Health Care in Libya

Nils Metzger

The Libyan government spent millions on flying hundreds of victims of the civil war to Germany for hospital treatment. While it was a life-saving intervention for many patients, others found themselves in the midst of chaos, confusion and shady deals.

On 12 October, even before Muammar al-Gaddafi had been captured, German Minister of Economics and Technology Philipp Rösler stood on the tarmac at Tripoli Airport. For this visit, he took the role of a penitent, representing the only Western member of the UN Security Council to have abstained from a critical vote that would help the rebels. To make amends, he had a conciliatory offer up his sleeve: visas for Libyan war wounded.

Less than a week later, on the afternoon of 18 October, a German military transport aircraft from Sfax in Tunisia landed at Cologne-Bonn airport carrying 39 injured Libyans, who would be transferred to five military hospitals. There to greet them was Stefan Kottmair, CEO of Munich assistance and health services provider Almeda. A subsidiary of reinsurance giant Munich Re, Almeda offers medical repatriation and IT systems for calculating the cost of medical treatment, and turned over EUR 23 million in 2010. It also handles treatment and transport orders worth more than EUR 50 million on behalf of insurance companies and hospitals each year.

Kottmair was counting himself lucky: the Global Healthcare Programme, which enabled Libya to send people who were wounded during the revolution to other countries for treatment, entrusted Almeda with contracts worth USD 60 million, according to the Programme’s latest figures. But for some of the wounded Libyans – and some of the hospitals involved – the collaboration was more of a nightmare than a dream come true.

The background to the deal dated back to the very beginning of the same month. On Saturday 1 October, the Temporary Financing Mechanism (TFM, the now defunct trustee organisation of the Transitional National Council, which handled the Gaddafi regime’s foreign funds and was behind the Global Healthcare Programme) contacted Munich Re subsidiary Daman Health in Abu Dhabi, saying it did not want to administer treatment abroad for the war wounded itself and would prefer to »make contact with hospitals via a third party«. It also wished to have all the necessary services organized by one company – and to focus on Germany, subject to a loan from Förderbank KfW, a development bank. Daman Health passed the job on to its sister company, Almeda.

Almeda lost no time in coming to an agreement with Libya. A contract was signed on 13 October, and the next day, Almeda sent a draft quotation of EUR 12.4 million to treat 300 Libyan patients. In an email to Almeda, Dietrich Becker, the permanent representative at the German embassy in Tripoli, said that former TFM Director Mazin Ramadan had come to him acting on his own account and pressed for urgency: »Normally the embassy intercedes on behalf of German companies. This time, very surprisingly, it was the other way around.«

The agreements between Almeda and the TFM are only a few pages long: patients who could not be treated in Tunisia were to be flown out; Almeda would collect all the invoices and patient files and pass them on to the TFM; within Germany, the wounded would be looked after by Arabic-speaking staff with the appropriate cultural training. The company charged three to six weeks of daily care costs, amounting to EUR 35,000, not including EUR 7,000 for the flights. The agreements state that the invoiced amounts were based on German flat-rate costs that specify precisely how much a hospital can charge for each service. Almeda itself was to receive approximately EUR 500 per month per patient to cover its administrative costs, according to the former deputy head of the TFM, Shihab Elborai.

»Normally the embassy intercedes on behalf of German companies. This time, very surprisingly, it was the other way around«

On 19 October, a team of doctors flew to Tunisia to select suitable patients. Within less than 24 hours, the first German civilian hospitals had indicated their readiness to receive Libyan patients. Now some are wondering whether they should have turned down the opportunity.

»For the first few days, the operations lasted for hours – people with serious gunshot wounds or brain injuries who had received only minimal treatment,« says a doctor from hospital group Asklepios-Klinikverbund in Hamburg. »When everything’s full here, we have to ask ourselves whether we can manage major efforts like that.« For example, the hospitals were saddled with a lot of extra work because almost all the Libyan patients were suffering antibiotic-resistant infections – a very expensive problem. »We didn’t know until we began that there was an infection problem,« says Bonnet.

The University Hospital of Schleswig-Holstein (UKSH) in Kiel and Lübeck has a more positive report to make on cooperation with Almeda. Yes, several times, a different number of patients arrived than they had prepared for, and with different medical diagnoses, but this was hardly surprising, given the circumstances, says media spokesman Oliver Grieve. For his hospital, which suffered a loss of millions of euros last year due to the E. coli outbreak, it had been worthwhile. »We charge enough to have a few pennies left over at the end.«

However, some of the patients from Libya spent several extra weeks at the UKSH hospitals because there were no appropriate rehabilitation facilities available. »Some facilities offered us places for EUR 4,000 per day,« says Grieve. Even for the German health care market, that is an unusually high quotation.

More importantly, such high prices fall outside the German statutory framework. »The flat rate for treatment also applies to foreigners,« adds Ortwin Schulte, who coordinates external development aid at the Ministry of Health. Barbara Walsh-Hanratty, from the International Cooperation department of the Munich Municipal Hospital Group, says they were not permitted to include extra charges for special cross-cultural services, interpreters or special food in their quotations.

Nevertheless, Almeda charged TFM 1.8 times the standard rate from the very beginning, as is clear from an invoice in zenith’s possession. The Almeda Munich hospitals were told at the end of October that they could also treat patients and charge 2.5 times the standard rate. Almeda said this had been agreed with the Libyan partners: »The charges and payments were negotiated individually with each hospital.«

Many of the patients say that the care they received in exchange for those payments was anything but first class. Particularly in November, when most of the patients arrived in Germany, complaints mounted up in a war wounded forum on Facebook. »It is not at all clear to patients what Almeda is responsible for,« wrote a family member of one of those affected. Almeda also failed to pay patients the daily allowance they were entitled to. »We have to make sure that Almeda never gets any more patients,« demanded one woman who had visited injured patients in Hamburg. However, that same month, Almeda was awarded an extended contract to look after 300 more patients, financed by a KfW loan to the TFM for EUR 100 million.

The TFM also became aware of patients’ criticisms and responded on 16 November with a statement on its website rebutting the accusations. Starting immediately, it said, each patient would be given EUR 500 upon arrival and the daily allowance would be increased to EUR 60 a day. Munich lawyer Armin Ritter is still highly critical, claiming that treatment was often cut short: »One patient’s doctor gave written instructions that he was to continue receiving treatment for several weeks, but the next day, Almeda checked him out of his hotel without even talking to him.« Contractually assured daily allowances had not been paid and there were not enough interpreters available.

Almeda charged 1.8 times the standard rate from the very beginning

Ritter also represents a caregiver who claims that Almeda did not pay him for the two months he spent transporting nine Libyan patients and interpreting for them. »They took advantage of my client’s good nature; he relied on their verbal agreements,« says Ritter. Almeda says the man never had a contract. In Frankfurt, a Bethanien Krankenhaus staff member responsible for international patients is even accusing Almeda of attempted misappropriation of funds in connection with the flat-rate payments. »The hospitals get the 1.8 rate, while Almeda gets the 2.5 rate from Libya. There are business interests behind it – they are playing Monopoly with patients.« Her hospital therefore broke off negotiations with Almeda.

When zenith enquired, Almeda rejected all the accusations, explaining that clients are »shown all the original invoices« and that the dispute with the patient in Munich who found himself out on the street so suddenly had been resolved in a private meeting.

Many of the patients displayed aggressive behaviour because of the trauma they experienced during the war and required a higher level of care, Almeda explained. This was another reason why the initial cost estimates of EUR 12.4 million for 300 patients rose to USD 60 million for 600 patients.

While Elborai regards these figures as justified, the Libyan ambassador in Germany is more guarded. »Yes, we did notice that the invoices were becoming more and more expensive,« says Masednah al-Kotany, who was a doctor before he joined the diplomatic corps last year. He says the embassy is in discussion with a large number of hospitals regarding the higher prices.

To see how offering to treat Libyan war wounded can get a company into a real mess, one need look no further than Hamburg, where an incident that escaped the official TFM Almeda cooperation went awry. On 28 November, a charter aircraft carrying 60 people with minor injuries landed without any of the local hospitals or health authorities having been told that they were coming. Upon arrival, they hung around at the airport, stranded. The Hamburg state health authority organised accommodation at short notice. The authority claims that consultants German Health Management & Consult (GHMC) were involved in organising the flight.

GHMC CEO Leonore Boscher says her firm was not involved in any way. »I didn’t have anything to do with how the patients got here,« she told zenith. »With my background and contacts, I was able to organise accommodation for these patients at short notice – for no payment of any kind, all the while giving urgent messages to the Libyan embassy that I needed a contract in order to do so.« Now she is trying – so far unsuccessfully – to negotiate payment for her services by the Libyan embassy.

In Boscher’s view, two omissions caused the chaos at Hamburg airport. The refusal by Libyan Ministries to cooperate with the embassy in Berlin, because although there was a new ambassador, the rest of the staff was the same as before the revolution, and the German immigration authorities’ policies with regard to visas. »There are clear rules for medical visas,« Boscher told zenith. On the ground, however, there were often no authoritative documents. »Time pressure probably meant that the Federal Foreign Office had to find pragmatic solutions.«

No-one at the Foreign Office in Berlin is willing to name the companies involved in the Hamburg fiasco, even off the record. »We don’t get in the way of economic cooperation,« says one diplomat. A Foreign Office spokeswoman will say only that the German embassy in Tripoli provided a treatment consent form and declaration of acceptance of costs by a hospital for each of the patients.

The UKSH hospitals in Kiel and Lübeck were amongst those that eventually admitted the patients – and are still waiting to be paid, as Grieve hastens to point out. He adds, however, that the hospital is »confident that the Libyan embassy will respond appropriately.« Several agencies and other hospitals are now also trying to obtain money that supposed and actual contact people within the Libyan government promised them.

One of these discontented parties is Olaf Haase, CEO of Premier Healthcare in Hamburg, who usually works mainly with the Asklepios group of hospitals. In the case of the North African war wounded, his agency dealt with several different Libyan organisations, with varying degrees of success. Much of the work was coordinated by the organisation Wounded Libyan Evacuation Team (WLET), which is based in the Netherlands. »Given the circumstances, they managed quite well,« says Haase.

In other cases, partners in Libya either did not keep their promises or sent random numbers of patients. »We had too many patients, and not all of them had been prepared for Germany.« Some of the patients had been directed to board the aeroplane as soon as they were given a visa.

According to WLET, the Asklepios hospital group is still waiting for payment of treatment costs amounting to EUR 800,000. WLET also reveals that it only takes a few hours to issue a German visa in Tripoli. The »documents’ submitted usually involve three sentences, two of which praise the skills or status of the treating doctor.

The contract between Almeda and the TFM was due to expire in April. »There have not been any requests from Libya to continue,« states Almeda. The Libyan embassy in Berlin drew its own lesson from the chaos by signing a cooperation contract with Berlin hospital operator Vivantes, while German Minister of Health Daniel Bahr, on a Libya visit in April, announced his intention to conclude a German-Libyan Health Agreement.