Introduction

Attacks on healthcare have further weakened the already fragile health system in the Central African Republic. We investigated attacks on healthcare in three conflict-affected prefectures—Ouaka, Haute-Kotto, and Vakaga—from 2016 to 2020. The study aim was to gain an in-depth understanding of the immediate and long-term effects of attacks on healthcare workers, facilities, supply chain, quality of care, and other components of the health system. We provide a qualitative description of the incidents, assess their impacts, identify mitigation efforts, and discuss challenges to recovery.

Methods

We used purposive and snowball sampling to identify participants in the study. Semi-structured key informant interviews were conducted with administrative and health authorities, front-line personnel, and staff of non-governmental organizations. Interviews were done in Sango, French, or English. Recorded interviews were transcribed and notes taken for non-recorded interviews. Transcripts and notes were analyzed using inductive coding, allowing participant responses to guide findings.

Results

Of 126 attacks identified over the study period, 36 key informants discussed 39 attacks. Attacks included killings, physical and sexual assault, abductions, arson, shelling with grenades, pillage, occupations, and verbal threats. The violence led to extended closures and debilitating shortages in healthcare services, disproportionately affecting vulnerable populations, such as children under five, or people who are elderly, chronically ill, or displaced. Healthcare workers faced psychological trauma and moral injury from repeated attacks and the inability to provide adequate care. Personnel and communities made enormous efforts to mitigate impacts, and advocate for assistance. They were limited by failed reporting mechanisms, ongoing insecurity, persistent lack of resources and external support.