There are five Palestine Red Crescent Society (PRCS) hospitals in Lebanon that offer health care for Palestinian refugees. Those five hospitals are Haifa Hospital in Burj Barajneh camp in the Southern suburbs of Beirut, Safad Hospital in Beddawi camp in North Lebanon, Balsam Hospital in Rashidieh camp in South Lebanon, Al Hamshari Hospital in Saida in South Lebanon and Al Nasira Hospital in Bar Elias, Zahle. While Al Hamshari and Haifa hospitals provide some tertiary care (i.e. joint replacement surgery, laparoscopic surgery and thyroidectomy), all five PRCS hospitals specialize in secondary care. The facilities consist of an emergency department, an intensive care unit (ICU) and several specialized departments including obstetrics and gynecology, surgical, medical, physiotherapy and pediatrics. PRCS-affiliated hospitals have their own blood banks and two ambulances each, including one equipped with a mobile ICU. Al Hamshari Hospital has three ambulances.
Although established to serve Palestinian refugees, PRCS-affiliated hospitals welcome patients of all nationalities. For example, 90 percent of Balsam Hospital patients are of Palestinian origins, including Palestinians, Palestinian-Lebanese and Palestinian-Syrians. An estimated 80 percent of patients treated at Safad Hospital are of Palestinian origins, the rest are Lebanese and Syrians. In Nasira hospital, 55 percent of patients are Palestinian-Lebanese and Palestinian Syrians, while 45 percent are of Lebanese, Syrian and other nationalities.
In June 2017, Defenders for Medical Impartiality (DMI) conducted in-person meetings with Dr. Khalil Mohawech, Dr. Ibrahim Yassine and Dr. Abed Antar, general managers of Haifa, Safad and Balsam hospitals, respectively. DMI also met with Dr. Samer Chehade, PRCS Director General in Lebanon. DMI conducted phone interviews with Al Hamshari general manager, Riad Einen and Al Nasira Hospital manger, Dr. Imad Koussa.
While many challenges are common to all five PRCS-affiliated hospitals (i.e. limited funding, low salaries, and shortage of staff and medical equipment), located inside the camps, Haifa, Balsam and Safad hospitals face unique barriers that are especially worthy of investigation.
- Established in 1978, began functioning as a hospital in 1985
- Located near Ain El Helwe refugee camp, the country’s largest refugee camp hosting more than 54,116 UNRWA-registered refugees. Hospital also serves refugees in nearby Mieh Mieh camp.
- First PRCS hospital to open a dialysis center in the early 90s
- Contains a total of 66 beds and 19 kidney dialysis chairs
- Employs 16 general practitioners, 40 specialists and 86 nurses
- Serves around 3,000 out-patients and 650-750 in-patients per month
- Shortage of nurses
- Water supply contaminated with pathogens
- Exterior wall leak
Al Nasira Hospital
- Established in 1978
- Located outside Bar Elias refugee camp. Hospital also serves Palestinian communities in Taalabaya and Saadnayel
- Contains a total of 26 beds
- Employs five general practitioners, at least 15 specialists and 40 nurses
- Serves around 100 in- and out-patients per day
- Shortage of general practitioners, specialists and midwives
- Old hospital beds
- Established in 1985
- Located in the Burj Barajneh camp, Southern suburbs of Beirut, which hosts at least 17,945 UNRWA-registered refugees. The total number of refugees ranges around 31,000, including thousands from Syria
- Contains a total of 40 beds
- Employs 120 staff. This includes 10 general practitioners, 22 specialists and 40 nurses
- Serves around 100 in- and out-patients per day
- Accessibility and security
- Established in 1992
- Located in Southern Lebanon’s Rashidieh refugee camp, hosting at least 31,478 UNRWA-registered refugees
- Contains 25 beds
- Employs a total of 90 medical workers, including seven general practitioners, 23 specialists and 33 nurses
- Serves around 40 to 50 outpatients and 10 to 15 inpatients on a daily basis
- Accessibility and security
- Established in 1993
- Located inside Al-Badawi camp in north Lebanon, which hosts more than 16,500 registered refugees
- In March 2017, the hospital opened a kidney dialysis treatment center co-funded by UNRWA, UNICEF, Welfare Association/Lebanon, Islamic Relief Worldwide, Palestine Children’s Relief Fund and Medical Relief Society. The unit contains seven dialysis machines and has the capacity to treat 30 patients. There are currently 13 regular patients. Palestinian refugees may also receive subsidized treatment at nearby Saydet Zgharta Hospital
- Contains 34 beds in total
- Employs 28 specialists, 12 general practitioners and 37 nurses
- Safad Hospital receives on average 130 patients per day
- Accessibility and security
- Shortage of nurses and specialists
The following section discusses the major obstacles that challenge the ability of Balsam, Safad and Haifa hospitals to deliver high quality care.
The dominating climate of instability, physical threats and sporadic fighting makes security a key concern for Balsam, Safad and Haifa hospitals. According to Dr. Samer Chehade, attacks on these hospitals have increased in recent months. “Drugs and arms are abundant inside the camps,” says Chehade. “Both of these factors endanger the security of the camp and its hospitals.” The PRCS is in regular contact with the Palestinian factions who are entrusted with the security of the camps. Chehade told DMI that PRCS is working on a new initiative to improve communication between the hospitals themselves and the camps’ committees.
In 2017, there were at least three violent altercations on Safad Hospital. According to Dr. Ibrahim Yassine, “These attacks are often caused by patient outrage.” At Safad Hospital, a patient’s son attacked a medical personnel for closing the surgery room door to operate on his father who was suffering from a heart attack. In another case, a man assaulted a nurse for asking him to leave a room where another female patient was being treated. Each of the incidents incidents were reported to the camp’s security committee. The hospital staff responded to these attacks by going on strike and closing the facility for five days. These attacks were reported to the camp’s security committee. Mohamad Fayad, a member of Al-Bedawi’s security committee told DMI that security guards were assigned to ensure the safety of the facility. “We do not live in an ideal society,” he says. “In the event of an assault, the perpetrator is detained for a day or two and a reconciliation is then reached.” To facilitate access to the facility and provide a safer environment, preparations are underway to move the hospital to a new location outside the camp by next year.
Similarly, three attacks were reported on Balsam hospital in 2017. According to Dr. Abed Antar, “Many residents possess arms. This makes [the hospital] an unsafe environment to work in.” Earlier this year, an ambulance driver asked a resident of the camp to leave the hospital premises. The man was frequently at the hospital for no apparent reason. He then hit the driver with metal chains on his head. Following this incident, the camp’s security committee handed the perpetrator over to the Lebanese authorities. The ambulance driver later dropped the case, and the attacker was released after two weeks of imprisonment. Ghassan Awad, a member of security committee in Rashidieh camp, informed DMI that the committee handed over 3 perpetrators of assaults on hospital staff to the Lebanese authorities between 2016 and 2017. “We installed cameras and assigned 20 guards to secure the facility.”
While attacks on Haifa Hospital’s staff are rare, attacks on the facility are common. “Electricity and water thefts are the norm,” says Dr. Khalil Mohawech. Located in the crowded camp of Burj Barajneh, the hospital is tightly squeezed between residential buildings. Electric wires hang above the entrance of the emergency room and motorbikes almost block the hospital’s entrance. In one case, the family of a patient, who required transfer to a nearby hospital, had to clear the road from Haifa Hospital to the camp’s entrance 30 minutes before the ambulance carrying their son left the facility.
Haifa Hospital administration requested security guards to be deployed around the facility. They renewed their request on 12 July 2017 but have yet to hear back from the camp’s committee. No security cameras are installed at the facility. The administration is hoping to move the facility to a new location by the camp’s entrance. The hospital administration believes that security concerns that are currently interfering with the quality of care delivered will be solved when the hospital moves to the new location. Plans are on hold until the Palestinian Authority purchases the $3.5 million land.
Low Salaries and Shortage of Medical Workers
Salaries of PRCS employees in Lebanon are paid by the Palestinian Authority. The starting salary of specialists or general practitioners is $600 per month and $300 per month for nurses. Low salaries contribute to a shortage of medical staff. All three hospitals are in need of additional medical workers to meet the needs of the communities they serve. To compensate for the labor shortage, hospitals hire doctors on a short term basis. For example, out of the 23 specialists at Balsam Hospital, only four work on a full-time basis. The rest are hired on a short-term contract basis. Further, the location of the hospital affects its ability to hire staff on a short term basis. “In many cases, we would hire specialists who would show up on the first few days then never come back,” says Dr. Abed Antar. This situation is similar at Haifa and Safad hospitals.
Low salaries together with a lack of retirement benefits drive medical workers to look for employment elsewhere. Most commonly, medical workers seek work abroad or at private hospitals and clinics in Lebanon. This has resulted in hospitals retaining employees beyond the age of retirement. Seven out of the 22 specialists at Haifa Hospital are above the age of 60. At Al Nasira Hospital, all five of the specialists who are full time are above the age of 60.
Patients receive treatment at PRCS hospitals for minimum fees. As a result, PRCS hospitals rely on UNRWA for their core funding. The agency pays approximately $100 per patient admitted to the hospital, which falls below the actual cost of treatment at these hospitals. A 2017 PRCS study reveals that the cost per bed per day per clinical department and hospital ranges between approximately $113 and $180. The study also found that the economic costs of surgical procedures at PRCS-affiliated hospitals are higher than UNRWA payments to PRCS. For example, UNRWA pays PRCS around $400 for a caesarean delivery, which costs the hospital around $733. UNRWA payment for a thyroidectomy, which costs around $966, is no more than $500. According to Dr. Chehade, the disparity between UNRWA coverage and the cost of treatment is contributing to a budget deficit. PRCS’s budget deficit increased from $593,000 in fiscal year 2014 to $690,000 in fiscal year 2015. The deficit in budget for fiscal year 2016 is expected remain the same or increase, Dr. Chehade said. PRCS’s limited budget restricts the medical capabilities of its hospitals, which are currently operating at substandard levels.
Medical Equipment and Medicines
All five PRCS-affiliated hospitals lack digital x-rays and magnetic resonance imaging (MRI) scanners. Patients in need of such equipment are transferred to nearby UNRWA-contracted hospitals, where they are required to pay 50 percent of the cost. There are 35 UNRWA-contracted hospitals located throughout Lebanon. While Al Hamshari Hospital is the only facility to host a CT scanner, the machine is a personal contribution. The contributor charges 25 percent of profits and contract is renewed on a yearly basis. Patients cannot receive an accurate diagnosis of heart conditions at PRCS hospitals, as these facilities lack a cardiac catheter. Further, these hospitals do not have the necessary equipment to perform head, heart or eye surgeries. At Balsam Hospital, there are only two anesthetic machines, one of which does not work properly. “We cannot perform two surgeries at the same time,” said Dr. Antar. The facility’s sterilization machine and its periscope are outdated. Al Nasira Hospital’s beds date back to 1993.
PRCS spends on average between $1,200,000 and $1,400,000 on medicines alone each year. PRCS-affiliated hospitals purchase medicines from PRCS warehouse at low profit margins, not exceeding 5 percent. When a drug is not available, the hospitals purchase the medicines from other providers at a 22.5 percent profit margin.
- Set payments to PRCS-affiliated hospitals at the actual cost of surgical and medical procedures; and
- Ensure that payments to PRCS-affiliated hospitals are received in a timely manner.
To Palestinian factions:
- Take effective measures to increase security and facilitate access to the PRCS-affiliated hospitals located inside the refugee camps; and
- Ensure that perpetrators of violent altercations at PRCS-affiliated hospitals are held accountable.
To Palestinian Authority:
- Increase starting wages of medical workers employed at PRCS-affiliated hospitals.