Lebanon’s public healthcare system was already in crisis when word of a new, deadly virus began to emanate from the Chinese city of Wuhan in January. Now, the arrival of coronavirus in Lebanon is putting further pressure on a crippled public health sector that has left some of the country’s most vulnerable at risk.
Lebanon’s healthcare system is made up of both public and private sector providers, but over the past decades the private sector has increased its dominance, leaving public healthcare services disused and underfunded.
According to a 2016 report, over 85 percent of hospital beds belonged to private hospitals. However, while private sector health services in Lebanon generally win praise for their quality, only around half the population has insurance coverage to access them reliably.
Public alternatives for those unable to access private healthcare have been neglected for decades, leaving Lebanon with vast inequality in access to healthcare. “The public sector is the poor cousin. It had been almost destroyed during the civil war and only partially rebuilt to respond to the real needs of the country,” said Salim Adib, professor of epidemiology and public health at the American University of Beirut. “There’s too much conflict of interest between the private sector and the people in government.”
Long-term stresses: influx of refugees and economic crisis
The recent surge of coronavirus patients to government hospitals has put stress on a system which was already feeling the strain from refugee and economic crises that stretched back years.
Following the outbreak of the war in Syria, hundreds of thousands of refugees sought shelter in Lebanon.
While this large, vulnerable population put further pressure on the public healthcare system – the proportion of Syrian beneficiaries at Rafic Hariri Governmental University Hospital (RHUH) increased from 2 percent in 2010 to 33 percent in 2014 – donations from major international NGOs and the EU provided a funding boost to local healthcare services.
More recently, Lebanon’s ongoing economic crisis hit the healthcare sector particularly hard as government funds to both private and public hospitals were delayed.
The Finance Ministry failed to pay private hospitals around $1.3 billion in dues since 2011, according to the head of the Syndicate of Private Hospitals, while RHUH told Human Rights Watch in a report published Tuesday that the hospital had been paid only 40 percent of its dues from 2019, and none of those from 2020.
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“The problem was [that] the local suppliers were not willing to bring these medical supplies from the country of origin because of the black market dollar exchange rate,” said Rawad Shehayeb, an assistant general manager at RHUH responsible for medical logistics. The hospital was forced to shift from its economical “Just in Time” stock keeping strategy to importing 2 months’ worth of materials, Shehayeb said.
A support system was put in place last October, around the time that massive anti-government protests began to take hold of the country, but the value of the dollar has only risen further since then: at one point the greenback’s value reached almost twice the official rate on the black market. Then-caretaker Health Minister Jamil Jabak warned in November of “a major lack of supplies and equipment, and if this continues we could reach a very dangerous situation.”
Coronavirus hits Lebanon
Lebanon confirmed its first case of coronavirus, also known as COVID-19, on February 21, a patient who was admitted to the public RHUH.
RHUH, and the public sector more broadly, has so far taken the lead in the country’s coronavirus response, especially as some private insurers have said that their insurance coverage does not extend to treatment for the virus, given its global pandemic status. Private hospitals are offering coronavirus testing, but at a cost of 150,000 Lebanese lira ($100 at the official exchange rate) – in contrast to the free testing at RHUH.
Despite a dearth of equipment - only around 250 respirators are currently available across the public and private sectors, and equipment importers say that have been unable to import medical equipment since September – the RHUH coronavirus treatment center has so far managed to accommodate the hundreds of patients it treats daily.
This is partly because the disease has spread comparatively slowly in Lebanon, a fact Adib puts down to social distancing techniques as well as the country’s young population - CIA statistics from 2018 put Lebanon’s median age at 30.5, compared to, for example, Italy at 45.5.
Cases continue to rise, however, with the total up to 333 confirmed cases and 6 recorded deaths on Wednesday, and it is unclear whether poorly funded public hospitals alone will be able to cope with an influx. Earlier this month, non-frontline staff at RHUH even called a strike to protest non-payment of wages and poor working conditions.
In response, Lebanon’s government recently approved a much-needed cash injection of $40 million in World Bank funding for government hospitals involved in the coronavirus response and the Association of Lebanese Banks announced on Tuesday a $6 million donation to government hospitals battling the virus.
More public hospitals are preparing to open their doors to patients, and Lebanon’s government has already asked private hospitals to be ready to accept patients – although it is unclear who would fund this.
Recent statistics from the Ministry of Public Health show that the private sector has around four times as many intensive care beds as the public sector, which could be vital in the country’s efforts to combat coronavirus.
“We believe that we have two critical weeks now,” said Dr Pierre Abi Hanna, an infectious disease expert at RHUH.
Normally, Abi Hanna said, RHUH is a “hospital of the very sick and the poor … [Now] the whole country is relying on the government hospital to take care of those people, to be the first line of defense in the country against this epidemic.”