Promoting Healthcare Partnerships: Delegation to T

In the subsequent Q&A, Nick Carter (Varian/Kalua Medical) thanked Prof Lenghi for an honest account of the problems faced by the Libyan national heath service and asked whether its future development would benefit from a more co-ordinated strategy. In response, Prof Lenghi agreed that while a “scattergun” approach was not the best policy to follow, the fact that Libya’s health service was deficient in so many areas meant that investment and development was required “across the board”. He also reiterated that the development of primary healthcare (PHC) services and facilities was the key to providing a broad and solid base on which a comprehensive national healthcare system could be built. Co-ordination of this development programme, he added, was largely dependent upon the adoption of an effective ICT system.

Stuart Smalley (DH International) said the collaborative relationship between the UK and Libyan governments (as set down in the recent Memorandum of Understanding signed by the Libyan and British Ministers for Health) was bearing fruit and that “putting foot soldiers on the ground” in Libya was the next important phase of this collaboration. He added that the current strategic focus was on working with UK universities and colleges and on “improving competencies of key staff to help accelerate healthcare programmes in Libya”. In this respect, he said, the current approach was indeed co-ordinated.

Muralee Menin (AJAI) asked whether the health authorities planned to look at re-branding PHC in Libya in order to raise public confidence in these new facilities and services.

In response, Prof Lenghi agreed that people in Libya typically use specialist hospitals as walk-in clinics because of the perception that this is where the best care can be accessed. He added that, as well as the physical provision and reorganisation of PHC in Libya, a re-branding exercise needed to be implemented to build public confidence in PHC. for more on this topic see the briefing "Regaining Public Trust in the Libyan National Health Service" below.

Professor Keith Britton (Healthshare International) suggested that one way of improving the quality of PHC and how it is regarded by the general population, would be for Libya to adopt a system similar to that employed in many countries where it is obligatory for ALL doctors to spend at least one or two years practising in a family GP surgery or primary healthcare facility out in the ‘provinces’ before they are allowed to follow a career in more specialised (and lucrative) areas of healthcare provision. In Libya, this would also ensure that people living in rural/desert regions would still be assured quality healthcare provision without having to travel to Tripoli or Benghazi (or even abroad) for basic treatment.

Prof Lenghi agreed that, until recently, the idea of a medical student becoming a family doctor and/or PHC specialist simply did not exist in Libya. But over the next five years, he added, the training and recruitment programmes that are being implemented will mean that there are enough new doctors to fulfil the needs of Libya’s growing population. With respect to co-ordination, he added that an electronic ID card system was being considered which would record individual patients’ personal details and history of treatment/care.

Dr Vince Ramprogus (Manchester Metropolitan University) questioned whether this focus on primary care would encompass recruitment and training in the variety of healthcare professions – such as physiotherapy, occupational therapy and community nursing – that make up a modern comprehensive GP practice. Stuart Smalley confirmed that the International Academy of Royal Colleges* is embracing a multi-disciplinary approach and Prof Lenghi stressed that the development of an effective management structure is also a priority, with Libyan hospitals entering into collaborative programmes with British partners based on European standards.

Dr Arhima’s presentation summarised the role of the National Food & Drug Control Centre and outlined the most important recent changes to the regulatory framework in which it operates. These changes have taken place since the reorganisation and centralisation of Libya’s national health authority and the formation of the General People’s Committee for Health and the Environment (GPCHE) in March 2006 – developments which also included the re-launch of the NFDCC and a revision of the agency’s regulatory role with respect to the importation of pharmaceutical supplies into Libya.

Dr Arhima’s presentation served to illustrate the clear benefits extended by Libya to UK (and European) importers of pharmaceutical products. Drugs coming in from Europe receive only cursory visual inspections in contrast to those imported from outside the EU which are subject to sample withdrawals, laboratory analyses and compliance tests.

He also showed that the current favourable environment for UK drugs companies is supported by the most recent official figures which reveal that during the past year the number of drugs shipments from Britain more than doubled from 118 in 2008 to over 300 during 2009. Given that the total number of annual shipments into Libya stands at around 6000, this means that the UK is responsible for about 5% of all drug imports into Libya – a figure which continues to grow, both in real terms and as a proportion of total shipments.

Dr Arhima concluded by emphasising how the NFDCC is actively extending the close collaborative relationship between the Libyan and British healthcare authorities. For example, a programme to work with the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK is presently being put into action which will, for example, help combat the spread of parallel or ‘grey’ imports into the Libyan pharmaceuticals market.

The aim of this presentation was to steer delegates through the most recent (and most important) developments in the government-to-government co-operation programme which has seen the UK and Libya extend and strengthen its relationship with regards healthcare provision.

Mr Smalley began by outlining the key elements of health policy development in Libya which, like the UK, are based upon the principle of free universal healthcare for all. This principle has been protected since 1973 by Public Health Law no. 106, which declares that health is the right of all people and it is guaranteed by the State, and which aims to “promote the development of comprehensive healthcare including public health, preventative services, mental health, occupational health and social care for the elderly” with a particular emphasis on promoting equity in access to healthcare systems.

He continued by identifying the key partnership programmes already being developed following the signing of memoranda of understanding between the Libyan and British health authorities, notably in the areas of Disease Surveillance (with the Health Protection Agency), Primary Care Development (including the marketing and re-branding of primary care in Libya), and Management Education, Postgraduate Education and General Management Projects (with a focus on “training the trainer” programmes to ensure that in the future Libya can continue to develop these areas autonomously).

Mr Smalley emphasised that a robust working relationship has now been established between Britain and Libya, adding that there is clear evidence that Libya wants to introduce private sector skills into the healthcare arena and has shown a preference for working with British expertise. He also said that while funding issues were initially a concern these have now been largely overcome.

In conclusion, Mr Smalley said that both the pace of change in Libya and the pace of collaboration with the UK is quickening – a situation which British firms and organisations would do well to take advantage of. He added the proviso that while the UK may be seen as the preferred partner, this market advantage will only be preserved as long as we continue to compete on price with other potential suppliers from elsewhere in Europe and beyond.

In the Q&A, in response to a question about whether a precise ‘roadmap’ had been drawn up for the development of the private [healthcare] sector in Libya, Mr Smalley explained: “A lack of finance has been the problem in the past, whereby we have failed to unlock the funds at the last-minute. But, on the Libyan side, the funding is now in place. I believe we need to progress in small steps or in bite-sized chunks. We can’t cater for the entire country all at once.” He added that he advocated an ad hoc (but NOT scattergun) approach – for example, by employing pilot schemes in discrete areas such as the training of GPs.

The main focus of Dr. Enaami’s presentation was the Libyan National Fund for Domestic Development (LNFDD). Worth around LYD20 billion (c.£10.5 billion) this new fund was created last year (2009) specifically to invest in local markets.

Dr Enaami explained that, during sanctions, healthcare in Libya had suffered major under-investment, and that the new fund will cover all sectors including healthcare, adding that the LIA would be receptive to hearing any ideas for joint investment projects or partnership initiatives which would create opportunities within the Libyan healthcare sector.

He also spoke about the increasing role of the private sector in Libya’s healthcare development. In recent years, he said, Libya has seen the private sector taking a big lead in healthcare and an end to over-reliance upon free public services. As a result, “the general public is now more accepting of having to pay for medical care and treatment; previously, if it wasn’t free then the people would not accept it.” Dr Enaami also identified potential opportunities in the medical insurance market. He said while there is presently no single domestic provider for medical insurance products in Libya, the management of the new Domestic Fund would be “more than willing to talk to medical insurance companies” about creating services for the medical care sector going forward.

Jerry Ryan (HKR) asked about how these new joint investment projects would be procured – i.e. whether they would be subject to the (often-prolonged) ‘committee system’ and, if so, whether a new committee would be established for this purpose. Mr Enaami said because the LIA Board of Directors were specialists in specific areas, the decision-making process would be much shorter than with the committee system.

In response to a question about whether or not new primary care clinics would be joint public-private (or ‘quasi-private’) ventures, Dr Enaami said he believed that while each case would be judged on its own merits, “overall, I think, we should be encouraging the private sector to handle healthcare [projects] due to the increased efficiencies derived from private sector competition.” Finally, John Parr (LBBC) asked about the recently-established London office of the LIA and how it has been tasked. Dr Enaami explained that the main rationale behind opening an office in London was “ease of access” – so the Authority’s team could be nearer to the City and benefit from the expertise gathered here to help them make better informed investment decisions.

Dr Seifennaser spoke about the challenge of re-branding the Libyan national health service, presenting in detail the necessary prerequisite actions that must be taken in order that both the professionals working within the system and the patients who benefit from it regain confidence in its capacity to provide high quality, comprehensive health care.

According to the WHO, over the past three decades Libya has invested billions of dinars in health services, which has resulted in major improvements in terms of both service delivery and in the general health of the population, as supported by all the key health indicators. Despite these improvements, however, Libya is still facing major health problems and the general population is almost universally discontent with the public health service, at every level.

Dr Seifennaser’s study details the current state of the Libyan healthcare system and the most pressing concerns from the point of view of three sets of stakeholders:- the patient, the service provider (i.e. local doctors) and the independent experts (i.e. WHO representatives). He then sets out a number of policy objectives which the Libyan health authorities should adopt in order to address these multiple issues, starting with the establishment of a Health Regulation Agency “authorised and legislated by law” and with a clear mandate to maintain a number of interrelated projects aimed at overhauling both primary care (family surgeries) and secondary care (public hospitals) facilities and processes.

At the broadest level, the agency would seek to achieve the following: offer people easy and fast GP access; offer effective, trusty and suitable hospital services; improve the performance health care providers; control malpractice and poor service; and ensure best use of resources. At the heart of this plan lies the establishment of an effective and comprehensive electronic patient records system.

Graeme Allen (Hiltron) asked when the proposed health regulation agency would be up and running and whether the policies laid out in the presentation were a reality or little more than wishful thinking…In reply, Dr Seifennaser said that while the aim was to make these plans accepted public policy, the most important prerequisite was the implementation of a working ICT system.

Professor Abudher spoke about the role of the NCIDC and how partnership with experts and organisations in the UK has helped Libya to develop state-of-the-art systems and processes for the surveillance and prevention of communicable diseases, such as measles, swine flu and HIV/AIDS.

The NCIDC is currently overseeing the development of a groundbreaking programme in collaboration with the UK’s Health Protection Agency (HPA).

ERS was formed in 2003 to provide a range of specialist rescue and medical training, consultancy and operational support services to Government agencies, large corporate bodies and SMEs. John is a highly qualified paramedic and resuscitation teacher, with significant experience of providing medical, rescue, and search and recovery services in remote environments. ERS MENAS has an office and training centre in Janzour, Tripoli, and despite having only been operating in Libya for a relatively short period is already working with the Libyan Ministry of Health as an accredited training partner. Here John provides a case study outlining how ERS has established itself as a Libyan Law 5 Company, evidence of the long-term commitment it has made to Libya.

In the Q&A session that followed, John was asked what he believed to be a reasonable and realistic investment in terms of time and money for a UK company trying to establish itself in Libya for the first time. In reply, John said ERS had spent around £400,000 over a period of about three years to get to where it is today, adding that these figures may, of course, vary from company to company and sector to sector. Peter Bolton (Bolton Surgical) raised the issue of credit and payment terms, asking what can be done in a scenario whereby payment is being delayed for extended periods (of up to 18 months). This led to the suggestion that companies operating in Libya might consider the services of a company such as Coface (see www.cofaceuk.com) which offers complete trade management solutions to businesses operating in international markets – including credit insurance, which protects companies against late or non-payment by a client.

Dr Attallah undertook his medical training in Tripoli and at the Charles University in the Czech Republic, where he specialised in paediatrics. Having worked as a regional shabiat (district) head of health services, since 2002 he has been the rapporteur for the Scientific Immunisation Committee at the Center for Disease Control and Prevention (CDC). Since July 2008, as Head of the Secretariat’s Primary Healthcare Department, he has been instrumental in making the development of primary care services and facilities a major priority as a model to improve access to basic healthcare for all Libyans. He is currently working with The Royal college of General Practitioners to co-ordinate a joint UK/Libyan project aimed at developing primary care services in Libya.

Professor Obeid began by highlighting the main deficiencies in Libya’s healthcare system, identifying disorganisation and inefficient (or non-existent) strategic planning and research at all levels of healthcare provision – from GP and family-oriented surgeries to polyclinics and large-scale medical facilities and public hospitals. As has been stated in previous talks, Prof Obeid said that the expectations of Libyan people with respect to healthcare services has always far exceeded supply, adding that this is a situation which is unlikely to change even if and when new more efficient and more effective services are introduced: “Whatever we do, we will never exceed [the public’s] expectations!”

He continued with a comprehensive review of the Benghazi Medical Center’s facilities, providing detailed facts and figures on everything from the number of buildings (46) and car park capacity (1774 cars) to the surface area of all the floors (168000 m2) and even the length of tunnel and passages which make up this new flagship medical centre (2045m)!? Perhaps more instructively, he also supplied information on the number of beds (1200) and their distribution by department together with details of the various medical disciplines which are currently practiced at BMC and the distribution of Libyan and non-Libyan staff. This last statistic was particularly interesting as it revealed that out of 545 nurses currently working at BMC, 478 or 88 percent are non-Libyan nationals.

The final part of the presentation examined ‘future planning and solutions’ and, particularly, how standards of hospital governance in Libya could be improved. Workshops in various areas of hospital administration and healthcare management are being set up and timeframes established for improvement programmes in key healthcare areas including GP services, polyclinics, emergency services, pharmaceutical supplies, medical equipment supply and maintenance and support services such as catering, laundry and housekeeping. Finally, Prof Obeid advocates the development of a National Council for Strategic Planning for Health Services and Education for every medical speciality and building a strong infrastructure for health research which involves all medical schools to encourage independent research.

Nick Carter (Varian/Kalua Medical) asked if BMC would be receptive to the idea of forming a twinning relationship with a UK medical institution to assist the programme of modernisation and improvement which Prof Obeid had outlined. He replied that this was a strategy which was already being employed but added that there was scope for much more to be done in partnership with UK hospitals. He said: “There are huge benefits to be gained from twinning and indeed BMC already relies heavily on overseas expertise…but this is clearly an area that we will be exploring further in the future.”

Paul Deeney’s presentation reviews the four basic forms of taxation which foreign businesses and individuals are subject to in Libya, i.e. corporate tax, personal tax, stamp duty and other miscellaneous taxes. On the whole, Libya has a comparatively business-friendly tax system for foreign companies – for example, in Libya, there is no Value Added Tax (VAT), no Capital Gains Tax (CGT) and no Withholding Tax (WHT), which is often imposed by governments on distributions being made to foreigners. Anyone considering setting up a business venture in Libya would do well to study all of the information contained in this presentation (see download for details) so that they are well-informed about the Libyan tax regime. Or for individual enquiries contact Paul direct at: paul.deeney@ly.pwc.com

The final presentation of the event was given by Dr Saleh El Gadi, a doctor with experience of living and working in both the UK and Libya. This highly entertaining talk provided a general overview of the potential for Libyan-British collaboration within the healthcare industry from the point of view of an experienced medical professional who recently established a private enterprise in Libya having worked for many years in the in the UK. Dr El Gadi used this opportunity to promote his own company, which he describes as a turnkey healthcare solutions provider focused on exploiting opportunities in Libya’s burgeoning healthcare market.

In the second part of his presentation, Dr El Gadi explored the potential for developing a common ICT system across Libya’s healthcare sector, demonstrating how a universally-approved system would create synergistic improvements across Libya’s diverse healthcare industry in almost every measurable area of medical care provision including productivity, waste reduction, resource allocation and utilisation, cost containment, communication, and patient safety and risk reduction. He concludes by suggesting that the introduction of a system of this kind would necessitate a complete transformation in working practices within Libya’s healthcare industry.

Nick Carter (Varian/Kalua Medical) asked the speaker if he believed the growth of the healthcare industry in Libya would ultimately be led by the public or private sector. Dr El Gadi said that while both sectors were displaying plenty of evidence for growth in multiple areas, the likelihood was that the private sector would in time become the main vehicle for development. For example, he said, the Leader has shown himself to be very serious about the introduction of health insurance for Libyan citizens and recognises that this could potentially be a key driver for growth of private healthcare services and facilities going forward.