IN A NUTSHELL
Author's note
This article looks at continuity of care for refugees and migrants in Libya, particularly across detention centres, disembarkation points, humanitarian services and the public health system. The central argument is that access to healthcare is only part of the story; what often breaks down is the connection between one episode of care and the next

By Meftah Lahwel
MD, Master in Sustainability in Health

 When People Move, Healthcare Stops

What Libya Reveals About Care Built Around Places Rather Than Patients

 

By the same Author on PEAH: HERE and HERE

 

A patient leaves a detention centre in Libya with a prescription and a referral, but no clear idea where the next consultation will happen. A doctor has seen him. Treatment may have started. Yet the next provider may not know what happened before, the medicine may not be available, and the patient may not know which facility will receive him or who is now responsible for the follow-up.

The illness continues. The care may not.

That simple gap between one consultation and the next is one of the less visible problems in healthcare for refugees and migrants in Libya. We are accustomed to asking whether a service was available: Was a doctor present? Was the patient examined? Was medicine provided? Was a referral made? These questions matter, but they describe encounters. They do not necessarily tell us whether care continued.

Migrants, refugees and asylum seekers are not one population. Their reasons for moving, legal situations, vulnerabilities and entitlements differ, and internally displaced Libyans face another set of circumstances. These distinctions should not be blurred. But from the perspective of continuity of care, movement creates a common practical problem: a patient can cross from one place, provider or institution to another while the health condition remains exactly the same.

In Libya, that movement often takes place across a health landscape made up of public facilities, humanitarian services, specialised national programmes and informal networks. None of these components is irrelevant. The problem is that they do not always connect around the patient.

At detention centres and disembarkation points, much of the documented direct healthcare for migrants and refugees has been delivered by international organisations and their partners. IOM’s current Libya response, for example, includes primary healthcare and referrals to secondary and tertiary care at detention centres, disembarkation points and migrant-dense locations. National health structures play a different role: they remain central to the wider public system and to disease surveillance and specialised programmes. Tuberculosis is one of the clearest examples, with diagnosis and treatment embedded in the national TB pathway while international actors support screening, referral and programme capacity.

This division of work has been necessary. It has filled gaps and, in many cases, allowed care to happen where it otherwise might not. But it also exposes the continuity problem. A patient may be seen at a disembarkation point, treated inside a detention centre, referred to a public facility and later need follow-up somewhere else. At each stage, a different actor may be doing exactly what its mandate requires. The patient’s illness, however, does not divide itself according to mandates.

The illness does not recognise the boundary between one mandate and another. The system does.

That is where access and continuity begin to separate. A referral may be correctly issued and still never be completed. A treatment plan may be clinically appropriate and still become impossible to maintain when the patient moves. Medical information may remain with the first provider while the next clinician has to reconstruct the history from memory, a photograph of a prescription or a laboratory paper carried in a bag. Transport, documentation, language, cost and medicine availability can turn a straightforward referral into another point at which care is lost.

For a person who needs one consultation, this fragmentation may be inconvenient. For someone with tuberculosis, diabetes, hypertension, a mental health condition, a complicated pregnancy or another condition requiring follow-up, it can change the course of the illness. Treatment is not only what happens while the patient is in front of the doctor. It is also what happens after the patient leaves.

This matters even more as the direction of policy moves, reasonably, away from permanent parallel humanitarian healthcare and towards greater use of Libya’s national health system. Lately, humanitarian actors advise refugees and asylum seekers to access public primary healthcare centres and hospitals rather than medical assistance through partners or private clinics. That is the right long-term direction. Humanitarian organisations cannot, and should not, become a second national health service.

But integration is not the same as continuity.

The public system people are being asked to use is itself under pressure. WHO has documented shortages of essential medicines and medical supplies and major limitations in facility functionality; in an assessment from December 2024, 84 per cent of assessed facilities were only partially functioning. UNHCR’s own public guidance also reflects practical barriers: identification is generally expected, and secondary and tertiary care usually involves fees. So the patient may leave a humanitarian service and enter a national system that is itself trying to manage shortages, costs and uneven service availability.

The result is an uncomfortable space between two reasonable positions. Humanitarian organisations cannot provide everything forever, and refugees and migrants should, where possible, be included in the national system. Yet neither statement answers the question that matters most at the moment of transition: where does this particular patient go next, and who makes sure the care actually continues?

In practice, that responsibility often shifts quietly onto the patient. People navigating fragmented healthcare become custodians of their own medical histories. They remember medicine names, or sometimes only what a tablet looked like. They keep photographs of prescriptions on their phones, carry laboratory reports with them and repeat the same history to each new clinician. They ask friends, relatives and community members which facility might receive them, where a medicine can be found or whether someone knows someone who can help with a referral.

These informal networks are important. Sometimes they are the reason care continues at all. But we should be careful about calling every act of improvisation resilience. When the patient has to transfer the information, locate the next provider, negotiate the referral and search for the medicine, the patient is doing part of the health system’s work.

That also makes continuity an equity issue. A person with money may buy a missing medicine privately. Someone who speaks Arabic may navigate a facility more easily. Someone with documentation may encounter fewer administrative obstacles. Someone with strong social connections may find a way through a referral pathway that appears closed to somebody else. Another person may simply stop treatment. The same fragmented system therefore produces very different outcomes depending on how much the patient can personally compensate for its gaps.

This is why the discussion has to move beyond access. It also has to move beyond the numbers with which humanitarian and health programmes usually describe success. Consultations, referrals, medicines distributed, facilities supported and people reached are all necessary measures. They tell us what was delivered. But they mostly measure activity, not continuity.

A referral issued is not the same as a referral completed. A prescription written is not the same as treatment maintained. A patient seen today is not necessarily a patient cared for tomorrow.

Libya makes this distinction unusually visible because public services, humanitarian programmes, detention centres, disembarkation points, urban communities and different forms of human mobility all meet within the same health landscape. It is possible for many actors to be present and for the patient still to experience a gap. Several available services do not automatically make one functioning system.

The answer is not to build another separate health architecture for migrants or refugees. Dedicated humanitarian services may remain indispensable in certain settings, particularly at detention centres and disembarkation points. But the long-term task is to make care survive the transition from one provider to another.

That requires less grand language and more practical connection: a medical summary that can move with the patient; a referral the receiving facility understands; communication between the provider sending the patient and the provider expected to receive them; a way of knowing whether an important referral was actually completed; continuity of essential medicines when somebody changes location; and primary healthcare that can reconnect a person with treatment already started elsewhere.

Digital health can help with some of this, but technology cannot solve a problem of responsibility. An electronic record has limited value if the next facility cannot access it, if the medicine is unavailable, if the referral is not recognised or if everyone assumes follow-up belongs to somebody else. Continuity begins when one part of the system accepts responsibility for connecting the patient with the next.

Libya has spent years responding to health needs through public services, humanitarian interventions, emergency arrangements, local initiatives and informal solutions. Much of that work has been necessary, and much of it has saved lives. The next question should not only be whether another service can be added. It should be whether the services already there can begin to behave more like a system.

Patients do not experience healthcare through organisational charts, mandates or funding agreements. They experience it as a sequence: a consultation, a prescription, a referral, a journey to another facility and the hope that somebody there will know what needs to happen next. When that connection fails, the system may still record a successful consultation while the patient experiences an interruption.

The patient should not have to carry the system. The system should carry the care.

Libya cannot remove mobility from its health reality. Humanitarian organisations cannot remain everywhere a patient may eventually go, and a strained public health system cannot simply absorb every additional need because another actor has completed its part. But continuity does not require an impossible promise that one provider will follow every person everywhere. It requires something more basic: that movement should not automatically erase what happened before.

A change in location should not unnecessarily become a break in healthcare. The health condition continues. The patient continues. Healthcare should too.