Healthcare has long been a source of pride in Lebanon. Visitors from across the region come to its hospitals and clinics to go under the knife, be it for open-heart surgery or a nose job.
Today, the sector represents between 3 to 4 percent of the country’s gross domestic product, taking in close to $1 billion annually, according to Sleiman Haroun, president of the Syndicate of Private Hospitals and the head of Zalka’s Haroun Hospital. It is an industry that employs 25,000 people, of which 5,000 are doctors.
The World Health Organization’s 2010 World Health Report shows that Lebanon’s total spending on health decreased from 10.9 percent of gross domestic product in 2000 to 8.8 percent in 2007. Over those same years though, total per capita spending on health (taking purchasing price parity into account) jumped from $801 to $921 while government expenditure per capita went from $240 to $411. Both per capita examples are much higher than average in the Eastern Mediterranean Region (in which Lebanon is grouped) and even globally.
Despite these figures, there are signs that Lebanon’s healthcare sector is ailing rather than thriving. The number of hospital beds in the country has dropped from 10,000 to 8,000 over the past few years. Staff have been lured abroad by better salaries, leaving hospitals shorthanded. Government insurance programs, which cover the majority of Lebanese citizens, have piled unpaid bills on hospitals already crippled by debt.
And as the problems mount, many are becoming more and more pessimistic as to whether solutions will arrive. At the same time, however, some hospitals are finding ways to survive, despite the obstacles in their path.
Despite Lebanon’s longstanding reputation for top-notch healthcare in the region, much of the talent behind the country’s standing is being poached by foreign hospitals.
“We’re losing a lot of human resources – they’re traveling for better conditions [regarding] salaries and working hours,” says Haroun.
Nurses are in especially short supply. “We need around 20,000 and we only have 5,000” he says. In Lebanon, salaries for nurses start at around $670 per month, according to Haroun, while European recruiters bring salary offers for Lebanese nurses of around $3,300 per month.
The money is the key draw; a 2007 study on the migration of Lebanese nurses conducted by American University of Beirut (AUB) found that 57 percent of nurses who left Lebanon did so for financial reasons, while 42 percent saw better opportunities for professional development abroad.
“It’s been building up over the years, but last year and this year were catastrophic because we have witnessed some European countries recruiting nurses in quite an aggressive way,” says Haroun. One in five nurses leave Lebanon for either the Gulf, Europe or North America within two years of graduating from nursing school, according to the AUB report. Many would leave sooner, but foreign hospitals often require a minimum amount of actual hospital experience from prospective nurses, usually about one year.
“It’s a brain drain for us” says Dr. Huda Huijer, the director of AUB’s Rafiq Hariri School of Nursing. The shortage is becoming more and more visible. According to statistics released by the World Health Organization (WHO), Lebanon has one of the lowest ratios of nurses to population in the Middle East, placing it ahead of only Sudan, Morocco and Yemen. The WHO numbers say that Lebanon has just more than one nurse per 1,000 citizens, though locally produced reports put that number at anywhere from one nurse per 567 citizens to one in 1,600.
In 2010, the Order of Nurses in Lebanon — the syndicate for the profession — registered more than 8,600 members, up from just 7,000 in 2008. Not all of the nurses registered with the syndicate work nor are all of the nurses in the country registered, making it difficult to get a pulse on the actual situation. Still, the murky figures all point to a very obvious nursing shortage.
“Senior nurses are very few in many hospitals — we are always bringing in new people to be trained,” says Huijer.
To add to the difficulties presented by the lure of foreign jobs, Huijer claims that nursing schools around the country are not seeing the enrollment numbers that they should be. Part of the reason stems from a lack of understanding about the profession, she says, making it essential for nursing schools to actively recruit. Other essential staff such as paramedics are also in low numbers, leading to problems keeping emergency rooms running at full potential, according to those in the sector.
The good news is that while nurses may be hard to come by in Lebanon, the country’s 5,000 doctors are more than enough to meet demands, according to Haroun. While some doctors leave Lebanon initially after their training, they often return to the country to practice medicine later.
Skipping out on the bill
The biggest financial burden that Lebanese hospitals face is still nonpayment of bills by the government’s public health insurance schemes. According to the Syndicate of Private Hospitals, the government has now run up a debt of $700 million with the country’s hospitals. In 2009, Executive reported that the National Social Security Fund (NSSF) — which provides insurance for more than 1.3 million Lebanese — had $400 million in unpaid hospital bills. As the debt stands, it represents almost the entire amount of money generated by the country’s healthcare sector annually.
Aside from the NSSF, many Lebanese fall under four other public insurance programs: some 1.5 million are covered under the Ministry of Public Health, 350,000 by the army, 195,000 in the Cooperative of Public Servants, 125,000 by the Internal Security Forces and 75,000 under municipalities and judges. The Syndicate of Private Hospitals estimates that government forms of insurance account for 80 percent of admissions.
Some 450,000 citizens have private insurance; these, and self-paying patients, have been essential for some hospitals to stay afloat as the NSSF digs itself deeper into debt. At the 200-bed St. George Hospital, about 45 percent of the patients hold a government form of insurance, 5 percent are self-paying and the remaining 50 percent have private insurance.
The hospital’s Chief Executive Officer Salam Rayes says that this has resulted in between $20 million and $25 million owed by the government. Still, the church and university-backed hospital has seemingly been doing well and has plans to fully open a new $65 million wing, doubling the hospital’s beds within three years. For other hospitals, the nonpayment can leave them unable to afford new equipment or hire staff, dulling their competitive edge.
“If you don’t have the ‘X’ piece of equipment, you’re not a good hospital. And people stop at that,” says Rayes.
Private vs. private
With a weak public health sector, private hospitals and clinics are generally the preferred choice for those who can afford them or have appropriate insurance. Private hospitals represent the majority of beds in the country and those who can afford to generally prefer them to the hospitals run by the Ministry of Public Health.
Rather than competing with the public healthcare sector, the private healthcare sector now competes within itself. A sharp rise in the number of specialized private clinics and hospitals — small outfits run by just a few doctors — over the years has presented a challenge to the established, larger hospitals in the country.
“My competitor is no longer Hotel Dieu or American University Hospital — it is the small hospital that has specialized in ‘X’ specialty,” says Rayes. “So ‘X’ hospital is my competitor in ophthalmology and ‘Y’ hospital is my competitor in orthopedics — it’s not one place, it’s different hospitals now because there are good doctors practicing in small hospitals.”
The advantage of big hospitals is that they can treat patients for a number of ailments rather than just one specialized area. To maintain a large hospital however, a diverse staff and new equipment are essential to keep an edge on the competition. With the ongoing public insurance crisis, such expenditures can be untenable without the funding of an outside institution.
In July 2009, Lebanese American University acquired Ashrafieh’s Rizk Hospital as part of a $120 million plan to widen the university’s scope of projects. Beirut’s other major university-affiliated hospitals include the American University Hospital, St. George Hospital (associated with Balamand University) and Hotel Dieu (Université St. Joseph).
There is little hope that the current state of the healthcare industry will be cured naturally or quickly.
“I’ve been in the healthcare sector since 1965 and the same problems repeat themselves,” says St. George’s Rayes. “Reimbursement problems with the government, equipment, staffing, human resources, financing — nothing has changed.”
The problems facing the healthcare industry today and the lack of any real government participation in tackling the problems as of yet means that hospitals have to adapt and take on their problems individually.
“Everybody solves his own problems. And the one who solves them better is surviving better — as simple as that,” he says.
Healthcare in 2010 was stagnant at best, showing little movement towards resolving the sector’s issues.
“We weren’t able to make any progress during the last year,” concedes Haroun.
With the reimbursement woes emanating from the mix of insurance schemes, much of the blame for the current state of Lebanon’s healthcare industry has fallen on the government. However, some critics have noted that the Minister of Health — Dr. Mohamad Jawad Khalifa — has been doing the best he can with relatively limited resources.
“I think that [Khalifa] is doing a lot better than previous ministers — after all he is a physician. The ones who were before him were just politicians,” says Rayes.
AUB School of Nursing’s Huijer — while admitting that the current nursing shortage is bad — believes that the situation could potentially be fixed if given the proper attention.
“The shortage can be remedied by improving the public image but also by improving the working conditions — and that’s what we keep telling our ministers,” she says. “They must really pay [nurses] better than what they are paying [now].”
For the healthcare industry’s problems to be solved though will require the active support and attention of the government. And, perhaps more importantly, a steady cash flow from the government’s coffers to clear its debt.
It is a frequently-diagnosed pathology among our politicians, however, to allow problems to degrade into terminal conditions before any sort of treatment is considered.