A Health Policy Assessment in Post-Conflict Libya
Photo Credit Brookings
A new discussion about the health sector in post-conflict Libya – one regarding strategic, bureaucratic and mismanagement issues in the health sector.
Health: A Post Conflict Policy Assessment
Since the February 17th revolution, the Libyan people have felt the effects of the brutal crimes inflicted by the former regime. There is no doubt that they will continue to uncover these atrocities for years to come and yet perhaps the most heinous crimes inflicted are not those of the past nine months, but the legacy of the past forty two years.
A closer look at the health sector in Libya reveals that although there have been many challenges resulting directly from the effects of the seven month conflict, the actual source of the majority of problems encountered predate the revolution and can be tracked back to the decades of mismanagement, corruption and neglect during the previous regime; the ugly scars of which are replicated across many different sectors in Libya.
This editorial aims to introduce an alternative discussion on the health sector in post-conflict Libya – one of strategy, bureaucracy and mis-management in the health sector.
Since the beginning of March, the health sector has mainly focused on providing humanitarian aid and to provide access to health care for all as the health system deteriorated. The main providers of which have been the Ministry of Health, international and national humanitarian NGOs and the influx of volunteers (many of which are Libyan expatriates) from around the world.
Failures and successes
There have been many success stories and failures of the health system during the crisis that make it difficult to conclude how the health system has performed overall. This would become clearer following a robust post-conflict needs assessment, which is a must, in order to diagnose the roots of the myriad of ills afflicting the health care system. In the interim, the best gauge is to assess in terms of policy and priorities what is meant by success (and failure).
During the crisis, the public health priority was to manage injuries sustained in conflict. Many of these were tremendously challenging – ranging from amputations to extremely complex polytraumas – the treatment mode for both which is almost entirely hospital-based.
Hospitals – particularly tertiary centers in large cities – were able to respond reasonably well to the high number of casualties throughout the crisis. It could be argued that had the public health priority been different (like a disease outbreak for example), the system would have had neither the capacity nor the network to respond as it did with injuries.
Libya has averaged over 2,000 deaths from road traffic accidents (RTAs) in the past four years – an average of six deaths per day – and according to the figures for 2009 alone, over 14,000 injuries from RTAs, almost half of which were severe injuries. This gives Libya one of the highest death rates from RTAs in the region. It is my contention therefore, that Libya’s strength in dealing with the immediate casualties, was one born of circumstance and thus not a strategic shift in management policy or reconfiguration of resources to deal with the crisis.
On the other hand, one example of a resounding failure would be the case of the mental health and psychosocial support services. Together, these form one of the greatest unmet needs of the health system.
Prewar, the psychiatry services are an image of a fragmented and neglected branch of medicine that never had the funding nor the appropriate resources allocated to it. Notably, psychiatrists have been omitted in the Ministry of Health’s breakdown of activities of medical specialization, nor have they been included in the distribution of graduates per specialty in the human resources section of the Health and Environment Annual Statistical Report.
During the conflict, the already fragmented and neglected mental health services have struggled to provide adequate care for chronically ill psychiatric patients due to a lack of resources. Further to this, there are the unmet needs of those that have suffered psychological trauma from the warfare as well as the more specific cases of gender-based violence.
Accountability
As the National Transitional Council (NTC) consolidated their power and gained increasing international recognition in the Eastern stronghold of Benghazi, it acquired an increased sense of accountability and the issue of those wounded in the war became a focal point. Early on, the NTC had extremely limited resources, as it could not yet access any of Libya’s frozen assets and so was mainly reliant on supporting countries that assisted in the evacuation of critical cases as well as international humanitarian organisations for food, fuel, supplies and medicine.
The post conflict period however presents a very different image. With the increasing access to funds and growth of the NTC has come the increased burden of accountability and responsibility. The treatment of injured combatants and civilians has become an ever-increasing political priority.
The former interim Prime Minister Mahmoud Jibril singled out the injured fighters (hereafter referred to as ‘war-wounded’) as a priority of the executive council with the allocation of USD400 million to treat wounded fighters. The head of the NTC, Mustafa Abdul Jaleel had also repeatedly made similar commitments and most recently was mobbed at the NTC headquarters in Benghazi by an angry crowd of protestors – amongst their demands was the treatment of the war-wounded abroad. At the announcement of the Transitional Government’s council of ministers (the cabinet), the current Prime Minister Abdulraheem Alkeeb mentioned the war-wounded as a high priority for the new government.
Due to these political commitments, there has been extensive demand from patients requesting treatment abroad. There is a perceived notion (some of which is undoubtedly true) that medical treatment abroad is of a higher quality and for this reason, there are a considerable number of patients that can be treated in Libya for minor or less complex ailments that feel that it is their right to be treated abroad.
Several initiatives to deal with the war-wounded issue have been attempted:
In cooperation with several countries, the Ministry of Health has evacuated war-wounded patients requiring specialized, advanced procedures (such as reconstructive surgery and complex nerve repairs) for treatment.
The Temporary Finance Mechanism (TFM) set up a Global health Programme that began in the last week of August 201114 to cover the costs of hospital and medical care in several countries through contracted third party administrators (TPA) – usually a medical insurance company.
The Ministry of War Wounded (MoWW) was created at the end of October in order to act as a focal point and manage the evacuation, treatment, rehabilitation and expatriation of war-wounded patients. The MoWW was subsequently dissolved and the Transitional Government Council of Ministers (the cabinet) approved a “Body for the Care of the Wounded” on 11th December 2011.
Local councils and committees have taken unilateral responsibility and attempted to evacuate patients to friendly nations offering medical care.
While there have been varying degrees of success in these initiatives, the common denominator has been that they have all been reactive responses to the issue rather than strategic, predefined policies. As such, the issue of accountability is constantly being both blurred and misplaced between various ministries. The structures in place reflect the lack of a coherent strategy and the severe mismanagement of resources. Handling of Libya’s war wounded has been a serious test for the government and the authorities face a serious threat to their credibility to manage state affairs, with potentially dire short-term consequences.
The resulting action of such discourse has had severe but disparate effects upon various ministries. In light of the political commitments and various initiatives that have been attempted, one can see how various ministries could seek to build political capital. In contrast, other ministries may fail and seek to shift accountability towards other ministries as taking on the full responsibility of the issue comes to be viewed as a poisoned chalice.
Next Steps
Transporting patients to other countries for treatment may ‘buy some time’ whilst patients complete their treatment courses, but many will require ongoing rehabilitation, have long-term disabilities and complex needs once they return to Libya. Robust, strategic and proactive plans need to be formulated by the government under the strong leadership of the Ministry of Health to manage these issues.
There will be a ‘second wave’ of health needs on the return of the war-wounded to Libya and this will consist of rehabilitation services, mental health needs, revision surgery, out-patient follow ups and psychosocial support. This is prior to considering the wider social needs of patients such as wheelchairs, disabled access, speech therapy, prosthetic revision/modification and reintegration into the community to name a few (these are mainly dealt with by the Ministry of Social Affairs).
As Sullivan et al.16 convincingly argue, using evidence from policy failures in Kosovo and Afghanistan, an evidence-based national health policy framework at the beginning of post-war reconstruction is absolutely essential. A comprehensive, national strategy to provide the best possible care for the war-wounded needs to be discussed, analysed and implemented as a matter of urgency. Such a strategy should be the top public health priority for the Ministry of Health, and the interim government should ensure that all necessary resources and tools are at the Ministry’s disposal in order for this to be achieved.
Policy recommendations
Now that a governmental body (the new Body for the Care of the Wounded headed by Mr Ashraf Ismail) has been set up specifically to co-ordinate care for the war wounded, it is imperative that its remit and scope be clearly defined. Many problems have stemmed from a lack of clarity in the lines of responsibility for patients and projects that has ultimately has led to a situation where accurate figures for the number of Libyan patients being cared for in other countries cannot be provided.
Defining roles, responsibilities and a clear handover procedure will allow other ministries – such as the Ministry of Health and Ministry of Social Affairs – to be able to manage patients effectively once they are transferred to their responsibility from the Body of the Care of the Wounded for long term follow up and management of their long term social needs. It will also provide an extra incentive for ministries and officials to take on their well-defined responsibilities as their success or failure will depend on meeting them. It is equally imperative for all of the stakeholders involved to coordinate the care of the wounded with one another in order to regulate and standardise treatment.
The current interim government’s lifespan is extremely short – with only six months left – and the Ministry of Health should focus in this period on short-term, high impact, realistic goals. Policy debate is fragmented across institutions and policy makers lack a deep knowledge of the very health system that is supposed to be governed and reformed by the policies that they are formulating.
A plethora of organisations, companies and countries are competing for highly attractive and lucrative contracts in the health sector. Although some of these offers may seem attractive from a Libyan perspective (perhaps even for short-term political goals), the information currently available is inadequate. These offers will continue to exist as they are both commercial and for-profit. Unless the proposals in question are a high priority from a humanitarian perspective, a measured approach would be to wait until a comprehensive post-conflict needs assessment is concluded. This will provide officials with a base analysis of the health sector profile based upon which evidence based decisions can be made for a strategic long-term vision of the health care system. It will also act to guide those that want to become stakeholders in Libya’s health system as to the requirements of the health sector.
Such strategic policy decisions will be the primary criterion of success for the interim government. The government has a short predefined lifespan and it is unrealistic for them to attempt to solve all of the problems that are faced in each sector. It is their response to strategic issues such as these that are a matter of national priority that will ultimately determine their success or failure.