Secondary and tertiary health care, January – April 2014

Syrian refugees in Lebanon
Secondary and tertiary health care, January ‒ April 2014
Photo credit: McConnell/UNHCR
UNHCR’s public health approach is based on the primary health care (PHC) strategy. In Lebanon, the government
provides services through the Ministry of Public Health (MOPH) and the Ministry of Social Affairs with nationals paying
part of the cost. In addition, PHC services are provided by private practitioners, local and international NGOs and other
charities.
Public secondary and tertiary health care institutions in Lebanon are semi-autonomous and referral care is expensive. Not
all adhere strictly to the MOPH flat rate for hospital care. To harmonise access to secondary health care and manage
costs, UNHCR has put in place referral guidelines in Lebanon. The costs covered by UNHCR vary by estimated cost of
care, vulnerability status, and type of care (e.g. emergency life-saving, obstetric, medical and surgical). For estimated
costs of USD <1500, 75% of costs are covered and the refugees cover the remaining 25%. If estimated costs are USD
≥1500 or refugees present outside the pre-approved hospital network, partner agencies are required to consult with
UNHCR. Emergency UNHCR approval is strictly for immediate life-saving or limb-saving cases. UNHCR refers all nonemergency cases to an Exceptional Care Committe that is responsible for authorisation of coverage. For the extremely
vulnerable refugees, UNHCR covers 100% of the costs.
Key findings
• Between January and April 2014, there were 19,214 referrals for secondary and tertiary health care in Lebanon; referrals by
region were Bekaa 6,615 (34%), North Lebanon 4,922 (26%), Beirut and Mt Lebanon 4,471 (23%) and South Lebanon 3,206
(17%).
• The referral rate was 5.7 per 100 refugees per year; the rate for 2013 was 7.9 per 100 refugees per year.
• Referrals were reported from 88 hospitals across the country. The top 20 hospitals accounted for 78% of referral. The
proportion of referrals to contracted hospitals by region was Beirut and Mt Lebanon 60%, Bekaa 86%, North Lebanon 86%
and South Lebanon 78%.
• Approx. 70% of patients were female and a quarter (25%) were among children younger than 5 years old. Considering that
only 52% of the population is female, the disproportionate referral among females is due to referrals for obstetric care
including deliveries.
• About 48% of referrals were for obstetric care. Other main reasons for referrals were respiratory infections (9%), and trauma
and other injuries (6%). Among obstetric care referrals, main reasons for seeking care were deliveries (84%), miscarriages
and other early pregnancy complications, and complications of labour and delivery. Among hospital deliveries, the
proportion of caeserean deliveries was 27% ‒ a decline from the 33% observed in 2013. A peak in referrals due to respiratory
infections was observed in Bekaa in February.
• The estimated total hospital bill for January to April 2014 was USD 11.3 million. The estimated share of the cost for UNHCR
was 8.3 million (73%). The finalised bill for January to April referrals (as of 23 May 2014) was USD 3.3 million. The estimated
annualised per capita hospital cost was USD 37 per registered refugee. Per capita cost was highest in South Lebanon (USD
46) and lowest in North Lebanon (USD 34).
• The average hospital cost per referral was USD 606; the highest average cost was observed among cases with neonatal or
congenital conditions (USD 1,774).
• Adjusted for disease category, gender and age, the average cost among the top 20 hospitals was lowest at Hermel hospital
19,214
17,874
Number of refugees referred
between January and April 2014
16,769
925
referred once
referred twice
137
43
referred thrice
referred 4 or more
times
Relationship
Total number of referrals between
with principal
January and April 2014
applicant
17,321
33
1,860
approved
directly or by
ECC*
approved after
consultations
with UNHCR
not approved**
*ECC: exceptional care committee tasked with reviewing referrals exceeding USD 1500
**Did not meet guideliness as per Standard Operating Procedure
1. Demographic information - Referrals
Beirut and Mt Lebanon
Bekaa
350,000
350,0 00
1700
1700
300,000
referrals between
January and April
6,615
Number of referrals
300, 000
1500
1500
1300
1300
200,000
20 0,00 0
1100
1100
150,000
150,0 00
900
900
100,000
100, 000
700
referrals in Bekaa
250,000
250 ,000
50,000
700
50, 000
500
0
0
500
Population
referrals in Beirut &
Mt Lebanon
4,922
referrals in North
South
350,0 00
1700
Referrals
350,000
1700
300,000
300, 000
1500
1500
250,000
250 ,000
Number of referrals
4,471
North
Registered Syrian refugees
19,214
Trends of referrals and population by region
1300
1300
200,000
20 0,00 0
1100
1100
150,000
150,0 00
900
900
100,000
100, 000
700
50, 000
500
0
Jan
Feb
Mar
Apr
50,000
700
Registered Syrian refugees
1.1 Referral cases
0
500
Jan
Feb
Mar
Apr
3,206
referrals in South
1.2 Gender
Cases by age and gender
70.3%
Female
1.3 Age group
24.5%
were under 5 years
14.4%
were under 1 years
1.2 Approval status
90.2%
Approved
Distribution by region
General exclusions
North
26%
0.2%
Approved after
consultations
9.7%
Not approved
Reasons referrals were not approved
Cancelled by provider
Double referral
Bekaa
34%
Missing Documents
45.7%
Covered by other insurance
company
Other*
35.0%
South
17%
12.8%
Beirut and Mt Lebanon
23%
2.6%
2.0%
*Other: includes presentating outside network, abuse, waiting
1.8%
2. Distribution by diagnosis
2.1 Referral reasons
Distribution of referral cases by diagnosis category
Number of referred cases
48.0%
0
Obstetric
Respiratory infections
Trauma and other injuries
Gastrointestinal condition
Neonatal or congenital condition
Cardiovascular disease
Chronic respiratory disease
Surgery
Hematological conditions
Nephro/urological disease
FUO
Hepatobiliary disease
Neoplasm (malignant or benign)
Gynaecological
Diabtetes and other endocrinological di
Neurology
Mental health condition
Other
were referred for
Obstetric care
9.2%
were referred for
Respiratory
infections
6.3%
were referred for
Trauma and other
injuries
5.9%
4.7%
were referred for
Neonatal or
congenital condition
4,000
6,000
8,000
10,000
48.0%
9.2%
6.3%
5.9%
4.7%
4.3%
3.9%
2.3%
2.2%
2.1%
1.6%
1.5%
0.9%
0.9%
0.6%
0.6%
0.5%
4.4%
Trends of admissions due to respiratory infections by region
80
70
Number of referrals
were referred for
Gastrointestinal
condition
2,000
60
50
40
30
20
10
2.2 What were the
obstetric referrals?
61.5%
for Normal delivery
22.8%
0
1
2
3
4
for Miscarriages and
other early
pregnancy
complications
6
7
8
9
10
11
12
13
14
15
16
Epidemiological week 2014
Beirut and Mt Lebanon
Bekaa
North
South
Reasons for obstetric referrals
Caeserean section
23%
Miscarriages and other early
pregnancy complications
6%
Complications of labour and delivery
2%
for Caeserean section
5.7%
5
Normal delivery
61%
Other pregnancy related conditions
8%
17
18
3. Hospital receiving referrals
3.1 Hospital counts
Proportion of referrals utilising contracted* hospitals
88
hospitals received
referrals
60
Beirut
and Mt Lebanon
Bekaa
85.7%
60.4%
hospitals received
referrals from Bekaa
69
hospitals received
referrals from Beirut
& Mt Leb
South
North
57
hospitals received
referrals from North
78.4%
86.2%
56
hospitals received
referrals from South
3.2 Referrals by
hospital
*contracted hospitals list as per the "Guidelines for Referral Health Care in Lebanon, UNHCR 2014"
Total referrals for the top 20 hospitals
Number of referred cases
2793
received by Taanayel
general hospital
1351
received by Notre
dame de la Paix
1271
received by Tripoli
gov hospital
1229
received by Rafic
Hariri hospital
0
500
1000
1500
2000
Taanayel general hospital
Notre dame de la Paix
Tripoli gov hospital
Rafic Hariri hospital
sahel hospital
farhat hospital
salam hospital
al rayan hospital
nabih berry university
lebanese italian hospital
saida gov hospital
iklim health foundation
mazloum hospital
chtaura hospital
kassab hospital
doctor's hospital - manara
dr. abdallah rassi gov hospital
bekaa hospital
hermel gov hospital
raee hospital
Beirut and Mt Lebanon
Bekaa
North
South
2500
3000
4. Costs snapshot by approval status and service provided
11,858,584
Referral
accepted
13,564,526
11,304,048
Referral
accepted
11,325,232
136,229
Accepted after
consultations with
UNHCR
Total
original
claim
21,184**
Accepted after
consultations with
UNHCR
Total
approved*
claim
1,569,813
Declined
0
Declined
*accepted cost of referral. Includes patient share. Not all costs are final
**some costs may still be in review and are therefore not included.
8,264,977
Accepted
3,039,373
8,285,859
UNHCR
share of cost
nonUNHCR*
share of cost
20,882
Accepted after
consultations
with UNHCR
3,039,071
Accepted
3,264,862
Accepted
3,264,862
Finalised
bills as of
23 May 2014
302
Accepted after
consultations
with UNHCR
0
Accepted after
consultations
with UNHCR
*non-UNHCR share is cost borne by patients, charities, NGOs, hospital etc
Finalised bills as of 23 May 2014 by provided service
RADIOLOGICAL OR LAB
INVESTIGATION
7%
PRESCRIPTIONS/TREATMENT
CONSULTATIONS
11%
8%
INVASIVE PROCEDURES
AND/OR SURGERY
12%
Finalised bills by
service provided
(USD 3,264,862)
GENERAL
HOSPITALIZATION COSTS
50%
INTENSIVE CARE
12%
50%
10%
49%
13% 13%
7% 8%
11%
BEIRUT AND MT LEBANON
51%
49%
12% 12% 9%
6%
13%
BEKAA
13% 11%
7% 6%
12%
NORTH
11% 13%
6% 7%
SOUTH
CONSULTATIONS
GENERAL HOSPITALIZATION COSTS
INTENSIVE CARE
INVASIVE PROCEDURES AND/OR SURGERY
PRESCRIPTIONS/TREATMENT
RADIOLOGICAL OR LAB INVESTIGATION
5. Costs snapshot for key diagnosis categories by service provided. Total finalised bill in parenthesis
DIABTETES AND OTHER
CARDIOVASCULAR DISEASE
(USD 450,158)
CHRONIC RESPIRATORY DISEASE
(USD 122,598)
FUO
(USD 14,283)
ENDOCRINOLOGICAL DISEASES
(USD 33,717)
50.6%
21.9%
15.3%
11.7%
18.0%
10.9%9.5%
6.5%
4.7%
GASTROINTESTINAL CONDITION
(USD 197,179)
12.3%12.1%
32.6%
29.7%
26.6%
20.6%
17.5%19.5%
17.3%
12.8%
12.2%
20.5%
15.0%
1.1% 1.0%
HEMATOLOGICAL CONDITIONS
(USD 46,575)
HEPATOBILIARY DISEASE
(USD 65,692)
MENTAL HEALTH CONDITION
(USD 21,244)
62.0%
37.2%
38.5%
26.5%
21.6%
16.2%
12.3%
10.0%
17.5%
2.8%
NEONATAL OR CONGENITAL
CONDITION
(USD 505,675)
13.6%
1.2% 2.6%
NEOPLASM (MALIGNANT OR
BENIGN)
(USD 31,682)
13.3%
6.6%
1.4%
10.2%
6.5%
22.3%
19.9%22.0%
16.0%
12.9%
6.9%
NEPHRO/UROLOGICAL DISEASE
(USD 81,088)
NEUROLOGY
(USD 28,348)
60.2%
47.9%
29.8%
22.5%
18.1%
20.9%
10.2%9.1%
6.9%
5.0%
OBSTETRIC
(USD 1,947,404)
5.4%
11.4%11.4%
9.6%
2.0%
16.6%
9.5%
3.6%
RESPIRATORY INFECTIONS
(USD 473,305)
SURGERY
(USD 70,086)
97.4%
23.4%
21.1%18.5%
13.9%
12.6%
10.6%
TRAUMA AND OTHER INJURIES
(USD 211,621)
96.1%
68.3%
0.6%
0.1% 0.9% 0.5% 0.5%
25.8%
20.4%
19.8%
15.2%
14.6%
4.2%
1.4% 0.6% 0.2%
0.4% 1.4%
7.7% 4.0% 6.1%
5.9% 7.9%
CONSULTATIONS
GENERAL HOSPITALIZATION COST
INTENSIVE CARE
INVASIVE PROCEDURES AND/OR SURGERY
PRESCRIPTIONS/TREATMENT
RADIOLOGICAL OR LAB INVESTIGATION
6. Estimated direct hospital costs of referrals
35.7%
UNHCR
1
3.0
0.95
2.5
0.9
2.0
0.85
85.7%
1.5
81.9%
85.1%
84.3%
0.8
1.0
Population in millions
1.05
8.1%
0.75
Proportion for whom
UNHCR paid at least
90% of cost
Apr
Estimated proportion
paid by UNHCR
partners
Total
Mar
73.2%
Population
Feb
Estimated total
hospital bill in USD
3.5
Jan
11,325,232
Estimated total hospital cost and estimated proportion paid by UNHCR by month
Estimated total cost, US dollars in
Millions
6.1 Overall
Estimated proportion
paid for obstetric care
Percent of hospital costs above USD 1500 by approval status
8.3%
Estimated proportion
paid for surgery
including for trauma
and other injuries
6%
40%
Approved directly
or by ECC
Approved after
consultations with
UNHCR
5%
13.6%
Estimated proportion
paid for neonatal and
congenital conditions
6.2 Average costs
Estimated average hospital cost per referral by diagnosis category
606
Average cost in USD
per referral
1,774
Highest average cost
observed in cases
with Neonatal or
congenital condition
368
Average cost in USD
for normal delivery
Average cost in USD
for caeserian section
Estimated mean cost of referrals, US dollars
500
1000
1500
0
Neonatal or congenital…
1,774
Cardiovascular disease
1,608
Neoplasm (malignant or…
1,219
Neurology
1,050
Diabtetes and other…
865
Surgery
730
Hepatobiliary disease
699
Mental health condition
685
Trauma and other injuries
680
Nephro/urological disease
676
Chronic respiratory disease
674
Gynaecological
605
Respiratory infections
Gastrointestinal condition
675.8
Not approved
Obstetric
Hematological conditions
FUO
556
481
469
361
298
2000
7.Costs and referrals per capita
37
Estimated annualised
per capita hospital cost
in USD
34
estimated annualised
per capita hospital cost
for Bekaa
3.5
1,200,000
3
1,000,000
2.5
800,000
2
600,000
1.5
400,000
1
200,000
0.5
0
0
Jan Feb Mar Apr May Jun
41
34
estimated annualised
per capita hospital cost
for North
46
estimated annualised
per capita hospital cost
for South
7.2 Average costs
822
Adjusted average cost
estimate for Rafic Hariri
hospital
Beirut
Aug Sep Oct Nov Dec Jan Feb Mar Apr
Bekaa
North
South
250
Beirut
Bekaa
200
North
150
South
Overall
100
50
0
Jan
Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan
Adjusted average cost
estimate for Bekaa
hospital
bekaa hospital
Adjusted average cost
estimate for Al Rayan
hospital
552
rafic hariri university hospital
822
563
chtaura hospital
631
al rayan hospital
680
raee hospital
600
616
633
602
622
590
579
notre dame de la paix hospital
iklim health foundation
sahel hospital
farhat hospital
nabih berry hospital
saida gov hospital
512
478
lebanese italian hospital (najem)
salam hospital
383
Adjusted average cost
estimate for Hermel
hospital
561
529
500
taanayel general hospital
dr. abdallah rassi gov
hermel gov hospital
doctor's hospital - manara
Other
1000
775
kassab hospital
tripoli governmental hospital
680
Feb Mar Apr
Average costs by hospital (adjusted for disease category, gender, and age)
Estimated mean cost of referrals, US dollars
0
200
400
600
800
mazloum hospital
775
Overall
Trends of per capita hospital cost by region since January 2013
Annualized estimated per capita
hospital costs, USD
estimated annualised
per capita hospital cost
for Beirut & Mt
Lebanon
Population
Jul
383
396
666
Crude mean
Adjusted mean
Registered Syrian refugee population
Trends of referrals by region since January 2013
Number of referrals per 100 refugees per month
7.1 Overall
Note: The information presented is based on the most recent and best available data. We are grateful to the Lebanese Ministry of Public Health, UNHCR Lebanon, the
International Medical Corps, Makhzoumi Foundation, Caritas Lebanese Migrant Centre, GlobMed and other local and international actors for providing services and/or data.
Analysis of data and preparation of information sheets was carried out by UNHCR Public Health Section, Geneva. UNHCR and its partners will continually update and, where
necessary, modify the data and analysis provided, in order to ensure that the most current and accurate view is available to key stakeholders and the public.

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