Care Pathways for a State in Turmoil: Health Systems Strengthening in Libya

Not long ago, the small seaside towns west of Tunis must have been genteel places of elegant white villas and quiet public squares. To the Libyan doctors, assembled in a comfortable beach hotel for our three-day introductory training in Generic Principles of Primary Care for Non-Communicable Diseases, these towns must look like a glimpse of a paradise they have lost. Unlike Tunisia, which managed a peaceful transition from dictatorship to a democratically elected government Libya has endured six years of chaos and violence, fuelled by political and tribal divisions. Its persistent instability remains ripe for lawlessness and exploitation. During these years of disruption, all public services have suffered from a lack of investment, and the health system is no exception. Before the revolution the country benefitted from a network of primary health centres, polyclinics and hospitals that were reasonably well-funded and very well staffed.

Now, only the physical infrastructure – and most of the staff – remain. The distribution system for medicines and other consumables has broken down, equipment has not been maintained and there is no proper power or water supply. Health professionals are not paid regularly and are acutely aware that they cannot provide the care their patients need. This deterioration in the public health service has led to the emergence of an expensive and poorly regulated, but thriving, private sector. Access to good care is possible – but only for those that can pay. As we listened to the doctors describing the daily problems they face, both as professionals and as people trying to live normal family lives in such a disordered country, our hearts went out to them. These are people who studied and began work at a different time, when their country was stable and flush with oil money. Now they watch as their children grow up without basic comforts, and with inadequate opportunities for education.

This training course marked the start of our organisation’s involvement in a project aimed at helping Libyans to rebuild their health system. It is being delivered by German development agency GIZ and is funded by the European Commission. Our remit is to work with Libyan doctors to agree primary care guidance, and design and implement care pathways for patients with chronic diseases like diabetes, hypertension and cardiovascular disease, asthma and COPD. Ideally, we would do this in Libya, and begin by visiting health centres and hospitals to talk to staff and learn about their strengths and the challenges they face, but travel inside the country is still too risky.

 So, our initial task was to try to identify the right individuals to work with: people with the commitment and skills to inspire their colleagues. During the three days we were with them, we found well-trained doctors, hungry for updates to their knowledge and skills, with enthusiasm and confidence. We have no doubt that they have what it takes to make the project succeed.

 Our next task will be to conduct consultations with a wide range of institutional stakeholders, creating an opportunity for them to shape meaningful new care pathways for this new landscape. The leadership and support of these stakeholders will be critical to enabling doctors to make change happen on the ground. We look forward to sharing more about these next steps in the coming months.