World Health Organization – Nine years after the fall of Muammar Gadhafi, Libya remains riven by armed conflict, economic collapse and disintegrating public services.
Continued violence and insecurity coupled with political stalemate have resulted in a governance vacuum accompanied by significant insecurity and a breakdown of the rule of law.
Thus far, the conflict has defend national and international efforts to find a political resolution. Of a total population of 6.7 million, almost 4 million people, mostly women and children, require humanitarian health assistance.
According to the health sector severity scale, almost 1.7 million people are in extreme need and more than 122 000 are in catastrophic need.
Many people have specific vulnerabilities (gender, age, disabilities, ill health and nationality) that undermine or limit their ability to withstand the effects of the conflict.
Other groups such as refugees and migrants often face abuses by state and non-state entities. Given their irregular legal status and lack of domestic support networks, they encounter racism, xenophobia and grave human rights violations. At the end of 2019, more than 3200 refugees and migrants were being arbitrarily held in appalling conditions in overcrowded detention centers, creating conditions ripe for the spread of diseases such as tuberculosis (TB). These unlawful detentions are serious human rights violations that exacerbate an already volatile situation.
Libya’s health system is close to collapse. Severe shortages of health staff, medicines, supplies and equipment have been compounded by years of under-investment in the health system and a chronic lack of transparency and accountability.
Around one quarter of public health care facilities are closed, around one quarter of public health care facilities are closed, and most of those that remain open do not provide any health care services for children under five years of age. Only five of 78 hospitals assessed by WHO offer all essential services.
There are acute shortages of medical specialists, midwives and nurses and huge gaps in coverage due to the uneven distribution of general physicians, most of whom work in urban areas. Although Libya has traditionally depended heavily on foreign health care workers, the overseas workforce has steadily dwindled since 2011 when the conflict began.
Some donors are understandably reluctant to fund humanitarian activities in oil-rich Libya. However, Libya¶s needs will remain significant
for the foreseeable future. The absence of a functioning government has made it impossible to unlock Libya’s abundant resources to support
the health system and meet critical health needs.
Oil production has slowed, USD 60 billion in Libyan assets have been frozen, and the country’s economic collapse has led to a major liquidity crisis. Short- and medium-term funding will be essential to stave off the further disintegration of health care and other public services and halt Libya’s spiral into further violence and decay.
While the primary responsibility for providing assistance lies with the Libyan authorities, the persistent political crisis and escalating conflict require the international humanitarian community to fill critical gaps. the World Health Organization will work to combine humanitarian and development approaches that will allow it to deliver essential health care services while laying the foundation for universal health coverage and Libyans’ right to health. Regardless of whether its operations are humanitarian or developmental, the Organization will scrupulously adhere to the four humanitarian principles of humanity, neutrality, impartiality and independence.
In a country where some political factions view the UN with deep suspicion, adherence to these principles will be more important than ever.
In 2019, Libya remained locked in conflict, violence and political instability. The situation was compounded by the existence of two competing governments. A Government of National Accord (GNA) in Tripoli was established in December 2015 with the support of the UN.
A rival government in the east (Benghazi) is backed by the Libyan National Army (LNA) headed by Field Marshal Khalifa Belqasim Haftar. The UN-backed government in Tripoli has struggled to exert control over territory held by rival factions and intensifying geographical
and political divisions between the east, west and south. Terrorist groups and armed militias have exploited the turmoil and used the country as a base for radicalization and organized crime. Libya is awash with weapons: arms from the Gaddafi era are plentiful, and materials of war continue to be shipped to the country in breach of the UN imposed arms embargo.
In April 2019, the LNA launched an offensive to capture Tripoli from the GNA. After initial advances, it has been locked in stalemate with government backed forces for several months. The continuing fighting in Tripoli has cut off access to hospitals and left thousands of people without health care.
At least 3000 people have been killed and injured and another 149 000 have been displaced. At the beginning of July, Tajoura detention center in Tripoli holding more than 600 migrants and refugees suffered a direct airstrike that killed 50 people and injured 130 others. This prompted the international community to renew its calls for the closure of detention centers across the country. As of 31 December 2019, around 250 000 civilians in Tripoli were living in areas directly affected by the conflict, and almost half of them were living very close to battle frontlines.
While the battle for Tripoli has dominated international attention, the situation in the south has been all too often overlooked. The region is critical to the stability of Libya, but it has been historically marginalized in the country¶s politics despite its ample natural resources. The United Nations Support Mission in Libya (UN6MIL) has expressed its deep concern about reports coming
from the south on the mobilization of armed forces and the escalating cycle of statements and counter-statements by warring factions, signalling the growing risks of imminent conflict.
In August 2019, the dangers of working in Libya were illustrated when a bomb exploded under a UN vehicle in Benghazi, instantly killing three UN staff and severely injuring several other staff and bystanders. No one has claimed responsibility for the incident investigations are under way by the United Nations.
The same month, approximately 100 people were killed, more than 200 were injured and over 30 000 were displaced when violence fared between rival tribes in Murzuq, south Libya. By the end of the year, the number of internally displaced people (ID3s) in Libya had almost doubled to 343 000.
The number of attacks on health care rose sharply. In the summer of 2019, airstrikes on two field hospitals and two ambulances in Tripoli killed at least four doctors and one paramedic and injured several others. The Special Representative of the Secretary-General for Libya Ghassan Salamé condemned this clear pattern of ruthless attacks against health workers and facilities in the strongest terms.
Outbreaks of measles and rubella and increasing rates of cutaneous leishmaniasis, tuberculosis, pertussis and acute jaundice syndrome
highlighted Libya’s vulnerability to large-scale disease outbreaks. Between 1000 and 1500 cases of acute diarrhoea have been reported each
The clear threat of outbreaks of vaccine preventable and other diseases is compounded by poor surveillance. Only 84% of the country’s
125 sentinel sites are sending regular surveillance data to the disease early warning and response system, which has very limited capacity to detect and respond to disease alerts.
Status of health care services
Libya’s health system suffers from severe shortages of staff, a poorly functioning medical supply chain and very weak disease surveillance and health information systems. The lack of detailed data on the main causes of mortality and morbidity has
hampered efforts to analyse needs and deliver a targeted response.
Approximately one fifth of Libyan hospitals and PHC facilities are closed. There are acute shortages of medical specialists, midwives and nurses and huge gaps in coverage due to the uneven distribution of general internists, most of whom are working in urban areas. In many
remote and hard-to-reach locations, poor and vulnerable communities have very limited access to health care. In areas affected by conflict, health care facilities were overwhelmed with patients.
Around 22% of Libyans and 18% of migrants and refugees faced difficulties accessing health care services . The most severe health needs were in districts affected by violence (e.g., Murzuq, Sirt and Tripoli) or that were hosting large numbers of IDPs (e.g., Benghazi, Ejdabia and Sebha).
Planning, managing and monitoring the delivery of health care services are seriously inadequate at all levels of the health system.
PHC facilities are not required to provide a standard package of services or maintain essential medicines, equipment and laboratory services to support the delivery of high-quality care. In many facilities, doctors are either not available full time or they are young and inexperienced.
There are frequent stock-outs of essential medicines and there are no electronic or paper medical records that allow
different physicians to monitor individual patients over time. Moreover, many PHC facilities remain open only three to four hours a day, and patients reportedly fnd them unsanitary. As a result, Libyans tend to bypass PHC services and go directly to the outpatient clinics or emergency services hospitals in the belief that they are likely to be referred to these facilities anyway. This leaves hospitals even more overstretched, forcing them to direct their limited resources from seriously ill patients to others who do not require either
emergency treatment or hospitalization.
Reproductive health services including anteand postnatal care, family planning and the management of sexually transmitted infections
have all but collapsed and there has been an alarming increase in rates of caesarean sections.
Mental health remains chronically neglected: there are only two public mental health hospitals in the entire country, and most patients are treated in private health facilities. Childhood vaccination programs have been interrupted and there have been widespread shortages of vaccines.
Private health care services have expanded to meet needs arising from the inadequate public healthcare system. In 2019, a report issued by the Libyan Ministry of Health (MoH) showed that the number of inpatient clinics, laboratories and pharmacies and diagnostic centers rose by 72%, 50% and 80% respectively between 2007 and 2018.
Private health care services are poorly regulated and their burgeoning growth has occurred mainly in urban areas. Many health care professionals in the public sector have left for the private sector where they are better remunerated: this has exacerbated the situation of poor patients, especially those living in remote areas. Since the conflict began , most injured patients have been treated in private health care facilities, with the costs of their care covered by the government. WHO will support the government’s efforts to build effective partnerships with the private health sector and reach Libya’s goal of universal health coverage by 2030.
Attacks on health care
The number of attacks on health care rose sharply, from 36 in 2018 to 62 in 2019. A total of 76 people were killed and scores more were
injured. More people were killed in Libya as a result of these attacks than in any other country worldwide. Most attacks occurred in and around Tripoli, which has the scene of intense fighting in 2019.
International humanitarian law (IHL) strictly prohibits attacks against hospitals and other medical facilities, medical personnel and medical transport. WHO has repeatedly condemned these attacks as egregious violations of IHL.
International humanitarian law (IHL) strictly prohibits attacks against hospitals and other medical facilities, medical personnel and medical transport. WHO has repeatedly condemned these attacks as egregious violations of IHL.
“Intentionally targeting health workers and health facilities and ambulances is a war crime, and when committed as part of widespread or systematic attacks directed against any civilian population, may constitute a crime against humanity. We will not stand idly by and watch doctors and paramedics targeted daily while risking their lives to save others.” Ghassan Salamé, the Special Representative of the Secretary-General for Libya.
Achievements in 2019
1 168 407 people were reached through WHO-supported fxed health care facilities or mobile teams .
68 907 people received health care services through emergency hospital teams and mobile medical teams.
82 hospitals and health care facilities received essential medicines and medical supplies.
463 standard medical kits as well as other supplies (containing enough medicines and supplies to treat 1 099 500 people) were distributed throughout the country.
1332 health care workers were trained on a wide range of topics including trauma care, primary health care, the management of NCDs,
the health information system, disease surveillance and response, and mental health care.
5 national guidelines and policies were prepared and adopted by the MoH with close technical support from WHO.
2 new MoH emergency operations centers (one in Tripoli and one in Benghazi) were fully equipped by WHO.
Deploying emergency medical teams
In contrast to other countries (e.g., Syria) where WHO relies heavily on national NGOs to provide essential PHC services, there are no national (and few international) health NGOs in Libya. Instead, WHO has relied on emergency medical teams to strengthen health care services in areas affected by conflict.
Emergency hospital teams
WHO supported the deployment of approximately 20 emergency hospital teams (EHTs) per month to help strengthen surgical and specialized health care services in hospitals and other health care facilities . Each EHT consisted of five specialists (a general physician, a general surgeon, an obstetrician/gynaecologist, an anaesthetist and a paediatrician) Just over 38800 people benefited from the services offered by the EHTs. Over 20% of the surgical operations carried out by the teams were on war-wounded patients – a grim reminder of the horrors of war.
WHO recruits EHT members based on standard terms of reference and trains them on triage and mass casualty management. The teams are also
trained on collecting patient data using standard forms provided by WHO. The information is disaggregated by patients’ age and gender and the types of consultations provided. This allows WHO to analyse the most common causes of consultations and make sure the medicines and supplies it procures are meeting needs.
Mobile medical teams
While the primary aim of EHTs is to strengthen surgical capacity in hospitals, mobile medical teams (MMTs) aim to provide general health
care services in remote, hard-to-reach and underserved areas. WHO supported the deployment of approximately four MMTs per month. Each MMT comprised a general physician, a paediatrician, a dermatologist and an obstetrician/gynaecologist.
Approximately 30100 people benefited from the services offered by MMTs in 2019.
Training health care workers
In 2019, WHO trained 1332 health care workers on topics including mental health in conflict settings, the case management of TB and NCDs, disease surveillance, the health information system and a family practice model for PHC facilities. Because of internal travel restrictions and security constraints, many of the courses had to be organized in neighbouring Tunisia, increasing their costs by a considerable margin.
Just under half of those trained were women. WHO encourages female staff to attend training courses by providing special incentives. For
example, in societies where the free movement of women is restricted, WHO facilitates the travel of an accompanying family member so that women do not have to travel alone when they attend training workshops.
Areas of Focus
Primary health care
PHC services are the backbone of health care in all countries. In late December 2017, WHO launched a two-year pilot project introducing
a standard family practice model comprising 13 core elements into six PHC centres in east, west and south Libya. The project ended in late 2019; based on the lessons learned from this experience, and subject to the availability of funds, WHO plans to introduce the model in over 80% of the country’s PHC facilities, using a phased approach. WHO trained 44 community health workers on the family practice model in Libya, based on adapted regional guidelines. Another 30 health care professionals were trained on using standard indicators to monitor and assess the quality of services in PHC facilities and help improve patient safety.
WHO supported a series of workshops to introduce 302 PHC nurses from south, east and west Libya to WHO’s new training package for nurses. The workshops comprised one week of theoretical sessions followed by a week of practical training. Those trained will go on to train fellow nurses inside Libya. In total, 554 managers, physicians, nurses and other clinical staff were trained on various aspects of PHC in 2019.
Secondary health care
WHO trained 30 health care staff on hospital emergency preparedness and supported the logistic arrangements for 12 surgeons from Libya’s
main referral hospitals who travelled to Poitiers, France for training on damage control surgery.
WHO also launched a pilot project to assess patient safety in hospitals. The results of the assessment will be published in early 2020.
WHO distributed or pre-positioned 113 trauma kits – enough to treat 11 300 wounded patients – to hospitals and clinics in conflict-affected areas and pre-positioned additional supplies to help respond to any escalation in violence. WHO deployed emergency teams to help hospitals cope with the influx of war-wounded, including IDPs and host communities. As the conflict continued in Tripoli,
the teams performed nearly 100 operations each week. The Organization also supported training on triaging patients during mass casualty events.
In 2019, Libya experienced small-scale outbreaks of measles, pertussis and rubella. The number of cases of cutaneous leishmaniasis rose sharply. Over 1000 cases of acute diarrhoea were reported each week – a clear indication of poor living conditions and inadequate water and sanitation. WHO has initiated discussions with the National Centre for Disease Control and national water companies on the steps required to improve water and sanitation services.
WHO supported the MoH’s efforts to tackle antimicrobial resistance (AMR), one of the most urgent health threats the world faces today.
Countries like Libya are more vulnerable to AMR because of weak regulatory systems and the over World Health Organization supported the MoH’s efforts to tackle
antimicrobial resistance (AMR), one of the most urgent health threats the world faces today.
Countries like Libya are more vulnerable to AMR because of weak regulatory systems and the over the-counter sale of antimicrobial medicines. In 2019, the MoH, with technical support from World Health Organization , adopted a national strategy and action plan to tackle AMR.
WHO faces many challenges implementing its humanitarian work in Libya. Divided governance structures and competing public administrations have undermined efforts to find medium- and longer-term solutions to rebuild the health system. The absence of national and international health NGOs has hampered the delivery of health care services in areas affected by conflict.
Access to many parts of the country is difficult and WHO has no partners on which it can rely to monitor the health response. WHO has recruited national field coordinators who travel to hard-to-reach areas to oversee the delivery of supplies, monitor operations and report back to the World Health Organization country office. WHO plans to expand its network of field coordinators and invest in additional training on data collection, conflict sensitivity and monitoring.
The sheer size of the country and its sparse population density, compounded by poor supply routes, especially in the south, have hampered
WHO’s emergency operations and increased their costs. To help overcome this, World Health Organization pre-positions contingency stocks in key locations whenever
$ll UN agencies and international NGOs
are encountering signifcant delays clearing emergency supplies through Libyan ports. Experience has shown that the process (from
the time the goods arrive till the time they clear customs) takes anywhere from two to four months.
World Health Organization incurs even longer delays because its medicines and medical supplies must undergo regulatory clearance by the country’s Food and Drug Administration. These delays greatly increase WHO’s procurement costs since goods that remain in customs incur significant demurrage and storage fees. WHO is attempting to negotiate fast-track procedures with the national authorities but has made little headway thus far. It will continue its efforts to resolve this issue.
The very limited presence of international staff inside the country has been another challenge. The UN has placed a ceiling on the number of international staff that each agency is allowed to have inside Libya at any one time. Currently, World Health Organization is allowed only three. International staff are important because they can cast a neutral eye on planning, managing and monitoring operations.
They have more international experience and exposure than national staff, who may be unused to working in emergencies. Moreover, national staff are at risk of being unfairly subjected to internal political pressures or other considerations.
To help overcome this difficulty, World Health Organization has asked for its quota to be increased to at least five. For future projects, WHO will rotate staff and consultants from Tunis to Tripoli based on whether their presence inside the country is essential and for how long. When deciding when and whether to rotate staff from Tripoli to Libya, security concerns will be the overriding consideration.
Lastly, security constraints restrict the travel of World Health Organization staff to many locations. The movement of World Health Organization staff is subject to strict UN security arrangements and out of the hands of the Organization. Tripoli’s only operational airport (Mitiga) is frequently closed because of skirmishes and rocket fre in the area. The situation seems unlikely to change for the immediate future. In the meantime, WHO plans to reinforce remote management through investing in tools to track goods and services delivered and recruiting third party monitors at central and sub-national levels.