Hospitals for the lucky
Health and wealth in Lebanon
Fahad al-Sudaid
Lebanon is a country of extremes, and its health sector perfectly captures the problem. Lebanese people speak with great pride about their many high-end hospitals and well-trained doctors. Yet they view state-run medical facilities, their staff, and government policy with the deepest prejudice. All would be fine if the sector’s most admired elements didn’t depend on its most despised. But because private institutions have prospered through a parasitic relationship with the state, which guaranteed their profitability, the latter’s bankruptcy could spell the former’s demise.
The sector’s inadequacies are coming to light amid overlapping crises. The collapse of the Lebanese banking sector has impoverished many residents; without safety nets to fall back on, they are unable to meet medical costs they previously took for granted. The bungled covid response has laid bare an anarchic approach to public health, precisely at a time when centralized planning and implementation are most needed. Top-notch medical institutions appear increasingly ill-suited to dealing with the country’s fast-changing needs, all the while continuing to suck up much of what resources remain.
For decades, this sector has hinged on private hospitals surreptitiously raking in profits at the expense of both state and society. Today, all three sides of this triangle are stretched to their breaking point. Inevitably, a new system will be forged from this reckoning. What will it look like? That will depend, first and foremost, on grasping why Lebanon’s health sector is so impressive yet so frail.
✜ A sector in its prime ✜
Lebanon has long prided itself on its healthcare system, and with good reason. Until recently, at least, the country had over three doctors per 1,000 inhabitants—triple what the World Health Organization (WHO) typically recommends. These professionals were often trained in Europe and the US, where they secured diplomas that would inspire trust back home. They had at their disposal the latest and most sophisticated machinery, including state-of-the-art imaging devices: In 2014, the WHO noted that Lebanon had 110 CT scanners per million inhabitants, compared to 46 in the US and 15 in France.
In years past, the sterling reputation of Beirut’s healthcare facilities made the city into a regional hub for medical tourism—earning it the moniker “hospital of the Middle East.” Although competition rose as neighboring states built up their own health sectors, Lebanon continued to draw a stream of patients seeking high quality yet affordable expertise. Lately, Iraqis in particular have favored Beirut’s private hospitals for major interventions such as open-heart surgery or cancer treatment. These operations often come bundled in packages that include hotel-like facilities for post-procedure recovery.
Medical tourism could also count on Lebanon’s expansive diaspora, whose members may face higher costs and longer waiting times wherever they reside. “American Lebanese travel to Beirut to get their teeth fixed,” said a Lebanese man who recently moved back from the US. “In Lebanon, they may pay 70 dollars for something that could run up to 1,000 dollars in the States, using the exact same technology.” The deputy director of a Lebanese NGO explained how she keeps her healthcare tethered to Beirut to this day, despite spending much time abroad: “I stick to a private insurance plan that covers expenses in Lebanon only. If I needed treatment elsewhere, I would rather come back anyway.”
Some medical professionals wax lyrical about their country's system
Some medical professionals wax lyrical about their country’s system, especially when talking to foreigners. A surgeon in the northern city of Tripoli boasted about the sophistication on display at the American University of Beirut Medical Center, or AUBMC: “They have intensive care units that you couldn’t even find in the US.” An internal medicine specialist at the renowned Hotel Dieu hospital echoed this favorable comparison to far richer countries: “Our health sector is on a par with the US or France, although our societies are different: Here we must deal with more poverty around us, which makes us learn more, help more, and become even better doctors than in the West.”
Yet if healthcare practitioners stress the sector’s strengths, they also note the downsides of a system that is overwhelmingly skewed toward high-level curative medicine—which consists of treating conditions as they arise, through generally costly interventions. By contrast, preventive medicine evinces far less interest, although it encompasses such essential fields as general medicine, neonatal care, and vaccination. It is not unusual, therefore, to find hospitals sporting spacious emergency rooms and spectacular surgical wards alongside lackluster family clinics, which generate far smaller invoices.
Such misplaced priorities reveal themselves most starkly in the degree to which the sector undervalues its nurses. A 2017 study in the scientific journal ‘PLOS One’ estimated that Lebanon had only three nurses per 1,000 inhabitants, compared to an average of eight in EU countries. Nurses are not just underrepresented in a sector where specialized doctors reign supreme; hospitals pay them poorly, and are quick to dispense with them altogether when business slows. “Nurses are worth nothing here,” complained a nurse employed in Tripoli, who hadn’t been paid in months. “We are treated like domestic workers who just happen to know something about medicine.”
Private hospitals encourage wasteful spending that inflates their own bills
While shedding costs wherever possible, private hospitals encourage wasteful spending that inflates their own bills, notably through widespread over-testing and over-prescription. Patients suffering from relatively minor conditions, such as knee injuries or lower-back pain, are routinely sent for an MRI. A retired surgeon explained: “Procurement policies and prescriptions are not always based on actual needs, but on which instruments and procedures generate the most profits.” Many patients, having endured convoluted and costly medical investigations, then expect the overmedication that all too often follows: It’s so much harder to settle on aspirin for a headache… after a brain scan.
Top dollar investments in specialized doctors and high-tech equipment create a vicious, profit-driven cycle. Heart catheters, open-heart operation rooms, and aesthetic laser machines are all costly to procure and run. To cover expenses, some private hospitals developed a policy of pressuring staff to focus on revenue-generating activities. A retired surgeon described how his former employer coerced its medical program directors into recovering costs:
Every month, senior management would grill us. ‘Why didn’t you perform more tests? Why didn’t you use our facilities to their full capacity? How many MRIs did you order? Why is your program not doing well this month?’ Then they punish poor performers by giving them only one night shift a week instead of two. Or they would simply replace you with someone they think will be more productive.
A final tradeoff in this competitive healthcare market concerns information. Hospitals are loath to disclose even the most basic data. Each institution traditionally keeps to itself, for instance, its numbers of admissions, diagnosed cases, or beds available. Private hospitals rarely share the records they store internally with central authorities—even after the Ministry of Public Health (MOPH) issued circulars in 2020, in a vain effort to centralize information about covid cases. This failed attempt among others illustrates how corporate secrecy undermines public health, which relies on a pool of information from all concerned. Without the countrywide data needed to monitor evolving needs and adapt to them, it is hard to speak of a health system per se.
✜ A state in poor health ✜
Yet these drawbacks are just symptoms of a deeper problem, rooted in the relationship between a hyper-privatized sector and the country’s decrepit public infrastructure. The best diagnosis comes directly from the MOPH itself, whose website lays out its structure and responsibilities: a diverse, conventional array of public health functions, from overseeing food safety to coordinating vaccination campaigns. Immediately thereafter, however, it makes a startling admission:
It is worth noting that some of the previously mentioned departments are almost dormant, and very few, if any, activities are performed, either due to the lack of personnel or motivation, or to the lack of funding. In addition, in 1996, a decree was issued to stop employment in the public sector, which resulted in overloaded personnel, with high average age structure and many neglected essential activities.
Although the MOPH commands the third largest budget of any service ministry in Lebanon, it is most notable for what it does not do. For example, unlike most such institutions around the world, it runs no nationwide blood bank or ambulance network. Nor, critically, does it maintain a national laboratory, which elsewhere would fulfill vital testing functions in relation to pharmaceutical quality control, environmental hazards, food safety, and epidemics. (Lebanon previously possessed such a facility, which in 1997 was entirely refurbished with Swedish funding, before being torn down—allegedly at the request of a politician living next door. No substitute was built, nor is the equipment accounted for.)
The ministry commands the third largest budget of any service ministry in Lebanon
Rather than shore up its own capacities in essential fields, the ministry has subcontracted ever larger portions of the healthcare sector to other, mostly profit-driven entities. In the absence of a national laboratory, for instance, polio samples are sent all the way to Jordan for analysis. Likewise, the MOPH pays private companies to offer dialysis services and implement diabetes control programs that fall squarely within its mandate. It also relies, in key areas such as vaccination campaigns, on non-profit partners such as international aid agencies and Lebanese charitable associations. But far from easing pressure on the state, this delegation of responsibility tends to create additional costs and delays in fighting debilitating diseases.
Indeed, the ministry falls short when it comes to essential forms of coordination, oversight, and regulation, in a sector kaleidoscopically divided between private hospitals, public facilities, civic organizations, and foreign actors. Although the MOPH does issue decrees and circulars intended to govern the sector, they are rarely implemented. A good example is the introduction in 2011 of unified medical prescriptions, designed to centralize data, nudge physicians to prescribe generic alternatives over expensive brands, and reduce overmedication. Administrative hurdles and corporate obstruction delayed the scheme’s rollout for four years, and enforcement remains lackadaisical to this day.
Rather than assume a leadership role, the MOPH ends up restricting its work to discrete functions, notably listing the drugs to be subsidized by the central bank, negotiating accreditations for private hospitals, appointing representatives to the boards of public hospitals, and supervising routine vaccination campaigns—usually performed by NGOs. Although it runs 29 public hospitals, this number pales in front of their for-profit counterparts: According to MOPH figures, the country boasts 157. The ministry’s diminutive role thus raises an obvious question: What, exactly, does it do with its considerable budget?
The answer resides in a track record of lavishing resources on privately-owned entities at the expense of its own infrastructure. This trend, as shown in a study published in the Eastern Mediterranean Health Journal, harks back to Lebanon’s civil war, during which the share of private healthcare within the MOPH’s budget went from 10 to a staggering 80 percent. A recent study by the Beirut-based Knowledge to Policy Center found that public hospitals received less than 2 percent of all money spent on healthcare in the country.
The bulk of MOPH handouts to private facilities comes from reimbursing expenses incurred by patients enjoying some form of state sponsorship. Indeed, a broad cross-section of society relies on state-backed social security schemes, including the National Social Security Fund (NSSF), the Civil Servants Cooperative, and coverage for army and security personnel. Even those with no insurance at all are technically entitled to subsidized medical care. In state-run facilities, public schemes cover up to 95 percent of bills; in private hospitals, they cover 85 percent. Given such a small disparity, many patients go for the better service. In 2008, per the MOPH’s own, sporadic figures, over two thirds of uninsured patients opted for private hospitals.
The resulting arrangement is shot through with perverse incentives
The resulting arrangement is shot through with perverse incentives. As patients default to private hospitals, the latter minimize their own spending while maximizing billing—including through the over-testing and invasive procedures discussed above. To make matters worse, the MOPH exerts no oversight on what it is reimbursing. Rather, it negotiates with each hospital an annual ceiling up to which the ministry will reimburse. Incredibly, this lump sum is not ultimately audited. Even the negotiation process may be distorted by profit-seeking. A doctor in Tripoli, who tried and failed to set up his own private hospital, denounced rampant corruption:
Private hospital accreditations are big business. For instance, a hospital may negotiate a ceiling of one billion pounds, but only after a suitcase of money is delivered to a third party who facilitates the deal. Then, if the hospital exceeds its limit on billing, it may need to deliver another suitcase of money! Bribery is a major problem in the sector, because it is all built around financial interests.
Such allegations cannot be independently corroborated, but the ministry’s structural bias toward the private sector is barefaced anyway. It was made more visible still by the covid epidemic, during which private hospitals have been reluctant to shoulder their share of responsibility in fighting the disease. The MOPH has continued nonetheless to award them covid-related resources at the expense of its own facilities. Only a quarter of the medical equipment provided through a Tunisian grant, for example, was sent to Rafik Hariri University Hospital (RHUH), which bore the brunt of the initial response to covid. The remainder was handed over to AUBMC, which already enjoys generous international support, and closed its accounts in 2019 with almost two billion dollars in assets.
Since the Lebanese economy crashed, the MOPH’s main concern has been to underwrite the private sector to the extent possible, by finding ways of paying its accumulating dues. But this attempt to sustain the system as it currently stands is financially untenable. Worse, it distracts the ministry from its central role in thinking through and facilitating an inevitable transformation of the sector. By starving itself of both money and power, the MOPH is failing to even begin to invest in the public health infrastructure that Lebanese need, as their purchasing power withers. Instead, citizens are left to their own devices, to seek affordable medical treatment in this increasingly disjointed, almost labyrinthine landscape.
✜ A public at a loss ✜
Ordinary Lebanese face obstacles to accessing adequate care even at the best of times. They must first figure out where to turn for treatment. In most countries, patients would begin by consulting general practitioners, who form the so-called primary layer of the health sector, and who refer patients to the relevant hospital department. In Lebanon, however, people tend to go directly to the second layer. This habit results, in part, from a lack of public awareness regarding primary care options, given the sector’s emphasis on specialized services. A young doctor training at Hotel Dieu observed: “We do have a family clinic with top quality doctors who provide consultations for a small fee. But no one seems to know it exists.”
As a result, patients resort to ad hoc and sometimes arbitrary ways of finding care—relying on past experiences, doctors among their acquaintances, and hearsay. They inevitably turn to whomever they trust most, rather than whomever is most qualified. Someone suffering from lower back pain—a condition relevant to a general practitioner—may see an orthopedic surgeon instead. A medical trainee mentioned how absurd such situations can become: “It is normal to see patients with urinary infections in the cardiology ward, just because a cardiologist they happen to know agreed to supervise their treatment.” Naturally, such improvisation can lead to insecurities; patients regularly turn to their networks in search of second opinions on diagnoses or prescriptions.
Once patients decide where to start, they immediately run a bureaucratic gauntlet: To gain admission into a hospital, patients must demonstrate upfront that their expenses will be covered by a private insurance policy, a social security scheme, the MOPH itself, or a deposit in cash. This step only kicks off an exhausting back-and-forth which continues throughout a patient’s medical journey, as each new procedure requires preapproval. A film director recalled her bitter experience following a car accident: “A medical emergency means entering the nightmare of figuring out who pays the bills. It never ends simply or serenely.” Having started her treatment in one hospital, she was then forced to move to another to stay within the budget her insurer agreed to.
Patients resort to ad hoc and sometimes arbitrary ways of finding care
Even those patients who are covered by the state must contend with sluggish and inauspicious procedures. For example, hospitals do not coordinate with the NSSF on behalf of patients, leaving the latter to manage the uncertain process themselves. Another, growing problem relates to the decreasing value of the Lebanese pound: Private hospitals match their bills to its black-market value, while the NSSF sticks to an older price list following the official exchange rate. As more and more patients struggle to pay their dues, the state is effectively covering less and less.
Navigating the sector is made all the more confusing by the fact that hospitals rarely provide a complete, coherent package of services. Without government regulation, private facilities enjoy unfettered freedom to pick and choose what services to offer—sometimes leaving glaring gaps. A migrant worker whose wife delivered in Lebanon described how the act of giving birth could involve three different establishments. One oversaw the delivery but did not perform postnatal tests. The second did the tests but did not interpret them. Finally, the couple found help from a doctor in a clinic, after a friend posted a plea for advice on Facebook. A medic involved said: “Imagine that such a basic process could take up to five days, with no sense of progress or idea of what to do next!”
As patients stumble their way through this maze, they are forced to improvise solutions at virtually every turn. Lack of coordination between private hospitals means that patients must assemble their own health records, and take them from one facility to the next. They activate their networks even to find the right medication, which may be unavailable in some pharmacies, prohibitively expensive in others, poorly stored (as in the case of cheaper alternatives imported illegally into the country), or merely counterfeit. Without a national blood bank, people also send out requests for specific blood types over social media.
Such twists and turns can become very costly for the individual patient. And, unsurprisingly, the burden falls heaviest on society’s most vulnerable. In principle, the MOPH guarantees coverage for uninsured patients even in private facilities. In practice, however, the latter openly discriminate against so-called “public patients,” who are likely to receive third-class beds, face dismissive attitudes on the part of doctors and nurses, and enjoy restricted treatment options. A medical trainee explained: “Management is wary of such patients because the ministry often fails to reimburse their expenses, or just makes the process harder by requiring more paperwork than usual.”
Such twists and turns become very costly for the individual patient
This bias means that needier patients often spend extravagant amounts of time seeking facilities that will treat them. When they do find care, many struggle to pay their share of the costs. An AUB study published in 2005 showed that the poor spent on average 20 percent of their total income on healthcare, more than twice as much as the rest of the population. A building concierge in southern Beirut, who underwent a toe amputation, recalled an exorbitant bill: “Between the X-rays, the operation itself, and the medicine, I only managed thanks to help from my sister and in-laws.”
Where family networks don’t suffice to pull together the needed resources, some Lebanese resort to political factions and leaders. “Patients who fail to pay their bills will find one politician or another to do so,” explained a doctor in Tripoli. “We are ruled by these people, so they should pay. And they do.” Such figures usually enjoy strong ties to specific medical establishments, from which they can obtain preferential conditions. They also frequently run foundations, charities, and dispensaries that provide affordable basic care as a form of patronage.
This cobbled-together sector finally includes an array of apolitical NGOs, both local and international, that have flourished in the country since the civil war. Thus, the Lebanese Red Cross provides the main emergency transport service. The Amel Association and Lebanon’s YMCA are among the many organizations who receive funding for diverse, sometimes overlapping services such as mobile clinics, medicine distribution, and chronic disease management. Meanwhile, UN agencies assume some of the medical costs related to Syrian and Palestinian refugees. This profusion of health providers, often dependent on streams of funding from abroad, further relieves the state of its own duties. It also reinforces a very Lebanese instinct, to trust anything more than the state—which consequently has even less incentive to change.
✜ ✜ ✜
There is a heavy price to pay for Lebanon’s decades of underinvestment in public health. The country has so far kept a lid on problems, through overreliance on curative measures and excessive medication. All the while, it has neglected preventive medicine, as well as basic sanitation, food security, and pollution control. As a result, we can now expect a steep increase in both infectious and chronic diseases, which the country is ill-prepared to tackle. The spread of asthma, the return of cholera, or an explosion of food poisonings are the kind of problems that cannot be solved by Lebanon’s traditional “do-it-yourself” approach.
In the minds of many Lebanese, a growing role for the private sector remains the answer, given the government’s bankruptcy and the MOPH’s gross mishandling of the covid crisis. But the reality is that most private institutions are no longer viable: Their middle-class client base is rapidly shrinking, medical tourism is waning, and the costs of their equipment is rising prohibitively. They are not unlike Lebanon’s banks, flamboyant only as long as the state foots the bill. International aid programs and local NGOs provide no fallback either. Their interventions are limited in scale, restricted in scope, and disconnected from one another; their overall efficiency will always be dependent on the state’s ability to coordinate the sector.
Given the ministry’s state of dereliction, setting overly ambitious goals will only guarantee that nothing at all happens. But the state need not be perfect: All it must do is begin to assume its most basic, fundamental roles, for which there simply is no substitute. First and foremost is the collection, analysis, and dissemination of information—much of which can be done at minimal cost. The obstacle indeed has mostly been cultural, as the MOPH has refrained from prying into the private sector’s records while failing to produce consistent data of its own.
A second priority is to start redirecting resources, by cutting back on subsidies flowing to the most expensive and inadequate private hospitals and branded drugs. A growing fraction of the ministry’s budget must shift to the benefit of primary healthcare centers and generic medication. Finally, it behooves the MOPH to fundamentally rethink the country’s social security system, if Lebanese are to enjoy some form of safety net in their moment of need. None of this can happen overnight. But the country must not tumble endlessly down a vicious spiral either: Simple steps are what it takes to begin to climb back up.
30 March 2021
Fahad al-Sudaid is a fellow with Synaps.
Illustration credits: Olga DeLawrence Prescription drugs and Sharon McCutcheon untitled, licensed by Unsplash, modified by Synaps.
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