Policy Brief: COVID-19 Response in Libya

Since the onset of the Arab Spring in the Middle East and North Africa (MENA) in 2011, Libya has become one of the most unstable countries in the region1Up to 90% of people fleeing across the Mediterranean Sea to Europe depart from Libya, with an additional hundreds of thousands of internally displaced persons and refugees within Libya2. The country has effectively split into warring factions in the east and west, with each claiming authority to govern with the support of foreign backers. This conflict has caused great damage to the Libyan health system, which was already stretched to its limits prior to its escalation in 20143.

The first person with COVID-19 in Libya was diagnosed on 25 March3. As of mid-August, there had been 7,050 confirmed cases, nearly triple the number three weeks ago4. According to the World Health Organisation (WHO), a strong health system, marked by good coordination and governance, is key to an effective COVID-19 response5 that contains the spread of the virus and minimises morbidity and mortality.

These brief analyses the Libyan health system’s preparedness and response to the COVID-19 pandemic thus far. It also discusses the main challenges faced in the (i) pre-transmission and (ii) response phases and (iii) within the governance and coordination of the response.

 

Political unrest 
During the 2011 series of anti-government protests in Arab countries, the so called “Arab Spring”, protests erupted in Libya against its leader at the time, Muammar Gaddafi. These protests gradually turned violent and led to his killing by armed rebels supported by NATO forces1. Following his killing, conflict erupted between the rebel factions, Islamist militant groups and the transitional government, leading to a civil war in 2014. Clashes continued between the U.N-backed Government of National Accord (GNA), based in the west in Tripoli, and the Libyan National Army (LNA) in the east, led by General Khalifa Haftar

The LNA has attempted to capture Tripoli since 2019, and fighting has continued during the pandemic despite multiple U.N. calls for a ceasefire3,6. Between 1 January and 31 March 2020, at least 64 people died and 67 others were injured as a result of the fighting7.

There are over one million Libyans (one third of whom are children) in need of humanitarian assistance as a result of the political instability and insecurity

According to the U.N. Office for the Coordination of Humanitarian Affairs, there are over one million Libyans (one third of whom are children) in need of humanitarian assistance as a result of the political instability and insecurity2,8. About half of those in need are refugees and migrants. The most essential humanitarian needs are protection, basic household goods and food; ample, clean drinking water; and crucial services such as education and health care8.

During the rule of Gaddafi, the Libyan health system was largely reliant on foreign health workers and thus not sustainable9. The health system continued to decline post-Gaddafi and was further damaged during and in the aftermath of the 2014 civil war. According to Elizabeth Hoff, head of mission for the World Health Organization in Libya, the health system “was close to collapse even before the coronavirus”3. Meanwhile, fighting between the GNA and LNA has escalated9. Between January and April alone, there have been 11 conflict-related incidents directly affecting field hospitals, health workers, ambulances and medical supplies. Tripoli’s al-Khadra General Hospital (which has 400 beds) was hit and damaged on 6 April. Four other hospitals in Sabratha and Surman, which had provided an average of 18,000 medical consultations a week7, closed due to the clashes.

The capacity of the Libyan health system is limited; the prolonged conflict has resulted in poor governance, weak surveillance and health-information systems, and limited equipment, medication and health personnel. Sebha, the largest city in southern Libya and a common transit or settlement destination for migrants, has a particularly weak health care system due to a longstanding lack of investment in infrastructure for water, electricity and medical treatment10.

 

COVID-19 

COVID-19 first was identified in Wuhan, China in December 2019. By mid-March 2020, it had spread to all six WHO regions, including 1,381 confirmed cases in the Eastern Mediterranean. The first person diagnosed with COVID-19 in Libya was on 25 March in Tripoli3: a man who entered Libya through Tunisia in early March after he had been in Saudi Arabia12. As of 11 August, there were 7,050 confirmed COVID-19 cases (816 of whom have recovered) and 135 deaths. The current number of active cases is 40 times more than those recorded two months ago (1 June 2020)4.

Initially, Libya was classified as having a minimal “cluster of cases” based on the WHO’s four scenarios of transmission. In August, it was reclassified to a more serious scenario known as “community transmission.” According to WHO, this classification means Libya is facing larger outbreaks spreading from one person to another, beyond exposure to travellers. Within Libya, both Tripoli and Sebha meet the criteria for “community transmission,” while eight other municipalities are only “clusters of cases”13. The municipalities reporting the most diagnosed cases are Tripoli (1,891), Misrata (1,548), Sebha (715), Benghazi (93) and Tubruq (49)4.

 

Health System Preparedness, Response and Coordination

 

Pre-transmission preparedness 

The prime minister of the GNA declared a state of emergency on 14 March, which mandated a (i) closure of all land, air and sea borders, (ii) shutdown of schools, universities and mosques, and (iii) limitation on the size of public gatherings. The prime minister also announced that 500 million Libyan dinars (LYD) (about 350 million USD) would be allocated for COVID-19 preparedness and response. National committees and task forces responsible for the pandemic response were established in both the east and west regions of Libya14,15. It is unclear whether these measures were enforced and if the LNA took similar actions. Despite these efforts, thousands of migrants continued to enter Libya from neighbouring countries. There was no coordinated national response plan during the pre-transmission stage15.

The Libyan health system lacked the required capacity to prepare for and respond to the pandemic. For example, the country has only 79 intensive care units (ICUs) in hospitals, and until the end of March, there was no clarity on which hospitals were responsible for taking COVID-19 cases. Although two hospitals were identified in the east, they had only 12 ICU beds available15. Plans for procuring tests and personal protective equipment (PPE) and for training medical staff were not in place prior to documented transmission of the virus. In addition, the National Centre for Disease Control (NCDC) had only six rapid-response teams for three regions in the country16, which is not sufficient to cover such a vast area. 

 

Response measures and capacity 

The first confirmed COVID-19 case in Libya was reported on 25 March 202015. By 29 March, the NCDC had conducted 120 tests and there were eight confirmed cases of COVID-19. This under-testing could mean that the numbers of cases were under-reported and that the actual number was higher at that time16. By 13 May, 4,155 tests had been done, but these were conducted by the only two available laboratories in the country (Tripoli, 3,005 tests, and Benghazi, 1,150). This explains why most reported cases at the time were in Tripoli (49 out of 64)17. Sebha, in the south, is one of the cities with the most COVID-19 cases (669). This is considered a high number, given that there is no testing laboratory in the city and less than 1% of its population have been tested10. Most likely, this means the actual number of people with the virus is significantly higher.

It is still unclear how LYD 500 million (USD 351 million) are being allocated by the Government of National Accord18. Nonetheless, there remains large financial and capacity shortages, with a significant need for PPE across the country19. Particularly in Sebha, there are shortages of medical staff, masks and essential medicine10. Fuel shortages in the south are limiting the ability of hospitals to meet the need, due to power cuts and the inability to transport equipment and cell samples for testing10. On 3 August, the NCDC suspended COVID-19 testing due to shortages, despite the allocated funds20.

 

Coordination and governance

There are many different actors and organisations in the Libyan health sector who are responding to the pandemic. U.N. organisations and other nongovernmental organisations that form the health cluster in Libya published a preparedness and response plan on 26 March (one day after the confirmation of the first case)15. However, government authorities were not involved in this plan. WHO reported that it wasn’t until mid-July that government officials endorsed the plan,21.

There is poor coordination between state and non-state actors, and the role of the private health care system in the COVID-19 response remains minimal, even the sector is growing22. The U.N. International Organisation for Migration is playing an essential role in supporting migrants and refugees10. Nonetheless, an April survey by the Mixed Migration Centre showed that 38% of 208 people interviewed stated that they do not know where to go to access health services23. Refugees face a particular challenge, since as they lack the required documentation24.

In addition, there are reports of poor coordination, duplication of services and fragmented information sharing by the various health actors10. In May, the U.N. Humanitarian Access Report documented 658 instances of restricted access for humanitarian organisations and goods entering Libya, and 260 such restrictions within the country, affecting the parties’ ability to respond to health and humanitarian needs during the pandemic25

 

Conclusion

COVID-19 is a significant public health threat in conflict areas such as Libya. It is essential to reach a resolution to the conflict in Libya, since it is the major cause of the severe gaps in the country’s health system. A ceasefire between the GNA and LNA must be maintained, and all humanitarian access restrictions must be lifted to ensure timely delivery of health and humanitarian care for those in need. 

A stronger and more collaborative health system is required in which all state and non-state actors, including those in the private sector, have clear roles and work in coordination to avoid duplication of work or insufficient response. Moreover, transparency regarding the government’s allocated budget for COVID-19 and how it is spent is essential.

More investment in preparedness and response efforts is needed in these areas:

  • Planning for accurate emergency procurement of essentials such as tests, masks, PPE, medication and equipment
  • Nationwide testing and enforcement of strict preventive measures, such as mask-wearing and limitations on large crowds.
  • Building and strengthening of local capacities, including short- and long-term training for health workers and rapid-response teams.

Finally, the needs of vulnerable populations, including migrants and refugees, must be urgently mapped and addressed. It is important to address all urgent needs to effectively combat the pandemic.

 

References 

  1. CFR. Civil War in Libya. July 2020. https://www.cfr.org/global-conflict-tracker/conflict/civil-war-libya
  2. UNHCR. Libya. October 2017. https://www.unhcr.org/libya.html
  3. Reuters. Libya confirms first coronavirus case amid fear over readiness. March 2020. https://www.reuters.com/article/us-health-coronavirus-libya-measures/libya-confirms-first-coronavirus-case-amid-fear-over-readiness-idUSKBN21B2SF
  4. NCDC. Libya COVID-19 Dashboard. 2020. https://ncdc.org.ly/Ar/libyan-covid-19-dashboard/
  5. World Health Organisation (WHO). Novel coronavirus: strategic preparedness and response plan. April 2020. https://www.who.int/publications/i/item/strategic-preparedness-and-response-plan-for-the-new-coronavirus
  6. United Nations (UN). Despite calls for ceasefire amid COVID-19 pandemic, unabated fighting could push Libya to new depth of Violence, acting special representative warns security council. May 2020. https://www.un.org/press/en/2020/sc14190.doc.htm
  7. OCHA. Libya Situation Report (29 April 2020). https://reliefweb.int/sites/reliefweb.int/files/resources/Situation%20Report%20-%20Libya%20-%2029%20Apr%202020.pdf
  8. OCHA. About OCHA Libya. https://www.unocha.org/libya/about-ocha-libya
  9. IOM Libya. Appeal COVID-19. April-December 2020. https://libya.iom.int/sites/default/files/news/IOM%20LIBYA_COVID-19%20PREPAREDNESS%20AND%20RESPONSE%20PLAN%20APPEAL_10042020.pdf
  10. REACH. COVID-19: Rapid Situation Analysis- Sebha, South Libya. July 2020.   https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/reach_lby_brief_covid-19-sebha_final.pdf
  11. BBC. Libya conflict: Opposition forces ‘seize strategic city Sirte’. January 2020. https://www.bbc.com/news/world-africa-51011039
  12. France 24. Fears that coronavirus could overwhelm war-torn Libya. March 2020. https://www.france24.com/en/20200329-fears-that-coronavirus-could-overwhelm-war-torn-libya
  13. WHO. Health response to COVID-19 in Libya (23 July - 5 August 2020). https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/libya_covid_update_12.pdf
  14. OCHA. Libya Situation Report (17 March 2020).  https://reliefweb.int/sites/reliefweb.int/files/resources/Libya_Humanitarian%20Update_17%20March%202020.pdf
  15. Health Sector Libya. COVID-19 preparedness and response plan for Libya. March 2020.  https://www.who.int/health-cluster/countries/libya/Libya-health-sector-covid-19-response-plan-26-march-2020.pdf?ua=1
  16. OCHA. Libya COVID-19 Flash Update (30 March 2020). https://reliefweb.int/sites/reliefweb.int/files/resources/Libya_COVID-19_Flash%20Update_No.1_30Mar2020.pdf
  17. WHO. Health response to COVID-19 in Libya (30 April - 13 May 2020). https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/libya_covid_update_6.pdf
  18. WHO. Health response to COVID-19 in Libya (16 – 22 April 2020). https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/libya_who_covid_update_22_apriil.pdf
  19. WHO. Health response to COVID-19 in Libya (9 – 22 July 2020). https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/libya_covid_update_11.pdf
  20. The Libya Observer. NCDC to suspend COVID-19 testing. August 2020. https://twitter.com/Lyobserver/status/1290592545840537600
  21. WHO. Health response to COVID-19 in Libya (25 June – 8 July 2020). https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/libya_covid_update_10.pdf
  22. Libya Herald. Findings of study on Libya’s private health sector revealed recommendations made on PPP and law amendment. September 2019.  https://www.libyaherald.com/2019/09/11/findings-of-study-on-libyas-private-health-sector-revealed-recommendations-made-on-ppp-and-law-amendment/
  23. Mixed Migration Centre.COVID-19 global update 1- 27 April 2020. Impact of COVID-19 on refugees and migrants. http://www.mixedmigration.org/wp-content/uploads/2020/05/097_Covid_Snapshot_Global_1.pdf
  24. OCHA. Libya Situation Report (22 June 2020).  https://reliefweb.int/sites/reliefweb.int/files/resources/covid-19_situation_report_no.7_libya_22june2020.pdf
  25. OCHA. Libya Humanitarian Access Report. May 2020. https://reliefweb.int/sites/reliefweb.int/files/resources/access_report_may_2020_v4.pdf

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