There are n=369 workers employed at the BRHC [29]. The organisational structure is hierarchical, with a General Manager, central administration services, and department heads reporting to the general manager across service types such as nursing, outpatients, therapy, and staff supervisors (who may have been department heads). According to the 2011 BRHC Annual Report [29] there were n=150 managerial and financial affairs workers; n=158 in the health care department; n=22 in the rehabilitation and social care department; n=17 in the prosthesis manufacturing department; n=25 in operation and maintenance. At the time of the study in 2012 there was one physician in the prosthetics department. BRHC nurses, therapists and prosthetic technicians were all trained in Libya. Although funded by the government, from time to time in 2011-2012, there were delays in payment of salaries, but staff continued to come to work in expectation that they would ultimately be paid because this had happened in the past.

Of 232 eligible staff, 30.6% participated (n=72). Participants had a mean age of 39.4 years (Mdn 38.1, range 26 to 66, SD 8.2, 3 missing); 56% (n=40) of participants were male (43%, n=31 female).
All lived in Benghazi, were Libyan citizens and had Arabic as their first language. In rank order from highest to lowest proportion education level was:-

- 28.2% intermediate secondary school (n=20; 6 females, 14 males);
- 22.5% University Bachelor degree (n=16; 9 females, 7 males);
- 16.9% senior high school (n=12; 7 females, 5 males);
- 14.1% college Diploma (n=10; 3 females, 7 males);
- 5.6% technical qualification (n=4; 1 female and 3 males) ;
- 5.6%% primary school (n=4; 3 females, 1 male); and
- 4.2% University Master's degree (n=3; 2 female and 1 male).

There was no association between gender and level of highest education (X2 =2.808; p=.246) when grouped into: (a) school (primary, secondary or high school leaving certificates); (b) college (Diploma or Technical Qualification); and (c) University (Bachelor, Masters).The statistical association between occupation and highest qualification was significant (X2 =11.053, p=.026) across three groups of (a) nurses, (b) therapists and technicians and (c) administrators and managers. These three aggregated groups were used to ensure cell sizes >5. More staff in management/administration held university qualifications; only three nurses and one therapist held bachelor degrees. Most therapists and one prosthetic technician held diplomas. Overall, in every group most workers had secondary school as their highest qualification.

Occupation: Most participants were therapists (26.7%, n=19; 4 females, 15 males), followed by administration officers 22.5% (n=16, 9 females, 7 males), nurses 19.70% (n=14; 12 females, 2 males) prosthesis technicians 12.70% (n=9; all males) and administrative managers 7% (n=5; 1 females, 4 males). Biomedical and x-ray technicians were grouped together as these were very small cohorts; 5.6% of participants came from this aggregate group (n=4; all female). There was one male physician in the sample. The highest response rate for an occupational group was therapists (n=19 of a total 30; 63%); followed by prosthesis technicians (n=9 from a total n= 14; 64.3%); nurses (n=14 of 67, 20.8%) and administration officers (n=16 of 135, 11.8%). There was a significant association (X2= 14.677, p=0.001) between occupation and gender. Most therapists and prosthetic technicians were male and most nurses and administrative workers were female.

Work arrangements: All staff were employees; in the past there were visiting physicians but not since the conflict. Apart from nurses who worked in shifts, the usual work day was 8 am to 2pm. At the time of the study a new policy had been issued by the Ministry of Social Affairs that the standard work hours for all BRHC would change from 8am-2pm to 8am-3:30pm. This new policy was still in the process of being implemented. Workers had to sign-on at commencement and sign-off before going home. Although work hours were prescribed there was some department flexibility. Separate clinical assessment and treatment areas were provided for male and female patients and staff preferred to work in same-gender areas. The closure of the female inpatient ward meant that female nurses had to work on the male ward and this was reported to be uncomfortable for some.

Recruitment and retention: The average length of employment at BRHC was 13.28 years (range 1 to 35 years; 13.87 years females; 12.82 years males); relationship of gender and average length of employment was not significant (t=-.506; p=.615). A third had worked there for over 20 years (21-25 years, 22.5%, n=6 females, n=10 males; over 26 years 9.8%, n=7, all males). Just under a third had worked over 10 to 20 years (30.9% 11-20 years, n=12 females, n=10 males); and less than a third worked 10 or less years (6-10 years, n=16, n=10 females, n=6 males; <5 years n=13, 5 females, 8 males).

Job descriptions and/or task-specific positions could not be identified. There was no formal documented human resources workforce planning or allocation system - managers
were aware of the labour needs of their areas. In some clinical areas there was reported to be a shortage of staff. Recruitment and selection of new staff was done when needed and when finance was available. There was no formal documented human resources turnover, retention or succession plan.

Teamwork: More than half the participants (53%) reported that they did not work as a part of a team; just 42% (n=30) did. The BRHC did not have a formal team system so when it did occur it consisted of episode-specific care teams such as: (a) nurse and therapist (8.5%); (b) therapist, prosthetics technician and orthopaedic physician (7%); or (c) therapist and prosthesis technician (2.8%).

Patient Education: The majority of participants did not provide training to patients or their families (n=48, 67.6%), but a minority did (n=22, 31%) (n=1 missing). These were predominantly technicians or therapists. Similarly provision of training to the community in general was very limited (n=8, 11.3%).

Perceptions of service provision before and after the revolution: Most 63.4% (n=45) participants indicated no change in the type of services provided at the BRHC from before the revolution to after it. In response to an open question about diagnoses seen at the centre after the revolution, n=28 participants reported stroke, n=25 said different types of physical disability, and n=17 specifically identified amputations. Other conditions mentioned by participants were fractures (n=8), cartilage damage (n=8), accident cases (n=8), spinal cord injuries (n=1), neck injuries (n=1), pelvis injuries (n=1), and damage to vertebra (n=1). These participant reports could not be corroborated against centre records because there were no aggregated patient information systems that could be used to track diagnostic categories or services provided.

Information management systems: Participants 53% (n=37) reported no centre-wide or out-patient information management system. Others identified there were patient records but these were not linked between different departments (n=45, 63%); for example inpatient nursing files and prosthesis workshop registration and service files. Some patients at the centre had initially received medical and rehabilitation treatment overseas before being repatriated and admitted to outpatient or inpatient services at the centre. A minority of participants had seen records sent from overseas for these patients (n= 16, 22%).

The lack of institution wide patient records meant that it was difficult to ascertain presentation number or type, services requested and used, diagnostic categories, co-morbidities, severity of conditions, length of stay, discharge destination, referral and service use patterns, patient demographics and treatments. This situation was exacerbated during and after the revolution when demand escalated.

Community Based Rehabilitation (CBR): 41% (n=29) thought there were no CBR or home services for people with disabilities; 48% (n=34) did not know (8.5%, n=6 missing). A few participants (n=6, 8.5%) reported there was CBR available- all of these people were senior professionals. No national or district policies, procedures or program reports on CBR could be located.

Awareness of the United Nations Convention on Rights or People with Disabilities (UNCRPD): More than half of participants (n=40, 58%) did not know that the United Nations had a CRPD, but 42% (n=29) did. These were therapists (n=9), prosthetic technicians (n=6), nurses (n=5), administrative managers (n=4), administrative officers (n=4) and one physician. Less than half of these people (n=11) knew that Libya had signed this Convention. This included all prosthesis technicians, half the administrative managers and one physician, therapist and administrative officer.

This study makes a unique contribution to disability services research in the Eastern Mediterranean Region (EMR) through a first-hand account and workforce survey of the only functioning physical disability service in post-revolutionary Libya. Such information will help inform disability service planning and management efforts in the future. The case study revealed a stable workforce continuing to function in spite of conflict and in difficult circumstances. It also revealed areas for workforce development and opportunities for disability service capacity building particularly in relation to discharge options and information system development. The key findings are now explored.

The study revealed that the BRHC had, in difficult circumstances, continued its work during and after the revolution, retaining sufficient clinical staff to maintain a physical rehabilitation program that included amputee care. Staff attributes may have contributed to workforce retention and continued service during and after the conflict: all study participants were Libyan, they could only speak Arabic and most had qualification levels that were lower than staff in equivalent positions in European countries - this may have limited their international mobility for work. They were Benghazi residents, most were long term employees and some had been at the centre for two or more decades - their families, networks and resources were thus concentrated in Benghazi. Thus being locally employed, longevity of tenure, lack of qualification mobility and mono-lingual status may enhance workforce stability - this did not affect expatriate staff who left during the conflict.

These workforce attributes are a strength during conflict and post-conflict periods - in-country training and hire of a local health workforce has been proposed to be an effective strategy to meet growing service needs in a globally competitive labour marketplace. The situation in this Libyan disability and rehabilitation service appears to support that suggestion. The highly specialised nature of facilities [29] may also have ensured retention of technicians, because workers could not perform their prosthetic work elsewhere. The disability and rehabilitation service was also able to continue because the security situation in that area of Benghazi was relatively stable - workers and deliveries could get to and from the centre safely even during the conflict. Stability around service centres is an important enabling factor for service continuity - health systems in "crisis-affected fragile states" need to be supported with security arrangements that permit access to and protection of infrastructure [26] and internal security during the 2011-2012 period seems to have been adequate in this part of Benghazi although it has now deteriorated [6].

El-jardhali et al., [31] identified problems affecting health services in the EMR and some of the same ones were identified in this case study. The lack of an integrated information management system was identified in 2006 [9] and again in this 2012 case study. A weak knowledge base as reflected in lower level qualifications in some of the professional staff was also found in the center. Across the EMR efforts are underway to enhance health service delivery and findings of this study suggest that those strategies may have relevance for disability services. There is a small but growing body of evidence relating to health systems in the EMR [31, 32, 33, 34], health and disability services and needs of the Middle East region and Libya in particular [7, 8, 25, 28, 35, 36, 37, 38, 39, 40], and post-revolutionary planning documents relating specifically to Libyan health [23, 27, 28] to help inform disability services planning which as yet has received little attention.

This study presents the first independent examination of a physical disability and rehabilitation service in Libya. The study site and workforce characteristics have been described. Findings reveal that clinical and administrative workers were retained during and after the conflict, providing evidence to support previous proposals that domestic recruits who are locally trained are more likely to stay.

Findings also reveal that professional development of clinical staff is needed. Some activities that could be considered in a post-conflict environment include: in service training for human services, information technology and rehabilitation equipment use; financial support or work release for qualification upgrades once suitable in-country courses are developed; and recognition of higher qualifications and specialist expertise in a disability services career path.

Information system development is urgently required. While access to computers and training and reliable electricity to use them is limited, paper-based systems could be considered to help build organisational practices and identify information system priorities.

Bed-block arising from the longevity of in-patients may reflect the lack of CBR or supported community care discharge options. Since the center was established as a specialised rehabilitation treatment facility (not a long term residential care service), in time appropriate discharge options should be developed so the specialised inpatient care can be focussed on active rehabilitation. Development of CBR and supported residential care in the community will help a post-conflict Libya meet commitments in the UNCRPD. CBR not only provides direct local services, but it also provides a catalyst for community inclusion and the environmental adaptations essential for participation in everyday life. In the future it is hoped that a coordinated approach to disability will involve specialist hubs and connected local community services. Places like the BRHC are expertise hubs. If specialist hubs can be safely connected with local CBR services, they can provide the hub-and-spokes model needed for long term rehabilitation, supported residential accommodation and chronic care of complex conditions.

There are many people with disability in Libya now and there will be more in the future. It is hoped that in time peace will come and the country will again be looking at post-conflict scenarios. Findings from this study may then inform coordinated disability and rehabilitation services planning, capacity building and service provision.