Opening the doors to patients – and controversy

Do we really need another hospital or is it just a waste of hours?

Lebanon’s largest public hospital, the very modern $150 million, 544-bed Beirut Government University Hospital in Bir Hassan, has opened its doors and hopes to be self-sufficient within three years. However, its critics have called it a waste of money in a sector that already has a surplus of hospital beds and question its viability in a system characterized by waste and abuse.

The first in-patients will be admitted in this month but only 250 out of the full quota of 1,000 nurses and other administrative employees needed to run the out-patient clinics, labs, and radio therapy clinics, radiology, rehabilitation and pathology departments, have been hired. It could be said that the BGUH has come a long way in a long time. The first stone was laid in 1995. The main buildings and interior were finished by 2000 and by 2003, all medical equipment was installed. The 90,000 m2 hospital boasts no less than 14 operating rooms, including two in the ER, one for cardiology, one for organ transplantation and one for burns. It will employ around 1,000 full time and part time doctors.

“What differentiates the BGUH from other hospitals,” explained Dr. Noureddine el Kouche, who, until January 15, was the hospital’s chairman and general manager, “is the extensive forensic, drug treatment and child psychology departments.”

Funded by the Saudi Fund for Development and the Islamic Development Bank, the hospital is the jewel in the crown of the government’s postwar national health scheme, which foresees a nationwide system of 28 new and rehabilitated public hospitals. “The BGUH is the largest and most sophisticated,” said Kouche, who studied medicine in Russia and the UK. “It will receive the most complicated cases, such as those patients needing open heart surgery or transplants, from the country’s other public hospitals.”

In general, Kouche is an enthusiastic advocate of public hospitals. “We have to accept anyone, no matter what his name or bank account,” he said. And yet, at times, he wishes the BCUH would operate outside public sector, for all the obvious reasons. “Here politics touch everything,” he sighed, reflecting on the fact that as the BGUH was the brainchild of former prime minister, Rafik Hariri, Hariri appointee Kouche had to make way for an apparently more politically palatable GM, Dr. Wasim Wazan, on January 15.

In fact, sources say that robust politicking is to blame for the fact that it took no less than 10 years to build and equip the hospital and until now, this is still no consensus on the final confessional blend of the hospital’s board of directors. Nonetheless, Kouche is determined to leave office with dignity. “I’m proud of what we have achieved and fortunately, I know Dr. Wazan very well and I will do everything in my power to make the transition as smooth as possible and to make this hospital a success story.”

But does Lebanon need such a large hospital, be it private or public? There is already a surplus of beds, a fact borne out by Roy Wakim, an external consultant working for the World Bank at the ministry of health, which shows that Lebanon’s largely private hospital sector saw an exceptional growth during the civil war, with the number of beds increasing from 1,562 in 1972 to over 8,000 beds in 1996.

After the war, the government decided to rehabilitate a handful of existing public hospitals and build two dozen new ones. The aim was to increase the number of 810 beds spread across 15 hospitals, a mere 10% of the country’s total, to some 3,000 beds over 28 hospitals. This, combined with an extra 1,000 beds commissioned by the country’s private hospital sector, will soon bring the total number of beds to 12,000.

On average, Lebanon currently counts approximately one bed for every 255 inhabitants, which is more than most countries in the region and similar to the ratio in most Western countries. Not a bad ration you might say, but these beds are actually unevenly divided. While there’s one bed for every 166 persons in Beirut, there is only one for every 762 in the North.

“The BGUH is opening in Greater Beirut and Mount Lebanon, the most densely hospitalized area of Lebanon,” Wakim explained. “Even without the extra beds, the average occupancy rate is a mere 55%, which is well below what is recommended by international standards.”

Not surprisingly, Kouche believes these statistics do not tell the whole story. He points to the fact that only 30% of Lebanon’s hospitals are up to international standards. “Sure there are enough hospitals in Lebanon,” he said, “but not enough quality hospitals.”

The World Bank report, however, shows that there are 3.3 open heart surgery centers for every one million people, a ratio that although may compare well with the USA, is in fact four times the ratio in Germany. The number of lithotripsy (advanced kidney stone removal) centers in Lebanon is five times the ratio in the USA and almost 20 times the ratio in Germany.

“Lebanon saw an exceptional growth in advanced equipment by the end of the 1990s,” said Wakim, “predominantly in medical disciplines covered by the ministry of public health. The existence of this equipment could generate an artificial demand for their utilization. Still, nationwide average use remains well below optimum. So, the average use of 60 MRI machines per week is only one third of what is internationally regarded as being efficient.”

Kouche is aware of those who label the public sector inefficient, but remains confident that the BGUH will be a success, even if the hospital’s aims are rather ambitious. After a period of three years, in which the ministry of health will finance the hospital to the tune of $15 million a year, the BGUH is supposed to be financially self-sufficient. From the 544 beds, 244 will be covered by the ministry of public health and be allocated to social security patients and armed forces personnel. The remaining 300 will be reserved for privately insured patients, including foreigners (the BGUH aims to be a regional player) and explains the presence of 50 furnished apartments.

“Yemen sends some 70,000 to 90,000 people to Jordanian hospitals every year,” Kouche explained. “We’ve already sent a mission to Sana’a to ensure that part of that flow will come to Lebanon in the near future. Likewise we have made contacts in the Gulf countries and Saudi Arabia, so Arab patients will come here instead of going to Europe or the United States.”

According to Kouche, the BGUH can compete with any hospital in the country or abroad, not only because of the high standard and services it is able to offer, but also because it is competitive. “The BGUH is a 100% paperless and filmless hospital,” he said, “which will keep operational costs down. There are about 700 PC’s in direct communication with each other through a fiber optic network, which makes this one of only a dozen fully digital hospitals in the world.”

He gave the following example: “A magnetic resolution x-ray or MRI costs on average in Lebanon about $400, while here it will cost no more than $200, as we don’t have to print a film, but directly burn the image onto a CD.” Another way of keeping the hospital’s costs down has been through university outsourcing; secondary activities, such as security, parking, cleaning, laundry, catering and landscaping are all in the hands of private companies. As a result, the hospital’s human resources needs are, in some areas, such as nursing, 33% less.

Wakim however, is still not convinced. Apart from the structural problem of over-bedding, he fears that on an administrative level, the hospital needs to be more efficient or it may risk losing the doctors it has hired, the outsourcing contracts it has signed and momentum and credibility. Secondly, he questions the ease with which the hospital will find some 700 nurses in a country where there already is a shortage. “Nurses are trained in Lebanon,” he said, ‘but then travel to Europe or the Gulf, where they are better paid,” he explained. Finally, the hospital’s Saudi design, which sees corridors on the outside, rooms on the inside for added privacy, is already outdated and doesn’t suit Lebanon’s more liberal climate. So far, not one hospital in Lebanon is self-sufficient. Since 1996, public hospitals have operated much in the same way as private ones, in the sense they are financed by a both the ministry of health, public agencies and private insurance companies. It is a system that has been characterized by waste for many years and one which is a severe drain on the public purse.

“We see that public hospitals develop much the same behavior as private ones,” Wakim said. “As inpatient treatment is reimbursed by the ministry of health and outpatient treatment is not, hospitals favor the first option, even if it is not necessary. In the Nabatieh public hospital for example, only 30% of hospital admissions actually underwent surgery. Don’t get me wrong, I truly hope the BGUH will be a success, but I fear it will be one big and costly white elephant.”

Peter Speetjens

Peter Speetjens is a Dutch journalist & analyst based in Beirut since 1996.