How are we going to rebuild public health in Libya?
Authors: Richard Sullivan, Brian McQuinn, Arnie Purushotham
Journal: Journal of the Royal Society of Medicine (2011)

Little is known about how armed conflict attenuates established public healthcare systems. Politics aside, Libya has been justifiably feted as one of the world's great success stories in public health. Its ability to deliver low cost healthcare with good outcomes is held as a model for other developing countries. The most cursory examination of the evidence from the UN's Human Development Index strongly supports this. On life expectancy alone, Libya is ranked 53rd at 74.5 (compared to 59.8 in 1980). This is above Russia (65th) and Brazil (73rd) and well above their neighbours Algeria (84th) and Egypt (101st). Under-five infant mortality rates also illustrate the robustness of the system with a rate of 17 per 1000. In comparison, the under-five infant mortality rate for Egypt is 23, for the most prosperous African state Nigeria it is 186, and for the conflict-ridden state of DR Congo it is 199. The public gains by Libya are also particularly noteworthy when one considers that the Arab world, despite its resources, has underachieved in public health terms. The reasons for this, outlined in the Arab Human Development Report of 2002, is that while some Arab countries have also achieved similar public health gains, e.g. Qatar, others such as Yemen with an under-five infant mortality rate of 66 per 1000, have not.

But all this is changing. The conflict in Libya is already altering mortality and morbidity rates as well as degrading public healthcare systems. While research on healthcare systems in post-conflict countries is well developed, little is known on how armed conflict degrades established functioning systems. One of the problems of defining what the post-conflict needs will be in Libya is the paucity of empirical research in many of these areas, despite the work already conducted in countries such as Afghanistan, Algeria, Chad, Lebanon, Sri Lanka and the West Bank. Public health is not short of theoretical models but actionable research from the ground to support the post-conflict reconstruction of Libya's public health system is seriously lacking.

Looking further afield it is clear from policy failures in Kosovo and Afghanistan that an evidence-based national health policy framework at the very beginning of post-war reconstruction is absolutely essential; leave it too late and the consequences are grave.1 However, while we have real-life general learning points from these conflicts they are no substitute for country-specific data. It is essential that research on the impact of the conflict on the Libyan healthcare system begins immediately. The desk-based public health risk assessment and interventions study published by the World Health Organization (WHO) in March (WHO/HSE/GAR/DCE/2011.1) is insufficient in scope and detail to deliver the necessary healthcare systems intelligence required for post-conflict reconstruction. A research ‘hot team’ using, for example, WHO's six essential inputs for a functioning healthcare system (Table 1),2 and a local skilled cadre could quickly and efficiently deliver such intelligence.



Table 1

Immediate actions for assessing and strengthening public health in Libya (based on the WHO designated six primary inputs as essential for functioning health systems)



The rebel Transitional National Council (TNC), now widely recognized as the legitimate government of Libya, has already endorsed rebuilding the healthcare systems in ways that strengthen equitable service capacity and the removal of barriers of access to care. Yet post-conflict countries face daunting economic and social challenges. We know from other conflicts that deterioration in public health is not due only to the direct effects of conflict. Long after the cessation of hostilities, ‘indirect’ mortality due to the disruption of livelihoods, inadequate food and water supplies, and the destruction of health systems, as well as to continued insecurity, continues to exert a downward pressure on health indices and/or causes stagnation. Yet conflict damage to public health systems is also due to the destruction of clinical infrastructure and the effect on healthcare professional human capital. While there has already been significant emigration from Libya there are no data yet on who has left the country nor what will be the long-term effect on healthcare professionals. Various scenarios are possible, but from studies of other African countries, the longer a conflict endures the more the healthcare system narrows to focus on the acute needs and delivery of care to support the conflict at the expense of all other domains of health.3

There are many unknowns that need to be acknowledged. The trajectory of the post-conflict environment has yet to play out and, unlike many other conflict states that were already fragile, Libya has a strong infrastructure and a ready source of capital. The danger is that Libya may well yet descend, as has been the case in the Israeli–Palestinian conflict into a state of chronic conflict with acute and constant insecurities. We know from studies of Afghanistan, Algeria, Chad, Lebanon and Sri Lanka4 that this drives substantial inequalities in healthcare with the rural poor relying on local primary care and the healthier, urban populations accessing secondary and tertiary facilities. Insecurity will only exacerbate this inequality. An even worse scenario would be the continued low intensity conflict that slowly erodes the national architecture leading to a ‘fragile’ state. In terms of preparation, some eventualities are more likely. For instance in post-conflict settings there is invariably a peak in violent deaths due to the combined effect of deprivation and the increased ‘weaponisation’ of the public. In policy terms, prior knowledge of these ‘highly likely’ trajectories is important to manage expectations and implement solutions. This avoids reactive politics when these problems are inevitably highlighted.

Advanced planning for the post-conflict period needs to be integrated not only with the lead countries – UK, France, USA, et cetera – but also with the myriad of humanitarian agencies that will be part of this process. In an ideal world this would involve a single integrated operational public health plan. Whatever course is adopted there is an urgent need to conduct this research now to provide long-term solutions and develop new approaches to public health in the post-conflict environment both in Libya and further afield.