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Strengthening quality of care in a health system destabilized by years of conflict

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Tane Luna is an obstetrician-gynaecologist. In June 2016 she undertook a placement in the maternity department of Al Marj General Hospital, near Benghazi in northeastern Libya. She describes a hospital system seriously affected by the conflict and political crisis that has engulfed the country for three years and forced hundreds of foreign health workers to flee.

“Since the Libyan revolution in 2011, the country has been experiencing great instability, and hundreds of foreign health workers who contributed a large part of the care and upkeep of Libyan hospitals have fled, leaving the health system in crisis. It is hard to imagine what it was like before, the buildings intact and a certain level of equipment available. Now we are facing a really destabilized health system,” says Dr Tane Luna. An obstetrician-gynaecologist and medical advisor on women’s health for MSF, Dr Luna has just returned from a one-month mission in the country.

The Al Marj Hospital where she worked serves a population of 400,000 in an area so far excluded from the fighting between different armed factions that continues in Benghazi. Up to 2011, partnerships with international organizations guaranteed the hospital a full complement of staff and support for training and medical equipment. But with the loss of that external assistance the situation has become very difficult.

With a fluctuating workforce, insufficient trained personnel, inoperative medical equipment due to the lack of spare parts or technicians to repair them, and significant problems with hygiene and upkeep, Al Marj hospital struggles to provide a high-quality care to thousands of Libyan women. Nevertheless, each month the medical team assists nearly 900 deliveries, including about 150 caesarean sections. This considerable proportion of caesareans is common in hospitals in major cities across Libya, but poses a problem when women have multiple births. This is because repeated caesareans increase the risk of uterine rupture in the subsequent pregnancy, a risk that can only be managed with high quality medical care.

Dr Tane Luna Ramirez
Tane Luna Ramirez, MD Obstetrican and Gynaecologist Women’s Health Advisor OCP Based in the Medical Unit Sydney, Tane supervises women’s health activities in countries including Ivory Coast, Nigeria and Pakistan. She also advises on sexual violence.
Meredith Schofield

“The Al Marj staff are dedicated and willing,” says Dr Luna. “I had a very good relationship with the young doctors, the nurses ... but for years they have had no training or supervision. They have also had little or no access to specific modules of training in obstetrics, and their workflow is generally not well organized. There is no established patient circuit, for example. They are also confronted with missing spare parts for their equipment. So the autoclave can only be used for sterilization when it is full, to limit its usage. Meanwhile, the entry doors to the surgical ward broke but were not repaired. This makes it difficult to control access by family and other people to an area that should be off-limits due to the risk of contamination.”

Al Marj Hospital, Libya
Lifa, an MSF gyneco-obstetrician is having an ultrasound with a Libyan patient as part of the antenatal care provided in the hospital.

The MSF team – seven international staff, five of them medical – have been working alongside their Libyan colleagues since 2015, supporting the hospital with training and donations of equipment and medical supplies alongside MSF’s financial support for running the hospital. Each hospital department is being addressed, one by one.

“We give training on hygiene, facility maintenance and cleaning – from staff uniforms to bedding to surgical areas,” says Dr Luna. “I was able to share my obstetric skills with the young staff and perform complex surgical operations, and ensure there would be follow-through with the placement of another obstetrician-gynaecologist for three months. But it is a very demanding programmed for MSF, involving change management, and we particularly need to bolster the team to be able to support the full breadth of our work there, while also up-skilling the young Libyan professionals to be able to replace the international staff. This is the first time I have experienced such a project: very demanding, in a complex environment, and undertaking European-level obstetrics. But it was also a great experience, although I would have liked to chat with more patients, but few of them spoke English and I don’t speak Arabic.”

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