Health care infrastructure under pressure

Long seen as the health care centre of the Middle East due to its developed
hospital infrastructure and presence of heavily qualified medical personnel,
Lebanon may well lose this title soon, due to a series of unfavorable factors,
including the economic crisis, the August 4 Beirut port explosion, and the
Covid-19 pandemic. Despite the efforts of its health care personnel to provide
adequate medical care and the current support of the Central Bank of
Lebanon by providing dollar subsidies to importers at a fixed rate of 1,500
LBP to the dollar, Lebanon’s health care infrastructure is currently in the midst
of its worst crisis in modern history with no clear end in sight.
The convergence of stresses on the health care system has revealed the lack
of up-to-date infrastructure; lack of medical personnel due to high emigration
rates among doctors; and difficulties in obtaining medical supplies due to the
devaluation of the Lebanese currency and reduced imports. Dr Charaf Abou
Charaf, president of the Lebanese Order of Physicians, recently estimated
that the total number of doctors who have chosen to leave Lebanon between
July and September to be more than 400, which represents roughly 3 percent
of the total number of Lebanese doctors. Nevertheless, at a level of three
doctors per thousand of population according to Ministry of Public Health
statistics for 2019, Lebanon is still in the upper tier in levels of doctors per
population, close to France and higher than the United Kingdom according to
thestreet.com, a financial news website. In addition, the August 4 Beirut
explosion resulted in heavy damages to hospitals in Beirut, and for the
moment reconstruction is stagnant.
Impact of the devaluation and BDL Circular
According to Dr. Jamil Borgi, a cardio-thoracic surgeon at the American
University of Beirut’s Medical Hospital (AUBMC), medicinal supplies have
become more expensive due to the devaluation of the Lebanese pound,
despite the fact that the Central bank subsidies 85 percent of the prices. This
leaves the other 15 percent of payment subject to currency fluctuations and
the difficulties of finding cash dollars (as per the BDL scheme, suppliers of
medical equipment must provide the BDL with 85 percent of the dollar price in
LBP at the official rate of 1500 LBP per dollar, and the rest in cash dollars).
Prices of insurance premiums and medical equipment are going up, and the
latter are not always covered, according to Dr. Jamil Borgi, which is putting
added pressure on hospitals and Lebanese citizens, both insured and
uninsured. This has highlighted the need to restructure the health care
infrastructure in Lebanon in order to be able to cope with the economic crisis,
the impact of Covid-19 and the destruction of the infrastructure in the Beirut
blast.
Due to the difficulties in obtaining cash dollars, there is a shortage of
medicinal supplies. Given that the current BDL subsidies are temporary, and
with no political solution to the economic turmoil, hospitals are worried that
supply costs may skyrocket, due to the possibility of having to buy medical

supplies at real market prices, with a currency rate which has fluctuated in the
last two months between LBP 6,000 and LBP 8,800.
According to Dr. Alexandre Nehme, Chief Medical Officer at the Saint
Georges Hospital University Medical Center (SGHUMC), the impact of the
devaluation of the currency on the availability of medical supplies might be
heavily affected due to the recent BDL Circular 573, which established that
medical suppliers, in order to obtain dollars from the Central Bank at the
official rate of 1,500 LBP to the dollar, must provide the Lebanese pounds
needed for the conversion in cash. Otherwise, the importers would not be able
to obtain dollars to pay their suppliers. According to him, this would add
pressure on Lebanese hospitals as they are mostly paid in credit cards and
SWIFT, and therefore if their suppliers were to insist on being paid in cash,
hospitals would have difficulties obtaining it due to the current capital controls
at Lebanese Banks.
Lebanon’s economic crisis casts a long shadow
The impact of the economic crisis on medical personnel has been two-fold:
the crisis has forced many hospitals to fire part of their medical personnel in
an effort to cut costs,with AUBMC having laid off between 800 and 850 of its
staff members on July 17th, 2020, and many have left the country in search of
more secure opportunities abroad. The lack of personnel was actively felt
during the aftermath of the August 4 explosion. “Our challenge is to keep our
working force; it is bleeding”, says Dr. Alexandre Nehme, highlighting the
need for hospitals to maintain an effective medical workforce.
In addition, the BDL circular 573 has come under heavy fire from prominent
hospitals due to the difficulty in obtaining cash money to finance the purchase
of medical supplies. Six university hospitals (the AUBMC, the Lebanese
American University Medical Centre – Rizk Hospital, the Saint Georges
University Hospital, the Hôpital Notre-Dame des Secours, the Hotel-Dieu
University Hospital, and the Mount Lebanon Hospital) have issued a joint
statement lamenting the current situation and apologizing for not being able to
provide medical services in this current situation.
Indeed, the Medical Equipment & Devices Importers’ Syndicate requested on
October 20th of hospitals that they pay 85 percent of their purchase bills in
LBP cash, which the above-mentioned hospitals deem impossible. For them,
requesting cash payment from their patients is near impossible, and will result
in an inability to provide their patients with the required care, especially as the
current limits on withdrawal make it very hard for many to spare the required
sums.
Dr. Firass Abiad, chairman and director general of the Rafic Hariri medical
hospital, has highlighted to Executive Magazine that “it is all about
preparation”, adding that the hospital has instigated a staff development
program which has allowed them to generate enough nurses and personnel
thanks to incentives. As a result the proportion of personnel that has left is
lower than other hospitals. Unlike many other hospitals, Rafic Hariri has hired
staff and trained them.

Dr. Abiad, says that, “We are facing three or four storms that are coming
together as a perfect storm,” referring to the financial crisis, the Corona
pandemic, and the staffing and equipment challenges in Lebanon.
Covid-19’s impact on Health Care
In seven weeks, from October 26 to December 17, the number of infections
rose from 72,186 to 153,049 and the number of deaths from 579 to 1248,
according to Worldometer. Intensive Care Units (ICUs) have had to be
expanded since the beginning of the pandemic and ICUs have reached a
critical occupancy rate of 85 percent according to a November 7 World Health
organization report. The AUBMC has created a Covid-19 Unit, but have
currently reached maximum capacity due to the rapid expansion of the
pandemic. At Saint Georges Hospital, many changes had to be put in place
after the August 4 explosion. Before the blast different departments at the
hospital were dealing with Covid-19, with half the emergency and half the
intensive care units (and around 25 additional rooms) dedicated to Covid
care. After the blast, St Georges’ damages were such that changes had to be
made to cope with the increase in Covid-19 cases in spite of heavily damaged
infrastructure. The changes included obtaining 14 hospital beds from the
Lebanese-Canadian Hospital, establishing a walk-in for PCR tests and a drive
through for the same. Damages at the hospital were estimated at $40 million,
noting that by the end of October the hospital obtained only $10 million.
The hospital amongst the most affected since the beginning of the Covid-19
pandemic has been the Rafic Hariri Hospital. According to its Chairman, Dr.
Firass Abiad, the Rafic Hariri hospital has expanded its ICU unit quickly, from
four beds before the pandemic to 22 in a matter of two weeks since the
beginning of the pandemic. “We bought a lot of time for the country”, he says,
due to the alleged rapidity and professionalism of the hospital staff in handling
the Covid-19 patients. Nevertheless, as the number of patients goes up, so
does the need of beds, especially as Covid-19 can be transmitted by air when
an infected person coughs, sneezes or breathes heavily in close contact
according to the World Health Organisation and therefore the medical staff
must be extra careful with regards to contact with patients.
Overall, Rafic Hariri Hospital reached 28 beds for Covid-19, an ICU with five
beds dedicated to children, and is working on nine more beds to become the
largest Covid-19 ICU in Lebanon. According to the latest World Health
Organization report dated November 7, hospitals in the Beirut governorate, for
example, have reached 100 percent occupancy rate.
This will only get worse should the situation stagnate without the help of
former and international donors to establish hospitals and ICU units.
According to Dr. Ghassan Skaff, head of the neurological surgery department
at AUBMC’s department of Surgery, in an Elsiyasa.com article dated
November 1,should Lebanon not enlist the help of international donors, the
country might reach a milestone of one million Covid-19 infections and around
10,000 deaths due to corona from here to June 2021.

In conclusion, Lebanon might have to relinquish its reputation as the health
care center of the Middle East. With medical personnel leaving, an expected
hike in the price of medical equipment, and difficulties in obtaining the much-
needed financing for importing the latter, which would result in the hospital
sector lagging behind, Lebanon might very well end up with a stagnating
medical sector, leaving no room for envy from its neighbors.

PULL QUOTES:
● Between July and September, 400 doctors have been estimated to leave Lebanon.
● Covid beds in Beirut governorate hospitals have reached 100 percent occupancy.

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