Central African Republic (CAR)

Project Information

Objective: The Health System Support Project seeks to expand the coverage and quality of critical reproductive, maternal and child health (RMCH) services, particularly targeting rural populations in five of CAR’s seven health regions.
Status: Active
Date Effective: 10/28/2012 to 03/31/2018
Financing: HRITF $11.2 million and IDA $17 million
Other Financial Contributions: Additional Financing, US$12 million

Photo credit: World Bank


After a decade of conflict and political stability, the Central African Republic (CAR) is faced with extremely poor maternal and child health outcomes, including about 176 under-five deaths per 1,000 live births and an estimated 540 maternal deaths per 100,000 live births (UNICEF, 2007). Only 32 percent of children aged 12-23 months are fully immunized. Stark geographic and economic disparities remain. For instance, while the adult HIV prevalence rate reaches about 15-18 percent across the country, it peaks at 25-30 percent in the forest and diamond areas of western CAR (World Bank, 2010). Rural areas are considerably worse-off in terms of health than urban areas. Further, available data suggests that physical and financial access and poor quality of care are important challenges in CAR. A national household survey found more than 50 percent of users were dissatisfied with health services, mainly because of the cost of care, lengthy waiting times, unavailable drugs, distance to and from the health facility, and the perceived ineffectiveness of the treatment. Financial barriers to health services also limit effective demand: out-of-pocket spending accounts for close to 50 percent of total health spending in CAR (ECASEB Report, 2008).


RBF Payments

The Health System Support Project includes a supply-side Performance-Based Financing (PBF) component, under which a Performance Purchasing Agency (PPA) contracts health posts, health centers as well as district and regional hospitals run by faith based organizations and non-governmental organizations to deliver an agreed package of RMCH services. Facilities are incentivized based on: (i) the volume of RMCH services delivered and (ii) on the technical quality of these services. RBF funds are held by the PPA and released quarterly upon the verification of results.


The RBF verification function is led by an External Evaluation Agency, which verifies both the quantity and the quality of services delivered. 


Status and Achievements

The Health System Support Project was placed on hold in 2013 because of the prevailing humanitarian crisis. It was subsequently restructured in 2014 to contribute to United Nations-led relief efforts. With renewed stability in 2015, the Project was reinitiated with additional financing (i.e. US$12 million from IDA). With preparatory and technical activities carried out since mid-2015, the PBF component of the Health System Support Project was launched in late 2016 and currently covers 40% of the country’s population.

Lessons learned

Many external events can challenge and delay program implementation. Thorough preparation is thus critical to designing and implementing a resilient project capable of absorbing shocks and overcoming external challenges when they arise.


Because of the conflict situation, the impact evaluation was cancelled. Although no formal impact evaluation is planned, baseline survey at health facility and household levels were conducted in project areas in 2016, and reports were finalized and disseminated in country.


Financing To Date


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