Dr. Roger Sfeir is one of Lebanon’s leading cardiovascular surgeons and has been a key advisor on national healthcare reforms. International bodies such as the World Bank and United Nations Development Program have sought his expertise for a number of studies. Executive sat with him to discuss recent developments in the sector and the problems that continue to beset healthcare in the country.

Is there an over-reliance on private sector financing for healthcare in Lebanon?

Provision of healthcare is nearly 90 percent private and the expenditures mainly go to these centers, so yes, it is skewed to the private sector.

What are the implications of that?

Well, we need to look at the financing, from where the money comes. Before 1998, the public hospitals were incredibly inefficient so in that year a law was passed called the Law of Autonomy of Public Hospitals, where they changed the legal structure of these hospitals.

So instead of being directly managed by the Ministry of Public Health (MoPH), each hospital had a board and a general manager under the supervision of the ministry, but it was supposed to operate like a private hospital, with its own budget. Its income would come from billing the government for the patients it serves.

Has the law been successful?

Not really.

Why not?

When this law was written, we were aware that as long as the manager and the board were appointed by the politicians then the same problems would occur again. As the law is written, the boards and managers are appointed by the MoPH, so they are not free of political interference. I believe now around 15 to 20 percent of the overall healthcare budget goes to public hospitals whereas it was around 10 percent back then.

Within healthcare in Lebanon, are there sufficient quality control measures?

Before the major effort to restructure the healthcare sector back in 1998, there wasn’t anything called quality control by the government in the hospitals. We wanted  something like the joint commission in the United States, but we ended up doing what is called the accreditation of hospitals, whereby a committee from the MoPH comes and checks the hospital including everything from the infrastructure to the nursing to the management.

How rigorous is the process?

It is working, but not very well. This is because of how it is being implemented. The problem is that the hospitals are audited by one of four companies selected by the ministry. [It is a situation] where the companies may give wrong results.

How?

[Laughs.] Well, if you know or have relations with the people who own the [ratings] company, then they can give better grades. With these contacts, they can help the hospital get an accreditation when maybe they shouldn’t. The way the system is built is not foolproof to prevent abuse.

How would you assess the balance of primary to secondary and tertiary healthcare spending?

There is too little [spending] on primary healthcare and preventative medicine. There has been an effort by the MoPH and [its] director general to improve the primary healthcare centers and put more effort into improving preventative medicine, because the dollar you put there can save you 10 further down the line. Private institutions can’t do this because it is not profitable.

How coherent and comprehensive is the data available for the sector?

There was lot of money put into a 1998 study for restructuring the sector. Part of this was to collect data in what is called the national health account, and it gave some alarming findings. For example, it found that total healthcare expenditure was 12.3 percent of gross domestic product, which was second only to the US. [Between] 2004 and 2005, it found it went down to around 9 percent. But we really have to take these figures with a large pinch of salt. There is [a possibility] for errors or even gross errors in the collection of this data.

How efficient is the pooling of resources and data within the sector?

Healthcare information is very important for the steward of the system, and this should be the MoPH. Now the ministry is a lot of things. It is the steward, it drafts the laws, implements the laws, treats patients and pays for the patients. All these should be split and divided. There should be checks and balances.

These proposals have been put forward many times but have not been implemented. Why not?

The ministry should be the steward for the system, put down the regulations and have a center for the collection of data. The one that owns the hospitals should be another entity, and the one that collects and pays the money should be the national healthcare fund. The government has not been able to implement these policies even though they were approved by the Council of Ministers [Lebanon’s Cabinet] way back in 1999.

Why not?

There is no political will. If you want to take from the National Social Security Fund (NSSF) the power of paying for the hospitals, then they will not be happy, and the same for the MoPH. If you want to create a national health fund, this will take from the MoPH and the NSSF. Neither of them will allow it.

How would you assess the efficacy and equity of the mix of payments from the public health ministry, insurers, NSSF and professional associations?

It is both inefficient and inequitable. The most inefficient way to pay for healthcare is out of pocket, and yet it amounts to around 60 percent of all healthcare spend here.  This also leads to inequality. If you are poor and don’t have insurance, you can’t afford to pay out of pocket so you go without. We need more prepaid systems.

The NSSF is in a bad state of affairs. What could be done to make it more sustainable?

The sickness fund portion of the NSSF used to have more money in the bank, but year after year you see the money available going down because the losses are more and more. It has passed zero and it is now losing billions of lira every year. Another set fund was created a few years ago for those people that are not insured. Who chose to join? The elderly who have no social security ­— and they are very sick, so within a couple of years the fund ran out of money. The government pays into the regular fund, but they have not been paying their share because they say there is a lot of theft and abuse of the system. The NSSF is going to remain in deficit unless there is a major change made, which I don’t see happening in the coming years.

What is the state of care for the elderly and palliative care in Lebanon?

I think one of the worst aspects of our healthcare system is that there is no proper adequate care for our elderly, either in terms of healthcare or nursing homes. Nothing. There are hospitals that have long-term contracts with the government for the elderly, but they are really paid minimal amounts per day. Not enough to pay the electricity. This is [a failure] of the system. Once you stop working at 65, your insurance stops and your health coverage stops and you get paid your social security, which [runs out] in one year. After that you have no medical coverage, so many of the elderly are left uncovered.

Twenty-one-year-old Peter Dagher has a rare type of leukemia, a form of blood cancer, and he needs a donor of hematopoietic stem cells (often referred to as bone marrow) for the treatment of his life-threatening disease.

Members of his family don’t match and nor do his friends, and Lebanon does not have a national registry where he could look for a potential donor.

Peter is not alone. The American University of Beirut’s Medical Center (AUBMC) comes across five to six patients a year in need of a such a procedure. Beirut’s Makassed Hospital currently has three patients anxiously awaiting a life-saving donor. 

With the absence of a registry where Peter and others like him can search for registered donors, they are left with two options: continue to ask people around them to undertake tests to see if they are a match — with each test costing between $300 to $470 — or reach out to international registries where chances of finding a match are even slimmer.

“We turned to registries in Europe, the United States and around the world, but finding a compatible donor from outside of Lebanon is difficult. Doctors told us that if the matches found abroad [which were not 100 percent compatible] were from the same country or region, they would have done the transplant. We need a national registry,” says Randa Dagher, Peter’s mother.  By not having a national registry, the opportunity to connect potential donors and future patients is lost.

Stem cell donation

Hematopoietic stem cell therapy is commonly known as a bone marrow transplant. These stem cells, the parents of all our cells, are found in their greatest abundance within bone marrow — the soft and fatty tissue that fills bone cavities. In the past, hematopoietic stem cells could only be collected from bone marrow via painful hip punctures. Now, medical advances mean the cells can be taken from the blood in a procedure called peripheral blood stem cell donation. (The centers that conduct the procedures are still named after the original procedure: “bone marrow transplant centers.”)

Whether harvested from bone marrow, umbilical cord blood (another rich source of stem cells) or peripheral blood, the transplant does not involve surgery, a persistent misconception. The procedure is similar to a
blood transfusion.

Although it is more complicated than going down to the Red Cross to give a pint of blood — it involves more testing, a few days of preparatory injections and a more intrusive machine — the simplified procedure has increased the popularity of stem cell donations in the past couple of years, increasing with it the likelihood of saving lives.

The two basic forms of transplants are autologous and allogeneic: the former makes use of a patient’s own stem cells and the latter uses cells from a donor of a matching type. The first hematopoietic stem cell transplant in Lebanon was autologous. It was performed at Makassed Hospital in 1997, 29 years after the world’s first truly successful attempt. 

In Lebanon, three hospitals — AUBMC, Makassed Hospital and Mount Lebanon Hospital (MLH) — conduct hematopoietic stem cell transplants. AUBMC and Makassed both have their own dedicated units where they conduct both autologous and allogeneic transplants. MLH only performs autologous transplants.

The majority of Lebanon’s transplants take place at AUBMC, where a total of 84 were performed in 2012, up from 45 in 2011.

Dr. Ahmad Ibrahim, head of the bone marrow transplant unit at Makassed Hospital, estimates that around 120 transplants were undertaken in the country last year.

Prohibitive costs

When a patient and their family are not losing sleep over the life-threatening disease, they are fretting about the hefty cost of the transplant. For an autologous transplant, prices vary from around $35,000 at MLH and Makassed to between $40,000 and $45,000 at AUBMC. When a donor is needed, the cost increases to $55,000 at Makassed and $75,000 at AUBMC. Currently Lebanon’s Ministry of Health only covers a small percentage of the costs of hematopoietic stem cell transfers.

When the donor is unrelated to the patient, additional medical needs push the cost even higher, to some $120,000 at AUBMC, the only hospital conducting such a procedure.

AUBMC performed Lebanon’s first transfer from a donor who was not related to the recipient in September 2011. The donor was found on the registry of the United States’ National Marrow Donor Program (NMDP), the world’s largest registry, and the stem cells were sent to Lebanon.

A match made in Lebanon

A donor’s compatibility is determined by testing for the human leukocyte antigen (HLA), a test of genetic markers on white blood cells. The chances of finding a perfect match is highest among siblings.

“The [head] of the laboratory sits with the family, draws the family tree and starts proceeding with tests within the family,” says Samar Okaily, nurse manager of the bone marrow transplant unit at AUBMC. When siblings and members of the family don’t match, then the probability of finding a match is higher among fellow Lebanese and Arabs. Still, finding one in Lebanon or even the Middle East is a Herculean task.

Besides Israel, there are only three countries in the region that have a bone marrow registry: Iran, the United Arab Emirates and Saudi Arabia. According to the Bone Marrow Donors Worldwide (BMDW), an aggregator of data from worldwide registries, Iran has around 5,000 registered donors, the UAE has just 45 and Saudi Arabia’s registry, established in 2011, is not even listed on the BMDW.

Donors from the Middle East account for a negligible 0.02 percent of the total 21 million registered potential donors on the BMDW, an alarmingly low figure. The US, with a population size close to the Middle East’s, accounts for over 35 percent of the registered donors.

More procedures, but still no registry

Dr. Ibrahim of Makassed Hospital, which has conducted over 400 transplants since 1997, says there are several reasons for the lack of a registry. First, the transplants have been around for just 15 years in Lebanon as opposed to half a century in some developed countries. Second, “in our population, families were big so you had a higher chance of finding a compatible donor among your siblings than in developed countries. As families have become smaller, there is a bigger need for a registry.”

Finally, and most importantly, Ibrahim believes economic and legal challenges have hindered the development of a national registry. “It needs money so the [stem cell] tests can be done for free, and it needs the [adequate] legal system to protect the donors’ [anonymity],” says Ibrahim, who estimates that it would cost a minimum of $3 million to establish such a registry in order to conduct the tests for free and raise awareness about stem cell donations. 

Dr. Fadi Nasr, who heads bone marrow transplants at MLH, blames the lack of a national registry on egos. “We disagree on [which doctor] will put his name on it; it’s politics,” he says, explaining that different hospitals are reluctant to share data with one another in order to establish a national registry. And with no law imposing such collaboration, he does not foresee the establishment of a registry in the near future.

Globally, more than 1 million blood stem cell transplants were performed as of the end of 2012, a medical procedure used in the treatment of over 70 diseases

Lebanon’s medical system is gearing up for an increasing number of transplants, with two of its leading hospitals planning to start performing more complex procedures in the near future.

When the European Group for Blood and Marrow Transplantation, a non-profit scientific forum, held its 2013 annual meeting last month, Dr. Ali Bazerbachi, who heads the bone marrow transplants unit at AUBMC, and Makassed’s Dr. Ibrahim were both speakers on high impact panels.

As Lebanon commits to saving lives with more complex hematopoietic stem cell procedures, it is critical that it provides a registry for patients in need of an unrelated donor, such as Peter. Without one, his life is at risk. “I want a donor now,” his mother told Executive. “I don’t know what to do”.