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Using mortality surveys to define humanitarian “crisis”: A case study from the Central African Republic Sean Healy1 1 Médecins Sans Frontières Operational Centre Amsterdam, Humanitarian Affairs Department



 Médecins Sans Frontières has been present in the Central African Republic since 1997 and supports nine hospitals and 36 health centres and health posts, principally in conflictaffected areas.  Very high levels of malaria, HIV, other infectious diseases and mortality mark the humanitarian setting.  Existing country-level epidemiological data, both from government and from international agencies, is of poor quality and appears to understate the problems: official national malaria numbers are reported to be below the total number of confirmed cases treated by MSF alone. 1  Further, the inertia among international humanitarian and health actors and declining commitment to assisting the country is apparent, and the lack of health data and evidence seems to contribute to this disinterest. The aim of the case study was to better understand the health and humanitarian situation, and advocate for greater international and national attention to the plight and needs of the population.

METHODS  To assess the attention given to the health needs of people caught up in crisis situations, we considered –through review of academic, and gray literature, medical statistics, including survey data– how well the health status of the population in CAR was understood in this context in order to readdress ‘aid delivery’ and its focus on the specific needs of the population concerned.  In 2011 MSF conducted four separate mortality surveys to ascertain the health situation in three different areas of the Country. These surveys revealed mortality results that were in some cases much higher than the “emergency threshold” or at least against the baseline data available for CAR the results showed high excess mortality during 2010, suggesting a protracted crisis.  The results alongside other contextual health data was then included in an advocacy report2 which formed the basis for lobbying international and national actors and the media.  The limitation of using such data is well documented and is related to poor quality baseline and population data, and not for scrutiny during this discussion.

OUTCOMES AND LESSONS LEARNT  Forty-three separate lobbying meetings took place in December 2011 and January 2012, with various representatives from the Government of CAR, donor and regional governments, UN agencies and other multilateral institutions. A round-table was also held with other humanitarian actors in January 2012.  The Government of CAR has now begun preparations for an Etats-Generaux de Sante, an allparty health conference, to discuss how to improve the health status of the population. The report and the advocacy round were part contributors to this process.  The surveys and the report provided clearer contextual evidence and proved useful in attracting interest to the situation in CAR, demonstrating the value of newly published, highquality medical data in advocacy.  However, it also spotlighted issues of a more fundamental nature than “lack of knowledge of the medical situation” which underpinned the weak international response, such as geopolitical factors (the lack of strategic interest of major powers in CAR).  Further, it also put into question the definition of “humanitarian crisis” used by many agencies, donors and partners. Even if medical indicators show a “crisis” or “emergency” situation, international actors will not respond adequately if a crisis is deemed “chronic” rather than “acute”.

CONCLUSIONS  MSF advocacy continues for CAR’s neglected medical crisis, presently focusing at countrylevel efforts aimed at the national government and the major UN agencies.  A fifth mortality survey is also being conducted in another area of concern.  The results of the advocacy efforts so far reveal that reference to medical data is useful in as much as the audience react on the evidence and refer to it themselves. Work done on the mortality surveys was universally acknowledged as valuable, and made an impression on all agencies targeted for advocacy activities.  In reality it is clear that leverage for funds and support for CAR is dependent on the compatibility with the ‘agenda’ of the various donors, government and other partners. International donors showed varying degree of interest especially with regard to any development-oriented endeavour or (non-humanitarian) assistance, as it was considered as difficult without improvements in governance within the country. The only significant exception was World Bank, which is planning new development programmes.  OCHA and, surprisingly, UNDP seemed to be more supportive than UNICEF and WHO, with the Peacebuilding Commission a good connection to follow up.  On the issue of how to re-define the concept of “crisis” to place more stress on the actual situation of the population than politicized definitions, more research is needed to contribute to the debate.

REFERENCES 1. World Health Organization (2010), World Malaria Report. [Online] Last accessed 14 January 2011, available at: 2. Médecins Sans Frontières (2011), Central African Republic: A State of Silent Crisis. MSF: Berlin. 3. Caleo G et al (2011), Sentinel site mortality surveillance of mortality and nutritional status: Boda, Boganda, Boganangone and Gadzy sous-prefectures, Central African Republic, 2010. Epicentre: Paris. 5. Cohuet S, C Marquer, S Abdallah (2011), Enquête de mortalité rétrospective et de couverture vaccinale dans les sous-préfectures de Carnot et de Gadzi, République Centrafrique. Epicentre: Paris. 4. E Espié (2011), Enquête de mortalité rétrospective dans la ville de Carnot, préfecture de Mambéré-Kadéi, République Centrafrique. Epicentre: Paris. 6. D Rasella (2011), Retrospective Mortality Survey: Axe Maitikoulou-Kdajama Kota. [Unpublished.] 7. OCHA (2011), Financial Tracking System: Central African Republic. [Database.] Accessed 10 September 2011, available at


Crude Mortality Rate /10,000/day Boda, Boganda, Boganangone 1.0 and Gadzi 3 (95% CI: 0.8-1.2) Carnot and Gadzi 4 3.3 (95% CI: 2.3-4.8) Carnot town 5 3.7 (95% CI: 2.96-4.61) Markounda 6 0.83 (95% CI: 0.51-1.33)

Under-5 Mortality Rate /10,000/day 2.0 (95% CI: 1.5-2.6) 3.7 (95% CI: 2.4-5.6) 7.0 (95% CI: 5.26-9.34) 1.81 (95% CI: 0.92-3.56)

Sean Healy Humanitarian Affairs Adviser Médecins Sans Frontières Germany 00 49 30 700 130 269

Using mortality surveys to define humanitarian “crisis”: A case study from the CAR