A.H. Abudejaja and R. Singh

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SUMMARY The Libyan Arab Jamahiriya is committed to the goal of health for all through primary health care. This review outlines the evolution of health services, and looks at the achievements, analyses current challenges and predicts future prospects for health for all in the country.

Introduction

The Libyan Arab Jamiahiriya is situated in North Africa and lies on the Mediterranean, with a coastline of 1770 km. Its surface area is estimated to be about 1 760 000 km², making it the fourth largest country in Africa. The country is currently divided administratively into 26 governorates. The estimated population increased from 2.422 million in 1978 to 4.664 million in 1997. The crude birth rate, crude death rate and natural growth rate per 1000 population for 1978 and 1997 respectively were 43.6 and 36.0, 5.6 and 7.0 and 3.8 and 2.9. The agrarian sector constitutes the cornerstone of socioeconomic development and cultivable land is estimated at 5% of the total land of the country. The industrial sector, founded on the production of crude mineral oil and natural gas, forms the backbone of the national economy, as oil and gas products constitute 97% of the total exports. The number of physicians for every 10 000 population in 1978 and 1996 was 15.8 and 14.0 respectively and the number of nurses and midwives for 1978 and 1996 was 5.9 and 36.0 respectively.

In this paper we review the evolution of the health services, current health situation, present challenges and future prospects. The sources of data are national reports, documents and publications as well as those of the World Health Organization Regional Office for the Eastern Mediterranean.

Evolution of health services

Health policy

The major emphasis in the country was on individual patient care until 1969, on community health facilities between 1970 and 1979 and has been on health for all since 1980. The national health policy declared by the General People's Committee For Health and Social Security provides a framework for the health strategy. In accordance with this, the health programmes are designed and implemented to deliver comprehensive medical care services to all citizens. Other articles of the same law provide for the supervision of public health, preventive health and other related matters. The national health policy is currently geared towards achieving a comprehensive and uniform distribution of health services among the population.

National health strategy

The national health strategy is an integral part of the comprehensive, socioeconomic development policy. It was very we1l laid out in the Five-year Plan of 1981-85, which proposed to extend health services to all, to upgrade and maintain quality, to give priority to integration of health services and to achieve nationalization of health personnel. Furthermore, there has been continued emphasis on eight global elements of primary health care and the inclusion of four national elements (mental health, occupational health, school health and social and health care of the elderly).

National health plan

The process of planned development in the country started in 1972. The first Three-year National Transformation Plan (1973-75) emphasized that access to health services was the right of every citizen.

At the national level the General People's Committee for Health coordinates, supervises and evaluates the implementation of national health programmes, medical services and community health activities. The secretary for the Committee is responsible for the initiation, coordination and consolidation of the health policy, national health strategies, programmes, activities and their evaluation process.

Health system levels

The present day (modem) health care system started functioning in 1951 with meagre resources — 14 hospitals (1600 bed capacity) and a few health centres. Presently, there are 102 hospitals (general, specialized and rural), 32 polyclinics, 154 basic health care centres and 804 basic health care units. Throughout the period of review, the health care system has been vacillating between being single or multisectoral and public or private in nature. At present, the Secretariat of Health and Social Security organizes its services under hospital services, community health activities and national health programmes.

At the first level, basic health care units provide curative and preventive services for 2000-5000 citizens. At the second level, basic health centres serve from 10 000-26 000 citizens and provide certain types of medical care for cases referred from the basic health care units. In addition, they deliver preventive services, maternal and child health care, school health services and health education. At the third level, polyclinics or combined clinics play an important role in cities as each one provides basic health care to 50 000-60 000 citizens, in addition to delivering secondary health care services.

Primary health care

The Secretariat of Planning requested the Secretary of Health and Social Security to elaborate the Five-year Health Development Plan in line with the Five-year Socioeconomic Plan of 1991-95. The national health strategy aims to provide health for all and to achieve high quality and uniform distribution of health services among the people. Basic health care has been given a high priority by creating the Department of Primary Health Care at the central level as well as at the provincial levels among the 26 governorates.

The national health plan is formulated in steps. First, health plans are studied by the Health Secretariat as well as by the Popular Health Committees in the governorates. Health Decree No. 24 in 1994 was formulated to restructure primary health care within the redesigned national health strategy that endorsed again the eight global elements of primary health care but also included mental health, school health, occupational health and social and health care of the elderly. Moreover, the decree promised to integrate health development with overall socioeconomic development and to streamline the entry to health care through family practice. The Faculty of Public Health in the near future will have schools of Public Health Nutrition, Environmental Health, Health Administration, Medical Technology and Nursing. Medical, dental, pharmacy and public health faculties are active partners in training health personnel, conducting and supervising research projects and providing health care. The Libyan Arab Red Crescent Society collaborates by running blood banks and providing health care and diagnostic centres.

Community health services and endemic disease control departments generally deliver primary health care in the Libyan Arab Jamahiriya. The running and funding of health care services has been mainly from the public sector. Health expenditure on primary health care is estimated to be 40% of the total health budget allocated to the governorates.

Health information system

Since 1995, the Centre for Statistics and Documentation has been issuing annual health reports that are based on the information supplied by the main departments of health services to the Secretariat of Health and Social Security. The monthly and annual reports are submitted by the departments of hospital services, community health and endemic diseases control and national health programmes.

Current situation

Achievements

• Health for all continues to be endorsed at the highest official level by the General People's Committee as was reconfirmed in 1994 by the reorganised health-for-all strategy.

• Mechanisms are being further developed for the effective implementation of health for all by making family health practice central to primary health care and by developing an effective system of referral to secondary and tertiary levels of health care. Furthermore, in future, health personnel will probably move from primary health care settings to secondary and tertiary levels for refresher training and vice versa for monitoring and supervision.

• The percentage of the gross national product spent on health has risen from 3.2% to about 5%. In addition, there has been an amalgamation of the health sector with social security to form the Secretariat of Health and Social Security to avoid duplication of expenditure and to unify their services, thereby achieving better results.

• Resources for primary health care constitute 40% of the total health expenditure, which has been adequate to achieve the present state of health.

• It is difficult to evaluate the equitability of distribution of resources for primary health care services because the emphasis has been more on uniform or equal rather than equitable distribution so far.

• The Libyan Arab Jamahiriya is financially self-sufficient as it is one of the main surplus oil-exporting countries. It has given aid to some Arab countries such as the Republic of Yemen for their primary health care programme.

• The availability of primary health care increased between 1978 and 1997. For example, the percentage of the population with access to a safe water supply rose from 90% to 95%, adequate excreta disposal facilities from 70% to 86%, immunization coverage of infants from 55% to 92%-99%, local health care from 76% to 100%, prenatal care by trained health personnel from 76% to 81%, delivery by trained health personnel from 76% to 99%, infant care by trained personnel from 95% to 100%, and contraceptive use by pregnant women from 5% to 45%. Regarding adequacy of nutritional status, the percentage of neonates weighing at least 2500 g increased marginally between 1978 and 1997 from 95% to 96%, and acceptable weight-for-age among under-5s increased to 85.5%.

• Infant mortality declined between 1978 and 1997 from 46 to 24 per 1000 live births, under-5 mortality from 70 to 30 per 1000 live births and the maternal mortality rate from 6.0 to 2.2 per 10 000 live births.

• The average life expectancy increased from 51.4 years to 65 years for males and from 54.5 to 67 years for females.

• Adult literacy increased from 63% to 91% for males and from 20% to 74% for females.

• The per capita gross national product in US dollars increased from US$ 6310 to US$ 6760.

Thus, 10 out of the 12 global targets have been achieved in the Libyan Arab Jamihiriya. Among the partially achieved targets were immunization coverage being 92% instead of 95%, prenatal care being 81% instead of 85%, immunization coverage of pregnant women by tetanus toxoid being 42% instead of 95% and the acceptable weight-for-age among under-5s being 85% instead of 90%.

Health care challenges

Although there has been a phenomenal growth and development in health care facilities, personnel development and health status, much still remains to be accomplished.

Changing role of the Secretariat of Health and Social Security

The Secretariat of Health and Social Security in the future will have to play a new role of planner, partner and evaluator rather than of direct provider of health care services. In addition, for the proper integration of hospital services and community health services, including primary health care and national health programmes, new legislation and agreements are required for their unification and the integration of their functions.

National health planning

A comprehensive national health plan has been lacking, although the first tentative one was formulated in 1986 but was not published. Preparation of a national health plan and an evaluation processes must focus on analysis of the health needs of the people.

Health personnel

The present medical education system, based mainly on tertiary medical institutions, needs to change its focus to the primary health care approach. The health personnel gap between medical professionals and auxiliary health workers has to be filled by public (community) health workers preferably trained in the same institutions where medical professionals are trained.

Financing of health services

Securing adequate funding of the health services is a challenging task. Financial resources, prestige and power should be bestowed upon those working in primary health care settings and community health projects. The ever-increasing quest of the people for advanced hospital medical care should be balanced with essential primary health care.

Future prospects

Health information, monitoring, surveillance and evaluation are inadequate to meet the requirements of the ever-changing health scenario and dwindling financial resources. The present health system requires a major overhaul and adjustments in health policy, strategy, planning, programmes and activities to meet the ever-growing health care needs of the people. Meeting the demands of all those involved in the health care system is another difficult task. For example, consumers want rapidly available high-quality services, health professionals want to acquire the latest knowledge and skills and to have the freedom to provide the best possible care, health care policy-makers want appropriate health care for all citizens and those responsible for finance demand the most cost-effective delivery of health care.

The Libyan Arab Jamihiriya has accepted the 10 global health targets for the 21st century and will work for their achievement in the next 20 years. The targets are: improved health equity; better survival; reversal of global trends of five major pandemics; eradication and elimination of certain diseases; improvement in access to water; sanitation; food and shelter; application of measures to improve health; development; implementation and monitoring of national health-for-all policies; improvement of access to comprehensive essential health care; maintenance of national health information and surveillance systems; and support for health research.

It has been proposed to prepare a health strategy for each governorate in order for them to be self-sufficient and provide a sustainable health care system. There is a consensus of opinion that the health services should be unified into a single integrated health care system as opposed to the presently existing tripartite system of hospital services, community services and national programmes. Health development should be an integral part of socioeconomic development. In order to complement the role of the government in the provision of health care, the reformulated national health strategy for health for all in 1994 officially recognized the role of the private health sector in the implementation of health for all in the 21st century.

Sources

1. Seventh volume of statistical abstracts of Libya. Tripoli, Libyan Arab Jamihiriya Planning, Census and Statistical Department, 1980.

2. Libyan Arab Jaimahiriya: vital statistics. Tripoli, Libyan Arab Jamihiriya, National Authority for Information and Documentation, Planning, Census and Statistical Department, 1998.

3. World population prospects: the 1998 revision. New York, United Nations, 1998.

4. Demographic and health indicators for countries of Eastern Mediterranean. Alexandria, World Health Organisation Regional Office for the Eastern Mediterranean, 1998.

5. Sixth report of world health situation: part two: review by country and area. Geneva, World Health Organisation, 1980.

6. Evaluation of the strategy for Health for All by the Year 2000. Seventh report on the world health situation, vol. 6. Eastern Mediterranean Region. Alexandria, World Health Organization Regional Office for the Eastern Mediterranean, 1987.

7. Ouakrim M.H. Health situation and trend assessment in Libyan Arab Jamahiriya. Alexandria, World Health Organisation Regional Office for the Eastern Mediterranean, 1989 (HST 12/7 LIY/HST/00 1).

8. Health for all. Second evaluation report. Tripoli, Libyan Arab Jamahiriya, Secretariat of Health and Social Security, 1991.

9. Strategy of health for all. Tripoli, Libyan Arab Jamahiriya, General People's Committee (Decree No. 24).

10. Health for all: country programme statement (1999-2004). Tripoli, Libyan Arab Jamahiriya, Secretariat of Health and Social Security, 1998.

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12. Primary health care: report of the International Conference on Primary Health Care, Alma-Ata, USSR 6-12 September 1978. Geneva, World Health Organization, 1978.

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