Libya crisis

August 2011 update

Health situation in Libya Injuries The conflict that started last February has According to official statistics, more than 11 000 substantially changed the country’s health status people in central and western Libya had been and system. In addition to noncommunicable wounded as of 1 June. Since the beginning of the diseases, that have traditionally been the main uprising, hospitals have been overwhelmed by cause of morbidity and mortality, war-related the number of casualties. These are concentrated traumas now dominate the health panorama, in Misrata, along the Ajdabia-Brega road, especially in urban areas. Elzawia, in the Nafusa mountains and in and The closure of primary health care centres around Tripoli. Even if the conflict abates from (because of damage caused by fighting, acute time to time, around 65 people per day are still shortages of funds, medicines and supplies or being wounded in Misrata. More than 630 people lack of health workers) compels people to seek have been killed and around 6000 wounded in health care in overburdened hospitals. Disrupted Misrata since 17 February. Although no immunization and disease prevention systematic data collection system is in place to programmes combined with weak disease back these numbers, the figures appear to be surveillance and outbreak control systems have credible. greatly increased the risk of communicable For comparison purposes, 17 790 cases of disease outbreaks. influenza and 14 747 cases of diarrhoea were 1 Replenishing stocks of essential medicines and reported in 2010 , which means that for the first medical supplies is the main health priority for half of 2011 injuries statistically exceed either of Libya. So far, the health system has managed to these priority diseases. prevent disease outbreaks and to maintain a high level of immunization. However, these achievements are at risk if shortages of staff, supplies and funds continue. 1GPCHE :Annual Statistical and Health Report, MOH/HIS, 2010

1 Death due to injuries is either immediate, within Chronic diseases several hours (usually due to lack of staff and supplies to treat non-fatal wounds) or within a The main causes of death reported by national few days (due to complications such as infections authorities in 2010 were cardiovascular diseases or multi-organ failure). For survivors, physical (37%), cancer (13%), and diabetes (5%). Road injuries can be accompanied by mental trauma traffic injuries accounted for 11% of all deaths. and permanent disabilities that place an As a result of drug shortages, supply cuts and the additional burden on society and infrastructures. urgent needs of wounded patients, the provision Despite the excellent work of nongovernmental of cancer treatment and kidney dialysis were organizations (NGOs) in Misrata, the gaps in severely cut back. There is no data on the number mental health services are still enormous. of deaths brought about by lack of access to essential obstetric and ante/postnatal care and to Communicable diseases treatment for chronic diseases, but more information can be uncovered through surveys Official statistics show that communicable and by putting health information systems in diseases were not a major problem in Libya place. before the conflict, since water and sanitation systems are good and vaccination coverage is near-universal. However, this could change if no Limited access to essential life- prevention and control system is put in place. saving services Apart from tuberculosis, both HIV and hepatitis Before the conflict, the population had reasonable C could become a major problem because of access to the country’s extensive health care deteriorating practices in terms of blood safety, network. However, the health care system’s injection and treatment in health care services, gradual deterioration in recent years has been and of the increased incidence of rape and exacerbated by the conflict. gender-based violence as a result of the breakdown in the social fabric. Shrinking health system In times of crisis, many communicable disease According to a Ministry of Health report, there outbreaks are caused by common, easily were 10 230 doctors (17/10 000 population) in preventable and treatable diseases such as acute February 2009, of which 84% were nationals. watery diarrhoea, dysentery and measles. These Libya had 96 hospitals (20 289 beds), 25 diseases can become major killers if malnutrition specialized units (5970 beds), 1355 basic health is added to the picture. centres, 37 policlinics and 17 quarantine units. 2 The 15 diseases most reported in 2010 were Anecdotal information reports that the primary influenza (17 790 cases), diarrhoea (14 747), health care system had begun deteriorating prior hepatitis B (2437), amoebic dysentery (1600), to the conflict, with hospitals gradually taking hepatitis C (1437), chicken pox (1236), mumps over the provision of primary health care (1027), food poisoning (904), leishmaniasis services. This is attributed to major health care (893), typhoid and paratyphoid fevers (829), rehabilitation projects that were started but never pulmonary TB (792), extra/pulmonary completed, mismanagement, negligence and tuberculosis (730), amoebiasis (725), Malta fever Libyans’ preference for going directly to (387) and H1N1 flu (304). Leishmaniasis is hospitals. However, one of the striking endemic in the western mountains and along the phenomena of the Libyan conflict is the dramatic north/west coast, with Nalut as the epicentre, shrinkage/collapse of the primary health care with 331 reported cases. health system in some areas. This was confirmed Cyclical (almost once a decade) outbreaks of in three WHO assessment missions to eastern plague are reported from Tobruk. The last Libya in May-June. outbreak (diagnosed in Benghazi) was in 2009. No cases of polio, neonatal tetanus, cholera and Health workforce yellow fever were reported. There were 26 According to reports, out of a total workforce of malaria cases, all from patients infected abroad. 113 000, around 20 000 expatriate health care There were 321 new cases of HIV, bringing the workers, many of them nurses, are thought to total number to 10 475 cases since 1989. have left the health care system. Many of them have been replaced by medical student 2Annual statistical and health report, MOH/HIS, 2010 volunteers.

2 Since many in the country’s extensive network of since people have only sporadic access to primary health care centres have shut down, preventive or curative health care. At the peak of many patients are obliged to travel long distances the crisis in Misrata, between March and May, to reach a hospital. around 100 000 persons fled the city and went to the coast, where many remained for two months.

At the same time, health care services were Fuel shortages disrupted for those who remained in the city. Because of the country’s size , the health system depends on fuel to run its transport system. However, at end of July, the Al Zawia Refinery Shortages of essential drugs, supplies near Tripoli was producing only 5% of the and consumables country’s fuel needs. All four of the other Before the conflict, the Ministry of Health spent refineries were not functioning. Eventually, Al approximately US$ 500-700 million on imported Zawia refinery will be unable to produce even drugs and supplies for the public sector. Around 30% that limited amount, since no crude oil is being of the drugs went to Benghazi, while Tripoli supplied pumped from the oil fields in the south. In the the rest of the country. east, Brega has also ceased production. Since the start of the crisis, supply lines have Benghazi depends on fuel imported by sea and on been cut between Libya and European suppliers the ability to make direct payment to the oil and, within Libya, between Tripoli and the east. tankers in its port. Libya’s man-made river which Around 40% of the last national tender was pumps underground water from the south to the frozen at the supplier stage. This did not north is also heavily dependent on fuel: more immediately affect health care facilities, which than 5 million litres per day are needed to pump were able to draw upon strategic stockpiles with drinking water to Benghazi. suppliers, at the central warehouse and at peripheral warehouses in Tripoli, Benghazi, Assessments showed that fuel shortages were a Sabha and Misrata.3 Tripoli was the least major factor limiting patients’ access to hospitals. affected, as it was able to utilize stockpiles in They also lead to increased absenteeism among both the central and Tripoli warehouses. health workers, who are unable to get to work. (Although no data has been provided, the inter- The international community’s inability to agency mission noticed long queues for fuel in provide Libya’s National Transitional Council in many areas of west Libya.) Lastly, it limits Benghazi with resources means the Council has Libyans’ possibilities of going abroad. no money to procure drugs and supplies, pay the salaries of health staff, or cover the running costs Shortages are hampering medical evacuation by of health care services for almost 30% of Libya’s land or air. In 2010, the Ministry of Health population. The National Transitional Council ambulance services handled 8225 referrals within have appealed to humanitarian agencies for help districts, 5378 referrals outside districts, and 575 with procuring supplies.4 aerial ambulance evacuations using nine planes. It also evacuated 2246 road traffic victims using Supplies are procured nationally and 602 ambulances. internationally. The Government of Libya is the only importer of 10 specific items including Population movements insulin, vaccines, chemotherapy and immunosuppressant drugs, psychotropics, UNHCR estimates that 732 000 people have left dialysis drugs, HIV drugs, hypnotics, laboratory Libya due to the conflict, including over 100 000 consumables and blood products. All other items Libyans. In addition, UNHCR estimates that are imported through local tendering with there are around 218 000 internally displaced companies representing multinational companies people (IDPs) inside Libya, including around 69 outside the country. 000 in opposition-controlled areas, 49 000 in and around Tripoli and 100 000 in the Nafusa With the interruption of this pipeline, some Mountains. These estimates have not been items, especially vaccines, laboratory confirmed and are subject to change due to consumables and HIV drugs, have been in short frequent population movements. supply. In Tripoli, vaccination activities were Many IDPs and refugees are moving back and 3 forth in areas that fluctuate between conflict and Six-month stockpiles with suppliers and in all peace. These uncoordinated population warehouses. 4 Note for the record of the May-June Health Cluster movements are a major public health challenge, Coordinator’s meeting in Benghazi.

3 stopped for over six weeks because of shortages. The donors were Australia (2 267 500), Norway A measles outbreak in Sabha in early June was (1 400 000), USAID/OFDA (1 000 000), DFID attributed to this gap. (652 258), the CERF (400 000) and Islamic Relief-USA (250 000). The depletion of the central warehouse is indicative of the ongoing crisis in the hospitals This funding support is enabling WHO to and to a lesser extent in primary health care provide support for the activities described facilities. The table below was updated during the below. inter-agency assessment mission 16-23 July.

These categories of drugs are imported and 1. Support the management of war-related distributed solely by the MoH through injuries, mental health and disabilities international tendering: In Misrata, WHO is supporting the treatment of

Expected shortages of drugs and supplies war injuries through the deployment of Arab by category Medical Union medical teams to the Al Hekma Hospital. The teams consist of four doctors on Item Stocks Stock out constant rotation to support trauma and Insulin - Early September emergency care for as long as the crisis persists. Vaccines - August Specialists include anaesthesiologists and Hypnotics Some are out Early September cardiovascular, trauma, neuro- and orthopaedic HIV drugs Out of stock Out of stock surgeons. Dialysis - Mid August Blood products Partially not Early September The departure of many of the expatriate medical available staff, especially nurses, left a gap in health care Chemotherapy - Early September provision. This gap has been largely filled by drugs Immuno- Only 40% Early September medical student volunteers. To respond to the suppressants available large numbers of casualties, WHO supported Psychiatric Only 30% Early September trainings in: drugs available Lab Out of stock Out of Stock • basic life support; consumables • first-aid and mass casualty management

for ambulance workers, first responders, Listed below are priorities of the Health Cluster. emergency room personnel and medical students; • Support the management of war-related injuries, mental health and disabilities; • advanced training on life support for ambulance and emergency room • Sustain equitable access to doctors; and, immunization, and services for non- communicable diseases, reproductive • personal safety training for health health and child care at all levels of the workers during mass casualty system including emergency management events. reproductive health services; Through a partnership with the Arab Scout • Provide drugs and medical supplies; Organization, WHO is establishing a community- level entry point that supports community • Detect and promptly respond to mobilization for first responders’ training courses communicable disease outbreaks; on first aid and patient transportation skills. • Provide coordination, health Regarding supplies, WHO has sent 45 surgical information and assessments. and trauma kits, with drugs and supplies to treat 4500 people.

WHO field operations 2. Sustain equitable access to immunization, and services for non-communicable In the Flash Appeal launched on 5 March 2011, diseases, reproductive health and child WHO had appealed for US$ 12.1 million to care at all levels of the system respond to the health aspects of the crisis, of which 51% had been funded as of 11 August. Besides procuring drugs and medical supplies, WHO is supporting the rehabilitation of damaged

4 hospitals and other health care centres such as the WHO conducted an assessment of the disease Misrata polyclinic through the provision of surveillance system within the country starting in laboratory supplies and equipment the east. The system, which was already (spectrophotometers, autosamplers, distillation ineffectual prior to the conflict, was further units, protein digesters, scrubber units, gas weakened by the fighting. chromatographs, counting chambers, etc.). An expert in communicable disease surveillance and early warning is currently working with 3. Provide drugs and medical supplies health authorities from the National Transitional Council to upgrade the disease surveillance At the onset of the conflict, WHO set up a system. Logistics Supply System (LSS) to improve the management of incoming medical donations. It was first set up at the Egyptian border and later 5. Provide coordination, health information moved to the Medical Supply Organization in and assessments Benghazi. Volunteers were trained to use this As Health Cluster lead, WHO established hubs in system in Benghazi, Selloum, Tobruk, Mesaeed, Benghazi and along the Egyptian (hub now Misrata and Ajdabia. The LSS combines closed) and Tunisian borders with additional procedures, human resources, equipment and support staff in its Regional Office in Cairo. In telecommunication to better monitor stocks, Tunisia, the hubs in Zarzis and Tataouine are shortages and expiry dates. used to backup UNHCR’s refugee health system, So far, WHO has provided approximately US$ to conduct missions to the Nafusa Mountains and 1.4 million worth of drugs and supplies to health establish a technical presence there. From these facilities within Libya and for Libyan refugees in hubs, WHO carries out assessments, manages Tunisia. The supplies include insulin, information, provides technical assistance to chemotherapy and dialysis drugs, HIV drugs, health authorities and disseminates guidelines to antivenom for snakes and scorpions as well as ensure interventions meet national and vaccines (tetanus, measles, pentavalent, OPV, international standards. BCG, Hep.B, MMR, DPT). In addition, So far, WHO has carried out three assessment emergency health kits were sent with enough missions to Misrata, three to Tripoli, two to drugs, laboratory supplies and equipment to Ajdabia and two to the Nafusa Mountains. A cover the needs of 155 000 people for three mission to Benghazi and the east is ongoing. months. Various missions were also organized to provide Around 60% of these supplies were sent to technical assistance for hospital biomedical National Transitional Council areas, where 40% support (such as waste management), essential of the population is living and almost half of the drugs, the Logistics Supply System (LSS), health care delivery network is located. disease surveillance and early warning and outbreak response. Combined with the appropriate training and coordination, these supplies contribute to reduce morbidity and mortality caused by injuries and to expand access to essential life-saving services Update on the procurement such as obstetric care, child health, vaccination, of essential supplies on and treatment for chronic diseases or HIV. behalf of the Libyan WHO is upgrading the Central Medical Store in Government Benghazi to ensure that goods are properly stored In response to the growing health crisis in Libya, and that receipt, inventory and dispatch are done the United Nations Sanctions Committee has speedily and efficiently. Forklifts and hand lifters approved the release of €100 million, from the as well as strapping and wrapping machines and Central Bank of Libya to WHO to ensure the shelving will be procured to facilitate provision of essential medicines, vaccines and transportation of goods and ensure that they are medical supplies for the whole of the country. properly stored and protected. While awaiting the receipt of these funds from

the Bank which is handling the transfer, a list of 4. Detect and promptly respond to priority items has been developed by WHO in communicable disease outbreaks collaboration with national authorities including the Ministry of Health in Tripoli and the

5 Transitional National Council health authorities • Use all available transport options to in Benghazi. It is expected that the first tranche distribute medical supplies to different of supplies will cover 8 weeks of consumption. areas within Libya. According to suppliers, there will be a three- • With local health authorities, conduct month lead time for many of the items included regular joint inspections of health care in this list despite advance work done by WHO facilities to monitor the availability and to prepare for this operation. use of the drugs and medical supplies. With the initial €100 million funding, WHO will • Work closely with Health Cluster undertake the following activities: partners to determine and respond to • Procure essential medicines and medical further medical supplies and transport supplies as listed by the Libyan needs. authorities and validated by WHO. An internal and external audit is planned after • Work closely with current health each phase of the project. The existing WHO authorities in Libya to draw up drug team of experts is already being supplemented to distribution plans and put systems in review and rationalize the procurement process. place to ensure that all medicines and WHO has prepared a Concept of Operation to medical supplies are received, stored, guide the practical aspects of the procurement inventoried and distributed according to and distribution. One of the main challenges will needs. be to ensure that the medical supplies are reaching the population in need, particularly • Establish an operational hub (in Malta considering the current fuel crisis. and/or Brindisi), where WHO will work closely with WFP to optimize available WHO will continue to assess the situation and logistic capacity. work with partners to provide support to the Libyan health sector.

For more information

Libya Dr Samir Ben Yahmed, Head of WHO Country Office [email protected]

WHO Regional Office for the Eastern Mediterranean Dr Naeema Algaseer, Assistant Regional Director [email protected] WHO Headquarters Ms Elizabeth Hoff, Director a.i. SPR/PEC [email protected] http://www.who.int/disasters

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