In Lebanon, as in virtually all other countries around the globe, health has in 2020 been catapulted to the top spot of social concern after the onset of the Covid-19 pandemic. To assess the correlation between the pandemic, national governance, the economic and liquidity crises, and the overall state of public health in Lebanon, Executive sat down with Dr. Walid Ammar, the director of the doctorate and research program in public health at St Joseph University and previously, up to the middle of this year, the director general of the Ministry of Public Health (MoPH).
How would you assess the resilience of the Lebanese healthcare system overall, when considering all of this year’s stresses, especially the Covid-19 pandemic?
Previously [in a 2018 interview] we discussed the elements of resilience in the Lebanese Healthcare system and the characteristics related to having a system of collaborative governance. Having a diversified system with multiple partners meant that when some [healthcare providers] were facing difficulties, the system could rely on the others, because [these partners] are working in a network with good collaborative governance. In principle, all the elements of the system [exist today] but I think we have a problem of governance at the ministry of health.
Additionally we have the financial crisis and the Covid-19 pandemic. But I would say that we have always operated in a context of crises. We were running different programs, such as accreditation and auditing hospitals, despite [living through] war time. We were conducting immunization campaigns in war times. What we are facing now is exceptionally difficult, but that is no excuse for us having this relatively bad performance in fighting Covid-19, compared to the first three or four months of the pandemic when we had an excellent performance. The situation also does not explain the very mediocre results in a recent immunization campaign [against polio, measles, mumps and rubella] in which we had on average 30 percent coverage. We did never have such low coverage; even during wars we were conducting campaigns then when we were not happy when we had 80 percent coverage because we wanted to exceed 90 percent coverage. Now it is 30 percent. This is of course a combination of many factors but I would say governance at the ministry is the problem.
Everybody is talking about the stresses on hospitals and healthcare professionals because of the coronavirus. How is the situation with regard to treatments and coverage of non-Covid-19 diseases such as heart and diabetes and other chronic diseases in 2020?
Covid-19 has undoubtedly affected all the other services for other diseases. For a certain period this was done on purpose [in order] to have enough beds for Covid-19. So elective surgery and [procedures for treating] chronic conditions were postponed. We don’t yet feel the implications of this on the population. I can say, however, that considering the economic crisis, patients for now have [held back] from demanding sophisticated treatments. Before, when a prosthesis was needed, people required the most sophisticated ones. Now we are not hearing people claiming this kind of service. I think that people’s expectations, perhaps for the first time in the history of Lebanon, have really been lowered and are going down.
Is the increased cost and difficulty of obtaining imported medicines and equipment a factor in patients abstaining from requesting the most sophisticated treatments?
I would say it is rather related to the mental situation and to the fact that people are depressed. Before we were using very expensive technologies, something which was disproportionate to our resources. People were requesting this. I think now there is a climate of depression and people are not enthusiastic anymore. They are losing hope.
In this context, how do you expect the healthcare system to perform in 2021 and going forward? Do you think that this depressed mode will persist? And how do you see potential treatments for Covid-19 impacting the Lebanese healthcare system?
Everybody expects hard times in the healthcare sector. However, I believe that the governance issue is very important because the governance style of the health sector has changed lately. The system of networking [in collaborative governance] is not really functioning as well as before. Some programs have been disrupted for no reason. They were stopped and the staff is demotivated. There is a real problem of leadership.
Is this demotivation and disruption of governance happening also at the level of hospitals, or is it mainly at the level of the government or ministry?
Anything that is related to providing services is there, but anything that is related to quality is not there anymore… Anything that is related to the information system and collecting data and indicators is also dysfunctional. The infrastructure is affected mainly because of the problem of governance.
So if we talk in terms of total number of hospital beds or primary care centers, what are the trends?
Quantitatively, everything is still there. As you know, three major hospitals were affected by the [August 4] blast but they are starting to operate [again]. This was an incident. But the overall primary healthcare system and hospital system is still entirely functioning. The number of services decreased because of Covid-19 and for obvious [other] reasons but this is not where the problem lies. They will still be able to provide services. However, the quality will be significantly affected.
The syndicate of physicians recently referred to several hundred doctors and nurses migrating away from Lebanon in the last months. Considering that universities have been and still are producing new medical graduates every year and that our ratio of physicians per 100,000 inhabitants is rather high, how severe do you see the impact of doctors’ leaving the country?
I don’t think it would affect the system because we always had [an] oversupply of physicians. In terms of medical practitioners and specialists, I don’t think we will be having a problem. This is not the case with nurses – [as] we have always had a problem with shortage of nurses, so this is not recent. However, if you ask the president of the order of nurses, she will tell you that we have too many nurses who are still in the country and who are unemployed . The migration is an issue but it is not the main problem for the time being.
One question regarding the local manufacture of pharmaceuticals. You have been concerned over many years at the Ministry of Public Health with the issues of local production, pricing of medications, and things such as the lists of registered pharmaceuticals and substitution drugs and generic drugs. Do you think it’s plausible to substitute imported medications with locally manufactured ones, and to what extent?
I think we have a good capacity to manufacture good drugs in this country. This is a time when local production should be boosted. Of course the raw material is imported from outside but this represents only 30 percent of the production cost. This is not negligible but [local drugs] can still be more competitive and [the manufacturers] have a good capacity to produce them.
It was indeed my assumption that there is a capacity to substitute many imported drugs for heart disease or diabetes and minor ailments with locally produced ones, even if this means using imported ingredients and production under foreign license. While there were many reports of people stocking up on medications for chronic conditions, however, I did not read or hear any media or industry comments on how much capacity we have to substitute such imported medicines with Lebanese-produced ones.
This has to do with the mentality of people and their trust in local manufacturing. For example, a few weeks ago we had a big problem that Panadol is not available in pharmacies. We have similar locally manufactured drugs. Drugs of similar quality and half the price exist but people made a scandal that Panadol is not available. We have Paracetamol and all drug manufacturers in Lebanon are producing these kinds of drugs. This has to do with the mentality of people.
“We have a good capacity to manufacture good drugs in this country. This is a time when local production should be boosted.”