitated, and a new maternity ward and, later, a new operating theater were built. Modern equipment, including new incubators, was procured, and solar panels and a water tower were installed to ensure uninterrupted access to electricity and water. A pharmaceutical warehouse was built, and a supply system was put in place to ensure medicines and vaccines were always available. A fence was erected to secure the hospital facilities, keep patients safe, and prevent domestic animals from wandering into the hospital's yard. Female health assistants have also been trained, and additional medical staff have been assigned to the hospital to ensure adequate patient care in all units.

Major Ndoumba Louise, in the pink gown, examines infants in the new maternity ward at the Sibut District Hospital. Credit: Abdoulaye Ndao-Layepro Photos / World Bank.

"We haven't recorded a single case of maternal or child mortality in years at the Sibut District Hospital," Ndoumba Lousie proudly stated. "There are also fewer home births," Dr. Alain Doté added. Pregnant women are flocking in droves to the hospital for consultations because prenatal care is free. Now they are better informed about how their pregnancies are progressing and more effectively monitored by midwives.

Out-of-hospital deliveries that still occur are often due to "poor planning," the chief doctor noted. Pregnant women who continue to undertake demanding household chores and engage in strenuous agricultural activities to feed their families are sometimes caught off guard by the onset of labor. To address this issue, a group of matrons is being trained in various localities nationwide to monitor pregnant women in their community, intervene in emergencies, and provide care to mothers and their infants before referring them to the nearest health center.

With a staff of three doctors, two midwives, six midwife assistants, and seven female health assistants, the Sibut District Hospital can now provide a comprehensive package of care to the most vulnerable populations. As Dr. Alain Doté noted: "The hospital serves between 1,400 and 1,500 patients on average each month, compared to fewer than 1,000 before targeted free health care was introduced." However, he believes this increase is also attributable to the hospital's mobile outreach strategy. Every weekend, a team comprising a medical assistant, a midwife, and lab workers travels the length and breadth of Sibut's peripheral areas to raise awareness, provide consultations, and treat patients. The sessions are usually held in the homes of village chiefs, who are briefed in advance to enable them to prepare the sites and mobilize the communities.

An exemplary and vital partnership

Delivery of medicines to the Sibut District Hospital. Credit: Abdoulaye Ndao-Layepro Photos / World Bank.

The progress made by the Sibut District Hospital is proof positive of the effectiveness of the health partnership between the Central African Republic and the World Bank. The core of the partnership is being formed around the Health Service Delivery and System Strengthening Project (SENI-Plus), which aims to increase the use of quality essential health services, particularly for women and children, and to protect essential social services for the people of the Central African Republic, especially in rural areas.

SENI-Plus received a $95 million grant from the International Development Association (IDA), and additional financing through the Global Financing Facility for Women, Children, and Adolescents (GFF), as well as from Swiss cooperation through the multidonor trust fund.

Since its rollout in 2022, SENI-Plus has enabled the recruitment and retention of 300 skilled health workers operating over 500 health centers, including 15 district hospitals. Almost 475,000 women and children have received essential health services, and more than 101,000 were fully vaccinated between October 2022 and May 2024.

Testimonies from a young mother anxious about her baby's well-being and from the dedicated medical staff at the Sibut District Hospital confirm the importance of collective action around an essential mission by designing a specific intervention model to strengthen the resilience of the health system in the Central African Republic and develop its human capital. This aspiration is shared by all who cherish the legitimate hope of a better future for the country.

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