Strengthening Libya’s primary healthcare workforce: a replicable model for health system resilience in fragile states

Abstract

BACKGROUND: Settings characterized by significant systemic challenges face profound difficulties in building a resilient health workforce, a critical component for achieving Universal Health Coverage (UHC). In Libya, a period of prolonged instability has fragmented the primary health care (PHC) system, resulting in uncoordinated training and a workforce ill-equipped to deliver essential services. This study evaluates a multi-year initiative designed to establish a standardized, nationally-owned in-service training (IST) system to strengthen PHC capacity. METHODS: A phased, multi-method intervention was implemented from 2021 to 2025. The programme comprised: (1) a national landscaping analysis using desk review and stakeholder interviews to diagnose systemic gaps; (2) collaborative development of a national IST Framework via a multi-stakeholder Technical Working Group; (3) co-creation of evidence-based training materials reviewed by a national scientific committee; and (4) implementation of a Train-the-Trainer (ToT) cascade model with supportive supervision. A programmatic evaluation was conducted using pre-post knowledge assessments and thematic analysis of qualitative feedback to measure outcomes. RESULTS: The programme achieved national endorsement of a standardized 5-pillar In-Service Training (IST) Framework. A cohort of 35 Master Trainers was established (66% female), with approximately 94% of the first cohort reporting increased facilitation confidence. This network trained 613 Primary Healthcare (PHC) workers (88% female) across 12 districts. Quantitative assessment (n = 599) revealed significant knowledge gains among trainees (p < 0.001), with mean scores increasing by 29.4% in the first cascade and 33.0% in the second. Thematic analysis of qualitative feedback identified themes of improved professional collaboration, empowerment, and accountability. CONCLUSION: This initiative successfully established the foundation for a coherent, nationally-led In-Service Training (IST) system in a challenging setting, demonstrating a replicable model for health workforce strengthening. The significant knowledge gains and development of sustainable training infrastructure underscore that systematic planning, deep local ownership, and adaptive management are critical for building health system resilience. Future efforts should focus on longitudinal evaluation including clinical audit to assess the impact on clinical practice and patient outcomes.