World Health Organization LIBYA ANNUAL
WHO Country Offce (Tripoli, Libya) REPORT Elizabeth Hoff, WHO Representative [email protected] 2019
WHO Country Offce (Tripoli, Libya) Yahya Bouzo, Communications Offcer [email protected]
WHO Regional Offce for the Eastern Mediterranean (Cairo, Egypt) Inas Hamam, Communications Offcer [email protected] 3 TABLE OF CONTENTS
Foreword 4 Situation in 2019 6 Overview 6 Status of health care services 7 Attacks on health care 9 Achievements in 2019 10 Support to hospitals and health care facilities 11 Delivering medicines and supplies 11 Deploying emergency medical teams 12 Training health care workers 13 Areas of focus 14 Primary health care 14 Secondary health care 15 Trauma care 15 Communicable diseases 16 Childhood vaccination 20 Disease surveillance and response 20 Tuberculosis 21 Leishmaniasis 21 Noncommunicable diseases 24 Mental health 25 Reproductive, maternal, newborn, child and adolescent health 25 Health information system 25 The humanitarian-development nexus 26 Coordination 27 Monitoring 28 Challenges 29 WHO’s presence in Libya 30 Looking ahead 31 Donors in 2019 35 Credit: WHO ANNEX 1: Main assessments conducted and technical guidelines and reports 36 published in 2019
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FOREWORD Nine years after the fall of Muammar Gadhaf, gaps in coverage due to the uneven distribution of Libya remains riven by armed confict, economic general physicians, most of whom work in urban collapse and disintegrating public services. areas. Although Libya has traditionally depended Continued violence and insecurity coupled with heavily on foreign health care workers, the political stalemate have resulted in a governance overseas workforce has steadily dwindled since vacuum accompanied by signifcant insecurity 2011 when the confict began. and a breakdown of the rule of law. Thus far, the confict has defed national and international Some donors are understandably reluctant to efforts to fnd a political resolution. fund humanitarian activities in oil-rich Libya. However, Libya s needs will remain signifcant Of a total population of 6.7 million, almost 4 for the foreseeable future. The absence of a million people, mostly women and children, functioning government has made it impossible require humanitarian health assistance. According to unlock Libya’s abundant resources to support to the health sector severity scale, almost 1.7 the health system and meet critical health needs. million people are in extreme need and more than Oil production has slowed, USD 60 billion in 122 000 are in catastrophic need. Many people have Libyan assets have been frozen, and the country’s specifc vulnerabilities (gender, age, disabilities, economic collapse has led to a major liquidity ill health and nationality) that undermine or crisis. Short- and medium-term funding will be limit their ability to withstand the effects of essential to stave off the further disintegration the confict. Other groups such as refugees and of health care and other public services and halt migrants often face abuses by state and non-state Libya’s spiral into further violence and decay. entities. Given their irregular legal status and lack of domestic support networks, they encounter While the primary responsibility for providing racism, xenophobia and grave human rights assistance lies with the Libyan authorities, violations. At the end of 2019, more than 3200 the persistent political crisis and escalating refugees and migrants were being arbitrarily held confict require the international humanitarian in appalling conditions in overcrowded detention community to fll critical gaps. WHO will work centres, creating conditions ripe for the spread of to combine humanitarian and development diseases such as tuberculosis (TB). These unlawful approaches that will allow it to deliver essential detentions are serious human rights violations health care services while laying the foundation that exacerbate an already volatile situation. for universal health coverage and Libyans’ right to health. Regardless of whether its operations are Libya’s health system is close to collapse. Severe humanitarian or developmental, the Organization shortages of health staff, medicines, supplies will scrupulously adhere to the four humanitarian and equipment have been compounded by years principles of humanity, neutrality, impartiality of under-investment in the health system and a and independence. In a country where some chronic lack of transparency and accountability. political factions view the UN with deep suspicion, Around one quarter of public health care facilities adherence to these principles will be more are closed, around one quarter of public health important than ever. Credit: WHO care facilities are closed, and most of those that remain open do not provide any health care services for children under fve years of age. Only fve of 78 hospitals assessed by WHO offer all essential services. There are acute shortages of medical specialists, midwives and nurses and huge
4 5 7 SITUATION condemned this clear pattern of ruthless attacks of acute diarrhoea have been reported each against health workers and facilities in the week. The clear threat of outbreaks of vaccine- IN 2019 strongest terms. preventable and other diseases is compounded by poor surveillance. Only 84% of the country’s Outbreaks of measles and rubella and increasing 125 sentinel sites are sending regular surveillance rates of cutaneous leishmaniasis, tuberculosis, data to the disease early warning and response pertussis and acute jaundice syndrome system, which has very limited capacity to detect highlighted Libya’s vulnerability to large-scale and respond to disease alerts. Overview disease outbreaks. Between 1000 and 1500 cases
In 2019, Libya remained locked in confict, confict, and almost half of them were living very violence and political instability. The situation was close to battle frontlines. compounded by the existence of two competing Status of health care services governments. A Government of National Accord hile the battle for Tripoli has dominated (GNA) in Tripoli was established in December 2015 international attention, the situation in the south Libya’s health system suffers from severe shortages uneven distribution of general internists, most with the support of the UN. A rival government in has been all too often overlooked. The region is of staff, a poorly functioning medical supply chain of whom are working in urban areas. In many the east (Benghazi) is backed by the Libyan National critical to the stability of Libya, but it has been and very weak disease surveillance and health remote and hard-to-reach locations, poor and Army (LNA) headed by Field Marshal Khalifa historically marginalized in the country s politics information systems. The lack of detailed data on vulnerable communities have very limited access Belqasim Haftar. The UN-backed government in despite its ample natural resources. The United the main causes of mortality and morbidity has to health care. In areas affected by confict, health Tripoli has struggled to exert control over territory Nations upport Mission in Libya (UN MIL) has hampered efforts to analyse needs and deliver a care facilities were overwhelmed with patients. held by rival factions and intensifying geographical expressed its deep concern about reports coming targeted response. Around 22% of Libyans and 18% of migrants and and political divisions between the east, west and from the south on the mobilization of armed refugees faced diffculties accessing health care Approximately one ffth of Libyan hospitals services2. The most severe health needs were in south. Terrorist groups and armed militias have forces and the escalating cycle of statements and 1 exploited the turmoil and used the country as a counter-statements by warring factions, signalling and PHC facilities are closed. There are acute districts affected by violence (e.g., Murzuq, Sirt base for radicalization and organized crime. Libya the growing risks of imminent confict. shortages of medical specialists, midwives and and Tripoli) or that were hosting large numbers of is awash with weapons: arms from the Gaddaf nurses and huge gaps in coverage due to the IDPs (e.g., Benghazi, Ejdabia and Sebha). era are plentiful, and materials of war continue In August 2019, the dangers of working in Libya to be shipped to the country in breach of the UN- were illustrated when a bomb exploded under a imposed arms embargo. UN vehicle in Benghazi, instantly killing three UN staff and severely injuring several other staff and In April 2019, the LNA launched an offensive to bystanders. No one has claimed responsibility for capture Tripoli from the GNA. After initial advances, the incident investigations are under way by the it has been locked in stalemate with government- United Nations. The same month, approximately backed forces for several months. The continuing 100 people were killed, more than 200 were fghting in Tripoli has cut off access to hospitals injured and over 30 000 were displaced when A WHO Libya staff member and left thousands of people without health care. violence fared between rival tribes in Murzuq, assesses needs in a health At least 3000 people have been killed and injured south Libya. By the end of the year, the number care facility serving people and another 149 000 have been displaced. At of internally displaced people (ID s) in Libya had displaced by the violence in Tripoli. the beginning of July, Tajoura detention centre almost doubled to 343 000. in Tripoli holding more than 600 migrants and Credit: WHO refugees suffered a direct airstrike that killed 50 The number of attacks on health care rose sharply. people and injured 130 others. This prompted the In the summer of 2019, airstrikes on two feld international community to renew its calls for the hospitals and two ambulances in Tripoli killed at closure of detention centres across the country. As least four doctors and one paramedic and injured of 31 December 2019, around 250 000 civilians in several others. The pecial epresentative of Tripoli were living in areas directly affected by the the ecretary-General for Libya Ghassan alam 1 Figures taken from WHO’s Service Availability and Readiness Assessment of 2017. 2 Humanitarian Needs Overview for Libya, 2020.
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Attacks on health care The number of attacks on health care rose ripoli, hi h as the s ene o intense f htin in sharply, from 36 in 2018 to 62 in 2019. A total 2019. International humanitarian law (IHL) strictly of 76 people were killed and scores more were prohibits attacks against hospitals and other injured. More people were killed in Libya as a medical facilities, medical personnel and medical result of these attacks than in any other country transport. WHO has repeatedly condemned these Planning, managing and monitoring the delivery Mental health remains chronically neglected: there worldwide. Most attacks occurred in and around attacks as egregious violations of IHL. of health care services are seriously inadequate are only two public mental health hospitals in the at all levels of the health system. PHC facilities entire country, and most patients are treated in are not required to provide a standard package private health facilities. Childhood vaccination of services or maintain essential medicines, programmes have been interrupted and there “Intentionally targeting health workers and health facilities and ambulances is a war crime, and when equipment and laboratory services to support the have been widespread shortages of vaccines. committed as part of widespread or systematic attacks directed against any civilian population, may delivery of high-quality care. In many facilities, constitute a crime against humanity. We will not stand idly by and watch doctors and paramedics targeted doctors are either not available full time or they Private health care services have expanded to meet daily while risking their lives to save others.” are young and inexperienced. There are frequent needs arising from the inadequate public health stock-outs of essential medicines and there are care system. In 2019, a report issued by the Libyan Ghassan Salamé, the Special Representative of the Secretary-General for Libya. no electronic or paper medical records that allow Ministry of Health (MoH) showed that the number different physicians to monitor individual patients of inpatient clinics, laboratories and pharmacies over time. Moreover, many PHC facilities remain and diagnostic centres rose by 72%, 50% and open only three to four hours a day, and patients 80% respectively between 2007 and 2018. Private reportedly fnd them unsanitary. As a result, health care services are poorly regulated and their Libyans tend to bypass PHC services and go directly burgeoning growth has occurred mainly in urban to the outpatient clinics or emergency services of areas. Many health care professionals in the public hospitals in the belief that they are likely to be sector have left for the private sector where they referred to these facilities anyway. This leaves are better remunerated: this has exacerbated the hospitals even more overstretched, forcing them situation of poor patients, especially those living to direct their limited resources from seriously in remote areas. in e the on i t e an, most ill patients to others who do not require either injured patients have been treated in private emergency treatment or hospitalization. health care facilities, with the costs of their care covered by the government. WHO will support Reproductive health services including ante- the government’s efforts to build effective and postnatal care, family planning and the partnerships with the private health sector and management of sexually transmitted infections reach Libya’s goal of universal health coverage by have all but collapsed and there has been an 2030. alarming increase in rates of caesarean sections.
8 9 11 SUPPORT TO HOSPITALS AND Throughout 2019, WHO supported the delivery of ACHIEVEMENTS HEALTH CARE health care services by providing medicines and supplies, deploying medical teams and training IN 2019 FACILITIES health care staff.
Delivering medicines and supplies WHO delivered enough medicines and supplies to treat 1 099 500 patients throughout Libya.
Inter-agency Noncommunicable Other Mantika emergency Trauma kits Surgical kits Total disease kits medicines health kits people were reached health care workers were trained Al Jabal Al Akhdar 2 1 5 8 1through 168 WHO-supported 407 fxed health care 1332on a wide range of topics including trauma care, Al Jabal Al Gharbi 5 7 5 1 4 22 facilities or mobile teams. primary health care, the management of NCDs, Aljfara 1 1 the health information system, disease surveillance Aljufra 2 3 3 1 2 11 and response, and mental health care. Alkufra 2 3 5 Almargeb 7 8 7 4 4 30 Azzawya 3 3 2 2 10 people received health care Benghazi 10 5 13 1 8 37 services68 through907 emergency hospital teams and Derna 2 1 2 1 6 mobile medical teams. national guidelines and policies were Ejdabia 21 2 1 14 38 prepared5 and adopted by the MoH with close Ghat 1 1 2 4 technical support from WHO. Misrata 10 6 5 2 4 27 Murzuq 10 7 6 1 24 Sebha 3 2 7 12 Sirt 1 1 2 4 hospitals and health care facilities received Tobruk 1 1 3 5 essential82 medicines and medical supplies. Tripoli 50 33 43 12 26 164 new MoH emergency operations centres 2 Ubari 14 5 2 8 29 (one in Tripoli and one in Benghazi) were fully Wadi Ashshati 9 3 2 6 20 equipped by WHO. Zwara 3 3 2 8 Total kits and supplies delivered 156 93 113 22 79 463 standard medical kits as well as 463other supplies (containing enough medicines and supplies to treat 1 099 500 people) were distributed throughout the country. In mid-September 2019, WHO delivered medicines and supplies to serve 220 000 patients for three months to hospitals and clinics throughout Libya. The supplies will be used to treat patients with infections, injuries and chronic diseases.
Credit: WHO
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Deploying emergency medical teams Mobile medical teams
In contrast to other countries (e.g., Syria) where WHO has relied on emergency medical teams to While the primary aim of EHTs is to strengthen approximately four MMTs per month. Each MMT WHO relies heavily on national NGOs to provide strengthen health care services in areas affected surgical capacity in hospitals, mobile medical comprised a general physician, a paediatrician, a essential PHC services, there are no national (and confict teams (MMTs) aim to provide general health dermatologist and an obstetrician/gynaecologist. few international) health NGOs in Libya. Instead, care services in remote, hard-to-reach and under- pp o imatel people ene ted om the served areas. WHO supported the deployment of services offered by MMTs in 2019. 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 A WHO mobile clinic in an acilities ach consisted o e specialists isolated area in east Libya. (a general physician, a general surgeon, an obstetrician/gynaecologist, an anaesthetist and a Credit: WHO paediat ician ust o e people ene ted 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 Training health care workers mass casualty management. The teams are also trained on collecting patient data using standard In 2019, WHO trained 1332 health care workers on Just under half of those trained were women. forms provided by WHO. The information is topics including mental health in confict settings, WHO encourages female staff to attend training This anaesthetist at a hospital in Ubari is part of the case management of TB and NCDs, disease courses by providing special incentives. For disaggregated by patients’ age and gender and a WHO emergency team providing health care surveillance, the health information system and a example, in societies where the free movement of the types of consultations provided. This allows services including surgery in south Libya. WHO to analyse the most common causes of family practice model for PHC facilities. Because of women is restricted, WHO facilitates the travel of consultations and make sure the medicines and Credit: WHO internal travel restrictions and security constraints, an accompanying family member so that women supplies it procures are meeting needs. many of the courses had to be organized in do not have to travel alone when they attend neighbouring Tunisia, increasing their costs by a training workshops. considerable margin. Breakdown of EHT services provided 13% Participants attend a 21% Dermatology training course in east Libya on the management of Paediatric diseases including TB, HIV, Gynaecology and obstetrics cholera, childhood illnesses 22% and leishmaniasis. Internal medicine Credit: WHO 29% Surgery 15%
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AREAS OF FOCUS
Primary health care
PHC services are the backbone of health care WHO supported a series of workshops to introduce in all countries. In late December 2017, WHO 302 PHC nurses from south, east and west Libya launched a two-year pilot project introducing to WHO’s new training package for nurses. The Participants at the a standard family practice model comprising 13 workshops comprised one week of theoretical WHO-supported nursing core elements3 into six PHC centres in east, west sessions followed by a week of practical training. workshop in November and south Libya. The project ended in late 2019; Those trained will go on to train fellow nurses 2019. based on the lessons learned from this experience, inside Libya. Credit: WHO and subject to the availability of funds, WHO plans to introduce the model in over 80% of the In total, 554 managers, physicians, nurses and country’s PHC facilities, using a phased approach. other clinical staff were trained on various aspects WHO trained 44 community health workers on of PHC in 2019. the family practice model in Libya, based on adapted regional guidelines. Another 30 health care professionals were trained on using standard Secondary health care Trauma care indicators to monitor and assess the quality of WHO trained 30 health care staff on hospital WHO distributed or pre-positioned 113 trauma kits services in PHC facilities and help improve patient emergency preparedness and supported the – enough to treat 11 300 wounded patients – to safety. logistic arrangements for 12 surgeons from Libya’s hospitals and clinics in confict-affected areas and main referral hospitals who travelled to Poitiers, pre-positioned additional supplies to help respond France for training on damage control surgery. to any escalation in violence. WHO deployed WHO also launched a pilot project to assess patient emergency teams to help hospitals cope with the safety in hospitals. The results of the assessment infux of war-wounded, including IDPs and host will be published in early 2020. communities. As the confict continued in Tripoli, the teams performed nearly 100 operations each week. The Organization also supported training 3 The 1 core elements of the family practice model are 1 a clearly de ned catchment population the a aila ility of family and indi idual on triaging patients during mass casualty events. patient les a family physician roster community engagement a standard package of essential health care ser ices a standard list of essential medicines a standard list of core staff and up-to-date o descriptions, a standard set of medical e uipment and furniture on-the- o training for general practitioners and support staff 10 up-to-date treatment protocols 11 a patient referral system 1 a health information and reporting system 1 ser ices accredited y an external ody.
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Communicable diseases In 2019, Libya experienced small-scale outbreaks and inadequate water and sanitation. WHO has of measles, pertussis and rubella. The number of initiated discussions with the National Centre for cases of cutaneous leishmaniasis rose sharply. Over Disease Control and national water companies on 1000 cases of acute diarrhoea were reported each the steps required to improve water and sanitation week – a clear indication of poor living conditions services.
Number of cases of acute diarrhoea by month, 2019
7000
6000
5000
4000
3000 Reported cases 2000
1000
0 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19
Number of cases of acute jaundice syndrome, measles and pertussis by month, 2019
300 Ajs
250 Measles
Pertussis 200
150
Reported cases 100
50
0 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19
WHO supported the MoH’s efforts to tackle the-counter sale of antimicrobial medicines. In antimicrobial resistance (AMR), one of the most 2019, the MoH, with technical support from WHO, urgent health threats the world faces today. adopted a national strategy and action plan to Countries like Libya are more vulnerable to AMR tackle AMR. because of weak regulatory systems and the over-
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Dr Abdulhameed Al Fakhery, the Director-General Caring for TB patients in south Libya of the NCDC in Sebha, says the centre urgently needs to be upgraded. TB is a growing concern: the centre has no capacity to treat patients with South Libya is one of the poorest, most deprived such as TB, HIV/AIDS and viral hepatitis. Despite its the multi-drug resistant form of the disease. These and historically neglected areas in the country. huge caseload, it has few medicines and supplies patients are referred to Tripoli, 800 km away, but The region has been signifcantly affected by and only two part-time doctors and 12 nurses. the journey is long and dangerous. Many patients the confict. Insecurity is rife and violent clashes Electricity cuts are a daily occurrence but the with active lung TB cannot be admitted because among armed groups are common. Electricity centre has no back-up generator to maintain its the centre’s isolation wards are full. This greatly is available only intermittently and there are power supply. Its sole X-ray machine – essential increases the risk of the spread of TB within the widespread shortages of water, food, medicine, for screening patients with pulmonary TB – works community. When people with active lung TB fuel and other basic items. Supply routes to the only sporadically. cough, sneeze or spit, they propel the TB bacilli Dr Abdulhameed Al Fakhery, the Director- south have been disrupted and the journey to into the air: a person needs to inhale only a few of General of the NCDC in Sebha. Tripoli is fraught with risk. Travellers are liable to Most patients admitted to the centre seek them to become infected. be attacked and robbed or intercepted by armed treatment for TB. TB is one of the top 10 causes Credit: WHO groups at unauthorized checkpoints and forced to of death worldwide, and rates of the disease are pay bribes for their safe passage. rising in Libya. Patients with active lung TB – i.e., those who can infect others by coughing – must be Nurse Fatema Tako says that many patients travel more medicines and supplies and diagnostic tests. Sebha, the regional capital of south Libya, lies quarantined until their sputum tests are negative long distances to reach the centre, paying travel Our isolation unit is always full but it is old and deep in the Libyan desert. Large numbers of and they can safely continue their treatment in costs they can ill afford. Approximately 40% of dilapidated and doesn’t offer patients or us the migrants pass through the town hoping to reach the community. However, medicines to treat these patients are refugees and migrants. “We try to protection they and we need.” Europe. The National Centre for Disease Control’s patients are in short supply. The centre’s isolation support our patients but it is hard. We see so many (NCDC) health care branch in Sebha covers a huge ward is poorly equipped and there are not enough people, but we have so little to offer them. Today, Forty-two-year-old Masoud Saad has tested catchment area that extends 700 km to the border beds to accommodate patients. As a result, many we saw a patient who had travelled hundreds of positive for active lung TB and has been placed in with Niger and Chad. The centre is responsible for of them are forced to remain in the community kilometres. We had to ask him to come back in isolation. He has come from Ubari, more than 150 treating all patients with communicable diseases where they can infect other people. three days, when a doctor would be on duty. The km away, in search of treatment for his chronic despair and distress of these patients are obvious. cough. His local hospital prescribed medicines, It is very diffcult to have to turn them away: all my but his cough worsened and so he undertook the humanity and training as a nurse go against this. long and diffcult journey to Sebha through dusty We need so much: more doctors, better training, desert roads.
Masoud in the isolation room at the NCDC Dr Radhia Shaban, centre in Sebha. WHO’s focal point in Sebha, inspects the Credit: WHO centre’s only X-ray machine.
Credit: WHO Thirty days into his treatment, Masoud says he I know that I will eventually be cured.” just wants to get better and return to his family. “I’m so grateful to the doctors here – I feel better In 2019, WHO supported the centre in Sebha with already – but I miss my children. I was shocked laboratory reagents, inter-agency emergency when I found out I had TB. But I am one of the health kits, intravenous fuids, antibiotics and lucky ones; I am getting the treatment I need and other medicines and supplies.
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Childhood vaccination Tuberculosis According to data recently released by the National of disease outbreaks. As a result, there continue Although Libya is a middle burden country for TB, screening exercise in eight detention centres. Out Centre for Disease Control, national vaccination to be sporadic, small-scale outbreaks of vaccine- it is hosting tens of thousands of migrants and of more than 3500 migrants who were screened coverage rates for the main childhood diseases preventable diseases such as measles and rubella. refugees from higher TB burden countries. Many for T seven ne cases ere i entife an 0 are over 90%. Thanks to signifcant efforts by of them are picked up by the Libyan coastguard e isting cases ere confr e . This high b r en the national health authorities, and with support n 0 9 strengthene its fe s ervision as they try to cross the Mediterranean to Europe requires immediate interventions to save lives, from WHO and UNICEF, the number of cases of of polio surveillance activities through rapid and subsequently taken to one of the country’s prevent deaths and stem the epidemic. measles has decreased substantially (from 1049 in assessments and on-the-job training for 17 detention centres. As of 31 July 2019, around 2018 to 188 in 2019). However, major challenges s rvei ance offcers in nine nici a ities. The 5000 people were being detained in these centres, n 0 9 traine hea th care rofessiona s remain. Although vaccination services are offered Organization also trained laboratory staff on many of them in unventilated, unsanitary and on managing TB patients (including those inside free-of-charge to Libyans and non-Libyans, the testing samples for measles and rubella, and overcrowded hangars with very limited access migrant detention centres), supported the country’s 600 vaccination centres have frequent provided reagents and equipment to support the to health care. These conditions are ripe for the preparation of updated national TB guidelines shortages of vaccines and lack detailed vaccination rapid diagnosis of these diseases. In 2020, WHO spread of TB. Over the course of a year, people an screening rotoco s base on s atest plans. There are no mobile vaccination services plans to strengthen national surveillance efforts, with active TB can infect up to 10-15 other people. guidance, and delivered medicines (including and no strategy or programmes in place to especially for polio, by improving the availability Without proper treatment, up to two thirds of drugs to treat patients with multi-drug resistant educate communities about the importance of of vaccines, strengthening vaccination services people with active TB will die. T to the ationa T berc osis rogra e T . vaccinating children. Moreover, the presence of (especially for IDPs and migrants) and enhancing a so e ivere fo r ene ert achines to undocumented migrants who enter the country the monitoring of and reporting on routine Data from WHO’s Global Tuberculosis Report 2019 the T for istrib tion to branches thro gho t through informal crossing points increases the risk immunization services. show that the number of people with detected the country. These state-of-the-art test machines an notife T in ibya increase by % bet een dramatically shorten the time to diagnose drug- 2017 and 2018. However, the real number is likely resistant strains of TB from weeks to only a Disease surveillance and response to be much higher given Libya’s weak health few hours. Allowing health workers to quickly information and disease surveillance systems. diagnose drug-resistant TB and enrol patients for Disease early warning systems provide an infection of 10 children. The WHO-trained rapid In August 2019, this was borne out by a major immediate treatment can help halt the spread of opportunity to detect and respond to cases of response team in Benghazi vaccinated 95 children this deadly form of the disease. epidemic-prone diseases at an early stage. In 2019, in the centre. approximately 85% of Libya’s 125 sentinel sites Leishmaniasis sent regular weekly reports to the WHO-supported In 2020, WHO will work with the national disease early and warning network (EWARN). authorities to increase the number of sentinel In the last two decades, cutaneous leishmaniasis WHO trained 419 health care workers on disease sites reporting to EWARN, train additional staff has become a major public health problem in surveillance and reporting to EWARN. Fifteen an revie an ate the case efnitions for Libya. Visceral leishmaniasis, a much rarer and WHO-trained rapid response teams were deployed notifab e iseases. deadlier form of the disease, has become more to 15 hospitals in Libya. Each team consisted of frequent in the east and south. t o e ica offcers a aboratory technician a s rvei ance offcer an a ata anager. The tea s were instrumental in responding to outbreaks Number of cases of cutaneous leishmaniasis by month, 2019 of acute jaundice syndrome and measles and 1800 preventing their further spread. In spite of these 1600 efforts, there are notable weaknesses in the 1400 isease s rvei ance syste . The a ity of the ata 1200 is often poor and doctors do not always follow the 1000 stan ar case efnitions for notifab e iseases. Moreover, neither private health care facilities 800 Reported cases 600 nor detention centres participate in EWARN. In A migrant child in Ganfouda detention centre July 2019, the dangers of this lack of involvement is vaccinated against measles. 400 became evident when a measles outbreak in 200 Ganfouda detention centre in Benghazi led to the Credit: WHO 0 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19
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The increase in rates of cutaneous leishmaniasis (see chart below). Most people with leishmaniasis Four-year-old Faris Hasan lives in Murzuq city The most effective way to treat people with can be directly linked to the confict, which has catch the disease during the summer months, in the south of Libya. In early 2019, he began visceral leishmaniasis is with injections of sodium led to population displacements, disrupted health when they are bitten by the sandfy that transmits experiencing acute abdominal pain accompanied stibogluconate. Unfortunately, this treatment was and water and sanitation systems and poor living the parasite that causes the disease. Cases start by bouts of fever and vomiting. His condition not available anywhere in the country. Faris was conditions. A similar experience was reported from appearing after a two to three-month incubation grew worse and he rapidly lost weight. Doctors at put on an alternative treatment but showed no Syria, where the number of cases of cutaneous period, with the peak of cases recorded between the local clinic were unable to diagnose his illness improvement. His parents were in despair. leishmaniasis rose sharply as a result of the confict October and November (see above chart). and referred to him to the Children’s Hospital in Benghazi for further examination. The hospital appealed to WHO for help. In September, WHO made an emergency purchase In July, Faris was admitted to the hospital with of sodium stibogluconate and rushed it to the fever, jaundice and an enlarged liver and spleen. hospital. Faris began treatment immediately Following a bone marrow biopsy, hospital and made a remarkable recovery. He has put on Yearly trend of CL cases reported in the Middle East (Source: Salam et al, 2014) doctors diagnosed him as suffering from visceral weight and has become a happy, mischievous little leishmaniasis. boy once again. 60000 Iraq 55000 Syria 50000 Visceral leishmaniasis, also known as kala-azar, WHO has donated enough sodium stibogluconate Saudi Arabia is caused by a parasite transmitted through the to the hospital to treat 30 patients for up to one 45000 Jordan 40000 bite of infected female sandfies. he disease year. Professor Al Teer, Head of the hospital’s 35000 is characterized by irregular bouts of fever, Infectious Disease Department, thanked WHO for 30000 substantial weight loss, swelling of the spleen and its support. “Thanks to this donation, we will be 25000 liver, and anaemia. If the disease is not treated, able to treat other patients like Faris whose long- Number of CL cases 20000 the case-fatality rate in developing countries can term chances of survival would otherwise be slim.” 15000 be as high as 100% within 2 years. 10000 Ms Elizabeth Hoff, the WHO Representative in 0 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 Outbreaks of visceral leishmaniasis are often Libya, said she was delighted that Faris had made fuelled by complex emergencies, mass population such a speedy recovery. “We will continue to movements, famine and malnutrition. Rates of work with the Ministry of Health and hospitals the disease have been rising in in south Libya, due and primary health care centres throughout Libya to the country’s prolonged crisis. to ll critical gaps in medical supplies and make sure that vulnerable patients receive the care they need.” WHO procured antileishmanial medicines and rapid diagnostic kits, and trained dermatologists from the National Centre for Disease Control’s Zoonotic Disease Control unit on leishmaniasis case management. t also organi ed a Scienti c ay on leishmaniasis in Tripoli in September 2019. The WHO staff member conference brought together approximately Dr Abdelaziz Alahla meets aris health care professionals to share experiences and Hasan following his learn about the latest advances in leishmaniasis treatment for visceral treatment and control. leishmaniasis.
Credit: WHO
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Noncommunicable diseases Mental health There is only one specialized mental health professional treating patients with common mental health disorders. Noncommunicable diseases (NCDs) are the leading for every 300 000 people in Libya (neighbouring Tunisia cause of death in Libya and account for 72% of has one mental health professional for every 100 000 In 2020, subject to the availability of funds, WHO plans the burden of disease. More than one third of eo e . On f e of ib s 2 cities – are offering mental to launch an ambitious project to scale up mental health adults smoke and there are high rates of obesity, health services, and only two cities (Tripoli and Benghazi) services in Libya. One of the SPHERE5 minimum standards cardiovascular disease and cancer. ro ide in tient ser ices. WHO is wor in to f ur ent for mental health is to ensure that every general health s in t e ost ffected re s. n 201 it su orted t e care facility has at least one trained staff member and a deployment of two psychiatrists (one to east and one to system in place to manage people with mental health 2016 TOTAL POPULATION: 6 293 000 2016 TOTAL DEATHS: 34 000 west ib . rou out 201 t e s w n er e of 110 conditions. The project aims to achieve this standard in patients per week. WHO also trained 65 PHC doctors on three Libyan cities to be selected.
RISK OF PREMATURE DEATH DUE TO NCDS (%) PROPORTIONAL MORTALITY
50 35% 18% Reproductive, maternal, newborn, Cardiovascular Other NCDs 40 diseases child and adolescent health 30 12% 8% In October 2019, WHO, UNICEF and the MoH convened of reproductive and maternal health interventions Cansers Communicable, covering pre-conception care, family planning, 20 maternal, perinatal NCDs are a workshop to adapt the WHO/UNICEF guidelines and nutritional estimated to antenatal and intra-partum care. In March 2019, 33 premature death premature Probability (%) of Probability 10 3% conditions account for 72% on the integrated management of neonatal and Chronic of all deaths. health care professionals underwent master training respiratory childhood illness (IMNCI) to the Libyan context. IMNCI 0 diseases on this package. Subject to the availability of funds, 2000 2005 2010 2015 2020 2025 20% is an integrated approach to neonatal and child health Injuries that focuses on the well-being of the whole child. It WHO plans to launch cascade training in 2020 to allow Past trends Projected lnear trends Global targets 4% the master trainers to pass on their knowledge to their Males Diabetes aims to reduce death, illness and disability and promote Females improved growth and development among children counterparts throughout Libya. under f e e rs of e. O er four d eriod fro 22 to 25 October 2019, child health specialists from the WHO also supported the preparation of a national strategy on the prevention of mother-to-child In 2019, WHO distributed 93 standard NCD kits to MoH, PHC facilities, universities and hospitals across transmission of HIV. The MoH plans to formally adopt PHC centres. The kits contained enough supplies t e countr de e o ed s ecifc uide ines for and implement the strategy in early 2020. to treat 930 000 chronic disease patients for three Libya. In addition, WHO completed work on a package months. Given the high rates of NCDs in Libya, demand for these kits has increased since they were frst introduced in June 2018. WHO briefed Health information system physicians and nurses in all three regions of Libya A well-functioning health information system is number in Libya) are now using the DHIS-2 to enter on the content of the kits. The Organization trained one of the six building blocks of a health system6. data on disease burden, access to health care, causes PHC doctors and nurses on managing the most WHO, donors and health partners are supporting of mortality, disease surveillance, HIV surveillance, and common NCDs including cardiovascular disease, the development and roll-out of the District Health the management of health human resources. Once chronic respiratory disease and diabetes, based Information System (DHIS-2) in Libya. The DHIS-2 is the DHIS is fully up and running, it will yield evidence on recently adapted national guidelines. It also an open-source software platform to report, analyse to help the MoH and partners plan and prioritize supported the MoH’s efforts to strengthen cancer and disseminate health information. In 2019, WHO health programmes. Further progress in this area will surveillance and the follow up of cancer patients. trained statisticians and end users on the DHIS-2. be subject to the availability of funds. It is working with the MoH to develop guidance on Approximately 120 PHC facilities (9% of the total the main risk factors for NCDs in Libya. 4 Libya has 14 cities with populations between 100 000 and 1 million, and 28 cities with populations between 10 000 and 100 000. 5 The Sphere movement was started in 1997 by a group of humanitarian professionals aiming to improve the quality of humanitarian work durin dis ster res onse. Wit t is o in ind t e de e o ed Hu nit ri n rter nd identifed set of st nd rds to be ied in n humanitarian response. 6 The six building blocks of a health system are: 1) good health services, 2) a well-performing health workforce, 3) well-functioning health infor tion s ste e uit b e ccess to essenti edic roducts ccines nd tec no o ies of ssured u it ood e t fn ncin nd 6) leadership and governance.
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THE HUMANITARIAN- DEVELOPMENT COORDINATION NEXUS
Humanitarian and development agencies in WHO participates in the nexus task force in Libya. The health sector in Libya was established in 2015. The health sector collaborates closely with the confict-affected countries have traditionally This will allow WHO and its partners to mobilize It brings together over 30 health partners under WASH and protection sectors. WHO participates worked in silos, with neither side being familiar additional resources for projects that will upgrade WHO’s co-leadership. Since 2018, the health sector regularly in humanitarian country team meetings with or able to capitalize on the knowledge the capacity of the MoH and lead to more in Tripoli has been supported by two sub-national and other intersectoral coordination meetings. and experience of the other. Simply put, the sustainable, long-term results that will restore and sectors in east and south Libya. In each of these humanitarian-development nexus (“the nexus”) stabilize the health system. WHO is also working locations, WHO and partners work closely together To strengthen coordination between WHO and the seeks to coordinate their activities by removing to foster closer alignment between the annual and meet regularly to review the emergency MoH, WHO supported the establishment of two barriers to collaboration. It calls for both Humanitarian Response Plans and the medium- response, identify and ll gaps, agree on priorities, MoH emergency operations centres (EOCs), one in humanitarian and development agencies to take term, development-oriented United Nations and adapt operations to meet evolving needs. Tripoli and the other in Benghazi. WHO provided the long view and work together over several Strategic Framework for Libya7. The health sector runs ve thematic working technical advice and installed IT equipment and years towards joint outcomes. This will facilitate groups (on gender-based violence, mental health, furniture. It will also train EOC staff on how to meaningful progress and ease the transition tuberculosis, reproductive health and migrant manage and monitor emergency operations. from humanitarian action to health system health). WHO has coordinated the formulation The centre in Tripoli was formally inaugurated in development. and implementation of the health component of December 2019. The inauguration of the centre in Humanitarian Response Plans for Libya since 2016. enghazi has been delayed due to the dif culties nding local IT companies and the suspension of all fights from Tripoli to enghazi8.
7 The United Nations Strategic Framework sets out the following goals to be reached by end 2020: 1) core government functions will be strengthened and ibyan institutions and civil society will be better able to respond to the needs of the people ) economic recovery will be initiated thanks to better public nancial management and economic, nancial and monetary policies that will stimulate investment ) ibyan institutions will have improved their capacity to design, develop and implement public and social policies that focus on quality social services delivery for all women and girls, men and boys (including vulnerable groups, migrants and refugees). 8 The centre opened in February 2020.
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MONITORING CHALLENGES WHO’s feld coordinators throughout the country regularly visited health care facilities and mobile clinics to report on health needs and current stocks of priority medicines. These reports were assembled following interviews with staff and health authorities and discussions with community leaders. Based on these reports, WHO shipped essential medicines directly to the identifed hospitals and health care centres. WHO feld understanding of the evolving health situation in WHO faces many challenges implementing its procedures with the national authorities but has coordinators also monitored the accuracy and the country and plan their response accordingly. humanitarian work in Libya. Divided governance made little headway thus far. It will continue its timeliness of the distribution of medicines and structures and competing public administrations efforts to resolve this issue. medical equipment and the continuous availability In early 2019, WHO launched a survey to assess have undermined efforts to fnd medium- and of medicines and supplies at points of care (fxed patients’ level of satisfaction with the health longer-term solutions to rebuild the health The very limited presence of international staff facilities and mobile clinics). care they received from EHTs in Sabha, Ubari, system. The absence of national and international inside the country has been another challenge. Tarhouna, Benghazi and Ejdabia. Between May health NGOs has hampered the delivery of health The UN has placed a ceiling on the number of In Libya, the weak capacity of the national and October 2019, completed questionnaires care services in areas affected by con ict. ccess international staff that each agency is allowed health information system has hampered efforts were collected from 486 patients who agreed to to many parts of the country is diffcult and WHO to have inside Libya at any one time. Currently, to gather overall data on the burden of disease, participate. Although many survey respondents has no partners on which it can rely to monitor WHO is allowed only three. International staff are the prevalence and main causes of morbidity reported that the medicines they needed were the health response. WHO has recruited national important because they can cast a neutral eye on and mortality, and the status of health care not available, 85% of participants said they were feld coordinators who travel to hard-to-reach planning, managing and monitoring operations. services across the country. WHO and other UN satisfed with services nonetheless. This high level areas to oversee the delivery of supplies, monitor They have more international experience and agencies (IOM and UNICEF) have invested heavily of satisfaction can be attributed to the fact that operations and report back to the WHO country exposure than national staff, who may be unused in supporting the development of the DHIS-2. before the teams arrived, many patients had no offce. WHO plans to expand its network of feld to working in emergencies. Moreover, national When the DHIS-2 is fully up and running, it will access to health care of any kind. coordinators and invest in additional training on staff are at risk of being unfairly subjected to allow both WHO and the MoH to have a better data collection, con ict sensitivity and monitoring. internal political pressures or other considerations. To help overcome this diffculty, WHO has asked for Satisfaction rate from 6 EHT Clinics May through December 2019 The sheer size of the country and its sparse its quota to be increased to at least fve. For future population density, compounded by poor supply projects, WHO will rotate staff and consultants 15% 2% 40% 28% 17% 7% 5% 2% 100% routes, especially in the south, have hampered from Tunis to Tripoli based on whether their WHO’s emergency operations and increased their presence inside the country is essential and for 80% costs. To help overcome this, WHO pre-positions how long. When deciding when and whether to 60% contingency stocks in key locations whenever rotate staff from Tripoli to Libya, security concerns
40% 85% 98% 60% 72% 83% 93% 95% 98% access permits. will be the overriding consideration. Percentage 20% ll UN agencies and international N Os Lastly, security constraints restrict the travel of WHO 0% are encountering signifcant delays clearing staff to many locations. The movement of WHO May June July August September October November December emergency supplies through Libyan ports. staff is subject to strict UN security arrangements
Satisfied Not Satisfied Experience has shown that the process (from and out of the hands of the Organization. Tripoli’s the time the goods arrive till the time they only operational airport (Mitiga) is frequently All complaints were recorded and followed up. For WHO is expanding the survey to cover additional clear customs) takes anywhere from two to four closed because of skirmishes and rocket fre in example, some patients expressed dissatisfaction municipalities. To avoid bias in reporting from the months. WHO incurs even longer delays because the area. The situation seems unlikely to change with the long distances they had to travel to reach EHTs, WHO’s feld coordinators will supervise the its medicines and medical supplies must undergo for the immediate future. In the meantime, WHO the nearest health care facilities; WHO responded administration of the questionnaires and collect regulatory clearance by the country’s Food and plans to reinforce remote management through by deploying mobile clinics to bring services patients’ feedback and complaints on a weekly Drug dministration. These delays greatly increase investing in tools to track goods and services closer to benefciaries. lso, an EHT member basis. WHO’s procurement costs since goods that remain delivered and recruiting third party monitors at was removed and replaced following repeated in customs incur signifcant demurrage and storage central and sub-national levels. complaints about her performance. fees. WHO is attempting to negotiate fast-track
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WHO’s main offce in Tripoli is supported by The political stalemate, armed hostilities and sub-offces in Benghazi and Sebha and national liquidity crisis appear likely to continue for the WHO’S emergency offcers in the three regions. Field LOOKING foreseeable future. The arms embargo has been coordinators across all districts of the country ineffective and the increased interference of PRESENCE IN conduct regular needs assessments, monitor the AHEAD foreign elements including armed groups from implementation of WHO’s activities and provide Chad, Sudan, Syria and Turkey poses a direct regular updates to the emergency coordinator in threat to the security and stability of Libya. The LIBYA Tripoli. WHO’s offce in Tunis, Tunisia serves as a need for humanitarian health assistance will backup base for additional staff and allows for the remain across the country, with further changes in possibility of remote management from there if political control likely to result in new population the security situation forces WHO to temporarily displacements and additional humanitarian needs, withdraw from Libya. placing a further strain on grossly inadequate health care facilities. Attacks on health care are likely to persist, further reducing patients’ access. Discrimination against some population groups may continue, with unintended consequences. For example, the inequitable treatment of migrants may lead to increased rates of life-threatening tuberculosis if those with untreated or undetected disease are released from detention centres into society at large.
Addressing urgent needs
In 2020, WHO’s response will focus on geographical to provide health care facilities with essential areas ranked 4 and 5 on the severity scale9. medicines, supplies and equipment to support On behalf of the health sector, it will work to their uninterrupted functioning. Mobile teams secure faster, more e ible approvals to deliver will supplement health care services in remote, medicines and supplies, support patient referrals rural and hard-to-reach areas and IDP settlements. and evacuations, conduct vaccination campaigns, Vulnerable groups including women and children, monitor health needs and assess the health people with mental disorders and physical response. Unimpeded access to all parts of Libya disabilities, and chronic disease patients will be will be essential. The Organization will continue prioritized.
9 The severity of needs in different geographic locations in Libya are classifed based on a scale from to . eople in areas ranked and are classifed as being in acute and immediate need of humanitarian assistance.
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Training Primary health care
Investing in the health workforce is an opportunity and under-served areas. Training activities will be In Libya, strengthening PHC and mental health patients in e er ency and con ict settin s to create decent employment opportunities, in decentralized to help ensure that the capacity of services are also priorities. WHO will support the The MSP will include emergency and trauma particular for women and youth. WHO will support health workers is built throughout the country. expansion of a comprehensive family practice care, the management of communicable and the MoH’s review of policies for the education, WHO will also explore how it can work with model, including mental health services in PHC noncommunicable diseases, maternal, neonatal employment, retention and performance of its community health structures to begin the long facilities. It will also support an interim, and and child health, mental health and psychosocial workforce and explore ways to ensure its more process of building health care capacity from the less comprehensive, minimum service package support, vaccination, disease surveillance and equitable distribution, especially in remote, rural bottom up while strengthening civil society. (MSP) designed to meet the acute needs of outbreak response.
Nursing workforce Mental health services Nurses devote their lives to caring for mothers nurses by 2030 because of the exodus of foreign and children; giving life-saving immunizations nurses and falling numbers of nurse trainees who Mental health services in Libya have been Aleppo and Damascus. The turning point came and health advice; looking after older people and could replace them. WHO will support the MoH’s traditionally under-funded and neglected, and when WHO convened a multi-stakeholder meeting generally meeting everyday health needs. They short- and medium-term strategies to increase the the reliance on conventional (institutionalized) to develop a plan to scale up mental health and are often the frst and only point of care in their number of nurses enrolled in training and provide models of care has resulted in limited service psychosocial support services. A key intervention communities. According to a study of medical and additional incentives for this critical component of coverage. Given that it will require many years to was the integration of mental health services in allied health education and training Institutions in the health workforce. establish nationwide, community-based mental PHC facilities. This was done by training general 10 Libya , the country will face an acute shortage of health ser ices ill foc s on fllin r ent physicians on how to manage patients with stress, gaps in the most affected areas. WHO has a long depression, psychosis, suicidal tendencies and history of successfully establishing mental health psychosomatic conditions, using WHO’s Mental services during crises. For example, in Syria, now Health Gap intervention guide. Mental health care in its ninth year of con ict ental health ser ices is now being offered in primary and secondary Summary of Production of Human Resources and Needs (2018-2030) are more widely available than ever before. health-care facilities in more than 10 Syrian cities (Based on maintaining the same exisiting ratios for each cadre) efore the yrian con ict e an the sit ation as in some of the most affected governorates in the comparable to that in Libya: mental health services country. WHO aims to replicate this experience in 25000 were available only in two psychiatric hospitals in Libya.
20,055 20000 16,731 15000 14,950 Disease surveillance 10000 7,800 7,319 WHO will work with local and national authorities
5000 to strengthen disease outbreak investigation and 3,541 response and increase the number of sentinel sites 1,484 1,014 reporting to the disease surveillance system. It will 0 strengthen efforts to improve screening for TB, Production Needed including in detention centres, and will continue to liaise between the NTP, UN agencies and international NGOs to coordinate and streamline health care services in the centres. 10 Published by the Libyan MoH in 2018.
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DONORS Accountability to benefciaries
WHO will also participate in the common feedback mechanism CF ) being introduced for IN 2019 humanitarian organizations in Libya. The CF will provide a toll-free, country-wide number that people can call to obtain information on humanitarian assistance programmes, submit feedback on services provided and obtain referrals to the humanitarian organizations best-suited to handle their requests and or complaints. Each request will be channelled to an organization best placed to respond. All participating organizations will be required to review and resolve all issues WHO thanks the following donors for their within an agreed time frame. The CF will allow support to its work in Libya in 2019. the humanitarian community to collect feedback from affected populations, better understand Donor Amount in US$ their needs and speedily resolve their problems. Federal Foreign Offce, Germany 2,054,795
Department for International Development (DFID), United Kingdom 1,094,891 Resource mobilization and advocacy Longer-term priorities United Nations Central Emergency Response Fund (CERF) 800,000 WHO will continue to appeal for short- and WHO will work with other partners to go beyond medium-term funding to prevent the further humanitarian relief and address structural issues Ministry of Foreign Affairs, Norway 653,951 disintegration of health care and other public that hinder national capacity to provide basic services, while at the same time advocating for social services. WHO will work with development Ministry of Foreign Affairs, Italy 568,182 the release of Libyan assets to restore the health agencies through the humanitarian-development system and fund critical health care needs. nexus to set joint outcomes - with realistic targets Ministry for Europe and Foreign Affairs (MEAE), France 448,934 and deadlines - that address urgent needs while building the foundation for strong public services 5,620,753 in support of Libya’s transition to a peaceful democracy.
34 35 ANNEX 1 MAIN ASSESSMENTS CONDUCTED AND TECHNICAL GUIDELINES AND REPORTS PUBLISHED IN 2019
Assessments conducted by WHO
Pilot assessment of patient safety in Libyan hospitals Assessment of Libyan Essential Medicines List 2019 Assessment of key essential indicators in public hospitals and PHC centres Assessment of national tuberculosis guidelines Assessment of national measles and rubella surveillance guidelines Assessment of national acute accid paralysis surveillance guidelines Assessment of Surveillance System for Attacks on Health Care Assessment of Early Warning Alert and Response Network
Guidelines and policies prepared and adopted by the MoH with technical support from WHO
National action plan to tackle antimicrobial resistance in Libya National measles guidelines pdated guidelines for the surveillance of acute accid paralysis National guidelines on the integrated management of neonatal and childhood illnesses Strategic plan for reproductive, maternal, newborn, child and adolescent health in Libya, 2019-2023
Reports published by the MoH with technical support from WHO
Mapping of private health facilities of Libya, 2019 Libyan cause of death report: analysis of cause of death data for 206-2017 Human resources for health observatory
36 World Health Organization LIBYA ANNUAL
WHO Country Offce (Tripoli, Libya) REPORT Elizabeth Hoff, WHO Representative [email protected] 2019
WHO Country Offce (Tripoli, Libya) Yahya Bouzo, Communications Offcer [email protected]
WHO Regional Offce for the Eastern Mediterranean (Cairo, Egypt) Inas Hamam, Communications Offcer [email protected]