N'dele, 1 March 2011 (IRIN) - After decades of political violence, displacement and insecurity caused by clashes between rebel groups and government forces, as well as armed bandits, thousands of people in Central African Republic (CAR) are vulnerable to disease and have little access to health services, aid agencies say.

According to the UN Office for the Coordination of Humanitarian Affairs (OCHA), many health centres in the north and southeast of CAR are either looted or not operational because medical workers are often compelled to leave the area.

Though in general access to health is very poor throughout the country, except in the capital Bangui, insecurity impedes or delays responses in northern and southern CAR, and especially in the rebel-hit prefectures in the east. NGOs use mobile services to help thousands of displaced in areas not covered by the Ministry of Health's basic facilities.

In the north, around Kaga Bandoro and Bocaranga, despite tension at times between the government and opposition forces, road access is generally granted; however, in more remote regions towards Kabo and Sida, and northern areas bordering Chad, insecurity poses greater challenges, limiting humanitarian access.

Most of CAR's 192,000 IDPs - 30,000 more since the beginning of 2010 - do not live in large managed camps. They seek sanctuary in small makeshift settlements close to their fields, set back a safe distance from the roads along which their villages are located.

Many villages once boasted functioning health posts and dispensaries, some with in-patient facilities. But now few are staffed and most have been looted.

"Some areas in the north of the country are completely cut off from any sorts of medical assistance. Humanitarian workers can move only along a few main roads and reaching those who ran to the bush or to areas not accessible to us is a great challenge," health workers told IRIN.

Most of the relief is distributed by UN Humanitarian Air Service (UNHAS) flights to crisis regions such as Ndele, Birao in the north and Zemio in the southeast.

"While UNHAS served this function very well, they've been overworked for some time and have little flexibility to respond to urgent needs. It's expected that the mission will receive the use of another plane, which should improve things considerably, but even so, transport by air alone is problematic for everyone," aid workers, who requested anonymity, told IRIN.

In the eastern Bamingui-Bangoran Prefecture, Médecins sans Frontières Spain, for instance, works with the Ministry of Health to deliver health services to the main referral hospital. Mobile health teams are also used in parts of the prefecture where access is difficult but limited to the two main roads of Ngarba and Miamani-Golongosso/Miamani Chari.

However, after events in Birao, Vakanga Province in the northeast of the country, in November 2010, when 8,000 people were displaced after a rebel attack, the government has advised NGOs to refrain from accessing some areas.

Unmet needs

Key issues such as rehabilitating infrastructure, understaffing and disease prevention "have never been [fully] addressed either by the [Ministry of Health] or the international community. All of us are responding to sporadic urgent crises related to seasonal epidemics or insufficient access to basic healthcare due to displacement and insecurity," an aid worker, who preferred anonymity, told IRIN.

"The incapacity of the government to provide services in the areas where NGOs have difficulty with access, and the fact that in some of these areas the statistics alone indicate a state of emergency, [means] one can easily understand why the health sector NGOs are still forced to provide emergency care," Leland Montell, director of International Rescue Committee, told IRIN.

Since 2008, the government has spent only 1.5 percent of GDP on public health, hence its dependency on some 19 medical NGOs to provide drugs and medical equipment and improve the skills of health workers.

Malaria remains the leading cause of morbidity, accounting for 13.8 percent of deaths. There are resurgent meningitis outbreaks as well as other communicable diseases such as wild poliovirus, measles and yellow fever but the principal afflictions are water-borne, skin and respiratory diseases.

The Consolidated Appeal Report 2011 states that only 30.5 percent of the population (28 percent in urban and 32 percent in rural areas) have access to safe drinking water , while the Food and Agriculture Organization (FAO) says that with rural agricultural production abandoned in many areas due to insecurity, farmers do not have access to productive capital, having lost seeds, tools and harvests when forced to flee. Sixty-seven percent of the population live on less than US$1 and thousands are food-insecure or relying on aid agencies.

According to the UN Children's Fund, 16 percent of children under-five are acutely malnourished, while 6.6 percent are severely acutely malnourished, but there are only 25 therapeutic feeding centres and 60 outpatient facilities, covering one-third of the cases that would have to be managed.

The country's health cluster reports that while the national vaccination coverage reached a record 87.76 percent for diphtheria, Pertussis and tetanus in 2006, displacement has made it impossible to maintain this level, which dropped to 76.4 percent in 2009.

Uder-five mortality is 176 deaths per 1,000 live births and infant mortality 106 deaths per 1,000 live births. The country also has the highest maternal mortality rate in Africa, with 1,355 deaths per 100,000 live births, reports the health cluster.

Source: The Integrated Regional Information Networks (http://www.irinnews.org )