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Health care infrastructure under pressure

Changes and challenges

by Nabil Makari

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.

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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Nabil Makari

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