Healthcare System in Libya Factual Report

January 2012

Hani Benamer benamer@doctors.org.uk

Contents
I. Introduction................................................................................................................................................3 II. Population of Libya ..................................................................................................................................4 III. Human Resources ...................................................................................................................................5 IV. Health Care Expenditure .......................................................................................................................7 V. Health Care Facilities ...............................................................................................................................9 V. Life Expectancy, Mortality and Disease Burden..................................................................................11 VI. Medical Education ................................................................................................................................13 VII. Medical Publication.............................................................................................................................15

I. Introduction
The main objective of this report is to present statistical data related to various health issues in Libya. In compiling this report the following points have been taken in consideration: 1. Libya was divided into the following geographical areas Tripoli Benghazi Jabal Gharbi (From Gharyan to Nalut) Jabal Akhdar & Marj Darnah & Albetnan Misratah & surrounding areas Marqab Jifarah Zawiyah & surrounding areas Zuwarah & surrounding areas Mantiqa Wusta (Adjabyia, Wahat, Sirte, Jufrah & Kufrah) Mantiqa Janubiya (Sabha, Murzuq, Ghat, Awbari & Adiri) 2. To put some of the data in context, Libya was compared with the United Kingdom (UK), Canada, Sweden, Malaysia, Oman, Tunisia and Egypt. 3. The report is factual and hence the author completely restrained from making any comments or drawing conclusions. That is left to the readers. 4. The data were carefully referenced. All references are available in the public domain, but the author will be happy to supply the readers with any reference on request. 5. The data available on health care in Libya are related to quantity NOT quality. 6. Medical education and publication were included as they are major contributors to the health service. 7. The report is not comprehensive; it is design just to give you a flavour about health indicators in Libya.

II. Population of Libya

Over the last 40 years there were 4 censuses (1973, 1984, 1995, and 2006). The population grew from 2,249,237 in 1973 to 5,657,692 in 2006, making the average growth rate 2.85% per year. However, the growth rate dropped from 4.48 during 19731984 to 1.56 during 1995-2006. The number of non-Libyans changed from 196,865 (8.75% of the population) in 1973 to 359,540 (6.35% of the population) in 2006. Libyan males composed 50.7% of the Libyan population in 2006.1 About 85% of the Libyan population is urban.2 The age distribution of the Libyan population shows that 31% of the population are below 15 years (Paediatric age group), 42% are below of age of 20, 38% are 20-40 years old, 52% are 20-60 years old and only 6% are above age of 60 years.1 Table 1: The population of various regions of Libya according to 15/04/2006 census Region Tripoli Benghazi Jabal Gharbi Jabal Akhdar & Marj Darnah & Albetnan Misratah & surrounding areas Marqab Jifarah Zawiyah & surrounding areas Zuwarah & surrounding areas Population 1,065,405 670,797 397,383 389,004 322,887 550,938 423,202 453,198 290,993 287,662

Mantiqa Wusta (Adjabyia, Wahat, Sirte, Jufrah & 420,871 Kufrah) Mantiqa Janubiya (Sabha, Murzuq,Ghat, Awbari 363,729 & Adiri) Total 5,323,991

III. Human Resources

In 2010 there were 113,631 employees (Libyans and non-Libyans) in the ministry of health.1 These employees were distributed as follows: 11,323 doctors, 40,926 nurses and midwives, 3176 dentists, 1100 pharmacists, 16,640 health professionals (? allied healthcare professionals; author), and 34,533 service management (not sure what this includes; author) making a total of 107,698.1 The other 5933 personnel are not accounted for. Libyan doctors in diaspora Clemens and Pettersson reported a total of 585 Libyan physicians when they used the destination-country census data of 2000 to estimate the number of African-born doctors who had immigrated to the UK, the USA, Australia, Canada, France, Spain, and Belgium.3 Mullan, when examining physician immigration to UK, USA, Australia and Canada in 2004, reported that 624 Libyan doctors were practising in these countries and that 63% of them were in the UK.4 Mullan estimated that 8.9% of all Libyan physicians were practicing in the USA, UK, Canada or Australia.4 Moreover, Libya was among the top five African countries when Arah calculated physician migration density, i.e. the number of migrating physician per 1000 population.5 Recently, the General Medical Council (GMC) confirmed that there are 707 doctors registered in the UK who obtained their primary medical qualifications in Libya.6 Of these, 211 doctors are registered in the GMC's Specialist Register and 20 are in the General Practitioner Register.7

Figure 1. Human resources per 10,000 population, international comparison8

UK Canada Sweden Pharmaceutical personnel Malaysia Oman Tunisia Egypt Libya 0

Libya Pharmaceutical personnel Dentistry personnel Nusing and midw if ery personnel Physician 3.6 6 68 19

Dentistry personnel Nusing and midwifery personnel Physician

20
Egypt 16.7 4.2 35.2 28.3

40
Tunisia 2 2.4 32.8 11.9

60
Oman 8.1 2 41.1 19

80

100

120
Canada 8.3 11.8 100.5 19.1 UK 6.6 5.2 103 27.4

140

Malaysia Sw eden 1.7 1.4 27.3 9.4 7.3 8.3 115.7 35.8

IV. Health Care Expenditure

Libya spent 3.13 billion Libyan Dinars (LD) on health in 2010, of which 1.3 billion were spent on salaries and 700 millions on drugs.1 Libya spent about 3% of its Gross Domestic Product (GDP) on health in 2008, less than the 3.3% it spent in 2002.8

Table 2. Health expenditure in Libya: international comparison8

Total expenditure as % of GDP Libya Egypt Tunisia Oman Malaysia Sweden Canada UK 3 4.8 6.4 2.1 4.3 9.4 9.8 8.7 Government expenditure on health as % of total expenditure 5.5 5.9 10.4 4.9 6.9 13.8 17.2 15.1 Government expenditure as % of total expenditure on health 70.3 42.2 54.1 75.5 44.1 78.1 69.5 82.6 Private expenditure as % of total expenditure on health 29.7 57.8 45.9 24.5 55.9 16.8 30.5 17.4 Out-of-pocket expenditure as % of private expenditure on health 100 97.7 87.1 61.4 73.2 92.8 50.9 63.7 Per capita total expenditure on health (US$) 458 97 248 459 353 4858 4445 3771 Per capita government expenditure on health (US$)

322 41 134 347 156 3794 3090 3116

V. Health Care Facilities

There are 1382 primary healthcare units (each of them serve 5000-1000 citizens) and primary care centres (each of them serve 10,000-26,000 citizens).2 There are 37 polyclinics (each of them serve 50,000 to 60,000 citizens).2 There were 20,689 beds in public hospitals (table 3), and 2088 in private sector in 2010.1 Libya has 37 hospital beds per 10,000 population, which is very high by international standards (table 4).8 However, the bed occupancy rate in Tripoli Medical Centre averaged 65.8% in the years 20052010.1 There are 40 CT and 20 MRI in the public sector and 20 CT and 12 MRI in the private sector.1 There are also 5 radiotherapy unites, 9 Echo and 201 X-ray machines in the public sector.1 There are 8 angiography units in the public sector and 3 in the private sector, all of them are in Tripoli and Benghazi.2 There were 925 dialysis machines in total in 2010.1 Table 3. Hospital beds in Libya in 2010 by region1
Region Tripoli Benghazi Jabal Gharbi Jabal Akhdar & Marj Darnah & Albetnan Misratah & surrounding areas Marqab Jifarah Zawiyah & surrounding areas Zuwarah & surrounding areas Mantiqa Wusta (Adjabyia, Wahat, Sirte, Jufrah & Kufrah) Mantiqa Janubiya (Sabha, Murzuq,Ghat, Awbari & Adiri) Total Hospital beds 6497 3645 1662 1367 1172 1360 864 402 616 843 1061 1200 20689

Table 4. Health infrastructure in Libya, international comparison8

Hospital beds per 10,000 population Radiotherapy units per 1,000,000 population Libya Egypt Tunisia Oman Malaysia Sweden Canada UK 37 17 21 19 18 34 34 0.9 0.7 1.1 0.7 1.7 7.9 7.7 5.4

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V. Life Expectancy, Mortality and Disease Burden

The top three causes of mortality in Libya are cardiac diseases (37%), tumours (13%) and road traffic accidents (11%), while the top three causes of morbidity and disability are antenatal and postnatal care and delivery (?pregnancy, delivery and postnatal related problems; author) , cardiovascular diseases, and road traffic accidents.2 In 2009 the prevalence of tuberculosis was 55 per 100,000 population and its incidence was 40 per 100,000 population.8 The number of reported cases of hepatitis B was 2437 and 1437 for hepatitis C in 2010.1 About 30% of the adult male Libyan population are regular smokers.2 About 15% of students use some form of tobacco and 6% of them smoke cigarettes.2 Road fatalities are 31.5 per 100,000 in comparison with 6.1 in the UK.2 Life expectancy and mortality in Libya are shown in table 5.

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Table 5. Life expectancy and mortality in Libya (2009), international comparison8

Life expectancy at birth Stillbirths per 1000 live births Neonatal mortality rate per 1000 live births Libya Egypt Tunisia Oman Malaysia Sweden Canada UK 72 71 75 74 73 81 81 80 10 13 10 7 6 3 3 4 11 11 11 6 3 2 4 3 17 18 18 9 6 2 5 5 19 21 21 12 6 3 6 5 Infant mortality rate per 1000 live births Under five mortality rate per 1000 live births Adult mortality rate per 1000 population 142 174 100 131 137 61 70 71 Maternal* mortality rate per 100,000 live births 64 82 60 20 31 5 12 12

*Year 2008

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VI. Medical Education

The first two medical schools in Libya started in the 1970s and a big expansion in the number of new schools followed in the 1990s.9 There are 24073 medical students in 2007/2008.9 All medical schools use traditional curricula,9 except the Libyan International Medical University who have introduced problem-based learning.10 The medical schools in Libya are listed in table 6. In the mid 1990s the Libyan Board of Medical Specialties (LBMS) was established with the aim of training doctors to specialist and consultant levels. To date, 536 doctors in various specialities graduated from the Board (table 7).1 Table 6. List of the medical schools in Libya (2007-2008)9
Name City Year of establishment 1970 1973 1987 1990 1997 1998 1999 2001 1999 2007 Number of students 3155 11072 812 775 1397 2424 1431 1910 920 177 Number of academic staff 570 678 38 63 59 113 53 60 92 30 Number of graduates 3945 5981 257 227 305 305 209 93 41 -

Benghazi University Tripoli University Sebha university Sirte University Misturata University Zawia University Elmergib University Omar Almukhtar University Ajabal Algharbi University Libyan International Medical University Total

Benghazi Tripoli Sebha Sirte Misurata Zawia Khums Bayda Ghayran Benghazi

24073

1693

11058

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Table 7. Number of trainees and graduates of Libya Board of Medical Specialties1

Speciality General surgery Orthopaedics ENT Urology Plastic General medical Paediatric Obstetrics & Gynaecology Anaesthesia & ITU Ophthalmology Family medicine Radiology Diagnostic radiology Radiotherapy Dermatology Laboratories medicine General pathology Emergency medicine Total 1608 875 754 230 184 32 103 100 62 122 4953 892 Trainees Graduates 73 29 13 24 11 86 113 52 44 22 22 17 9 17 4 536

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VII. Medical Publication

Libya did not appear in the top 20 African countries when the total number and the average annual number of biomedical publications were counted for each African country from 1996 to 2005.11 Also, in the same study Libya was not ranked among the top 20 countries in Africa when the number of biomedical publications was normalised to annual publication rate per million inhabitants.11 Libya ranked lower than Morocco, Tunisia and Yemen in total number of PubMed publications between 2002 and 2006.12 The same result was found when the data was normalised to GDP.12 Shaban and AbuZidan studied the medical publications from 20 Arab countries.13 Libya ranked 12th in the average annual publication rate, 10th when the data was normalised to the population, and 15th when normalised to GDP.13 PubMed and the Science Citation Index Expanded were searched for original biomedical studies affiliated with Libya up to December 2007 and found 329 original papers.14 The first study was published in 1973.14 Publication rate peaked between 1986-1996 with an average of 15.2 studies per year.14 From 1997 to 2007 the production rate decreased to an average of 8.8 studies per year (p<0.001).14 Of 166 first authors, 41% were Libyans and 59% were non Libyans. The latter contributed 104 studies between 1986 and 1996, and 36 studies between 1997 and 2007, while the Libyans contributed 63 and 61 studies in the two respective periods.14 Authors affiliated with Benghazi produced 67% of the published studies, while authors from Tripoli produced 30%, and other medical schools, hospitals and research centres from other Libyan cities produced only 3%.14 Another study analysed the publications record of the Libyan medical schools in international journals indexed in PubMed between 1988 and 2007.15 Of 417 papers affiliated to Libya, 348 (83.5%) are affiliated to the medical schools and related hospitals. More than 60% of the 348 papers are affiliated to Benghazi medical school, while Tripoli medical school contributed 103 papers (29.6%).15 The rest of the papers (n=25, 7.2%) were published by medical schools in other parts of the country.15 The publication rate declined by 2.6% annually between 1988 and 2007.15 The decline was mainly due to a decrease in the publication rate by Benghazi medical school.15 Overall, nine departments produced 10 or more papers each.15 Of about 1675 staff members, only 148 show up as first authors and

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207 as last authors. The estimated annual publication rate is 0.72 papers per 100 academic staff members in Libya15 compared with 27.3 papers in Tunisia16 and 45 in the American University of Beirut, Lebanon.17 The first medical journal in Libya, Garyounis Medical Journal, was published by Benghazi medical school in 1978.9 The last volume of this journal was published in 2005.9 Several other journals appeared in the last two decades: Alfateh Medical Journal, Sebha University Journal of Medical Sciences, Libyan Journal of Medical Research, Zuara Medical Journal, Libyan Orthopaedic Journal, El-Razi Medical Gazette, Jamahiria Medical Journal, and Libyan Journal of Infectious Diseases.9 Most of these journals have not survived.9 Two journals were established mainly by Libyan doctors practising in Europe and North America: Libyan Journal of Medicine18 and Ibnosina Journal of Medicine and Biomedical Sciences.19 Recently, the Libyan Journal of Medicine has been indexed in PubMed Central/PubMed.20

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VIII. References
1. Health Information Centre Tripoli, Libya. Health & Environment Annual Statistical report. 2011. 2. Eastern Mediterranean regional health Systems Observatory. Health System profile: Libya. World Health Organization 2007. 3. Clemens MA, Pettersson G. New data on African health professionals abroad. Hum.Resour.Health 2008;6:1. 4. Mullan F. The metrics of the physician brain drain. N.Engl.J Med 2005;353:1810-8. 5. Arah OA. The metrics and correlates of physician migration from Africa. BMC.Public Health 2007;7:83. 6. Sarah Leigh, Information Access Team Administrator in GMC. Number of Libyan doctors in the UK. 19-12-2011. E-mail Communication 7. Sarah Leigh, Information Access Team Administrator in GMC. Number of Libyan doctors in the UK. 20-12-2011. E-mail Communication 8. World Heath Organization. World Health Statistics 2011. 9. Benamer HT, Bakoush O. Medical education in Libya: the challenges. Med Teach. 2009;31:493-6. 10. Libyan International Medical University. http://www.limu.edu.ly . 11. Uthman OA, Uthman MB. Geography of Africa biomedical publications: an analysis of 19962005 PubMed papers. Int.J Health Geogr. 2007;6:46. 12. Bakoush O, Al-Tubuly AA, Ashammakhi N, and Elkhammas EA. PubMed Medical Publications From Libya. Libyan J Med. AOP:070625. 2007. 13. Shaban SF, Abu-Zidan FM. A quantitative analysis of medical publications from Arab countries. Saudi.Med.J. 2003;24:294-6. 14. Benamer HT, Bredan A, Bakoush O. A negative trend of biomedical research in Libya: a bibliometric study. Health Info.Libr.J 2009;26:240-5. 15. Benamer HT, Bredan A, Bakoush O. Scientific publication productivity of Libyan medical schools: A bibliometric study of papers listed in pubMed, 1988-2007. Eductaion for Health 2009;22:310. 16. Ben AA, Abdelali M, Khmakhem A. Bibliometric profile of Tunisians medicals publications indexed in Medline from 2000 to 2003 party 1: productivity and cartography. Tunis Med 2006;84:794-9. 17. Dakik HA, Kaidbey H, Sabra R. Research productivity of the medical faculty at the American University of Beirut. Postgrad.Med J 2006;82:462-4. 17

18. Libyan Medical Journal. http://www.libyanjournalofmedicine.net/index.php/ljm . 19. Ibnosina Journal of Medicine and Biomedical Sciences. http://journals.sfu.ca/ijmbs/index.php/ijmbs . 20. Libyan Medical Journal; PubMed. http://www.libyanjournalofmedicine.net/index.php/ljm/announcement .

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