The confict in Libya continued in 2020, fuelled by external powers that channelled money and weapons to factions inside the country. The country’s porous borders, especially in the south, allowed the smuggling of migrants, foreign fghters and weapons to continue unabated.
Two competing governments – the Government of National Accord (GNA) in Tripoli and the rival government in the east backed by the Libyan National Army (LNA) continued to fght for power and resources. The situation was exacerbated by local conficts between various factions and ethnic groups that laid bare the country’s deep tribal and political divides. Although Libya has the largest oil reserves in Africa, the continuing blockade of the oil sector devastated its economy. In addition, the coronavirus disease (COVID-19) pandemic led to national lockdowns, rocketing food prices and signifcant loss of livelihoods, especially for the refugees and migrants who make up approximately 9% of Libya’s population.
At the beginning of the year, international diplomatic initiatives seeking to end the confict were short-lived. In January 2020, the Berlin Conference on Libya emphasized the need for a political solution to end the confict. The following month, the United Nations Security Council unanimously endorsed the conclusions of the conference and called for a lasting ceasefre.
Despite this, skirmishes between the GNA and LNA continued, with control of key locations passing back and forth between them. The LNA continued its prolonged attempt to gain control of Tripoli and surrounding areas. In mid-April, LNA-controlled towns along the western coastal road were seized by the GNA. The town of Tarhouna, a strategic stronghold of the LNA, became a fashpoint and was attacked and besieged the same month. In June, GNA forces retook Tarhouna and other cities on the coastal road and then regained full control of Tripoli and nearby areas. The subsequent discovery of several mass graves, most of them in Tarhouna, prompted calls from the UN SecretaryGeneral for a thorough investigation and for the perpetrators to be brought to justice.
Water and electricity cuts were used as instruments of war. In April 2020, more than two million people in Tripoli and surrounding areas were left without water for more than a week. In the spring of 2020, military activity around Tripoli disrupted hospitals’ electricity supplies and damaged the only factory producing oxygen tanks, just when oxygen was critically needed for the COVID-19 response. At the height of the summer, when temperatures reached well over 40C, continued fghting in the west cut off water and electricity supplies for prolonged periods. By July 2020, daily blackouts were averaging 12 hours per day.
In October 2020, prospects for lasting peace improved when military offcers from the LNA and GNA signed a permanent ceasefre agreement in Geneva under the auspices of UN6MIL. By the end of the year, the agreement had been breached several times.
On 14 March 2020, in the face of the threat posed by the virus, Libya declared a state of emergency and closed all its air and sea ports. Ten days later, it reported its frst confrmed case of the disease.
By the end of the year, almost 100 000 people had been infected with the virus. The pandemic exposed the country’s inequalities and placed a huge strain on its already severely disrupted health system. Many households were plunged into poverty. Border closures, movement restrictions and curfews imposed to reduce the spread of the virus drove up the cost of food and essential items by 20%. Many of the country’s more than half million migrants and refugees no longer had access to the informal work opportunities they once had.
Because of their displacement or legal status, they had limited access to health care services. Those who tried to return home found they could no longer do so because travel was extremely diffcult and their sources of income had disappeared.
The extraordinarily complex political and security environment in Libya hampered efforts to contain the spread of the pandemic. Unequal access to health care put the most vulnerable, particularly refugees and migrants, at a disadvantage.
There was very little coordination between the GNA in the west and the LNA in the east. Both governments attempted to make political capital out of the COVID-19 crisis by discrediting their opponents and claiming they had the capacity to respond on their own. The lack of accountability and internal tensions within and between different government departments delayed critical decisions about releasing urgently needed funds to procure vaccines or support the COVID-19 response. In Tripoli, the position of Minister of Health remained vacant for most of the year, and the deputy Minister was wanted on corruption charges. By the end of the year, the COVID-19 national preparedness and response plan, drafted at the beginning of the pandemic, had still not been formally endorsed.
The health system, already severely damaged by years of under-investment, struggled to cope with the additional demands brought by COVID-19. At the start of the pandemic, reports indicated that in some areas, up to 90% of primary health care (PHC) centres had closed and several hospitals had been forced to suspend services because health care staff refused to report for duty without PPE.
Health care workers were paid only sporadically and many were no longer reporting for duty.
People in need of humanitarian health assistance
Beset by confict and insecurity, almost 900 000 people in the country needed humanitarian assistance, including close to 400 000 Libyans (about 6% of the population) who had been displaced. )ollowing the LNA’s failed military offensive, people slowly began returning home, particularly in the areas around southern Tripoli.
By the end of the year, the number of displaced people had fallen to around 392 000. However, the presence of landmines and unexploded ordnance posed a signifcant threat to returnees.
Status of health care services
More than half of Libya’s health care facilities that were functioning in 2019 were forced to close in 2020. Closures were especially severe in rural areas, mainly because of security threats and lack of national and health sector funding. Those that remained open suffered frequent electricity cuts that were exacerbated by shortages of fuel to run back-up generators. Repeated stockouts of critical vaccines disrupted immunization schedules and put children at risk of life-threatening diseases such as measles and polio. WHO and UNICEF estimated that more than a quarter of a million children had missed their doses of essential vaccines. Nationwide, over two thirds of PHC centres had no antibiotics, analgesics, insulin, blood pressure medication or any of Libya’s other top 20 essential medicines. Most health care staff had to wait months to receive their salaries. In particularly in the areas around southern Tripoli.
By the end of the year, the number of displaced people had fallen to around 392 000. However, the presence of landmines and unexploded ordnance posed a signifcant threat to returnees. addition, many of them were reluctant to report for duty for fear of being infected with the SARSCoV-2 virus. Between January and August 2020, only 70% of disease alerts were investigated and responded to within 72 hours.
In 2020, WHO assessed the health situation and health needs in 9 Libyan communities (comprising over 850 000 people) in 111 of Libya’s 22 districts.
Over 90% of these communities were in areas ranked as 3 or above on the severity scale2 . The assessment found that although hypertension and diabetes were the most commonly reported diseases, medicines to treat them were widely unavailable. The nearest health care facility for patients was on average 14 km away, and this meant that they were inaccessible for many people.
An assessment of the availability of fve essential health care services in the historically underserved south revealed that only 12% of primary health care (PHC) facilities had all fve services. Moreover, only 3% of facilities had stocks of all top 20 essential medicines, and almost one third had no essential medicines at all. Three quarters of communities had no antenatal care services or health care services for children under fve years of age.
Trauma care and disability services were available only in Libya’s main cities, and mental health services were almost non-existent. Immunization services experienced repeated vaccine stockouts.
COVID-19 lockdowns and curfews further reduced people’s access to PHC services.
Patients were increasingly referred for treatment to the main cities of Tripoli, Benghazi, Misrata and Sebha. However, referrals were hampered by the lack of reliable ways to transfer patients for secondary or tertiary level care. Moreover, many hospitals were forced to suspend their services due to the high rates of COVID-19 infection among patients and staff, further exacerbating gaps in the health system. Many people were forced to seek private health care, diverting resources from overstretched family budgets.