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Supporting healthcare in Libya: Mission impossible?

Collective efforts to curb the spread of COVID-19 continue amid ongoing conflicts

Doctors and operators of the national COVID-19 hotline being coached in communication skills and in dealing with difficult calls

Libya is facing enormous challenges, ranging from brutal fighting to attacks on hospitals. Close to 400,000 Libyans have been displaced since the start of the conflict– around half of them within the past year. And now there is also the COVID-19 pandemic. In a double emergency, how can German Cooperation and the EU assist effectively?

With the turmoil that has prevailed in the North African country since 2011, Libya’s healthcare system was already fragile when the coronavirus reached and crossed its borders. The everyday struggles of ordinary Libyans and their health care workers are enormous: Many parts of the country are ravaged by fighting, armed groups are seizing medical supplies and rockets regularly strike hospital facilities. The COVID-19 pandemic is now adding to this burden.

To mitigate its effects, Libya’s Ministry of Health and the World Health Organisation (WHO) developed a national COVID-19 preparedness and response plan. On March 14, the Prime Minster declared a state of emergency and Libya closed its borders. The country´s first COVID-19 case was officially confirmed on March 24. Since then, the number of confirmed cases has steadily risen.  By May 14, Libya had 64 confirmed cases and 5 COVID-19 related deaths, out of a total of 3483 performed tests. Given the country´s low testing capacity, it can be assumed that the actual number of cases is much higher. 

Jointly funded by the EU and Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), the GIZ Libya programme is supporting Libya’s efforts to curb the spread of the pandemic.

Mounting a pandemic response in a health system marked by years of conflict

When Libya’s first case of COVID-19 was identified, only three hospitals in the country had the capacity to treat patients with severe symptoms. In April, one of them was hit by a rocket attack that destroyed infrastructure and equipment and wounded six healthcare workers. In May, another strike on a hospital in Benghazi left at least 14 people injured and damaged the intensive care equipment that is vital for COVID-19 patients.

Manuela Peters, one of the project leaders of the GIZ Libya Programme, states that it is challenging to respond to a public health emergency in a country marked by years of conflict. But it is possible to mitigate the impact of the pandemic collectively. ‘Thanks to the excellent working relationships with our Libyan partner ministries and the mayors of our partner municipalities we have supported them in mounting a first response to COVID-19’, she explains.

When seeking healthcare becomes a risky business

Non-governmental organisations such as the International Medical Corps assist the GIZ programme in its efforts. According to Talal Burnaz, Deputy Programme Director at the International Medical Corps Libya, supporting access to primary healthcare for the Libyan population has been challenging even before the pandemic started. Outside of the capital, many local clinics lack medical supplies. People have to travel longer distances to find the treatment they need - a risky business. ‘You can be stopped at a checkpoint by an armed group, in some places you could be hijacked or kidnapped,’ Burnaz explains. Attempts by the Ministry of Health to provide healthcare locally are under threat: ‘They are trying to deliver drugs and equipment to remote municipalities, but too often armed gangs simply confiscate them. Recently this has been getting worse,’ he adds.

Assessing what Libyan partners need for their COVID-19 response

To support the Libyan COVID-19 Preparedness and Response Plan as effectively as possible, GIZ initially conducted a rapid needs assessment in its sixteen partner municipalities, interviewing mayors, health representatives and hospital managers in person or over the phone. ‘The interviews helped us to get a picture of our partners’ capacities in dealing with the pandemic’ explains Peters.

‘It quickly became clear in which areas our support was needed most,’ she adds. The newly formed Municipality Emergency COVID-19 Coordination Committees needed capacity building in risk communication and municipal outbreak management. Health facilities needed support in caring for COVID-19 patients while continuing to provide essential health services. The general population needed answers to their numerous questions about the virus. And personal protective equipment was needed everywhere. 

Together with their partner municipalities, the GIZ projects proceeded to design and implement immediate response measures. What did this entail?

Providing training through a series of webinars

Dr. Alia Shiboub provides a webinar-based orientation training on COVID-19

As a first step, GIZ supported Libya’s National Center for Disease Control (NCDC) in organising three webinar-based trainings as part of NCDC’s ‘Back to Zero’ campaign. All 16 Municipal Coordination Committees took part in these webinars. The 175 participants learned which steps they have to take to track and reduce COVID-19 transmission. 

Dr. Alia Shiboub, Head of Education and Counselling and Psychosocial Support in the National AIDS Programme at the NCDC, and her team facilitated the webinars. According to her, ‘Organising the webinars was a challenge because of the frequent power outages and the poor quality of the internet in most cities. Still, we managed to reach most of them by repeating the training several times’. Asked about the webinar’s core purpose, Dr Shiboub replies: ‘The most effective way to stop the spread of any infectious disease is to make sure that people know how it is transmitted. This is the same for COVID-19.’ In her view, the webinars must continue: ‘Many Municipality Coordination Committees, volunteers and even health workers have not yet been trained in COVID-19 management and prevention. This must change.’

Supporting primary healthcare centres

‘Primary healthcare centres are the facilities that the population needs most – and they are most affected by the longstanding conflicts’, says Talal Burnaz. According to him, their remote locations render them more vulnerable to attacks and most of them lack basic equipment and supplies. Unsurprisingly, most health workers prefer to work in bigger hospitals. COVID-19 has added yet more complications: ‘People in need of medical treatment are now afraid to visit the centres, they don’t want to get infected. Others who have longer distances to cover are afraid that they might violate the curfew if they run into unforeseen problems on the way’, he says.

To support the primary healthcare centres in this difficult situation, GIZ commissioned the International Medical Corps to implement capacity building measures: First, Rapid Response Teams in the municipalities were trained in COVID-19 case detection and contact tracing. Next, healthcare centre staff learnt how to manage COVID-19 patients whilst maintaining essential health services and ensuring all the precautions necessary to avoid additional infections. In addition, GIZ provided many of the centres with COVID-19 testing kits, personal protective equipment, drugs and medical supplies.

‘Germany’s support is already making a difference on the ground,’ says Burnaz. ‘More patients are now coming to the healthcare centres because they know that health workers are there and medication can be provided. Some of the health facilities we support are in areas with many internally displaced persons (IDPs). We hear from the health facilities’ managers that more and more migrants as well as locals are now coming to the centres to ask for help.’ 


PPE made in Libya

Production of personal protection equipment at the Libyan Korean Center in Tripoli

Like in many other countries, adequate personal protection equipment (PPE) for Libyan health workers and Libya’s general population is in very short supply. To fill this gap in a more sustainable fashion and to provide much-needed livelihoods, GIZ supports existing municipal women development and training centres in producing protection gowns, masks and other protective clothing. Project-trained trainers are now running sewing courses for the local population. ‘The trainings are open to everybody – women from the community, from vulnerable groups, migrants, IDPs - everyone is welcome to be trained and acquire skills to gain an income,’ says Sabine Hartig, who is also a GIZ Project Leader. ‘So far, the women’s centres have produced around 400 protective blouses. In the coming weeks and months, we will support them to produce at least 120,000 masks, 20,000 gowns and other required protection equipment,’ she adds.

A COVID-19 hotline

To respond to the population’s numerous questions about the virus, the NCDC set up a national COVID-19 hotline that can be reached 24 hours a day. To strengthen this service, GIZ coached 30 hotline doctors and operators in communication skills and in dealing sensitively with difficult calls. ‘Some of the callers are quite aggressive, others are anxious to the point of panicking, ’explains Hartig. ‘Many Libyans have lived in crisis mode for years on end and they are traumatised. COVID-19 now presents an additional threat. The hotline is there to listen to citizens’ individual concerns and to reassure them,’ she adds.

New challenges continue to arise

While the Libyan authorities and their partners are busy addressing the immediate problems, new challenges continue to arise. Given the poor state of the facilities, security threats and other factors, many Libyans refuse to stay in hospital isolation, while others refuse to comply with contact tracing efforts. Public health experts who are familiar with the situation in Libya see other disease outbreaks looming on the horizon. ‘Many important immunisation programmes have been stopped, first because of the conflicts and now also because of the pandemic. Libya needs to implement proper infection control measures to ensure that there is not a re-surge of a measles outbreak,‘ says Peters referring to one that took a serious toll in 2018. As a result of the COVID-19 prevention measures, access to routine immunization services has been disrupted over recent months, leading to an increased risk of a resurgence of measles and polio outbreaks. According to UNICEF, over quarter of a million children in Libya are now at risk from vaccine-preventable diseases.

Building on their early achievements, the GIZ Programme in Libya will continue to support its municipal partners in their COVID-19 response and beyond.  ‘We want to use the current crisis to strengthen the country’s resilience wherever we can,’ says Hartig. 

Inna Lazareva, June 2020


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