By Michel Cousins.
Tripoli, 13 August:
Within a couple of weeks or so, probably just after Eid, there will be a ministerial change of guard. A new prime minister and government will be appointed by the recently-elected National Congress. It remains to be seen whether some or any of the existing ministers are reappointed.
The present administration led by Prime Minister Abdurrahim Al-Kib has been in office since November last year. It has not had an easy time of it, balancing enormous expectations against severe limitations, in terms of not only of human and financial resources, but of infrastructure and systems that were either broken or downright non-existent.
No minister has been under more pressure or come in for more criticism in that short time than Fatima Hamroush, the Health Minister. She has taken the flak, not just because of the failings of the Libyan heath service, which was in a dire state when she took over, but also because expectations of improvement that have been wildly optimistic. The public seemingly thought she had a magic wand to turn the service into an instant success — and then resented the fact that the impossible did not happen.
The health ministry and health service has not been totally turned round. Libyans who fall ill still opt to head to Jordan or Tunisia or Turkey if they can afford it, but Hamroush is proud of what has been achieved in the nine months since taking over. “A good bit of work” has been done, Hamroush told the Libya Herald in an interview. It has been a case of effectively rebuilding the health service, if not from scratch, not far off it.
It was very different last November. “We inherited a mess”, she says. Stores were drained, assets frozen, buildings and facilities wrecked, staff dispersed. Worse, it was not just that the system was not working as a result of the revolution. “There was no system”, she says. Most of the other ministries were in the same boat, she admits, but the difference was that people’s demands were so much greater in the case of healthcare.
“Add to that the human resources”, she notes. The quality of staff both within the ministry and in hospitals had deteriorated. “It was good years ago, but in the past 15 to 20 years, it went downhill.” Under the Qaddafi regime, she says, students were accepted for medical training who were well below standard. “There was no proper planning for the future. They took 1,000 medical students a year”, even though that was far too many for the country’s healthcare needs. As a result there is now a surfeit of qualified medics without a job or who have never had a job at all in the sector.
Another problem has been infection control in hospitals. “Doctors have been giving out antibiotics to everyone”, says the minister. As a result there are now untreatable strains of bacteria. “There are young injured with untreatable wounds due to the development of resistant strains“, she explains.
One of the biggest headaches, for has been the lack of funding.
“We had no money”, Hamroush says. Apart from paying salaries, the budget only came into effect on 1 June. “But we managed to run the system. We kept it going. Despite all the various crises, we ran it well.”
One crisis was the lack of medications. “There were no drugs to treat HIV for a whole year”, she reveals. Dealing with this took time. But it has been dealt with, she points out. “Apart from a few exceptions, stores are full of everything we need.” A considerable proportion of the supplies was brought in from Britain using Libyan frozen funds abroad.
But matters have not been helped by the lack of computerisation. Linkages between hospitals, stores and pharmacies has had to be done manually. “It has caused delays”, Hamroush says. “But again, we dealt with it.”
The biggest crisis she had to face was the treatment of the injured revolutionaries abroad and the massive abuse of the service. In fact it was not a ministry of health matter. It was administered by the Committee for the Care of the Injured, which was in effect a separate ministry. But because of the general perception that Hamroush’s ministry was in charge, it and she were blamed.
The service was a complete mess — “badly administered” says Hamroush, in what has to be a generous understatement.
It was a disaster. Officials did not know what bills were for. Separating the genuine from the fraudulent was difficult – and there was rampant fraud. Exorbitant bills came in such as one for a €7,000 taxi ride for an injured thuwar from airport to hospital. Many were paid.
The system was also exploited mercilessly by Libyans who found that all they needed to do was say that they were injured revolutionaries and they and their families could have an all-expenses-paid holiday in Jordan or Tunisia. Others got treatment for conditions that had no possible connection to the revolution. Hundreds of couples, for example, managed to obtain in vitro fertilisation treatment in Jordan under the programme, Many others went for cochlear implants to aid their hearing.
Hamroush tells of many supposedly injured people (but in reality fraudsters) asking doctors abroad to sign letters saying that they needed extra treatment and more time to recuperate, so that they could have an even longer holiday at government expense.
“It drained our country”, says Hamroush. She estimates that so far, Libya has paid out over $3 billion for the revolutionaries’ treatment programme.
“I called for the whole thing to be stopped. I decided to take it under the ministry’s control”, she says.
That finally happened at the end of June, although the ministry started taking over the files in March.
There was an immediate crackdown. It started with Jordan, where at the height of the programme, there were 40,000 Libyans being looked after in the country. Allowances paid to patients and their families were slashed and those whose treatment could be dealt with in Libya were told to return or continue in Jordan at their own expense. Most returned. Numbers there are down to 3,000, Hamroush says.
The ministry then decided to repeat the exercise in other countries where Libyans were being treated, such as Egypt.
“This created a huge wave of violence against the ministry”, says Hamroush, alluding to the demonstrations in Tripoli earlier this year.
At the end of June, she started a legal inquiry into the bills in countries were Libyans were treated, hiring a forensic accountancy company to review them.
“Now we are collecting bills and looking into them”, Hamroush says. “We believe that a number of bills are exaggerated. Some are simply imaginary.”
Officials in the ministry are now also asking questions about what has been spent. They want to know who was responsible for sending people abroad for treatment, why such decisions made, where did the money go and to whom, and how was it spent.
Dealing with the whole messy issue clearly tops Hamroush’s pride list at the ministry. Nonetheless, it has made the ministry very wary about sending people abroad in future for healthcare.
“People can choose to go abroad for treatment, but at their own expense”, Hamrush insists. Only if the treatment is considered absolutely necessary will the authorities pay. “If it’s not available in Libya, we’ll pay.” Even then, it will not be a free-for-all. “We’re going to have government-to-government contracts.” That means that only certain hospitals abroad will be approved. The result will be that “far fewer people will be treated abroad”, she says.
The ministry is also looking to collaborate with the private sector within the country. Where necessary, patients are already being referred to private Libyan hospitals and clinics.
Another issue facing Hamroush when she took over, was the number of unfinished projects, the most famous probably being the Benghazi Medical Centre. It is testimony to the combination of malevolence and incompetence that typified the Qaddafi regime. It was started during the time of King Idris and is still not finished.
Choices had to be made about what to work on and, given the shortage of funds, that was not easy. There was the added problem that some of foreign companies that had been involved in the various projects were worried about the security situation and reluctant to return to Libya. Others put up prices to cover increased demands from employees and insurance companies, in some cases tripling project costs. There were also companies that simply had been too closely involved with the Qaddafi regime. Decisions were made but only at the end of June, when funding was released. “That will show in the next few weeks”, Hamroush said a few days ago.
In fact, it is already showing. Last week, it was announced that work on the second tower building at the Benghazi Medical Centre would begin shortly.
What the ministry has to do now, says Hamroush, is restore trust in Libyan healthcare. “We need to regain confidence in the healthcare sector”, she says.
Moves are being made. She points to the recently reopened oncology centre in Sabratha, to the new radiology centre in Benghazi and the infertility unit in Misrata; two other specialist centres are set to open in Tripoli and Benghazi. New renal dialysis centres have been opened and cochlear implant surgery has started at Benghazi Medical Centre. Even so, she has no illusions about the scale of the mountain to climb.
There are four areas that Hamroush sees as crucial to the ministry’s future success: its human resources, training and education, its administrative skills and medical ethics.
The first means getting the right people to do the job. It means managers who deliver. That too has already started within the ministry. “We got rid of some of the dead wood and got in some people who could take over”, she says.
Human resources also means more qualified doctors and nurses. Some have come back, she says, but many more are needed. So there have had to be incentives, including monetary ones. Offers of salaries double the usual rate have been made. But even that may not be enough to entice back the many Libya doctors working abroad, notably in the UK. Hamroush agrees that the whole issue of new salaries structures for doctors, nurses and health workers will have to be reviewed. They are “abysmally low” she admits.
She says she wanted them to be much higher, to compete with those in other countries, especially in the Arabian Gulf. However, some cabinet colleagues objected, on the grounds that it was unfair to single out the health sector for special treatment.
The issue of salaries in the health service is still being looked into, Hamroush says, and will probably only be addressed next year when state sector salaries are reviewed.
But for the moment, “there is a great difficulty in getting people from abroad”, she explains.
That makes training of local staff all the more important. They will also be needed when the system recovers and develops.
Dealing with Libya’s mountain of healthcare problems has not been easy and might have broken a weaker person. But Hamroush is clearly as much as fighter as anyone who took part in the revolution last year. It has not got her down. She has stood up to her critics.
A new government will be appointed shortly and it may be someone else who takes the helm at the ministry. But Hamroush is clearly proud that despite the problems, despite the crises, “services did not stop”, even though plans and projects had to be stopped and revised. She is proud too that out of the wreck created by the indifference of the Qaddafi years and the turmoil of the revolution, she has helped rebuild a healthcare system that she is firmly convinced is going to work.
There seems every reason to think she is right.