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© / Handicap International - Libya
2016
RAPID ASSESSMENT OF HEALTH STRUCTURES IN
WESTERN LIBYA This assessment, funded by the Government of Switzerland’s Swiss Agency for Development and Cooperation was conducted between February - March 2016 in two rounds on thirteen selected health structures of Western Libya. It particularly focuses on health care and rehabilitation services for People with Disabilities (PwDs) and injuries (PwI), including mine/explosive remnants of war (ERW) and small arms and light weapons (SALW) victims, and underlines the necessity of implementing comprehensive Victim Assistance projects, combining support to health and rehabilitation structures, and direct support to PwDs in Libya.
© Giovanni Diffidenti/Handicap International
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Acknowledgment Handicap International is grateful to the constant support and advice received from the Libyan
Mine Action Centre (LibMAC) and the Ministry of Health to carry out this study.
Handicap International also wishes to thank the Swiss Agency for Development & Cooperation
(SDC) for their support throughout the project “Emergency Risk Awareness response to reduce the
direct threats from Conventional Weapons to communities in western Libya”, as well as all of the
respondents who provided valuable information during the course of the study.
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Acronyms
CCM Convention on Cluster Munitions CSO DPO
Civil Society Organisation Disabled Persons Organisation
DTM Displacement Tracking Matrix
ERW Explosive Remnants of War
HCT Humanitarian Country Team
HI Handicap International ICRC IDP IED
International Committee of the Red Cross Internally Displaced Person Improvised Explosive Device
IMC IMSMA
International Medical Corps Information Management System for Mine Action
INGO International Non-Governmental Organisation
IOM International Organisation for Migration
LibMAC Libyan Mine Action Centre
MHPSS Mental Health and Psychosocial Support
MSF Médecins sans Frontiers/ Doctors without Borders
MSNA Multi-sector Needs Assessment
NGO Non-Governmental Organisation
OPD Outpatient Department
P&0 Prosthetics and Orthotics
PwD People with Disabilities PwI PwK
People with Injuries People with Knowledge
RE Risk Education
SALW Small Arms and Light Weapons
SDC Swiss Agency for Development and Cooperation UN UNCRPD UXO
United Nations UN Convention on the Rights of People with Disabilities Unexploded Ordnance
VA Victim Assistance
WHO World Health Organisation
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Contents Executive Summary ..................................................................................................................................... 4
Background ................................................................................................................................................... 5
Limitations of the survey ............................................................................................................................ 7
The Health System in Libya ........................................................................................................................ 7
Health services from the user’s perspective ......................................................................................... 9
General availability and accessibility ................................................................................................. 9
Availability and accessibility for internally displaced persons ..................................................... 10
Availability and accessibility for refugees, migrants and asylum-seekers ................................... 11
Mental Health and Psychosocial Support ................................................................................................ 12
Health Care and the Rehabilitation System for People with Disabilities and Injuries ......................... 14
HI 2016 Health Structures Assessment ................................................................................................... 17
Basic profile of health facilities ............................................................................................................ 17
Catchment population ....................................................................................................................... 18
Ambulatory and Emergency Capacity ............................................................................................. 19
Services Availability and Accessibility ............................................................................................. 20
Referral System ................................................................................................................................. 23
Information on inpatients ..................................................................................................................... 24
General information .......................................................................................................................... 24
Inpatients with disabilities, injuries and MHPSS issues ................................................................. 25
Weapon and mine/ERW wounded patients .................................................................................... 25
Information on Human Resources ....................................................................................................... 28
General HR structures and HR needs .............................................................................................. 28
HR needs in rehabilitation and rehabilitation continuum ............................................................. 30
Infrastructure, equipment, materials & supplies ................................................................................ 32
Equipment needs in rehabilitation .................................................................................................. 32
Focus on 5 health facilities ................................................................................................................... 33
Al-Swani Rehabilitation Centre ........................................................................................................ 34
Accidents and Emergency Abusleem Hospital ................................................................................ 34
Gharyan Educational Hospital .......................................................................................................... 35
Tripoli Central Hospital .................................................................................................................... 35
Burns and Plastic Surgery Hospital ................................................................................................. 36
Conclusion and Recommendations ...................................................................................................... 36
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HI strategy of intervention and perspectives ...................................................................................... 38
Executive Summary The western region in Libya is one of the priority areas targeted for intervention under Handicap
International’s (HI) Risk Reduction strategy for 2015/2016 in the country. In this framework, HI
assessed the current capacity and needs of 13 selected health structures across 8 different
municipalities in Western Libya.
The assessment focused on:
Organisation of health and rehabilitation centres since mid-2014 to date;
Capacity and availability of the health infrastructures;
The situation with regards to human resources in the health and rehabilitation sector;
Access (physical distance, user fees etc.) to adequate preventive and curative health
services to address conflict-affected victims and persons with disabilities (PwDs);
The performance of health and rehabilitation services;
Availability and capacity of psychosocial and mental health services;
Availability and efficiency of referral mechanisms.
Since mid-2014, the health sector in Libya has been impacted by the ongoing conflict, in human
resources, equipment and availability of operational facilities. Access to health care is more difficult
to some of the most vulnerable, for security and cost reasons. The results of this assessment will
serve for further assistance to victims of the conflict and referral of conflict-related victims and
PwDs. On the other hand, the needs highlighted shall inform future HI interventions to support
health structures and rehabilitation centres in terms of technical expertise as well as human
resources, equipment and supplies.
The assessment findings stressed the need to support the rehabilitation sector in Libya, which was
already underdeveloped and inadequate in 20111. Since the beginning of the 2011 conflict and
especially since the events in 2014, this sector has been tremendously affected. Nowadays, 40
percent of the health system seems to not function, and the functional part of the health system
presents significant weaknesses:
o Lack of human resources due to the departure of qualified foreign health staff;
o Lack of capacities in para-medical field (Prosthetics & Orthotics (P&O) especially);
o Shortage of medicines and equipment;
o Obsolete and low-quality mobility devices;
o Increasing of needs due to the ongoing fighting, leading to an overloading of the services
already weakened and a decreasing of the quality of the services provided;
o Shortage of funds to support the health sector.
1 STEPS consulting Social for Handicap International : Rapport d’Evaluation “Prise en Charge des personnes en situation de handicap en Libye”, réalisée pour le compte de Handicap International Novembre 2011
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The Mental Health/Psychosocial Support (MHPSS) sector is underdeveloped, and not included in
the rehabilitation pathway of inpatients. Health structure staff require training and capacity-
building to provide PSS services and refer adequately inpatients. Only 1 health structure, Al Razi
Mental Health and Psychiatric Hospital serves as a referral structure for mental health disorders.
Background
Handicap International conducted a rapid assessment of health structures from February to March
2016 in 13 structures of Western Libya (public and private sector). Despite accessibility constraints
due to security issues, reliable data was collected from key personnel of health structures including
the heads of health facilities, Human Resource managers, social workers and statistical officers,
with a focus on the structure’s current capacity to address the needs of people with disabilities and
injuries, including mine, explosive remnants of war (ERW) and small arms and light weapons
(SALW) victims. The purpose of the assessment was to better understand the current capacity and
needs of health and rehabilitation services in order to inform further organisational programming,
and feed a future Victim Assistance (VA) strategy in the country that would reflect the needs of
conflict-affected communities.
Health structures were selected based on the specialised services they were offering, their current
inpatient flow, and their technical capacity to provide services to people with disabilities and
injuries, within HI’s areas of intervention. The methodology the assessment comprised of the
development of a rapid assessment tool, interviews with key health staff and surveyor’s
observations. The data collected was compared to other assessments made by HI in 2011 and by
other international agencies more recently, to ensure its coherence. A second round of assessment
was implemented in March 2016 in 4 health structures, in order to collect qualitative data on
rehabilitation (functional and psychosocial) through in-depth interviews. The surveyed structures
included:
Name Structure Type Management
Al-Swani Rehabilitation Centre Health Centre Ministry of Social Security
Gharyan Educational Hospital Central Hospital Ministry of Health
Al-Firdous Clinic Private clinic Private
Tripoli Eyes Hospital General Hospital Ministry of Health
National Cardiac Centre Central Hospital Ministry of Health Al-Razi Mental and Psychiatric Hospital Specialized Hospital Ministry of Health
Abusitta TB Centre Specialized Hospital Ministry of Health
Burns & Plastic Surgery Hospital Specialized Hospital Ministry of Health
Accidents & Emergency Abusleem Hospital General Hospital Ministry of Health
Tripoli Central Hospital General Hospital Ministry of Health
Al-Afia Clinic Private clinic Private
Al-Istiqlal Hospital (Al-Khadra) General Hospital Ministry of Health
Tripoli Medical Centre General Hospital Ministry of Health
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Tripoli Medical Centre
National Cardiac Centre
Abusitta TB Hospital
Al Afia Clinic
(private)
Al-Swani Rehabilitation Centre
Tripoli Eyes Hospital
Tripoli Central Hospital Burns and Plastic
Surgery Hospital
Al-Razi Mental and Psychiatric Hospital
Al Firdous
Clinic (private)
Accident & Emergency Abusleem Hospital
Al Istiqlal (Al Khadra) Hospital
Gharyan Educational Hospital
TRIPOLI
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Limitations of the survey
Security Context
The survey was implemented from February to March 2016, as HI’s team had to face increased
security issues due to active conflict and kidnappings in Tripoli and surrounding areas. This has
been especially challenging for the assessment conducted at Tripoli Medical Centre, which could
not be entirely completed at the end of March. The process for HI to obtain authorization from the
Libyan Ministry of Health took longer than expected, and the validation from Libyan authorities
was not communicated adequately to the health structures. HI staff had to visit health structures
several times before completing the survey and faced time constraints that did not allow
conducting more in-depth and qualitative interviews and on-site observations. Moreover, HI
intended to collect data on casualties resulting from the conflict registered as inpatients in the
health structures. Data collection on conflict victims is sensitive in Libya, as many armed groups are
willing to avoid a future transitional justice, and due collection of data and testimonies. Only a few
health structures could communicate their data to HI.
Availability of key health structure staff for interview
To conduct the assessment, HI staff had to meet the heads of the health facilities, Human Resource
managers and statistical officers. Despite the authorisation given by the Ministry of Health,
surveyors had difficulties in getting appointments and thoroughly completing their questionnaires,
due to key staff availability. Where the head of department was not available, HI staff had to
continue the interview with other medical staff that was able to provide information. The
questionnaire was developed in order to be as simple and rapid as possible, in order not to
inconvenience medical staff in their daily tasks. However, the change in key-informant might have
affected the accuracy and reliability of the data collected.
Availability and accuracy of data provided by health structures
Most of the health structures did not have an information management system in place to track
with accuracy the number of inpatients received in each department, their pathologies and cause of
registration, and the care received. Moreover, if a data collection system was in place in some
structures (Abu Saleem Hospital, Tripoli Central Hospital…), the data collection system was not
harmonized, and relevant data is measured in different ways by different health structures. This
might cause a lack of data and reliability of data in certain fields of the assessment.
The Health System in Libya
General overview
The United Nations and other humanitarian partners estimated in October 2015 that 3.08 million
people, almost half of the population (6.3 million), have been affected by the armed conflict in Libya
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and an estimated 435,000 people have been forcibly displaced from their homes and another 1.75
million non-displaced Libyans, most residing in urban centres, have been affected by the crisis.
There are an estimated 150,000 vulnerable migrants and approximately 100,000 vulnerable
refugees and asylum-seekers in Libya2. In February 2016, the second round of the Displacement
Tracking Matrix (DTM) identified 322.000 displaced people in Libya3.
Strengthening of Libya’s health care system is a priority sector for the international community, as
1.9 million people (including 0.7million IDPs) are in need of healthcare, representing 62% of those
affected by the conflict4. 40% of health facilities are currently not functioning and 80% of nursing
staff were evacuated in 2014. A lot of medical staff in general were foreigners and left the country
with the start of the 2014 conflict.
Western Libya, and particularly Tripoli, had historically a more equipped and efficient health
system, compared to the rest of the country. The health situation has deteriorated since 2014 in an
already weakened system seeing low investment in the sector and worsened by the multiple crises
over the last 5 years. The Primary Health Care network has been particularly affected in the main
cities of Tripoli and Benghazi.
Overcrowded services, obsolete equipment, insufficient qualified and available medical staff,
inadequate follow-up of patients and damaged infrastructures are all indicators that the Libyan
health care system is collapsing.
In general, health needs have increased in conflict-affected areas, while available health care was
shrinking, not being able to absorb the demand and grant access to its usual catchment population,
but also to new internally displaced persons (IDPs), refugees and migrants. The main health needs
faced by those populations, all over the country, are as follows, according to Libya Humanitarian
Needs Overview (September 2015) and the World Health Organisation (WHO) “priority health
concerns” (Feb 2016)5:
Severe shortage and uncontrolled resources in medical supply chain, including essential
medicines, surgical supplies and vaccines ;
Limited access to primary health care services, including mental, reproductive and child
health;
limited access to secondary health care services, such as hospitals, including emergency and
obstetric care;
Increased morbidity risk due to inefficient health care prevention, health promotion and
emergency response -
o increased mortality and morbidity of non-communicable diseases, due to
inadequate supply of medicines, poor diagnostic capacity, increase of IDPs and weak
primary health care;
2 HCT (2015a): Libya Humanitarian Need Overview, September 2015 3 Displacement Tracking Matrix round 3, IOM, March 2016 4 http://img.static.reliefweb.int/report/libya/2015-libya-humanitarian-needs-overview-september-2015-enar 5 Presentation for Health Working Group, “WHO priority Health Concerns” February 18th 2016
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o expected increase of transmission of communicable diseases, due to inadequate
surveillance system, poor diagnostic capacity and increase in population
displacement, including migrants.
Limited access to health care services due to non-functioning and/or overwhelmed health
facilities, and high concentration of health services in urban areas, preventing rural
populations from receiving proper health care;
Interrupted medical services and treatment to many, including vulnerable groups such as
women, children, patients with chronic disease, Cancer, Psychiatric disorders and HIV etc.;
Poor access to MHPSS services, due to insufficient trained and available human resources,
and increased needs in MHPSS due to distress caused by continuing conflict, changing and
uncertain social patterns, loss and trauma.
Public health risks are summarized in the heat matrix below, provided by WHO to the Health
Working Group on Libya6:
Very high High Moderate Low
Health services from the user’s perspective
General availability and accessibility
6 Presentation for Health Working Group, “WHO priority Health Concerns” February 18th 2016
Disruption of health supplies Overload of health services Trauma and injuries Maternal mortality Mental Health disorders Neonatal mortality Complications of Non Communicable diseases Acute respiratory infections Measles and Polio Severe acute malnutrition Chemical hazards
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The Libya Multi-Sector Needs Assessment (MSNA) reports (August 2015 and February 2016)7 state
that, “the availability of health services appears to be significantly affected across the
country”, reflected in the map above8. Also noticeable, “in the West, private facilities appear to
be faring much better than public facilities, with 88% of key informants reporting private facilities
as fully functioning. Despite a better overall availability of health services in the West than in the
other regions, less than 45% of key informants report public hospitals, primary healthcare centres
or mobile clinics to be fully functioning.”
Also according to the MSNA9, key informants report difficulties in accessing health services. The
main reasons in the West is that health facilities are overcrowded and forced to refuse new
patients, followed by a lack of adequate medical staff and significant distance to health facilities
from the place of residence.
“A significant majority, 83%, of key informants reported that people in their community paid for
consultations, treatment procedures and drugs during the previous month.”
Availability and accessibility for internally displaced persons
The Protection Assessment in Libya conducted by Handicap International and Save the Children10,
focusing on IDPs and host communities, stressed that “the majority of households, and especially
IDPs, are poorly informed about available assistance and support in their communities, and in
7 REACH Multi-Sector Needs Assessment Report August 2015 and February 2016 : http://www.reachresourcecentre.info/system/files/resource-documents/reach_lby_report_libya_multi_sector_needs_assessment_aug_2015.pdf;http://www.reach-initiative.org/libya-reach-multi-sector-needs-assessment-update 8 REACH Multi-Sector Needs Assessment Report August 2015, page 28 : http://www.reachresourcecentre.info/system/files/resource-documents/reach_lby_report_libya_multi_sector_needs_assessment_aug_2015.pdf 9 REACH Multi-Sector Needs Assessment Report August 2015, page 28 : http://www.reachresourcecentre.info/system/files/resource-documents/reach_lby_report_libya_multi_sector_needs_assessment_aug_2015.pdf 10 Protection Assessment in Libya, Handicap International and Save the Children, March 2016 -http://reliefweb.int/sites/reliefweb.int/files/resources/160322%20FINAL%20PAL%20Report.pdf
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particular how to access healthcare. Moreover, health was identified by households and key
informants as a priority need, among IDPs and resident populations:
For IDPs, shelter is a first priority need for IDPs, followed by access to health and food;
Non-displaced, resident populations identified health and food as their first priorities for
humanitarian assistance, followed by protection.
IDP and host communities are using an important part of their income to cover health expenses.
Reflecting the priority needs above, IDP households in Benghazi would allocate a higher proportion
to cover shelter needs such as cost for renting and housing, whereas households in Tripoli would
pay more to cover their health needs. The focus on health needs and expenditure on health in
Tripoli is linked to the fact that hospitals are both overcrowded with patients and have severely
reduced capacity, following the massive exodus of foreign health workers after 2011. In addition,
physical access to hospitals in conflict zones is restricted not only by the prevailing insecurity but
also by fuel shortages and poor communications11. In this assessment, Tripoli reports the highest
percentage of households with persons with disabilities and chronic illnesses, which further
underlines the importance of health. In urban Tripoli, a health facilities assessment conducted by
International Medical Corps (IMC) in 2015 reported that one primary care facility and two
secondary care facilities covering the needs of the city and the surroundings are not receiving any
support and have no partners supporting those facilities to overcome shortages12.
Availability and accessibility for refugees, migrants and asylum-seekers
For refugees and migrants, the accessibility to health services is even more difficult. There are an
estimated 250,000 vulnerable refugees, asylum-seekers and migrants in Libya, mostly
undocumented and who have limited or no legal rights. They are frequently denied access to basic
services, including healthcare, education and legal support as a result of their status. 44% of
refugees and 33% migrants surveyed in MSNA13 have limited or no access to health facilities. It is
generally found migrants and refugees/asylum-seekers have less access to protection and basic
services than IDPs, returnees or the host community.
11 HCT (2015a): Libya Humanitarian Need Overview, September 2015 12 IMC (2015): Libya Rapid Health Assessment, October 2015 13 MSNA, Reach, August 2015
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Mental Health and Psychosocial Support
The long-lasting instability
in Libya, punctuated by
severe outbursts of violence
since 2011, has left many
Libyans with psychological
distress and mental health
disorders. Uncertainty,
separation from family
members, forced
displacement, direct
targeting of civilians,
families and children, inter
and intra-community
rivalries, and the
perpetration of crimes left
unpunished until now are components of patterns of psychosocial distress and mental health
disorders that can vary in intensity, depending on the exposure to violence and each individual
coping capacity. The IASC14 pyramid shows a layered system of different mental health and
psychosocial activities and considerations, ranging from basic support needed by most of an
affected population, to very specialized mental health services that are needed only by a small
proportion of affected people. The different types of activities are complementary, and illustrate
that people are affected in different ways, and require different kinds of support, following an
emergency.
An assessment conducted in October 2014 by the Danish Institute Against Torture through 2,692
household interviews on the consequences of torture and organized violence in Libya15, shows the
consequences of the conflict on the mental and psychosocial wellbeing of Libyans: “The
consequences at the level of the population are massive: 29% of individuals report anxiety and 30%
report depression, while Post Trauma Stress Disorder symptoms were reported by 6%.” Violence
exposure to shooting, shelling, beating and sexual violence was measured during the assessment.
Half of the respondents reported witnessing beatings (49%) and shootings (51.3%), followed by
shelling (38.3%) during demonstrations. Only 7.3% reported having witnessed sexual abuse, but
one third of respondents reported hearing about it.
Through the 2015 SCELTA report, based on civil society organisations (CSOs) and key informant
interviews, Save the Children underlined “the prevailing health problems for children in Tripoli are
14 Inter-Agency Standing Committee (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. IASC: Geneva. 15 Consequences of torture and organized violence : a needs assessment in Libya, Danish Institute Against Torture, October 2014
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mostly psychological distress and anxiety. Signs of psychosocial distress are frequently observed at
all age groups, including stuttering and bed-wetting16.
According to general estimates of mental health problems following humanitarian emergencies, the
WHO estimates that most people will experience psychological distress reactions while the number
of people with common mental disorders may double from a baseline of 10% to about 20%. The
percentage of individuals with severe mental disorders is expected to increase from about 1% to
2%. Furthermore, people with pre-existing mental disorders especially the vulnerable during times
of conflict and instability as they may not be able to access needed care and medication, as shown in
the table below17.
The PSS needs are vast, and the capacity of the sector is very low, for three main reasons18 :
Libyan have a practice of not seeking support for psychological problems, and the few
trained psychologists and psychiatrists have very limited experience of treating trauma and
consequences of torture and war. A common form of help seeking behavior is meeting with
traditional healers or ‘Sheikhs’ or religious leaders.
Severe social stigma exists regarding those affected by mental illness. Mental illness is by
many considered a demonic possession and psychiatric symptoms are attributed to the act
of pagan symbols like the evil eye, magic, sorcery or “Jinns”. Both the Benghazi and Tripoli
Psychiatric Hospitals are known to be “frightening” places only for “crazy” people with
severe mental disorders19.
16 SCELTA final report Save the Children Report, June 2015 17 “Assessing mental health and psychosocial needs and resources, Toolkit for humanitarian settings” , p.18 http://apps.who.int/iris/bitstream/10665/76796/1/9789241548533_eng.pdf?ua=1 18 Consequences of torture and organized violence : a needs assessment in Libya, Danish Institute Against Torture, October 2014 and IMC MHPSS assessment report, November 2011 19 IMC MHPSS assessment, November 2011
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Persistent barriers to the provision of accessible and quality mental health services in Libya.
As detailed in IMC MHPSS report:
o Mental health in Libya has historically been underfunded and there is no official
allocation for MH funding in the health sector;
o Lack of knowledge of clinical skills or best practices across disciplines and including
directors of clinics;
o Short staffing hours;
o Many senior medical staff are not seeing patients, while younger staff bear most of
the burden of a heavy case load, and little experience (especially in the psychiatric
hospitals).
It is worth adding20:
o The absence of systematic diagnosis and referral of patients in need of psychosocial
support. Health care is mainly focused on the physical trauma;
o Over-medicalization of psychological distress, leading to prescription of drugs and
neglect of psychosocial support alternative;
o Only a few CSOs are active in the field of psychosocial support and do not have the
capacity to advocate efficiently for their cause, and provide support to more
beneficiaries.
Health Care and the Rehabilitation System for People with Disabilities
and Injuries
HI conducted an evaluation in November 2011 on medical and psychosocial support for People
with Disability in Libya21. Although the findings shall be updated with a new assessment, the
situation is likely to be worse now than in 2011, given the significant damages caused to the health
care system.
Regarding the legal framework in Libya, it is worth noting that Libya signed the UN Convention on
the Rights of People with Disabilities (UNCRPD) in May 2008, but never ratified it. The Law Number
5 (1987) protects the rights of people with disabilities, but was never applied, nor revised
according to the formulations and obligations of the UNCRPD. In 2011 the Constitutional
Declaration required the state to provide monetary and other types of social assistance, but did not
explicitly prohibit discrimination. In 2014, the government did not effectively enforce these
provisions due to administrative incapacity. Only a few public buildings were accessible to persons
with disabilities, resulting in restricted access to employment, education, and healthcare.22 The
person with disabilities resulting “liberation battle” are considered differently by Article 1 of Law 4
of 2013, and are supposed to receive more benefits than other people with disabilities. The non-
governmental organisation (NGO) Lawyers for Justice in Libya noted that the disparity “highlights
inequality in the treatment of people with disabilities as well as discriminating between them on
20 HI interviews conducted in February-March with local MHPSS actors 21 STEPS consulting Social for Handicap International : Rapport d’Evaluation “Prise en Charge des personnes en situation de handicap en Libye”, réalisée pour le compte de Handicap International Novembre 2011 22Landmine and cluster munitions monitor : http://the-monitor.org/en-gb/reports/2015/libya/casualties-and-victim-assistance.aspx
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the basis of political association”23, which is contrary to the UNCRPD and the Convention on Cluster
Munitions (CCM)24 non-discriminatory principles. The new draft of the Libyan Constitution,
released in April 2016, addresses the rights of people with disabilities in Article 69 “The State shall
be committed to guaranteeing the health, social, educational, economic, and political, sports and
entertainment rights of persons with disability on equal footing with others. The State shall
customize public and private facilities and surrounding environment that enable them to integrate
into society in a complete and effective manner. The State shall take the necessary measures to
activate the laws that guarantee that.”25 Disabled People Organizations (DPOs) in Libya are active,
and are demanding measures to improve the rights of equal treatment of people with disabilities.
Emergency and rehabilitation care for mine/ERW and SALW victims is lacunar, due to the
departure of most foreign medical professionals, lack of funding and lack of medical supplies. As
stated in the Landmine Monitor: “By 2013, there were three prosthetics and orthotics service
providers and two rehabilitation centres in the country. In 2013, the University of Misrata worked
to set up, within the compound of the University hospital, a small physical rehabilitation centre for
disabled people in the area, with the support of the ICRC. Other organizations limited some
activities or withdrew from the country26. Handicap International’s interviews with ICRC and IMC27
confirmed that the capacity in emergency trauma care and rehabilitation is limited, and only the
University of Misrata is now having prosthetics and orthotics services, with Human Resources yet
to be trained properly in receiving inpatients and more complex cases.
30,000 Libyans are thought to have been injured by the conflict over the last few years. This figure
is probably much higher, but the lack of reliable statistics is an obstacle to advocate at international
level to fund victim assistance programmes. There could be more than 900,000 people with
disabilities in Libya, and, among them, more than 90,000 people in need of functional rehabilitation,
and 30,000 in need of prosthetics and orthotics services. Each year, one third of those 30,000
people would need a renewal of prosthesis or orthosis28.
Despite the efforts of NGOs and INGOs such as IMC, MSF and ICRC to support primary health care
and hospital in Misrata, Benghazi and Tripoli and 1 rehabilitation centre with a Prosthetic and
Orthotic (P&O) service in Misrata (supported by ICRC), gaps are widening since HI’s last
assessment in 2011 for accessibility of people with disabilities and injuries to access basic and
specialized services such as:
23 Lawyers for Justice in Libya, “Civil society organisations welcome Libya’s UN human rights review and call on the State of Libya to accept and implement recommendations,” 19 May 2015 24 Convention on Cluster Munition, Article 5 ““Each State Party with respect to cluster munition victims in areas under its jurisdiction or control shall, in accordance with applicable international humanitarian and human rights law, adequately provide age- and gender-sensitive assistance, including medical care, rehabilitation and psychological support, as well as provide for their social and economic inclusion. Each State Party shall make every effort to collect reliable relevant data with respect to cluster munition victims.” 25 Constitution Drafting Assembly-Draft Libyan Constitution, non-official English translation (UNSMIL) released in May 2016. 26 http://the-monitor.org/en-gb/reports/2015/libya/casualties-and-victim-assistance.aspx 27 Interviews conducted in February 2016 by Handicap International Emergency Unit Roving Team 28 STEPS consulting Social for Handicap International : Rapport d’Evaluation “Prise en Charge des personnes en situation de handicap en Libye”, réalisée pour le compte de Handicap International Novembre 2011
16
Inpatient seek proper
healthcare in foreign countries
Demand for rehabilitation
and P&O services in low in
Libya
The need to establish specific
services is not seen as a priority
Few rehabilitation
and P&O services are
supported and created
Few available and efficient rehabilitation
and P&0 services
There is no rehabilitation system per se, integrating physical and psychosocial
rehabilitation, and including health structure department coordination, and coordination of
health structures for referral.
P&O: There is no local capacity, as there is no speciality available in medical schools in
Libya. The University of Misrata is the only P&O centre in capacity to provide Prosthetics
and Orthotics services.
Physical and functional rehabilitation is not sufficiently developed and is provided by a few
health structures only. The lack of physiotherapists is worth noting, as HI’s report in 2011
already pointed that the number of physiotherapist should be doubled to answer the needs
in Libya. Physiotherapists are often underpaid in public structures and some chose to work
in private clinics instead.
In general the health and rehabilitation system lacks key specialized and non-specialized
human resources: nurses, physiotherapists, occupational therapists, speech therapists and
psychologists, and specialized surgeons (orthopaedic, cardiac, neurological surgery). They
are, most of the time, the most underfunded departments. The follow-up of patients is
neglected.
Mobility aids and devices are most of the time obsolete, or not adapted to the patients,
causing pain, discomfort, sloughing, and posture problems.
On top of these difficulties to the sector, other elements (detailed above) can affect the situation of
people with disabilities and injuries in need of health support, and can cause a prejudice to
disability prevention and care:
Mental and psychosocial support: underdeveloped and lack of trained human resources.
Shortage of medicines, dressing and vaccines throughout Libya.
Lack of support of emergency medical services.
Dysfunction in health supply chain management.
As a result, the wealthiest Libyans are then
going abroad to receive proper health care,
especially rehabilitation 29 .This probably
encouraged the Libyan state not to develop
the rehabilitation and referral system earlier
on. With the increasing needs, it remains too
weak to deliver appropriate care and patient
follow-up in Libya, following the vicious circle
(right).
From a user’s perspective, the MSNA report
(2016), based on interviews conducted with
“People with Knowledge” (PwK) throughout
Libya, states that “the reported adequacy of
services for special needs among the majority
29 Patients are mainly referring to health structures in Tunisia, Egypt, Jordan, Qatar, Turkey, and Europe (Italy, Germany and France)
17
PwK suggests that they remain widely inadequate and are unable to cater for people affected by
disabilities. Services for people with difficulty walking were most commonly reported to be very
inadequate with 21% of PwK indicating this response. The figure below, from the MSNA report,
shows the perceived adequacy of services by type of disability.
% Respondents reporting the adequacy of services for people with special needs in their city/village, whole of Libya30
HI 2016 Health Structures Assessment
Basic profile of health facilities
Among the 13 health facilities surveyed, 11 (85%) were government owned, localized in urban area
of the capital Tripoli or other major municipalities of Western Libya, either general or central
health centres. The general and central health centres serve as the referral point for other clinics
and health centres for such services like essential surgical services (10 structures with surgery
capacity), and further medical care. Bed capacity of a general centre is above 350.
30 MSNA report, February 2016, page 44, Figure 36
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Very adequate
Adequate
Inadequate
Very inadequate
Don't know
18
Catchment population
Apart from Al Firdous private clinic (catchment of between 20,000 to 40,000 people), Al Aswani
Rehabilitation Centre (40,000 to 60,000 people) and Tripoli Eyes Hospital (60 000 to 80 000
people), who offer more specialized services, the catchment population of the health structure
surveyed is reaching up to 100,000 people. All structures declared that their catchment area was
the municipality where they are located. This map shows an important concentration of secondary
health care structures and specialized services in the Tripoli coastal belt, which is a major obstacle
to health care for patients living in other municipalities. The surveyor’s observations emphasized
the lack of availability of public transport to reach hospitals, leaving behind inpatients without their
own vehicles. Moreover, Al Alswani Rehabilitation Centre, in Warshefana, the only structure
offering comprehensive rehabilitation services, is 30 minutes away from Tripoli centre, and 71 km
from Gharyan (the main town in the Western Mountains). Its location can cause accessibility
problems for people with disabilities and mine/ERW victims.
Tripoli
>100,000 people
60,000 to 80,000 people
40,000 to 60,000 people
20,000 to 40,000 people
Gasr Ben
Gashir
Gharyan
19
Ambulatory and Emergency Capacity
The admission capacity for ambulatory services is varying a lot between structures. The health
system is thus polarised between major health structures offering a wide range of services, and
smaller, more specialized structures, or private structures (Al Firdous and Al Afia) who can offer
more personalized services and privacy to patients who can afford it.
The ambulatory capacity of certain structures, reaching above 1,000 beds for Tripoli Medical Centre
and Tripoli Central Hospital is not reflected in their emergency capacity. As an example, emergency
capacity of Tripoli Central Hospital is 55 patients who can be treated simultaneously, while Al
Istiqlal and Tripoli Medical Centre declared an emergency capacity of 200 inpatients, followed by
the Burns & Plastic Surgery Hospital (148 inpatients), the Eyes hospital (100 inpatients). The
Accidents and Emergency Hospital of Abusleem declared an emergency capacity of only 13
inpatients.
40 170 68 64 350
211 500
78 65
480 200
1400 1200
Ab
usitta TB
Ce
ntre
Accid
ents &
Eme
rgency
Ab
usleem
Ho
spital
Al-A
fia Clin
ic
Al-Fird
ou
s Clin
ic
Al-Istiq
lal Ho
spital (A
l-K
had
ra)
Al-R
azi Me
ntal an
d p
sycatricH
osp
ital
Al-Sw
ani R
ahab
Ce
ntre
Bu
rns &
Plastic Su
rgery
Ho
spital
Eyes H
osp
ital
Gh
eryan
Edu
cation
alH
osp
ital
Natio
nal C
ardiac C
en
tre
Tripo
li Ce
ntral H
osp
ital
Tripo
li Med
ical Cen
tre
Number of beds available per health structure
20
It is worth noting than in general and central health structures; the surveyors all noted the
overcrowded emergency services, and complaints of inpatients. Those facts confirm the
observations and findings of past assessments, and represent a serious concern: in case of a
deepening conflict scenario, characterized by violent attacks on civilians, the emergency capacity of
the main health structures of Western Libya is too limited to face massive inpatient influx, some of
them in severe trauma. Al Swani declared to have an emergency capacity of 20 to 25 patients, but
that the emergency department is not functioning any more. Al Swani is however an important
rehabilitation structure, with more than 500 beds available for inpatients.
The number of wards varies from 2 to 11 for most of the structures. It is worth noting that Tripoli
Medical Centre has only 8 wards, despite its important ambulatory capacity (1,200 beds). On the
other hand, Tripoli Central Hospital has 36 wards for an ambulatory capacity of 1,400 beds. The
Burns and Plastic Surgery Hospital has 13 wards whilst Tripoli Central Hospital has 36 wards.
Services Availability and Accessibility
All structures surveyed declared to have emergency surgery capacity, except Al Swani
Rehabilitation Centre, Al Razi Mental and Psychiatric hospital, Abusitta TB Centre.
The Health facilities provide different services; most of them currently provide emergency surgery
(non-life threatening) (92%), X-Ray/Imagery (92%), emergency surgery (85%) and Physiotherapy
(75%).
30 13 6 10
200
35 25
148
100
20 10
55
200
Ab
usitta TB
Ce
ntre
Accid
ents &
Eme
rgency A
bu
sleem…
Al-A
fia Clin
ic
Al-Fird
ou
s Clin
ic
Al-Istiq
lal Ho
spital (A
l-K
had
ra)
Al-R
azi Me
ntal an
dp
sycatric Ho
spital
Al-Sw
ani R
ahab
Ce
ntre
Bu
rns &
Plastic Su
rgery
Ho
spital
Eyes H
osp
ital
Gh
eryan
Edu
cation
alH
osp
ital
Natio
nal C
ardiac
Ce
ntre
Tripo
li Ce
ntral H
osp
ital
Tripo
li Med
ical Cen
tre
Emergency capacity of health structures (number of emergency inpatients who can be treated simultaneously)
21
On the other hand they lack of other services related to the needs of rehabilitation services
available to ERW/SALW survivors, and persons with disabilities, namely occupational therapy (8%)
and Psychosocial/Mental support (23%).
During the survey, 75% of health facilities reported a lack of essential medicines in the past 30
days.
The structures declared that physical accessibility is generally easy, with only 2 structures, Al Razi
Mental Health and Psychiatric Hospital and Al Swani Rehabilitation Centre declaring that there
were obstacles to physical accessibility of their structures. For the same reason, Al Swani
Rehabilitation Centre declared that accessibility for female inpatients was currently hindered due
to the security situation in Warshefana. The security situation and unsafe roads generate unequal
access to rehabilitation services for women with disabilities and injuries. Al Swani and Al Afia Clinic
(near Tripoli’s Airport Road) declared they were in unsafe areas. Most of the health structures
seemed to have been impacted by the level of insecurity in their area, and have put in place safety
measures (guards at the entrance, police patrols and fences), Al Istiqlal and Tripoli Medical Centre
are even fully fenced, with security teams watching and filtering the entrance.
22
All health facilities declared they were financially accessible to all population, except Al Afia and Al
Firdous private clinics. In public structures, services are provided to the local population as well as
foreigners. But whilst locals just need to show identification, for foreigners a small fee is requested.
In the light of the MSNA report, access seems to be more difficult for migrants and refugees, who
cannot pay the fee they are requested. In the light of the Protection assessment conducted by HI
and Save the Children, IDPs have also difficulties in accessing healthcare, due to the lack of public or
individual transport, but also due to the shortage of medicines in the health structures. IDPs and
host community members interviewed reported that they would spend more on health for their
families, since the medicines provided usually for free in hospitals are not any more available, they
are compelled to buy them in pharmacies.
Name of Health structure
Name of closest referral capacity structure
Distance to referral structure
Are vehicles or other means of transport available for referrals?
Al-Swani Rahab Centre
- A&E Abusleem Hospital 30 km Yes
Gheryan Educational Hospital
- Sbe'a (Ali Omar Askar) Hospital,
- Tripoli Medical Centre - A&E Abusleem
85 km Yes
Al-Firdous Clinic - Al-Istiqlal - Tripoli Medical Centre - A&E Abusleem Hospital
15 km Yes
Eyes Hospital - Tripoli Medical Centre 10 km Yes
National Cardiac Centre
- Tripoli Medical Centre - Tripoli Central Hospital
20 km Yes
Al-Razi Mental and Psychiatric Hospital
- Tripoli Medical Centre 15 km Yes
Abusitta TB Centre
No
Burns & Plastic Surgery Hospital
- Tripoli Central Hospital 0.1 km Yes
Accidents & Emergency Abusleem Hospital
- Al-Istiqlal Hospital 0.5 km Yes
Tripoli Central Hospital
- A&E Abusleem Hospital 2 km Yes
Al-Afia Clinic - Sbe’a Ali Omar Askar hospital, - A&E Abusleem Hospital - Tripoli Central Hospital
15 km Yes
Al-Istiqlal Hospital (Al-Khadra)
- Tripoli Medical Centre 5 km Yes
Tripoli Medical Centre
- Al-Istiqlal - A&E Abusleem Hospital
5-6 km Yes
23
Referral System
A referral system seems to be in place, and depends on the pathologies of each patient. Most
frequent referrals are directed to Tripoli Medical Centre and Tripoli Central Hospital and Al Istiqlal
Hospital, probably due to their wide range of services and equipment, but also due to their
admission capacity (1,200 to 1,400 beds). The Accident and Emergency at Abusleem Hospital, being
more specialized in traumatology, is also used as a referral structure by 5 of the structures
surveyed. All structures have ambulances or vehicle allowing them to refer patients to other
structures, except Abusitta TB Centre.
It is worth noting that Gharyan Educational Hospital is located at more than 1h30 distance from any
referral structure, which can pose a serious problem for emergency referrals, moreover when the
security situation is critical. In the first 3 months of 2016, the main road from Tripoli to Gharyan
was unsafe and closed for security reasons.
For people with injuries, a surgery and physical rehabilitation pathway seems to emerge from the
findings of the survey, although no hospital declared to have any formal referral system in place for
people with injuries or disabilities.
Security conditions did not allow the HI team to continue data collection with Tripoli Medical
Centre for the following questions, as access roads were blocked.
PWI coming
from all over
Libya
PWI coming
from Tripoli &
surroundings
PWI coming
from the W.
Mountains
Abusleem Hospital
Tripoli Central
Hospital Gharyan Education
Hospital
Tripoli Medical
Centre Al
Istiqlal
Outpatient rehabilitation services (OPD) for physiotherapy, P&O, PSS, occupational
therapy etc.
Al Swani Rehabilitation
Centre
Exit (no follow-
up)
Foreign health
structures
Private Clinics
Burns
and
Plastic
24
Information on inpatients
General information
Due to the lack of a harmonized statistical system shared by health structures, and the absence of
systematic data collection on inpatient flow and pathologies, HI recommends to analyze the
following data carefully. As an example, only 3 public hospitals (Eye Hospital, National Cardiac
Centre and Al Istiqlal hospital) were able to share data for year 2014 and 2015. For monthly
inpatient admissions, Al Istiqlal and Gharyan Educational Hospital were unable to provide the
necessary information. Also worth noting, some figures of daily admissions seem not to be in
accordance (too high or too low) with the ambulatory and emergency capacity declared by each
health structure. This can be due to the fact that inpatients are registered in the system at different
steps of their pathway, depending on the structure they are in. The hypothesis that health
structures are not used to their full capacity is denied during much of the survey.
The only records available for year 2014-2015 show an increase in patient admission (+200),
except for National Centre, which shows a difference of 750 admitted inpatients between 2014 and
2015. This would require more in-depth interviews with the structures and a cross-check of
statistics with the data available from the Ministry of Health to draw and confirm a realistic
hypothesis. The increase is surprising, as 2014 was one of the peak years for civilian casualties
since 2011, but this fact does not reflect in a decrease of admission in 2015.
200
880
89
180
514
4800 3000
1200
1500
210 Number of inpatients per month
Al-Swani Rahab Centre
Al-Firdous Clinic
Eyes Hospital
National Cardiac Centre
Al-Razi Mental and psycatricHospitalBurns & Plastic Surgery Hospital
Accidents & Emergency AbusleemHospitalTripoli Central Hospital
Al-Afia Clinic
25
Inpatients with disabilities, injuries and MHPSS issues
The lack of detailed data on inpatients (type of pathologies, number of patients admitted per type of
pathology) is hindering the ability to have a clear picture about inpatients with disabilities, injuries
or psychosocial distress.
However, 75% of the structures (except Al Firdous Clinic, Abusitta TB Centre and Abusleem)
declared to provide health care to inpatients suffering from Chronic Diseases.
50% of the structures surveyed declared that “there is evidence of psychological stress” among
their inpatients.
More than two thirds of the structures declared that they had patients currently following a
treatment for war-related impairment, 80% being for mobility/physical impairment, except for Al
Razi Mental and Psychiatric Hospital, who are specialized in dealing with mental impairment and
psychological distress. Al Swani Rehabilitation Centre is currently treating 350 patients with war-
related impairment, and 100 inpatients for non-war related impairment. Not enough reliable data
was provided to the surveyors in order to evaluate the ratio between non-war related impairments
and war related impairments across the structures.
Regarding war-related injuries, and the cause of injuries, some health structures were able to
provide data on the number of weapon-wounded and mine/ERW wounded patients admitted.
Weapon and mine/ERW wounded patients
The Burns and Plastic Surgery Hospital reported 3 mine/ERW injured patients, and A&E Abusleem
hospital reported 931 mine/ERW injured inpatients, a total of 934 mine/ERW patients for the year
2015 in two structures alone. Other hospitals did not have reliable data on the cause of injuries of
their patients.
1240 1950
23081
1070 2700
21990
Eyes Hospital NationalCardiacCentre
Al-IstiqlalHospital (Al-
Khadra)
Number ofinpatients in 2015
number of inpatientsin 2014
26
Most cases of mine/ERW injuries seem to be referred to A&E Abusleem Hospital, as this structure is
specialized in traumatology.
Other interesting data is the number of other weapon-wounded31 inpatients admitted in health
structures, much higher than the number of reported mine/ERW casualties. 5 health structures
have kept records of weapon-wounded inpatients and declared a total of 1895 weapon-injured
inpatients:
Al-Swani Rehabilitation Centre 44
Gharyan Educational Hospital 88
Al-Firdous Clinic no data
Eyes Hospital no data
National Cardiac Centre no data
Al-Razi Mental and Psychiatric Hospital no data
Abusitta TB Centre no data
Burns & Plastic Surgery Hospital no data
Accidents & Emergency Abusleem Hospital 1000
Tripoli Central Hospital 600
Al-Afia Clinic 163
Al-Istiqlal Hospital (Al-Khadra) no data
The limited data provided by the health structures is points to the lack of a comprehensive data
collection system in Libya on mine/ERW and SALW casualties. The Information Management
System for Mine Action (IMSMA) for mine/ERW victims, managed by the LibMAC, has recorded
only 5 victims for the year 2015 and Action on Armed Violence’s report on “monitoring explosive
violence”32 is noting that they were 734 casualties of explosive violence in 2015 for the whole
country.
When focusing on major structures, the number of mine/ERW and SALW casualties is representing
10% of the total number of inpatients admitted in Abusleem Hospital, and 6% of the number of
surgical operations performed in Tripoli Central Hospital.
However, as many health structures do not have records on the cause of injuries, one can assume
that the number of casualties from explosive devices and SALW is much higher.
31 The definition of weapon-wounded by hospital is unclear – it could mean SALW or an improvised explosive device (IED), or in some cases could refer to mines/ERW. 32 Action on Armed violence report on “Unacceptable Harm : Monitoring explosive violence 2015”, April 2016
27
The data given by health structures can be analyzed in the light of the 2016 MSNA report33, and the
result of interviews conducted with selected PwK. The MSNA report states that “When asked to
report of injuries and deaths resulting from landmines/unexploded ordnance (UXO) and SALW, the
majority of PwK cited incidents linked to small arms with a small proportion indicating injuries and
deaths caused by landmines/UXO. The reported incidence of injuries and deaths resulting from
SALW was particularly acute in the South and West of the country according to PwK. The table
below from the MSNA report show the percentage of respondents reporting victims of
injuries/death by landmines/UXO and SALW in their city, by demographic group, across the whole
of Libya.
33 MSNA, Reach, February 2016
931, 5% 1000, 5%
17751, 90%
Accidents & Emergency Abusleem Hospital Casualties/Total number of inpatients admitted
Number of mine injuries /Explosive Remnants of War (ERW)admitted
Number of weapon-woundedpatients admitted
Number of other medicalinpatients admitted
600, 6%
10289, 94%
Tripoli Central Hospital Number of weapon wounded patients/number
of surgical operations performed
Number of weapon-wounded patientsadmitted
Number of surgicaloperations performed
28
Reported incidence of death/injury
Child female (under 18)
Child male (under 18)
Adult female (18+)
Adult male (18+)
Injuries by landmines/UXO 46% 70% 28% 74%
Deaths by landmines/UXO 40% 56% 27% 77%
Injuries by small arms 42% 45% 40% 94%
Deaths by small arms 32% 42% 38% 96%
In the West, the PwK reported an incidence of death and injuries from landmines/UXO of
respectively 15% and 10% and an incidence of death and injuries from SALW of 53% and 63%
respectively.
The number of casualties from mines/ERW and SALW is probably much higher than most of the
figures reported by the Libyan authorities. This shows the urgent need of data collection in order to
advocate effectively for mine/ERW and SALW victims, and develop Risk Education, Victim
Assistance and demining activities. HI has trained 12 Hospital Focal Points in collecting data on
mine/ERW victims through IMSMA forms and reporting to LibMAC, in order to ensure that the
Libyan Mine Action Centre will be able to collect relevant and reliable data in the future, from the
health structures themselves.
Information on Human Resources
General HR structures and HR needs
The information provided by health structures is complete, except for Tripoli Central Hospital who
was not able to provide details about medical staffing.
The graph below shows the lack of specialist doctors and surgeons, which was also highlighted
during the interviews with the surveyors. Also worth noting is the absence of psychologists and
psychiatrists in all health structures, except Al Razi Mental Health Hospital (21 psychiatrists). The
National Cardiac Centre, specialized in cardiac surgery, declared to have only 9 surgeons for 177
Generalist doctors, as Abusleem Hospital declared 38 surgeons and Al Istiqlal 30 surgeons. On the
other hand, Al Afia and Al Firdous private clinics declared to have respectively 17 and 90 surgeons,
despite the smaller number of inpatients they receive per month. This gap has to be investigated
further, as it suggest that specialized human resources are probably insufficient to cater the needs
of inpatients in the public sector, while the private sector offers better work conditions and
positions to surgeons. The hypothesis should be cross-checked with the Libyan Ministry of Health,
but is probable, given that the Libyan health sector is underfunded, and public medical staff was
reported to have low wages and faced delays in salary payments due to the crisis.
29
19%
5%
6%
46%
5%
0% 7%
9% 3%
Human Resources available
Generalist Doctors
Specialists Doctors
Physical/OcupationalTherapists
Nurses
Surgeons
Psychologist /Psychiatrist
Social workers
Lab technicians
Generalist
Doctors
Specialists
Doctors
Physical/O
cupational
Therapists
Nurses Surgeons
Psycholo
gist
/Psychiat
rist
Social
workers
Lab
technicia
ns
Others Total
Al-Swani Rahab Centre 20 3 150 200 0 0 300 30 0 703
Gheryan Educational Hospital 20 10 70 5 20 60 185
Al-Firdous Clinic 10 220 90 30 0 350
Eyes Hospital 90 33 0 103 60 6 32 0 324
National Cardiac Centre 177 35 0 278 9 0 0 115 0 614
Al-Razi Mental and psycatric Hospital 21 7 16 161 0 21 16 5 2 249
Abusitta TB Centre 52 0 0 31 0 0 2 20 0 105
Burns & Plastic Surgery Hospital 0 64 0 285 0 0 1 45 0 395
A& E Abusleem Hospital 264 42 41 482 38 0 3 54 0 924
Tripoli Central Hospital no data no data no data no data no data no data 15 no data no data 15
Al-Afia Clinic 25 37 0 134 17 0 0 25 0 238
Al-Istiqlal Hospital (Al-Khadra) 301 52 104 402 30 0 3 62 73 1027
Total 980 283 311 2366 249 21 346 438 135 5129
Name of Health structure
Nb of Medical Staff available
30
Al-Swani Rahab Centre 497
Gheryan Educational Hospital 170
Al-Firdous Clinic 120
Eyes Hospital 149
National Cardiac Centre 480
Al-Razi Mental and psycatric Hospital 15
Abusitta TB Centre no data provided
Burns & Plastic Surgery Hospital 218
Accidents & Emergency Abusleem Hospital 310
Tripoli Central Hospital no data provided
Al-Afia Clinic 136
Al-Istiqlal Hospital (Al-Khadra) 201
Total 2296
Name of Health structure Nb of Admin staff
Regarding administrative staff, the global ratio of administrative staff compared to the total human
resources of the health structures is 30%, reaching more than 47% for Gharyan Educational
Hospital, 43% for National Cardiac Centre, 41% for Al Swani Rehabilitation Centre and 35% for the
Burns and Plastic Surgery Hospital. Only Al Istiqlal and Abusleem hospital are showing a more
realistic ratio of respectively 16% and 25%.
Most of the structures declared that their human resources are in sufficient quantity. Only 3
structures declared that the number of existing medical personnel was not suiting the needs.
Gharyan Educational Hospital and Al Istiqlal Hospital underline the important need to hire qualified
medical personnel and key medical human resources:
Al Afia Clinic specified that it needed 30 “foreign nurses”, highlighting the low level of qualification
of Libyan nurses who are often hired without proper medical education. Al Razi highlighted the lack
of specialists in the Mental Health and Psychiatric sector.
All structures pointed at the need of capacity-building of their existing human resources, except Al
Firdous private clinic. The priority needs in capacity-building are “nursing”, emphasizing again the
lack of qualified nurses in public structures, training and qualification of specialist and general
doctors, and improvement of administrative work. Al Swani Rehabilitation Centre indicated that
training on autism and speech therapy was a priority.
HR needs in rehabilitation and rehabilitation continuum
Generalist
Doctors
Specialists
Doctors
Physical/O
cupational
Therapists
Nurses SurgeonsPsychologist
/Psychiatrist
Social
workers
Lab
technicia
ns
Others
Gheryan Educational Hospital 150 50 200 10 2 10 3
Al-Afia Clinic 30 3
Al-Istiqlal Hospital (Al-Khadra) 100 10 250 300 5 3 1 20 30
Name of Health structure
How many additional staff is required for each position to suit your needs?
31
The surveyed health structures were asked if they had needs in capacity building for rehabilitation
and rehabilitation continuum, and asked to rank priorities from 1 (high priority) to 5 (low priority).
All health structure declared to have needs in HR rehabilitation capacity-building, ranked in the
heat-chart below:
The main high priority needs of the health structures, ranked 1, 2 and 3 are:
Psychosocial support and Physiotherapy
Social work and Rehabilitation for HIV/Aids care
Rehabilitation for chronic diseases and orthosis
For rehabilitation continuum, psychological first aid has been rated as a top priority by 7 different
health structures and Orthopedics by 3 health structures.
Name of Health structureProsthesi
s
Physioth
erapyOrthesis
Occupati
onal
therapy
Social
work
Psychoso
cial
support
Rehabilitat
ion for Non
Communic
able
diseases
Rehabilit
ation for
HIV/Aids
care
Speech
Therapy
Al-Swani Rahab Centre 1 1 4 3 3 1 5 5 1
Gheryan Educational Hospital 5 5 5 5 5 5 5 5 5
Al-Firdous Clinic 5 1 5 5 5 1 5 5 5
Eyes Hospital 5 5 5 5 5 5 5 5 5
National Cardiac Centre 5 5 5 5 5 5 5 5 5
Al-Razi Mental Hospital 5 5 5 5 1 1 5 1 5
Abusitta TB Centre 5 5 5 5 1 1 1 1 5
Burns & Plastic Surgery Hospital 5 1 2 2 2 2 1 1 5
A & E Abusleem Hospital 5 5 5 5 5 5 5 5 5
Tripoli Central Hospital 2 1 5 5 1 1 2 3 5
Al-Afia Clinic 5 3 3 5 3 2 2 2 5
Al-Istiqlal Hospital (Al-Khadra) 1 5 5 5 5 5 5 5 5
Do you have capacity-building needs in rehabilitation?
Name of Health structure OrthopedicPsychological
first aid
Sign
Language Al-Swani Rahab Centre 5 1 1
Gheryan Educational Hospital 5 5 5
Al-Firdous Clinic 1 5 5
Eyes Hospital 5 5 5
National Cardiac Centre 5 1 5
Al-Razi Mental Hospital 5 1 1
Abusitta TB Centre 5 5 5
Burns & Plastic Surgery Hospital 5 1 2
A & E Abusleem Hospital 5 5 5
Tripoli Central Hospital 1 1 5
Al-Afia Clinic 5 1 5
Al-Istiqlal Hospital (Al-Khadra) 1 1 5
Do you have capacity-building needs in
rehabilitation continuum?
32
Infrastructure, equipment, materials & supplies
All of the facilities surveyed depended on the national grid for electricity and 10 (75%) had access
to back up generators. All of them had a safe source of water supply. However, there existed a
shortage of electricity and water supply, adversely affecting their routine functioning, especially in
the public facilities. Many public health facilities (75%) reported more stock-out of essential
medicines, pharmaceuticals and consumable in the past 30 days. They are all dependent on the
Ministry of Health for the provision of medical supplies, except Al Aswani Rehabilitation Centre
(Ministry of Social Security) and Al Afia private clinic. The National Cardiac Centre also reported
shortages in heart medication, and Al Razi Mental and Psychiatric hospital a need in
pharmaceuticals, beds and clothing.
5 structures reported needs in re-construction and building maintenance, and 4 structures
reported needs in fixing water, sewage and electricity systems.
Other needs highlighted by health structures are presented in the heat-chart below, priority needs
are visibly Ambulances, access to electricity and water, and improvement of the sterilization
system:
This reported lack of access to electricity, water, and need to improve sterilization can be a
contributor to the nosocomial infection rate within the surveyed health structures, which is
believed to be already high in Libya34.
Equipment needs in rehabilitation
34 Nosocomial Infections in a Surgical Department, Tripoli Central Hospital, Tripoli, Libya, 2013 : Ibnosina Journal of Medicine and Biomedical Sciences http://journals.sfu.ca/ijmbs/index.php/ijmbs/article/viewFile/336/745
Name of Health structure AmbulanceAccess to
water
Access to
electricity
Cold chain
(refrigerator)
Sterilization
(surgical
instruments
and
materials)
Al-Swani Rahab Centre 5 5 2 5 5
Gheryan Educational Hospital 1 1 3 1 3
Al-Firdous Clinic 5 5 5 5 5
Eyes Hospital 1 5 5 5 5
National Cardiac Centre 5 5 2 5 1
Al-Razi Mental and psycatric Hospital 5 5 5 5 3
Abusitta TB Centre 2 4 1 1 1
Burns & Plastic Surgery Hospital 1 4 4 4 2
Accidents & Emergency Abusleem Hospital 1 2 1 5 5
Tripoli Central Hospital 5 3 3 3 3
Al-Afia Clinic 5 5 5 5 2
Al-Istiqlal Hospital (Al-Khadra) 5 5 5 5 5
33
Equipment needs in rehabilitation are a priority for 5 structures (out of 12), most of them ranking physiotherapy/occupational therapy equipment as a top priority need. Other needs were highlighted, such as heart surgery equipment (National Cardiac Centre) and Chemo-therapy equipment (Al Istiqlal).
The top priorities in supply needs for rehabilitation/disability prevention were: wheelchairs, other mobility devices, physiotherapy and occupational therapy equipment.
Focus on 5 health facilities
Regarding the referral pathway and the results of a first round of the health facilities assessment, HI
decided to focus on 5 facilities to collect more information, and possible partnership in the future,
to support those health facilities in rehabilitation and victim assistance.
The criteria proposed to select the 5 health facilities were:
Services free of charge;
Orthopedic machinesPhysiotherapy/
occupational therapy equipment
Al-Swani Rahab Centre 5 5
Gheryan Educational Hospital 1 3
Al-Firdous Clinic 5 5
Eyes Hospital 5 5
National Cardiac Centre 5 5
Al-Razi Mental and psycatric Hospital 5 1
Abusitta TB Centre 5 5
Burns & Plastic Surgery Hospital 2 1
Accidents & Emergency Abusleem Hospital 5 5
Tripoli Central Hospital 1 1
Al-Afia Clinic 1 3
Al-Istiqlal Hospital (Al-Khadra) 5 5
Equipment needs in rehabilitation/
disability prevention Name of Health structure
Name of Health structure
Supplies needs in rehabilitation/disability prevention (PwDs, War Victims and conflict affected people)
1: Top priority
Wheelchairs Crutches
Other
mobility
devices
OrthesisProsthesi
s
Orthopedic
consummables
Orthopedic
tools
Physiothera
py
equipment
Occupation
al therapy
equipment
Other
rehabilitatio
n
equipment
Beds
Al-Swani Rahab Centre 5 5 1 5 5 5 5 5 5 5 1
Gheryan Educational Hospital 1 1 1 5 5 2 1 3 5 5 5
Al-Firdous Clinic 5 5 5 5 5 5 5 5 5 5 5
Eyes Hospital 5 5 5 5 1 5 5 5 5 5 5
National Cardiac Centre 1 5 1 5 5 5 5 1 5 5 5
Al-Razi Mental Hospital 5 5 5 5 5 5 5 5 1 5 5
Abusitta TB Centre 1 5 5 5 5 5 5 5 5 5 5
Burns & Plastic Surgery Hospital 1 1 1 2 5 5 5 1 5 5 5
A & E Abusleem Hospital 5 5 5 5 1 1 1 1 1 5 5
Tripoli Central Hospital 1 5 1 3 1 3 3 3 3 3 5
Al-Afia Clinic 4 4 2 3 5 1 1 4 2 5 5
Name of Health structure
34
Facilities currently providing rehabilitation services and having active rehabilitation
staff (physiotherapists) and rehabilitation-related staff (nurses);
Facilities having an OPD ward to ensure follow-up of inpatients;
Facilities implied in the referral pathway of PwI in western Libya regularly receiving
PwI;
Facilities expressing needs of material and/or training.
Al-Swani Rehabilitation Centre
Al Swani is the only dedicated rehabilitation center in Libya. Located in Warshefana, it seems to
function but presents issues of accessibility for security reasons, especially for women. They had a
specialized rehabilitation school, but it is not functioning anymore. According to the results of the
first round of the assessment, they should have rehabilitation equipment and assistive devices but
they are lacking and training is required in emergency rehabilitation and MHPSS. Al Swani key staff
said the rehabilitation centre was under its full capacity, and receives approximately 200 war-
related patients per month. For MHPSS cases, they usually refer to Al Razi Mental and Psychiatric
Hospital, and for cases that require surgery to A&E Abusleem Hospital. They have an ambulance to
refer cases. For physical and functional rehabilitation, its maximum capacity for simultaneous
treatment of inpatients is 86 inpatients per day. Physical and functional rehabilitation consists of:
Manual treatment: massage
Thermal treatment: infrared rays and ultrasound rays
Electrical treatment: electrical vibration
Positive and negative treatments
Some medicine treatment
For people in need of Prosthesis and Orthosis, Al Swani refers to Abusleem Hospital and
outside of Libya.
Al Swani key staff underlined that “not enough space is used, although there are a lot of free spaces
that can be used for housing and other treatment purposes, in addition to some other treatment
equipment and machines”. Ideally, Al Swani should be supported with P&0 equipment and training,
but also in MHPSS, as it is the only centre of its kind in Western Libya that could offer
comprehensive rehabilitation services for PwI and PwD.
Accidents and Emergency Abusleem Hospital
Abusleem Hospital has an excellent reputation for treating complicated multi-fracture/poly-trauma
cases. PwI are referred from the whole Libya. They have an emergency ward, a rehabilitation ward
and an OPD ward, including a diabetic clinic. Abusleem seem to be a structure of referral for P&O,
and expressed important supply needs to continue its rehabilitation activities: high priority needs
are orthopedic consumables, prosthesis, orthopedic tools, physiotherapy and occupational therapy
equipment. Abusleem Hospital expressed no need in rehabilitation training and seems to have
already qualified staff. The hospital is already supported by ICRC and WHO with the provision of
emergency medical kits. The hospital is safe, and accessible for all, and all services provided by the
35
hospital are completely free or charge. But currently due to the lack of supplies/medications the
patients are forced to do some blood tests outside, buy medication outside, x-ray/CT outside, etc.
Abusleem has also a statistics department and collects and computerizes data daily on inpatients.
ICRC’s in depth assessment of Abusleem Hospital35 states that the building in general is in good
condition, but that the hospital is suffering from weak electricity, water leakages and lack of water
in certain departments. Moreover “bathroom sanitation is terrible, very poor, patients complain
about not being able to shower due to the terrible condition of the bathrooms”. Also from ICRC’s
report “Approximately 250 patients in total are seen every day. The number is reduced due to the
patients knowing that public hospitals have a huge lack of supplies. Note, on the day of ICRC’s
assessment up to 11:00am, 21 cases were seen at ortho OPD, 5 patients at the general surgery OPD
and 20 patients at the plastic OPD.” Abusleem said to have received 155 war-related cases in
February 2016. It does not have MHPSS services and usually refers cases to Al Razi Mental and
Psychiatric Hospital. It also stated that “Abusleem has artificial limbs, but the department is closed
because of the lack of resources”.
Abusleem Hospital should be supported to receive PwI and PwD with equipment and supplies for
rehabilitation, allowing continuing qualitative rehabilitation, and be provided with artificial limbs
to reopen its department, as it is the only structure which provides such services in Tripoli area.
Gharyan Educational Hospital
PwI and PwD are referred from the Western Mountains area to Gharyan Educational Hospital. It has
a rehabilitation ward and an OPD ward. According to the data collected through the study, they
would need some rehabilitation equipment and assistive devices, but would not need any training
in emergency rehabilitation and MHPSS. Gharyan Education Hospital said to have most of its wards
overloaded, particularly the Obstetrics and Gynecology Department. The hospital stated to have
received 10 war-related inpatients in February 2016. It also said that “the number of patients in
need of MHPSS has increased in the last 6 months, due to (a) wide spread of weapons and artillery.”
Also it does not have a MHPSS capacity, Gharyan Educational Hospital refers MHPSS cases to Al Razi
Mental and Psychiatric Hospital (15 patients were referred in February 2016), which is
approximately 80 kms north, covering their transportation costs. They have limited capacity in
rehabilitation, but said that the needs in functional and physical rehabilitation of inpatients have
increased in the last 6 months. Gharyan Hospital was supported in 2011-2012 by IMC, and is
currently receiving no external support. Its main needs are staffing, medicines and medical
equipment, infrastructural rehabilitation and support for medical waste management system.36
As a health structure of reference in the Western Mountains, Gharyan Educational Hospital should
be supported with trained staff, and rehabilitation equipment and supplies. In the absence of
support, Gharyan Educational Hospital will continue to refer cases to structures in Tripoli (Sbe'a
(Ali Omar Askar) Hospital, Tripoli Medical Centre, A&E Abusleem) which are already overloaded.
Tripoli Central Hospital
35 ICRC « Abu Sleem Hospital in depth assessment, », January 2016 36 IMC Rapid Health Assessment
36
Tripoli Central Hospital is one of the biggest hospitals of Northern Africa in terms of size. People are
referred there from all over Libya. It is supported by the WHO with the provision of emergency
medical kits. It has a rehabilitation ward and an OPD ward, its ambulatory capacity is significant
and a lot of structures are referring inpatients to Tripoli Central Hospital, due to the wide range of
services it offers. Tripoli Central Hospital key staff expressed important needs in staff training in
physiotherapy, prosthesis, social work, psychosocial support and rehabilitation for non-
communicable diseases. High priority needs for rehabilitation equipment in supplies are:
orthopedic machines, physiotherapy/occupational therapy equipment, wheelchairs and other
mobility devices and prosthesis. Tripoli Central Hospital also emphasized the need of building
maintenance and essential medicines. Due to the security conditions, HI could not conduct an in-
depth assessment in the hospital to gather more precise information on its rehabilitation capacity.
However, as a major structure of referral for cases of PwI from all Libya, this structure should be
considered for support, given its HR, emergency and ambulatory capacity.
Burns and Plastic Surgery Hospital
The Burns and Plastic Surgery Hospital has a rehabilitation ward and OPD ward where patients are
followed-up. Key hospital staff said that the hospital was “under its full capacity” and could
welcome more inpatients. The hospital is offering small-scale psychosocial support services “with
help of psychiatric doctors” but received only 3 patients in the month of February 2016 for PSS.
Only 1 staff from the psychosocial ward has received proper training, and the hospital expressed
high priority needs in psychological first aid capacity-building, as the key-staff interviewed
commented that “the number of patients in need of MHPSS has increased in the last 6 months”.
Functional and rehabilitation needs have also increased during the last 6 months, and the Burns
and Plastic Surgery Hospital said to have received 450 patients during the month of February 2016.
They provide infra-red beam, red beams and electrical therapy, as well as a massage room, hand
exercises and physiotherapy exercises. When asked, the key staff of the hospital declared an
unavailability of equipment (physiotherapy/occupational therapy) and supplies (wheelchairs,
crutches and mobility devices mainly), that the department was too small and lacked qualified staff
(physiotherapy, rehabilitation for non-communicable diseases and psychosocial first aid being top
priorities).
The Burns and Plastic Surgery Hospital is the only health structure that provides rehabilitation and
psychosocial support, but not to its full capacity. This structure could be supported through training
and provision of rehabilitation equipment and supplies in order to unload other structures such as
Abusleem hospital.
Conclusion and Recommendations
Public health facilities are delivering services with the constraints of financial, technical and
managerial capacities. The findings of HI’s study reinforce the need to improve the building blocks
of the health care system (e.g. availability of staff, medicines and equipment), but also to invest in
the rehabilitation system that is underdeveloped in Libya, not being able to address the needs of
people with injuries and people with disabilities. The health system is underfunded and unable to
face the demand. Some structures need infrastructure rehabilitation, and support to electricity and
37
water provision and waste and sewage management. The provision of equipment, medicines,
financial and logistical support and infrastructure rehabilitation shall prevent the health system to
deteriorate further; the lack of specialised and trained staff, particularly in rehabilitation should be
addressed; health structures should also be supported in information management, in coordination
with the Ministry of Health, to ensure that the data collected on inpatients allows to better monitor
the health care system, implement prevention programmes and advocate efficiently to fund
increased funding; and community health actors should be empowered to inform and orient
community members, particularly among IDPs, refugees and migrants; engaging NGO and private
health facilities to provide health services. Regarding the rehabilitation system, emergency and
long-term measures should be triggered, in addition to the general recommendations above:
On infrastructure rehabilitation, and investment in quality rehabilitation materials and
equipment
o Rehabilitation of infrastructures, particularly OPD wards and rehabilitation wards;
o Better use of existing materials and equipment, by connecting medical staff training to
available equipment in the infrastructures;
o Replace existing and obsolete rehabilitation equipment that can be used by existing medical
staff;
o Reactivate P&O services in existing structures;
o Ensure provision of affordable quality prosthesis, orthosis and mobility devices by widening
the competency between providers;
o Develop disability and injury prevention campaigns on non-communicable diseases,
mine/ERW and SALW Risk Education, road safety and security;
o Develop an injury surveillance system at community and health structure level.
On training and qualification of rehabilitation professionals
o Develop complementary training to general doctors and nurses on physical and functional
rehabilitation and MHPSS;
o Develop a training continuum for medical staff, through national and regional workshops;
o Develop quality training of paramedical staff, specially nurses, physiotherapists,
occupational therapists and speech therapists;
o Develop the MHPSS sector within major health structures, first through Psychological First
Aid Training;
o Training of orthotic and prosthetic technicians at a regional level;
o Develop partnerships with training centres for MHPSS, P&O, physiotherapy, speech therapy
and occupational therapy.
On structure’s management
o Develop a more harmonized and rigorous information management system shared by all
public sector structures on inpatient pathway, services and structure activity and centralize
data at national level (Ministry of Health);
o Support to health structures in HR, administration, finance and stock management;
o Formalize referral system between structures to distribute cases adequately, avoid
overload/underload of health structures and ensure patients follow-up;
At political level
o Redistribution of rehabilitation and health services in the country more harmoniously and
decentralize the health and rehabilitation system;
38
o Invest in the health and rehabilitation system at structure and university level;
o Develop physical accessibility of services through inclusive public transport and inclusive
health structures;
o Develop regional exchange between Libya and
neighbouring countries to exchange on practices and
policies for people with disabilities and injuries;
o Ratify the Convention on Rights of People with
Disabilities, signed in 2008.
HI strategy of intervention and perspectives
Based on the outcomes of this health assessment, HI
developed a strategy of intervention to improve access to
services of the most vulnerable people affected by the
crisis by developing a twin track approach:
- At community level: provision of direct physical and
functional rehabilitation and MHPSS services and/or
orientation toward existing services of the vulnerable
persons with physical, functional limitations, psychosocial
or mental disabilities themselves in order to address their
specific needs and so enhance their own
capacities/abilities.
- At services/centre level: support to existing services in
order to reinforce the response to the needs of the
vulnerable persons with physical, functional limitations,
psychosocial or mental disabilities.
The flow chart above summarizes HI strategy of
intervention regarding the health sector. Upon funding,
the strategy shall be implemented in close coordination
with the Libyan Ministry of Health, and other major health
and rehabilitation actors operating in Libya (WHO, ICRC,
IMC, MSF).
Handicap International
June 2016
