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Health Challenges in Post-Conflict Libya
Dr Nagi Giumma Barakat Former Minister of Health, Libya Reading Room, May 7 2015, 1400-1700
Dr Nagi Giumma Barakat was Minister for Health in the National Transitional Council of Libya during 2011, following the overthrow of Muammar Gaddafi. On 7 May, Dr Barakat will give a private briefing at RUSI on the state of healthcare services in Libya following the recent history of Civil War.
Libya currently faces serious challenges from infectious diseases, including how to prevent outbreaks and how to prevent those that do happen from spreading out of control. Poor border control is feeding the problem as illegal migrants and workers from neighbouring countries including Egypt, Sudan, Tunisia and Algeria bring infectious diseases including HIV into Libya. Shortages of vaccines and weak vaccination programmes threaten children under two years of age with diseases such as polio and measles, particularly in rural areas and smaller cities.
In the past decade, many Libyan doctors and nurses have left the country, as have foreign workers who provided healthcare in poorer areas. This lack of expertise is exacerbated by lack of money. Libya’s main income is generated through the export of oil and gas but since the crisis, export has fallen to extremely low levels: the country currently exports around 200,000 barrels of oil per day, compared with 1.8 million barrels per day pre-revolution. As the Libyan healthcare sector imports all equipment and pharmaceuticals from abroad, this drop in income has had a particularly strong impact on health service as budgets have dropped considerably, negatively influencing all aspects of patient care across the country.
All of these factors are having a serious effect on Libya itself and also threaten the international community as Libyans travel and migrate into Europe. Help is needed from the international community to ensure that Libya is able to develop and maintain an effective prevention and treatment programme for infectious disease, and is able to make effective plans for how, in the event of a serious disease outbreak in Libya, its spread outside of the country can be prevented.
This discussion offers a unique opportunity to hear about the challenges with Dr Barakat, and to discuss what the international community might do to assist.
To RSVP or for more information, please contact:
Jennifer Cole, Senior Research Fellow Resilience and Emergency Management
Tel: 020 7747 4958
The fourth anniversary of 17th Feb. revolution in Libya is approaching. While both Tunisia and Egypt are on the verge of becoming stable countries, Libya is struggling to become a successful and prosperous state as many Libyans dreamt it would when they came out four years ago chanting slogans against Gadhafi: “People want to topple the regime”.
The West and specifically NATO and their allies supported Libya without any concessions and hurried to protect them as per UN resolution 1973. Soon Gadhafi, his supporters, militia and family were defeated and left Libya. Soon after this, NATO and its allies held up their hands saying, “Libyans are able to sort out their differences and build their country “.
Qatar supported the Islamists to flourish and cause political and military instability in Libya for the last three years. They play a major part by appointing pro Islamist Mr Abdul Rahim Elkeeb as PM and the majority of his cabinet are from the Islamic Brotherhood. He is the most failed PM in all-Libyan history with domination of Islamist in NTC and later on NGC from November 2011-December 2012. There were many opportunities during his period to put Libya on the right track but he failed to do so as he could not make decisions and was controlled by the Islamic brotherhood who were very influenced by the Egyptian government at that time.
UAE supported the liberal group whose leader, Mr Mahmoud Jebril, has no interest in anything except seeing himself on top of everything and he does not want anyone to be better than him. He failed to gain any position and he pushed some of his weakest helpers to prominent positions. All the ministers he nominated are very weak and are all failures like Ali Zidan who was also one of the most failed PM in Libyan history after Abdul Rahim Elkeeb. Now UAE, Egypt and KSA are supporting ex-army man Mr Kalifah Hafter who spent 22 years in USA after he was defeated in Libyan-Teshad war more than 22 years ago. He used to be very loyal to Gaddafi and did not participate much or do anything successfully during the early 9 months of 17th Feb uprising in Libya. He is now saying his militia and others are fighting the Islamists in Benghazi. He seems to be defeating them but this dignity war will not end or settle for a long time as per Lebanon and Iraq.
USA and EU countries are waiting to see who is victorious on the ground so they can rally behind them. Which is not new to them as they will support who prevailing on the ground. For over two years, they turned blind eyes on the Islamic brotherhood and other Islamist groups in Libya. They even went further insisting that the Islamic brotherhood are important partners and allies in any political solution in Libya. The Islamic brotherhood failed in Egypt and other countries e.g. Tunisia and Morocco. Following this, The EU and USA say they do not want to pull the rug under the feet of Islamists in Libya and they still feel they are important allies for them and still want them to be the fourth leg of any table of negotiation in Libya.
The damage in Libya is done and it will take many years to heal the wounds between Libyans. Socially, politically and economically, Libyans themselves, with aid and interference from NATO and their allied countries who toppled Gaddafi, have destroyed the state of Libya. It is not directly but behind the scenes and also not implementing the last UN resolution to stop fighting and announce the list of all terrorists, warlords and others who are hindering any political solution in Libya. There is no doubt that NATO and allies helped Libya to get rid of Gaddafi however, they did not complete the job by helping moderate Libyan to make their state a successful country. Some countries like Qatar, UAE, Sudan and Egypt provided weapons, turning blind eyes on money laundering and weapon smuggling into and out of Libya, which should be stopped. The largest two countries for money laundering from Libya is Malta and Turkey, both never show any economic growth better than the last 2 years.
The killing and torture in Libya now is worse than in the time of Gadhafi. Human right abusers, corruption and stealing the state’s money is even worse, kidnapping and slaughtering people is happening while those who supported the revolution are watching and doing nothing. The UN appointed a very weak person by the name of Mr Tarqe Metery who is holding the stick from the middle and he is always leaning towards the Islamists as he has been instructed. Unfortunately, after two years, he came out with a plan with approval of Islamists in Libya only and none of the liberals has been consulted. Libyan GNC and political elites refuse his initiative. Mr Bernardino newly appointees by UN who is facing rivalry from different countries including the UK who want the lead and France who want the country to be divided so they can control the south of Libya. While the USA is not interested at all in Libya affair as they cannot see any benefited from Libya as long as Gulf States are the milking cow and faithful allies.
It is too late for NATO and its allies to do anything as Libya has entered civil war status. They should have intervened from the beginning, as Libya has no army or police forces. They have experience with Iraq and Somalia. Militia can never be a successful body in taking any state to become a successful country. They stood far away watching, encouraging, allowing weapons to be smuggled into Libya, they let money be laundered, they forgave the human right abusers and on top of that, they met with everyone who were responsible for all of this and gave them status. They also failed to announce the list of the entire terrorist, killers, thieves, warlords, militia leaders and politicians who are directly responsible for all that is happening in Libya and the countries who supporting them.
More Libyans were killed after 23/10/2011, more kidnapped, more than 250 billion Libyan dinar was wasted, and the majority of it was in hands of militia leaders and warlords in Libya. Everyone knows that Libyans are the main causers of the fall of their country with the help of some NATO countries and other allies especially from Arab world. Any solution to the Libyan civil war and failed state has to be produced and implemented by a third party with the help of Libyan who do not have their hands in the mud yet. Everyone hurried to support Libya to get rid of Gaddafi but not to get rid of militia, Islamists and warlords who are destroying Libya and want it to be an anarchy state with no prosperous future. Libya remains and those anarchists are mortal.
Dr Nagi Giumma Barakat, Ex-Health minister- NTC, firstname.lastname@example.org
اصبحنا نتفاءل ونتمنى بأن يكون لدينا شرطة او جيش.
اصبحنا نتجاذب في اطراف الحديث عن دولة الحرية والقانون
اصبحنا نتسارع ونتعانق عندما نري شرطي يقوم بإيقاف الخارجين عن القانون
اصبحنا نلوم في بعضنا البعض ونخون بعضنا البعض بعد ما كنا نحب ونساند بعضنا البعض
اصبحنا نجري وراء الغريب والأجنبي لكي يتعاطف معنا ونحن اولى بأن نتعاطف مع بعض
اصبحنا نلعن في اي شخص يتولى منصب وزاري ونقول له فاسد وسارق وخائن دون سبق معرفة بهذا الشخص وتاريخه
اصبحنا نجلس مع بعض ولا نصدق بعضنا البعض ونخشي ان ننقد اي شخص خوفا من القتل والترهيب
اصبحنا نصارع في انفسنا بأننا قدمنا شيء للوطن في حين نطلب من الوطن ان يعطينا اكثر واكثر
اصبحنا نذهب بعيدا ونترك الوطن حتي لا ينعتنا الاخرين بنعوتات حزينة ومخزيه
متي نجلس مع بعض ونتحاور ونصل الى طريق واحد والذي سيقوم بإيصالنا الى الطريق الصحيح من اجل هذا الوطن ومن اجل ان ينعم ابنائنا وبناتنا بخيراته. هل سيتحقق هذا في ضل هذه الظروف الصعبة بعد ما غاب عن الجميع اتباع تحكيم العقل والذي ميزنا الله تعالي به عن الحيوان
by Dr Nagi Barakat-17/02/2012 18:58:00
The health services in Libya are suffering badly before and now. I was the director (Minister) of health services in Libya during the uprising till 30/11/2011. I was very close to everything at that time and I knew what the problems were. For those reasons I would like to share with my readers the challenges facing the health services in Libya. I am sure everyone knows what problems there are by listening to people, and also from the employees in this sector. Very rarely will you hear someone telling you what the solution could be. I have met many of the health services employees and the majority of them were talking about personal issues and what that person did or what that employee thinks about himself or herself.
I must admire the work done by the health services employees during the liberation and now. I really feel proud about their contribution and dedication to help patients, freedom fighters and the public. The majority of them worked hard and did what they could do with very limited resources and in unsafe environment. Many thanks to all of them and Libya needs even more dedicated people to build up these services and raise the standard of health care in Libya, where patient satisfaction will be the cornerstone of these services.
I met the newly MOH twice, one back at the end of September 2011 and one on 29th November 2011. At the first meeting she was apologising for her campaign against me since I had been appointed and asking to be appointed as the director of health office in Ireland which I did. The second meeting was a hand over meeting and we spent 150 minutes and she wrote down everything. The newly appointed MOH is trying very hard to put a face on health services in Libya with the help of very junior administrators. They are doing their best with what is available to them in very difficult circumstances and a very unsafe environment. They are not getting much support and they are struggling to cover all Libya due to lack of resources and no strategic planning in place.
The NTC and the government did not draw up a structured program with clear measured outcomes and left them alone to manage the health services without strict control and follow-up. They cannot be blamed for everything but they share the burden of failed system with all the employees of the health services in Libya. As we all know, there is no systematic approach to anything in Libya yet.
The ambulance services are not appropriate even to run a small city and Libya is totally dependent on importing everything from abroad to run the health services.
The challenges facing the health services in Libya:
The absence of quality leaderships in health services and the recent choice of a minister of health with very little experience in management are the major challenges facing the government and NTC. There are no real changes in delivering any clear program and everything is still haphazard without real planning or thinking. There is no any credibility for the work the MOH is trying to do and this has brought on her too many problems. This was started by appointing family members to higher positions and then firing them after complaints were made and being asked by the prime minister to dismiss her sister and two other members of her team.
This was followed by changing every head of administration which is a fatal mistake and this is still going on. The majority of them are very experienced and they know everything in MOH and health services. Changing them now is a foolish mistake which indicates lack of experience and that she does not have a clue about the management system in the administration field. The leadership quality in health services management is absent from the MOH and other sectors of health services.
The Minister at the MOH never held any higher position, the prime minister and his team put the MOH in a very awkward position when they asked her to submit her CV for the Minister position. They share the responsibility and the Minister should not be blamed for all of her mistakes because she has no leadership quality and no experience in management. This is very obvious and no one can deny it.
The lack of leadership in health services is not new in Libya and it used to be run by a group of Gaddafi loyalists and no chances were given to develop this field and also to develop the management sector at the level of MOH and PHC and hospitals. It is time to search for young good quality managers and train them for potential lead on improving the administration part of health services. Leaders should be made not appointed.
The most important challenges are to get trust back to health services in Libya. This will take time and this will not happen overnight. The worst thing is to come out and say, I will do this and that and then you cannot deliver it. The current MOH did not set any priorities and if any were set, they are not yet out for the public to see and start believing there will be changes. If there are any, they should come forward now and start implementing them very quickly. The most important priority now is to speed up importing medication, consumables, and spare parts for equipments. There are severe shortages now as the MOH stopped all contracts done by the previous director and his team. The second important point is to establish 3 centres of excellence and 5 rehabilitation centres. If the MOH works on these I am sure public confidence will be restored in health services and building on this trust would began.
There are no national rehabilitation programs and everyone is talking about it and there are many proposals but nothing on the ground. This is because the MOH does not trust anyone and wants to start everything from scratch and not build on what the previous director and his team had done. It is another fatal mistake to try to scrap everything and start from zero. This is one area which has shown up the lack of experience from both the MOH and the advisors surrounding her, most of whom have never done any executive job or worked in leadership positions. These rehabilitation centres can be established as many of the injured and traumatised freedom fighters will be back, if they’re not already in Libya. Working with some credible NGOs will help to get it off the ground. The ownership of this program should be handled by the government and the Prime Minister or the NTC president should lead on this as well. This will give it strength and credibility. The current MOH will not be able to do that as she has not got the vision or the strategies to do that. This is the truth and not a personal issue.
The other challenge is to stop the corruption in MOH and other sectors. The worst corruption happens when buying medicine and medical equipment. The only way to stop it is to negotiate contracts directly with the producing companies as we did when we were in Benghazi to buy medicine worth 370 million dinar to cover Libya for 6 months and payments after 6 months. This was stopped by MOH for reasons we do not understand which have led to severe shortages of everything. The producing company will be happy and long term contracts should be agreed and this will prevent MOH employees as well as hospitals managers from doing any businesses/ deals. The other areas of corruption which we found were in the fields of catering, cleaning and maintenance in hospitals, clinics and health centres. Issuing one contract with clear guidelines and robust control and follow-up department will help. Quality is paramount for any services provided to hospitals and other sectors. Starting quality control programs across all departments at MOH and hospital levels should prevent corruption and will deliver good services.
All of these need a substantive budget built on clear planning and excellent financial control. At the moment the worst corrupted people are the finance controllers. I think we should get rid of them all and make the audit authorities (financial control) more robust and effective and punish anyone who is trying to steal from public money.
The health services need good quality leadership, experienced managers, dedicated working doctors, nurses and technicians. The management should be left to the managers who are trained to do that and doctors should keep away and they are the worst as chief executives for hospitals. I am sure some doing doctors are doing a fantastic job at running hospitals but the majority are not. The Libyan experts who are living abroad should make sacrifices and go back and help in treating patients, help in managing hospitals – not to become directors, but to help in training and to reform health services. Libya needs to make sacrifices as many freedom fighters sacrificed themselves to give all Libyans the freedom they dreamed about, doctors who are practicing and living abroad should go back whenever possible to settle there, take career break for a certain period or as frequent visitors aiming to settle there when the time comes. Gaddafi is gone and his revolutionary committees are also gone away from Libya and no excuses.
Health services in Libya have many problems and no need to solve them all now. It will take many years to correct many of them. It is important now to work on the priorities mentioned above and with new government and hopefully with the help of experts, a clear vision, with strategy and systematic planning plus a comprehensive budget over next 5 years, health services reform in Libya could start after 12 months from now.
The most important thing for the Prime Minister to do is to make courageous decisions about the health services and its leadership. If we leave everything as it is, I am sure the public and the health services employees will not be happy and many will come out onto the streets. We should all help in this situation and doors should be open to listen to experts’ views as well to the strategists. To continue to ignore what is going on is not a good idea and can be very counter-productive and patients will suffer and many lives will be lost because of poor quality of leadership and the absence of experts in this field.
Libya will be free and will rise up against all odds and Libyans will govern Libya and guard it from anyone who thinks he can harm the Libyan people.
The writer is former Minister of Health. He contributed this article to The Tripoli Post.
by dr Nagi Barakat
Since late 70s many Libyan doctors left Libya for postgraduate training in many western countries and specifically English speaking and very limited numbers went to Germany or France or Eastern Europe and settled there. Majority who complete there studies did not go back to Libya and the total number of Libyan doctors abroad, no one know it. Libyan doctors abroad never agreed to form a body that represent them as many others do. There are attempts and first was LDS in UK in Feb 2002, which did not flourish due to many reasons. Majority of them are sponsored by Libyan government for their post-graduation studies and few who did make it by themselves and I am one of them. The number of Libyan doctors who are practicing in UK and registered are 707 (2), and at least 200 are at consultant levels in different specialities and 20 general practioner. There may be other 1000 or more, they are practicing all over the world and the second most popular place is Middle East countries (Gulf States).
All Libyan doctors are a higher achiever and leading expert in there field of specialisation and very well respected from the native people where ever they provide services. Over the last 10 years, few make it back and many stories about why they went back and few left the country again. Since the revolution I only heard three at consultant level are returned to Libya from UK and one from UAE. There are many reasons why doctors do not want to go back before revolution which are:
1- Brutality of the regimen
2- No democracy and no respect to the human being in Libya and respect to the professionals
3- Corrupted health services in Libya and nothing moving forward
4- Poor patient-doctors relationship and mistrust each other
5- No real plans to develop health services and no good quality leadership with doctors leading on management
6- Family issues and education facilities to there children who are in higher education or Universities levels
7- Life style and struggle to get the basic need
8- No systems in managing, running day to day health services in Libya
9- Poor quality of the training which produce very incompetent doctors which is not there fault, it is the fault of the higher training committees at LBMS.
10- Friction between doctors in Libya and doctors coming from abroad.
These reasons and many others kept Libyan doctors not even thinking of coming back and help. There are attempts on individual basis and small groups to visit and perform teaching, training and see patients and all of these documented and known among Libyan doctors. Some done a lot and kept on going others just watching and criticising and later accusing those who done most of the work as collaborators with Gaddafi regimen. It is very easy to find an excuse not going back and help, but the reals once never been mentioned.
Incentives play a major role here and most of doctors are entrepreneur and live good quality of life as they worked hard to get to this position. This is universal and where ever you go, you find doctors earning a lot and live a good quality of life. Libyan is similar and no one can blame them as they worked hard and they are higher achiever and should be rewarded for that.
As the revolution started, many of them involved in all aspect of charitable work. From first few days of fighting in Benghazi, Musrata and western mountain, Libyan doctors from abroad went back in groups and helped in treating war wounded and saved many lives side by side with there colleagues in Libya. Myself, I have been honoured to lead on health services during the revolution till end November 2011. It was a privilege to be part of the revolution and Libyan history. We did our best to manage the crises with the help of colleagues from inside Libya and whenever possible from colleagues outside Libya (3). Unfortunately health services still suffering and many challenges are facing the new minister of health. Any help will be appreciated and the real one should settle in Libya whenever possible.
Until now, there are not many who returned to Libya and only few and some of them continue going as a visitors for few days to deliver lectures, see patients or do courses. Why they are not willing to go now?
1- No security and no stability yet in Libya, even so it start improving
2- No real plans for health services as the new MOH is having priorities which some of it targeting the Libyan doctors from abroad.
3- Schools, places for living, places for work, are not guaranteed to be found yet.
4- Salaries are very low and no real plan yet how this can be sorted
5- Children are now in universities or higher education and they do not want to disrupt them
6- Style of life, they get use on certain style of life and some of them have spent 30 years or more outside Libya and the shortest will be round 15-20 years.
7- Fear from failure as hospitals are not very will be governed by systems, standards, policies and regulations.
8- Few are may never come back
9- There is cultural of not welcoming them and only from small group who unfortunately some of them in leading positions in many hospitals in Libya who are putting many obstacles and preventing any one joining that hospital.
10- Rural hospitals are not will equipped and patient safety cannot be guaranteed nor doctors themselves
All of these and many others making them reluctant to come and work in Libya. I am sure majority of them, would love to come and work but not now as they will be not effective and will not give all what they have learned due to poor system and lack of organisation and facilities. To over come this problem a group of them has to scarify and go back and help in building systems, organisation and lead in certain areas including the training. This may take 3-5 years.
What things may encourage Libyan doctors to come back :
1- The hospital management should be given to a management companies from abroad and to run the hospitals with the help of locals aiming to create a system in each hospital leading to implement standards, policies and regulations similar to the other health services world wide
2- The incentives have to be changed and adopting payment by results will encourage the productivity and ensure good quality of patient care. Every one capable of doing this if the right management,environment and facilities are available to every doctor.
3- The appraisal process has to be implemented to all doctors, nurses and other health services employees. By doing this will guarantee good delivery of services, patient trust regained and communication will improve between all health sectors provided
4- Clear and aimed health service plan for next 5-10 years from the government, so every one are expected to deliver, participate and take part in this plan.
5- Ethic and law should be endorsed to protect patients from doctors and also protect health services employees rights
6- Structured and dedicated training programs to all juniors doctors, nurses and administrators, so they can participate and take part as well
7- Encourage and implement the roles of doctors, nurses association and membership should be compulsory
8- Help with accommodation, education of their children, family and facilitate there move to Libya on stages.
9- There should be a call for a meeting by the prime minister and the head of national general congress to all Libyan doctors and listen to there needs and work with them. This can be done in stages in Libya and invitation should be done by the head of the state Mr Ali Zidan and Dr Nurredin Dogman
10- The government should instruct all hospitals not to reject any applicant from rare subspecialties to work in any hospital of his or her choice or anyone who is been a consultant for more than 10 years in any specialities.
It is time to start thinking about Libyan patient and how much they do suffer when they go to a foreign country and how they are been treated.
It is time to save a lot of money been spent on treatment abroad and given away to our neighbouring countries whose doctors are not better than Libyan doctors who achieved a lot abroad and in Libya.
It is time to stop the miss trust between patient and doctors and work toward improving patient care at all levels.
It is time to stop corruption at ministry of health and at all hospitals. It is time to build the primary health care in Libya which will save a lot of money, time and shorten the patient journey.
The state has to decide about the health system in Libya weather it is public funded or public and private or totally private. This should happen over next five years and moving toward private funded with 40% public.
Libyan doctors are there and not far away and I am sure many of them will go back and helped there beloved Libya. Some of them are excellent in there field and some are not good which similar situation for doctors inside Libya. All are willing to help and any one who are not good, should think to train him and it is the responsibility of MOH to train him or her. We also should know, Libya is not Benghazi and Tripoli, Libyan patients are every where and where ever there is a space, people should go and help patients. I am sure the current government will work very closely with who is wanting to lead on making the distance between doctors inside and outside even closer and to work together for the seek of the Libyan patients.
Libya is free and always will be free
Dr Nagi Giumma Barakat Consultant Paediatric Neurologist-UK Ex-Minister of Health-NTC Libya
1- http://www.libyaherald.com/2013/02/02/health-data-in-libya-inadequate-and-misleading/ 2- http://wmclibya.org/wp-content/uploads/2012/01/Libya Health report.pdf 3- http://www.libyaherald.com/wp-content/uploads/2012/11/Libya-Herald-supplement-Nov2012.pdf
Health data in Libya……… Inadequate and misleading
By Dr Nagi Giumma Barakat.
A data base is vital for the effective operation of the Libyan health system (Photo:Libya Herald).
London, 2 February 2013:
The former health minister says that major investment into data collection has to be made into the health service to make it work properly and that it is a golden opportunity for information service companies.
Any leader who has a vision to develop a sector or organisation, whatever it is, needs data so he or she can put forward a strategic plan to improve or move the sector forward. Without accurate data, it is very difficult to develop anything. Unfortunately, Libya lacks such data — and that is true in all ministries.
Nowhere is that more so than in the Libyan health service. Data is insufficient, at best patchy, and it is vital to make plans in health services. Under the old regime, there was no systematic collection of data or accurate analysis. What existed is not very accurate. It always collected in a hurry and to please ministers or Qaddafi himself. The managers and administrators were terrified when asked to do survey and found multiple problems or indicators showing incompetence. So they went and forged the data and kept the decisions makers blind. There was a systematic policy to cover up any mistakes, whether it was data collection, decision-making or implementing certain measures to improve any services in Libya.
Since the success of 17th February revolution, and new governments in Libya, no attention has been paid to this issue, yet it is vital and important in helping ministers achieve their strategic goals. Is it because of inexperience? Or lack of expertise? Or instability or is it a case that there are other priorities? I think information collection is very important for crisis management — and it was not done by Libyan governments before and since the revolution.
Both in the past and now, the health ministry has faced major obstacles in collecting data due to the following reasons:
- No funds allocated to fund data collection at the level of the Ministry of Health or local health authorities;
- No funds allocated for collecting data or analysing it due to the inexperience of people who now running the data collection centre at the Ministry of Health;
- There is no money to train hospital and primary healthcare staff to collect data, so the staff continue to provide inaccurate data due to their ignorance and poor experience in this field;
- Doctors often make up data, either because they do not care or have no experience in collecting and analysing it due to lack of training in this field at medical schools and when they start practicing medicine.
- Doctors tend to protect their image by providing excessive numbers of patients they have treated, but not the numbers who died or who were infected or suffered other consequences because of their malpractices;
- The managers and administrator lack the experience and training in understanding the value of collecting data; this lead them to focus their efforts on other activities and to ignore their role as data collectors;
- Many managers and administrators deliberately hide significant data so they will not exposed to criticism and only provide data that may generate incentives for them rather than helping to improve quality of services and care to public;
- Many systems are too poorly managed across all sectors, and worse at the level of ministry of health to allow the managers and administrators to exercise more control over what information they release;
- Doctors do not value data collection, nor pay attention to it;
- Hospital management does not support data collection because it could demonstrate their inability to run the hospital efficiently.
The Health Information Centre in Libya is the prime source of information for the sector in Libya but it lacks of leadership, money and plans. Measures need to be taken to improve the centre in order to achieve the Health Ministry’s strategic plans. Without implementing such measures, it will be very difficult to build a quality health care system in Libya. Data gathering and propers analysis will help the Health Ministry convince the Planning Minister to agree to strategic plan put by it to develop health services in Libya.
These measures needing to be taken include:
- A central department for health information with annual statistical reports from other centres feeding information regularly to this centre;
- Staff trained on how to gather and use data for decision-making related to public healthcare and for achieving goals drawn up by a strategic committee at the chaired by the Minister of Health;
- A culture of keeping medical records (patients’ notes, activities of inpatient and outpatient care, primary health care activities, medicine, staff, appraisal, mortality and morbidity, and so forth;
- Managers, doctors and administrators encouraged to use statistical approaches to evaluate their work and measure their achievement through policies and standards;
- Build up expertise within the health information centres that develops statistical documentation and analyses data effectively and accurately;
- Provide information technology for collecting, storing and analysing data;
- Health surveys, a central data base and library are very important departments in gathering information as well as providing proper statistical information;
- As a result of data collection and analysis, the dissemination of information about disease in Libya and surrounding areas so as to enable the Heath Ministry to make plans for control and eradication;
- Should introduce and encourage studies in health statistics to learn methodologies in different areas;
- Promote epidemiological studies and coordinate work between different centres to enable the Heath Ministry to plan and impact on all people across Libya;
- Periodic evaluation of the health information centre (audit, commissioning and appraisal)
There is an excellent opportunity here for investors to come forward with a proposal to help Libyan government tackle the data collection issue. Expertise in this field are scarce. The new Libyan government should not be ashamed to ask for help ; data collection is a vital tool for all decision makers.
Information in regards to the health sector is absent in Libya and it is one of reasons so much money been spent on building, importing different drugs, equipment and hiring foreign employees. This all done without clear data available to enable decision-makers to know what is needed in next five to ten years.
The lack of data is a massive impediment. For example, no one knows how many people were injured during the liberation or even how many were killed or went missing during the struggle. The numbers are inaccurate because there have been no systematic collection of data. I myself instructed the director of the information centre at Health Ministry to set up ten committee to collect data from all over Libya as to the war wounded, martyrs and missing persons. This was to enable us to know how to provide adequate health care for this group and was to be a priority. Unfortunately, nothing was done before I left office and till today nothing still has been done. Whether this is due to inability or obstruction or something else remains to be seen.
It is now a major priority for Libya to create information centres for everything and each minister should be planning his own centre, setting forth measures, as above, to make it effective. If this does not happen, Libya will keep spending money as if pouring water down a hole. Strategic planning needs accurate data and without data Libya will take decades to stand on its feet.
Dr Nagi Giumma Barakat Former Minister of Health, NTC Consultant paediatric neurologist
By Dr. Nagi Barakat,
On Aug. 20, 2013, Libyans celebrated the second anniversary of the liberation of Libya’s capital Tripoli. That day in 2011 had been a difficult one and after breaking fast in Tripoli everyone had a mission. Tripoli residents came out and with the help of rebels from Zintan, Zawia, Ghariyan, eastern Libya, and then later from Misurata Tripoli was liberated.
I was in charge of the Ministry of Health at the time so I contacted a number of colleagues in Tripoli in order to deal with the crisis. My first contact was with Dr. Khaled Elmaghbub from the childrens hospital in Tripoli whom I asked to establish a medical crisis committee and to report back to me on the hospitals in Tripoli whenever possible.
After the liberation of Tripoli I visited field hospitals in Tajora and Souk Al Jumma and saw the work being done by Tripoli residents, both by doctors and ordinary people. Those days of the revolution were tough yet beautiful, everyone fought against a common enemy, nobody worried about petty affairs – we all knew who the enemy was and we were united in the fight to overthrow Gaddhafi
Two years on, and after a successful revolution, that momentum has been thwarted by the militias and not a lot of real progress has been made. Everyone is pointing the finger of blame at someone else; some are accusing Qatar, others the Islamic Brotherhood or the secularists, liberals, federalists etc… but we forget that the problem is in us.
We had established two MoH crisis committees during the revolution one for Benghazi and one for Tripoli, and these were operational before the announcement of liberation on 23/10/2011. A lot of work and organization went into them and we served tirelessly for the supply of medicines, blood transfusion, deportation of the wounded, treating patients, vaccinations and helping to release any bottlenecks and obstacles in many cities.
The committee members reached to the far south and contributed significantly in preventing a health disaster in Libya during the revolution. After the liberation of Libya, everything was handed over to the newly appointed minister Dr. Fatma al-Hamroush. The first thing al-Hamroush did was to dismantle both committees and start from scratch all over again!
New names and faces arrived who never been on the stage before the liberation of all Libya, but with little or no experience to build on, they set the country’s health service onto the path of chaos where nothing was achieved and it was doomed to become the worst period ever in the management of health services in Libya.
Some went further and said it was even worse than in Gaddafi’s era in spite of all the money that was available, and the goodwill of the general public.
The next Minister of Health to arrive is the current minister Dr. Noureddine Dougman who, without any further consideration, continued on the same path as his predecessor. I was against his appointment from the start as I felt his leadership and decision-making skills were very weak as I had experienced working with him while he was a member of the crisis medical committee in Benghazi.
Many colleagues asked me to support him and they assured me he would be happy to meet with me and listen to my suggestions. I did meet with him in January 2013 and we shared many ideas. I advised him to have a list of priorities and the high-ups on the list would be medicines, equipment, emergency medical care and inviting visiting doctors to help with difficult cases.
I put forward proposals for cardiac surgery, plastic surgery and neurosurgery and six neuro-rehab centres in Libya. Treatment in Libya is far more cost-effective as each 10 patients treated in Libya will save the Ministry of Health £500,000.
I also suggested a few names that would be helpful for him in his tasks at the ministry, but he ignored this. Dr Dougman and the third deputy to PM in Libya (Elgadi) asked me and Dr Nuerrdin Erabi to nominate advisors to Dougman which we did and explained clearly the responsibilities of these advisors. The minister of health ignored this as well.
However, the worst decision ever made by Dougman was to take back the treatment of the war wounded from their dedicated ministry to be a part of the MoH. He also endorsed the centralization of everything back to Tripoli and wanted to take over everything by himself without using any of his deputies.
After a few meetings with him and various discussions, it became clear that he just had ideas and notions about what he wanted to see happen, but no tangible plans or priorities.
What should be done about the health services and to save it from catastrophic events?
1- To reinstate or establish the crisis committees in Benghazi, and Tripoli which were operating during the liberation as the country is still in crisis.
2- There should be three deputies to the Minister of Health:
a. One to lead the eastern part of medical crisis committee and look after the eastern and southern regions’ medical needs in Libya.
b. The second for the western and middle regions.
c. The third to help the minister at the Ministry of Health on a day to day basis.
3- The existing or the new Minister of Health should have charisma, leadership and experience in dealing with crisis. He/she should set up priorities for the whole of his/her period of leadership, which should include short term plans to be implemented over 6 months and a long term plan which should be continued even when transitioning from one minister to another, without starting again from scratch.
4- The polyclinics in Libya should all be activated and the current lead on primary health care should be replaced as he is inexperienced and has been twice rejected from MOH positions.
5- The European Union committee should be transparent, effective and accountable at all times. They should include more experienced people than what they have and from all Libya rather than just Tripoli and Benghazi and the two inexperienced people who have no idea about health services in Libya, and are neither strategists nor managers.
6- The priorities should include, supply of medicine, equipment, emergency care including child birth and accident and emergency departments.
7- There should be 3 centres that will look after complicated cases and continue to care for the war wounded to save money. This can be operated by visiting experienced doctors – Libyans or non-Libyans and managed by a foreign team/s with Libyan help.
8- Building capacities and human resources is very important and to develop a long-term program to improve and develop hospitals, medical education and training for all health services employees and medical colleges.
We hope that the Prime Minister and the General National Congress will pay attention to this vital sector and service. The performance of the Minister of Health is very poor after 7 months in the office in spite of there being a lot of money to use and support from PM and GNC. It is about time to re-evaluate performance and if he is doing well, should be supported but if he is a failure should be substituted very quickly and someone else be appointed with clear vision and deliverable plans.
The new Minister of Health should be given all the support he/she needs and scrutinize progress on a regular basis with advisors and deputies to support him/ her.
Finally, we must continue to be honest and faithful to Libya and put aside all our differences, completely leave them behind, so that we can concentrate on making a decent future for our country and people.
Yet what is happening these days make me sad and frustrated. Those who were key players in the process of change have now been marginalized and excluded, with obstacles placed ahead of them to block their way and contributions, and even with trumped up accusations of corruption and theft being thrown at them!
What nation on earth treats its honourable revolutionaries and others who risked their lives and contributed so importantly to its people’s victory in this way? They are not expecting rewards but at least some recognition and respect for their contributions, and inclusion in the process of moving forward.
Hatred and exclusion is flourishing in Libya against these honorable people – but even more so against each other. Although Tripoli and Libya were liberated from the tyrant and we have started moving forward in small steps, many want to lead Libya into a dark tunnel; but this tunnel must be demolished so that Libyans can begin to see the light of day again.
The writer is ex-Minister of Health under the National Transitional Council. He contributed this article to The Tripoli Post. He can be reached at: email@example.com
To lead a change, there are usually Principles and values, but this does not happen in Libya these days due to the absence of leadership in the current government. It is customary in Libya and in third world countries where there is no democracy, for everyone to assume that when he or she holds any ministerial position, he/she will bring with them their family, family friends, people from his/her tribe and very close people to his friends.
This is without taking into account the competence and experience of the person chosen to carry out responsibilities and decision-making burden of that position. For example, lack of experience, you can find this on the biography of some of the current government ministers, including Dr. Abdul Rahim Elkeeb himself.
Leading change has principles and foundations as John Kotter, prize winning author of the Faculty of Business Administration at Harvard University, summarised into 8 points in his book “Leading Change” as follows:
1. Establishing a Sense of Urgency (Examine market and competitive realities, and identify and discuss crises, potential crises, or major opportunities)
2. Creating the Guiding Coalition (Assemble a group with enough power to lead the change effort, and encourage the group to work as a team)
3. Developing a Change Vision (Create a vision to help direct the change effort, and develop strategies for achieving that vision)
4. Communicating the Vision for Buy-in (Use every vehicle possible to communicate the new vision and strategies, and teach new behaviours by the example of the Guiding Coalition)
5. Empowering Broad-based Action (Remove obstacles to change, change systems or structures that seriously undermine the vision, and encourage risk-taking and non-traditional ideas, activities, and actions)
6. Generating Short-term Wins (Plan for visible performance improvements, create those improvements, recognise and reward employees involved in the improvements)
7. Never Letting Up (Use increased credibility to change systems, structures, and policies that don’t fit the vision, also hire, promote, and develop employees who can implement the vision, and finally reinvigorate the process with new projects, themes, and change agents)
8. Incorporating Changes into the Culture (Articulate the connections between the new behaviours and organizational success, and develop the means to ensure leadership development and succession)
Change is a process of transformation of reality, and its success relies on choosing the right team.
Leadership is the ability to influence others and direct behaviour to achieve common goals. It is therefore a responsibility towards the group to reach the set objectives which are planned by the leader. It is also a process aimed at influencing the behaviour of individuals and coordinating their efforts to achieve certain goals.
Leader: A person who uses his influence and power to affect the behaviour and attitudes of individuals around him to accomplish the specific objectives agreed upon with his team.
This is not found in the current Libyan government because the selection was random. Although random sometimes comes with good results, this was not the case when choosing this present head of government in Libya.
When Mr Elkeeb chose the members of his cabinet, he did not hold meetings with his prospective ministers and he totally depended on word of mouth, recommendation by someone close to him or relying on curriculum vitae of these individuals which in some cases had translation problems. The biography of some ministers can be found on this website, https://www.pm.gov.ly.
Some of the ministers are scandalously unqualified for the job but some of them have very good CVs but no experience in holding higher positions; nevertheless they are doing very well.
It is true that most of them have experience, but a group of them lack any leadership or managerial skills nor have the charisma to be ministers. The latter are those who are failing badly.
There is a difference between management and leadership; both are complementary to each other provided there is the presence of an effective team.
A leader also needs to be an administrator to achieve his vision and develop his strategy. He will draw up a plan of action with his team for short and long term objectives with details of the implementation of the plan.
There is a big difference between leadership and management. Talking about leadership is as old as history, while talking about administration only began in the last decades of the nineteenth century.
Leadership is a branch of the science of management whilst administration focuses on five key processes: planning, organization, direction, supervision and control.
Leadership focuses on three head of operations are:
i- Determine the direction and vision.
ii- Mobilize the forces under this vision.
iii- Motivation and building of momentum
That person will be responsible to lead his team and within the requirements of leadership should be:
a- Effective: has the ability to change others or find what convinces them.
b- Influential: has the ability to give orders to implement his strategy and not to be self-centred.
c- With legal authority: the right given to the commander to act according to laws and regulations
Leaders cannot be appointed but only can be created through training and climbing up the ladder over many years to become a leader. To create a leader will need a lot of effort, training and money. To lead on a change, you need a leader who can lead and make courageous decisions with his team.
There are many examples. The McKenzie Institute International (http://www.mckenziemdt.org/), is the finest company in the training and making of leaders, especially in the areas of development and training.
No one person can lead a change, it needs a team that is efficient, with expertise and political direction that the change successful. This needs a politically minded leader with significant administrative experience.
Unfortunately Dr Abdurrahim Elkeeb does not have all these qualities and he has lost it in the last few days by starting to blame the NTC for his leadership failure.
The 17th Feb. revolution has lost its momentum inside and outside Libya and we have almost been forgotten by the world. This is due to poor performance of the leadership in both NTC and the government.
The NTC is doing its best to reach out to the world and Mr Abduljeleel is meeting many world leaders who seem to believe in him as many Libyans do.
The world, however, seems not to have confidence in the Prime Minister as he does not possess the above-described qualities of leadership. For this reason and many others, Libyans fear that the 17th Feb revolution has lost its momentum because of this. The enthusiasm from the public to rally behind the leaders of 17th Feb has started to decline.
But the Libyan people have never lost faith in the 17 February Revolution despite the failures of the new leaders have started pointing fingers to each other only to come public when it reached the highest levels between the NTC and the government.
When the leader starts blaming others for mistakes affecting national security and stability, this means that he has lost control and should accept responsibility.
If the NTC blames Dr Elkeeb for all that is happening in Libya today, they should also blame themselves as they were advised before appointing him of his “poor leadership qualities”.
The major change which happened in Libya was the removal of Gaddafi and not all of his followers but the real change will take years to flourish in Libya. Because of that, there should be creative programmes for leaders, innovators, entrepreneurs, and strategists with political minds.
Libya will be well on the path of progress somewhere in 5-10 years’ time and in less than 20 years I am sure it will be in a much better shape. All of this needs security, implementation of the rule of law and to learn from others.
There is no way to create good quality leaders in 1-2 weeks as has been going on in Libya now by a religious cleric from Kuwait (Tareq Suwaidan). Always learn to walk before you run!
Leading change was led by the National Transitional council and the Executive Office. It was a difficult stage, but it gained the support of the Libyan people and the real revolutionaries of Libya.
Everyone helped and accelerated the removal of the tyrant until he was killed in Sirt on 20/10/2011. But this change, which was acceptable to the Libyan people and the world, did not continue on the same steps as was started by the leading executive office who were forced to resign collectively as was agreed with NTC regulations.
This opened the way for the current head of government to bring his friends and his family, and friends of friends to the government without taking into account the efficiency and conditions of the transition.
We did not see him in Benghazi until end of June 2011, but after the Doha conference when he delivered a speech on behalf of the people of Tripoli, as the original speaker was forced to withdraw as he was not a very religious man nor is his family. This was all orchestrated by a religious fanatic group which we will write more about in another article.
After the liberation of Libya, he became very close to Mr Abdul-Jalil and a glowing picture was painted about him to Mr Abdul-Jalil by a group affiliated to the Islamic brotherhood. This is how he became the front runner for the Prime minister’s office in the transitional government after the liberation.
I hope someone can write about those days of 23-25/11/2011. Many important events took place then and I will share some of them with you next time. It was a wrong choice and now it is time to correct the mistakes.
Some ministers should be exempted from their ministerial positions, including the ministers of Foreign Affairs, Health, Justice, Finance, Defence, Interior, Youth, Sports and Culture and Prime Minister himself.
It is true that time is short to reshuffle the ministries but it is very important to do so; this will regain the momentum of the Libyan people towards the 17th Feb revolution and the NTC leadership. This also will regain the confidence of the world in Libyan government and NTC.
There are a few steps which will help in making the changes successful. These can be measured in time and all Ministers are held accountable:
1. Some of the ministers should be exempted from their ministerial posts and the Prime Minister is one of them. This is due to the poor performance, lack of planning, poor communication with the public and the outside world and the continued deterioration of security and stability of Libya.
2. The Transitional National Council should ask every minister to draw up a plan of action to overcome the most common problems according to priorities; he/she should correct them during the transitional phase.
3. All ministries should be held accountable after 3-6 months and all those who are failing should be replaced by the Prime Minister and not by NTC
4. The replacement ministers should be chosen according to their political, leadership and administration experience and interviewing them is a must
5. Security is the priority for the Prime minister as well as looking after the real freedom fighters and negotiations should start with them ASAP about their future role in Libya.
6. The Prime Minister and his cabinet should take courageous decisions aimed at strengthening security and stability in Libya. The NTC should not interfere and support these decisions.
7. Election must be held in time for the national assembly with the help of the United Nations.
8. Foreign policy should be one of the priorities especially with neighbouring countries.
There is still great opportunity and not much time has been wasted. The momentum of the 17th Feb revolution is still buzzing in the hearts and minds of the Libyan people if the right prime minister is found to be leading on this transitional period.
Everyone is talking about it and the majority of Libyans have never experienced anything like this. I am sure that if they see Libya heading in the right direction, they will stand behind the government and support them.
It is very easy to mobilise the public against any danger which may hinder the success of the government, provided there is good leadership at the highest level.
Libya will remain free and the Libyan people will not allow anyone – not even the pseudo-freedom fighters – to destabilize the security, integrity and stability of their country.
Libya is at a very critical stage in its post-revolution era and it is essential that the right leadership takes control and puts into effect the changes that have already been started by the earlier Executive Office of NTC.
We don’t want Libya to end up like another rogue state governed chaotically and without strategic forward planning.
The writer is former Minister of Health in the Executive Office of the National Transitional Council until November 2011