Written on behalf of the Healthcare Delivery and Reform Group
The outbreak of the novel coronavirus has challenged healthcare systems worldwide. As of 8 February 2021, cases have been documented in 219 countries. Lebanon documented its first case on 21 February 2020. With airport closure and a series of lockdowns, Lebanon was able to keep the number of daily new cases and hospitalizations relatively under control. However, the 4 August 2020 explosion at the Beirut port coupled with relaxed restrictions in October and December saw a massive soar in cases, reaching 4,594 new daily cases in mid-January 2021. What is more concerning is the increase in the number of hospitalizations where ICU occupancy in the whole country approached 95% in January 2021. With the meteoric rise in the number of infections and hospitalizations, concerns have arisen regarding the vulnerability and safety of healthcare workers, whose own infection rates also increased and of whom many were forced into quarantine, hospitalized, or killed because of the virus. It is needless to say that healthcare workers are at a higher risk than the general population and can amplify outbreaks in healthcare centers when infected.
A healthcare worker is one who delivers care and services to the sick, either directly such as doctors and nurses, or indirectly such as helpers, laboratory technicians, or medical waste handlers. Healthcare workers also include dentists, physiotherapy personnel, students and trainees, dietary and food services staff, administrative staff, and others.
In this paper, we describe the toll of the COVID-19 crisis on healthcare workers in Lebanon, particularly physicians, without discounting the crucial role of other healthcare workers. Some of the discussed points can apply to all healthcare workers, though physicians are unique in many aspects regarding their protection and coverage. The sad experience with physician hospitalization and mortality due to COVID-19 has highlighted the need to revisit laws, policies, and decrees related to health insurance coverage, and disability and mortality compensation for physicians, including those in training. The paper also presents recommendations on how best to address the gaps in insurance coverage during the pandemic, particularly for the most vulnerable among physicians.
COVID-19 Among Healthcare Workers
The number of infections among healthcare workers increased by more than 50% during the month of September 2020 and steadily increased after that to reach 2,429 cases by the beginning of February 2021. Ideally, we would compare this number to the total number of healthcare workers, obtain the number of physicians infected, and compare it to the total number of physicians actively practicing in Lebanon in order to obtain a better indicator of how much the workforce combatting the coronavirus is affected. However, these numbers are difficult to accurately ascertain since many physicians may still be registered as active members of the Lebanese Order of Physicians (LOP) but are not currently practicing in Lebanon. The LOP estimates this number to be around 8000 physicians. An estimate from a large medical center in Beirut shows that 26% of the hospital staff had been infected with the coronavirus as of late January. As this paper is written, 26 physicians have died due to the coronavirus. The head of the LOP recently sounded the alarm at the increasing number of coronavirus infections among medical personnel and called upon insurance agencies and providers to cover 100% of the hospital bills for hospitalized physicians, and upon hospitals to ensure protective measures are taken to prevent infection. It is fitting here to also mention the heavy toll that the pandemic has exacted on healthcare workers’ mental health, as a recent study showed that half of the participants were at high risk of acute stress.
Regarding physician protection, it has been shown that the adequacy of personal protective equipment (PPE) and the clinical setting have a role in determining the risk of healthcare worker infection. Globally, there is a shortage of PPE available, along with an increase in prices. Lebanon depends entirely on imports for its supply of N95 masks and ventilators , making it difficult to ensure adequate supply from an already-strained global market. This challenge is further intensified by the financial crisis that the country has been facing for more than a year, making foreign currency needed for importing PPE and medical supplies scarce and expensive, at around eight times the old exchange rate. The central bank tried to remedy the issue by supplying 85% of the required foreign currency at the old low exchange rate. However, many suppliers still put cash restraints on hospitals for the delivery of medical supplies. This led to a shortage of PPE in the beginning that was experienced by all healthcare workers, which prompted the head of the LOP to urge hospitals to provide doctors with protective equipment to help stop the spread of the virus among medical teams. Even though PPE is now more available than it was earlier in the pandemic, there still is no strategy in place to ensure Lebanon does not face a shortage again, should it come under strenuous circumstances.
Rights and Duties
Physician Healthcare Coverage and Compensation for Death and Disability.
Practicing medicine is considered a “free profession,” physicians are thus not employees and their relationship with the hospital they practice at is dictated by the contract each doctor signs. Physicians can also hold private practices and thus have no contractual relationship to any hospital. By law, a physician should be registered with the LOP to practice medicine. Through the LOP, a physician can buy a health insurance policy with a group-priced premium. They can also enroll in the healthcare fund of the National Social Security Fund (NSSF), which would further reduce their premium. The LOP, since 2004, has been covering co-pays required by insurance policies or the NSSF. On the other hand, should a physician who is a member of the LOP, become temporarily disabled or kept out of work for a long time due to COVID, the order pays up to LBP 1,200,000 (equivalent to USD 150 at the current market rate) per month in disability coverage. In cases where physicians pass away after contracting the coronavirus, the LOP has to pay their families a sum of LBP 50 million (equivalent to USD 6,250 at the current market rate).
Another category of physicians includes trainee physicians. Trainee physicians are those who have obtained their medical degrees and are pursuing further specialty training. They sign a contract with a teaching hospital and receive their training and a regular salary from that hospital. Many trainee physicians do not register with the LOP due to their inability to pay the registration and annual fees. Although by law, only those who register with the LOP can practice medicine, trainees exceptionally practice under the license of their supervising physicians, who are held legally liable for any errors. While supervising physicians are held legally liable for medical errors and malpractice, they are not responsible for the trainee physician’s healthcare and safety coverage, as the trainee’s contract is with the hospital and not with the supervising physician. Without being registered with the LOP, trainees and their families are not entitled to compensation from the order. Since they should be salaried by the hospitals, by law, the cost of hospitalization for any work-related injury is the responsibility of the employer. In case of death due to a work-related injury, it is the responsibility of the employer to compensate the family of the deceased with a sum, the value of which depends on the salary last earned by the deceased. Trainees also have the right to receive the same wage from the hospital for up to 9 months, if their disability is caused by a work-related injury.
Gaps Uncovered by the COVID-19 Pandemic:
Physicians who contract the virus and require hospitalization are being treated by the hospitals they work with. However, when beds are no longer available for them at their hospitals or in cases where physicians work at hospitals with no COVID units or do not work at hospitals at all, they are treated like any other patient and given no priority. The Ministry of Public Health (MOPH) helps with some of the costs, just as for all other citizens. While the LOP does cover the deductibles required by the NSSF and insurance policies, certain parts of the hospital bill, are not covered for physicians, as is the case with other patients, leading the head of the LOP to urge hospitals to cover 100% of the bill for physicians being treated for COVID.
One major gap in compensation and coverage concerns trainee physicians. While a few teaching hospitals adhere to the law and ethical ideals and offer their trainees healthcare coverage, others do not offer any compensation. In fact, many trainee physicians do not receive any payments or benefits during their training. There is also no standard contract for trainees, which leaves room for huge disparities among different training centers.
Lebanese law clearly states that it is the responsibility of the employer to provide all that is needed to ensure the safety and health of employees in all areas where they perform their employment duties. It is also the employer’s responsibility to take all necessary measures to protect all those employed and to maintain their health while providing their services. Furthermore, failure to meet such responsibility can lead to the application of penal code statutes penalizing employers.
These laws are legally binding in the relationship between employer and employee as specified in the law of contracts and obligations where the employee is the one who puts their work under the direction of the employer. This is the case of employee healthcare workers, and trainee physicians. Non-trainee physicians who work at hospitals are not considered employees, which is the same for physicians with independent practice.
The World Health Organization, through its constitution and the Alma Ata Declaration, has stressed the need to protect the healthcare professionals during their work through taking precautions against workplace dangers and combatting those dangers.
Failure to provide adequate PPE puts healthcare workers at risk while performing their duties and would be a violation of these laws and principles. Endangering the lives of healthcare workers at this juncture compounds an already-ailing system with a disastrous action. The consequences would be catastrophic, especially in light of the economically driven exodus of physicians and nurses from the country.
It is important to note that physicians should not be and are not held liable if they deny a patient urgent care when the provision of care exposes the physicians to danger. Based on that, a physician cannot be held liable for not providing care to a coronavirus patient if necessary PPE is not available.
The coronavirus pandemic is an exceptional time and has put physicians in a strenuous situation. Unfortunately, the law is silent as to what should be done in such situations as there are no laws that cover exceptional circumstances. The non-inclusion of physicians under labor laws is also an important gap. Amending labor laws and LOP regulations to cover emergency or exceptional situations can remove ambiguity and clarify rights and duties. Moreover, legislations that are specific to healthcare worker protection and compensation due to COVID-19 can clarify roles and ensure better protection and fairness to healthcare workers.
Improving Physician Healthcare Coverage and Compensation
A. Non-Trainee/Senior Physicians
The laws in place for healthcare coverage and compensation are not specific for physicians; they are for employees in general. Since medicine can be an independent practice, physicians are not always covered by employment laws. These gaps are true cracks in the system where many physicians fall and should be addressed to ensure fairness.
The compensation for disability or death given by the LOP (for both COVID-19 and non-COVID-19 related illness) is a fixed amount for all physicians. A value calculated based on declared income or potential income would be a fairer alternative. This may require the LOP to avail registered physicians of a broader spectrum of coverage options based on a scale of registration fees adjusted to declared income or based on optional purchase of additional coverage at a group negotiated rate. In addition, experience during the pandemic raised questions as to what is covered by the NSSF and other agencies on the treatment bill and what is not. A clear written protocol should therefore be put in place to specify how such decisions ought to be made.
B. Trainee Physicians
Another major gap to be addressed are protections for trainee physicians, particularly those working with hospitals or institutions that do not offer healthcare coverage. Many of them receive little or no income and live below the poverty line, placing them in the most vulnerable category of healthcare practitioners. Addressing their plight involves a multi-pronged approach:
First, the LOP can facilitate their induction into the order by creating affordable categories of membership for trainees and medical students, thereby providing them with necessary healthcare coverage and disability compensation. This membership status can be time limited by age or number of postgraduate years. After that, the ‘young member’ would become a full member and pay regular membership dues. Recently the LOP made it possible for trainees to pay membership fees over 24 installments using a bank loan, with the LOP covering the interest due.
Second, the LOP and the MOPH can push to set minimum standards for the contractual relationship between the trainee and the teaching hospital. These standards would include full healthcare, disability, and death coverage of the trainee physician, as well as minimum compensation for their work during training. Non-compliance with these standards would put the hospitals at risk of losing their academic and training credentialing, and potentially losing their accreditation by MOPH. Trainees should also be made aware that they are entitled to NSSF enrollment by virtue of their status as university affiliated trainees.
Ensuring better Safety in the Workplace
In general, practicing physicians are not covered by labor laws, and there are no regulations for their protection in the workplace. As for salaried physicians, including trainee physicians, the Lebanese law places responsibility on employers to ensure the protection of their workers. This has put hospitals in a predicament in light of the current difficulties in procuring PPEs. Simply penalizing hospitals is not a solution to ensure the adequate availability of PPE. Adequate policies and measures should be implemented by governing bodies in order to ensure protection of healthcare workers and subsequently the survival of the healthcare sector. These policies could also set the standards against which hospitals can be held accountable. Provisions that are specific to healthcare worker protection from COVID-19 must be enacted promptly to ensure standards are set for all to follow. To implement and enforce these provisions, the MOPH, in collaboration with the Ministry of Labor, should establish a national program/agency that is specific to healthcare worker protection with a mission to develop these provisions and oversee their implementation nationwide. A good example to emulate would be the Occupational Safety and Health Administration (OSHA) created by the US Congress to ensure safe and healthful working conditions for workers by setting and enforcing standards and by providing training, outreach, education, and assistance. This can include senior physicians who work in hospitals but are not employees, as well as those with independent practice. Physicians in independent practice are at a disadvantage with regards to PPE procurement as they are responsible for their own PPE. They do not benefit from bulk discounts on PPEs that hospitals can negotiate and have a hard time procuring PPE during shortage periods. Open bids for medical supplies and group negotiated prices by the LOP can help independent physicians procure their practice needs, including PPE, at more affordable rates.
Adequate Availability of PPE
It has been shown that adequate availability of PPE and the quality of PPE decrease the risk of infection by COVID-19, while the re-use of PPE might confer increased risk. Ensuring the quality and availability of PPE should be the goal of any policy. Calculators that can forecast the quantity needed for PPE have been developed and tested in Lebanon. These calculators also show the dependence on stringency in social distancing policies, where the more stringent the policies are the less the need for PPE; conversely, relieving restrictions is associated with a higher need for PPE.
WHO proposes a framework of three principles to ensure the availability of PPE. These principles are: reducing the need for PPE; appropriate use of PPE; and supply chain coordination. Reducing the need for PPE occurs through changes in patient and healthcare worker scheduling, while appropriate use of PPE is the application of PPE as per indications. Both of these principles are mostly the responsibility of the hospitals and their respective professional bodies. Supply chain coordination is the responsibility of the government where it should ensure that all parties receive their needed supply and prevent stockpiling. The government can also take all necessary steps to incentivize the local production of PPE. Transparency is important here; in this sense, the authorities should keep the public informed vis-à-vis PPE availability and distribution plans to various areas and hospitals. The government’s role is to oversee adequate procurement and distribution of the needed safety resources and to ensure both that the consumption of specific PPE (such as N95 respirators and surgical masks) is not abused and also that distribution is prioritized for healthcare use in times of shortage. Given the scarcity of PPE supply and the need to procure it from any available source, quality assurance is necessary. Unfortunately, this has yet to happen and governmental authorities need to step up and fulfill their duty in terms of quality review and certification of healthcare products.
With the imbalance between short supply and high demand for PPE, procurement could be a challenge. To decrease competition between parties over PPE supplies, WHO and Doctors Without Borders (MSF) have established a supply portal through which countries can order PPE. Collaborative procurement efforts have also been made between unions such as that between the African Union and the European Union. Starting a collaboration with other countries as part of trade deals for PPE, for example, may be a strategy that the Lebanese government can use to ensure adequate provision. Quality assurance should be taken into consideration when entering those deals. Even though there is currently enough PPE available in Lebanon, a long-term strategy should be adopted to ensure the country always has a sufficient supply to cover demanding situations, similar to what we experienced during surges of COVID-19. The gaps identified and the proposed solutions are summarized in table 1 below.
Table 1: Summary of gaps identified in physician coverage and protection and policy suggestions for each of these gaps. (LOP: Lebanese Order of Physicians, MOPH: Ministry of Public Health, PPE: Personal Protective Equipment)
|Physician Healthcare Coverage and Benefits
||Facilitating LOP Enrollment
|Standardizing training/work contracts
||Compensation for Disability or Death based on declared income
|Protocol between MOPH, Lebanese Syndicate of Hospitals, and LOP on payment of uncovered parts of hospital bill
|Safety in the workplace
||Absence of Specific Health Care Worker Labor Laws
||Legislating laws for specific healthcare worker hazards (e.g. COVID-19) and exceptional circumstances
|Absence of Regulatory Bodies for Workplace Safety
||Regulatory Agency ensuring adequate standards are met
||Inapplicability of Labor Law employment relationship to Physicians
||Inclusion of physicians in specific healthcare worker safety laws
||Private Practice Physicians have to secure their own PPE
||Collective Bargaining for PPE via LOP.
||Lack of National Strategy for continual availability
With the rising numbers of COVID-19 cases, healthcare worker coverage and protection are critical for the survival and performance of this vital sector. There are many loopholes in the laws and regulations protecting physicians’ health and welfare. The COVID-19 pandemic has brought these gaps to light more than any other crisis before. In the absence of laws that are specific for the COVID-19 pandemic, or for exceptional situations in general, action is needed now to set uniform standards for all to follow. The LOP regulations should be adapted to facilitate trainee physician enrollment so that they can benefit from the protections that the order affords its physician members. Furthermore, policies should be enacted to ensure safety and adequate supply of safety resources (PPE) in the country, with a clear and effective national response coordinated by the MOPH. The wellbeing and safety of healthcare workers is paramount, especially in these trying times and society cannot afford exposing them to otherwise avoidable risks and uncertainties in their healthcare coverage and safety – both personal and financial. This article focused on the specific needs of physician, but similar needs exist for other healthcare workers, including nurses, as they are a crucial part of the healthcare system and have also felt the toll of the COVID-19 pandemic.