Published on: 2/10/2023
Lebanon’s health sector has shown remarkable progress over the past twenty years. Many economic, social, and cultural factors have contributed to this progress; in addition, the ingenuity of the Lebanese society, the fairly good governance by the public sector, and the relative absence of catastrophic external factors have played a role.
Ultimately, the success of any health governance is measured by several indicators: first, the ability of its health system to live up to people’s society’s expectations for improved health; second, by its resilience in coping with new challenges; and third, by its proficiency in making the most of the resources its society can mobilize for health. In Lebanon’s case, such achievements went well beyond expectations, given the country’s recent history and geopolitical environment.
Healthcare Challenges
The Lebanese healthcare sector has been receiving many blows during the last years, which affected its nature and the quality of healthcare delivery. Lebanon, once one of the major health hubs in the region known for its health tourism, is slowly shifting towards almost exclusively primary care. More than half of the Lebanese population does not currently benefit from any form of healthcare coverage, limiting access to affordable and comprehensive healthcare services and increasing out-of-pocket expenditures on health.
At the governance level:
For decades, the Ministry of Public Health (MOPH) has struggled to regulate the healthcare sector. Weak organizational structures, insufficiency of qualified human resources, and poor infrastructure have hindered MOPH’s ability to fulfill its essential public health functions. Inadequate accountability mechanisms have led to corruption in the healthcare sector, which was exacerbated during the crisis. Consequently, the government has struggled to control the sale, distribution, and smuggling of counterfeit drugs, particularly for cancer medication.
The lack of coordination between various financing agents and service providers has also created siloed and disconnected operating mechanisms. Moreover, the absence of political will has been a significant barrier to strengthening the healthcare sector. A law for universal healthcare coverage (UHC) has been previously proposed and rescinded in 2023 due to gaps in the law. Currently, a revised draft for a UHC law has been submitted and is up for discussion in the health parliamentary committee.
Attempts to alleviate the effects of the economic crisis have been hampered by the lack of a shared vision among stakeholders in the healthcare sector, such as the MOPH and NSSF. Despite the urgency and magnitude of this problem, Lebanon continues to lack a comprehensive and well-defined national strategy to tackle the critical aspects of recruitment, training, and retention of human resources for health.
At the financing level:
Insufficient public oversight in the healthcare sector has resulted in inefficient resource allocation and a budgeting structure that doesn’t rely on performance indicators. This is evident in healthcare expenditure, whereby public healthcare services receive limited resources, particularly for primary and preventive care, while a significant percentage is spent on hospital-based care.
The Sin- taxation: A sin tax is an excise tax on specific goods and services due to their ability, or perception, to be harmful or costly to society fragmentation of Lebanon’s insurance funds and inadequate coordination among entities involved in healthcare financing and delivery have long plagued the healthcare system. For example, the NSSF, the largest public fund, has faced challenges due to weak accounting processes, under-declaration of salaries, and difficulties in providing coverage.
The devaluation of the national currency has led to increased medical costs and inflation, posing challenges for insurers and impacting access to private health insurance. Private insurers transitioned to accepting only USD payments, limiting access to higher socioeconomic backgrounds, while public insurance funds continue to accept subscriptions in the rapidly deteriorating Lebanese lira, resulting in limited coverage for beneficiaries' medical costs.
At the delivery level:
Lebanon's healthcare system is dominated by the private sector, focused largely on hospital and curative care. To counter this, the MOPH has partnered with NGOs and private entities to expand the network of primary healthcare centers (PHCs), reaching 245 centers in 2021. However, the dominance of the private sector limits the effectiveness of PHCs in acting as gatekeepers for regulating access to higher-level care.
Lebanon has historically faced a shortage of healthcare professionals, including nurses and family medicine practitioners, due to the absence of financial incentives and scarcity of relevant programs. This has led to professionals migrating in search of better opportunities. Thus, as the economic crisis deepened, the vast majority of healthcare professionals left in search of jobs that would offer better financial benefits and work conditions.
In terms of medication supply, local manufacturing has not been incentivized in Lebanon, resulting in only 12 local manufacturers. The preference for brand-name drugs over generics and reliance on expensive imported medications have made medicines inaccessible and unaffordable during the economic crisis.
Main Policy Issues for Reforming Lebanon’s Health Care System
1. Sustainability
Lebanon allocates over 12% of its GDP to healthcare, hence straining their financial resources. If the current health expenditure trend continues, healthcare quality and accessibility will be lowered to ensure long term sustainability.
2. Cost Containment
MOPH needs to strengthen their controls on healthcare financing and cost controls. The fact that budgeting control and some managerial roles are overseen by different ministries provides a gap in cost containment.
3. Rationalizing Hospital Capacity
Even though more than half of public expenditures is directed towards healthcare, the quality and accessibility should match the investment.
4. Shifting Focus to Primary Health Care
Of the expenditure directed towards healthcare, only 10% is channeled to primary health care. There should be a change in this to increase spending for primary health care.
5. Managing Medical Technology Investments
The government should control the investment channeled towards latest medical technology. Any investment should result in improvement in value of health care to Lebanese residents.
6. Expanding Health Insurance Coverage
The current scenario of health insurance being issued by employment hinders coverage for low-income households, and individuals in informal employment. Availability of many insurance coverage options also lead to high cost coupled with high inefficiency.
This analysis underscores critical policy issues facing Lebanon’s healthcare system, emphasizing the need for comprehensive reforms to address cost, access, quality, and sustainability challenges.
Stake holders in health reforms in Lebanon
The implementation of health reforms in Lebanon involved multiple stakeholders, each playing a crucial role in shaping the future of the healthcare system. These stakeholders included:
Government agencies
The government had a central role in formulating and implementing health reforms.
It allocated budget resources, developed policies, and regulated the healthcare sector to ensure effective and sustainable healthcare delivery.
Healthcare providers
Healthcare facilities and professionals, both in the public and private sectors, were key stakeholders in the reforms.
They were responsible for delivering quality healthcare services, adhering to regulations, and contributing to the overall improvement of healthcare delivery.
Civil society organizations
Civil society organizations, including non-governmental organizations (NGOs) and patient advocacy groups, played an important role in advocating for the rights and needs of patients.
Apart from their valuable input and feedback on the reforms, they also ensured that the voices of the community were heard.
International partners
International organizations and donors played a vital role in supporting the health reforms in Lebanon.
Their role was to give technical assistance, financial support, and expertise to help implement the reforms effectively. Collaboration with international partners strengthened the capacity of the healthcare system and accelerated progress in achieving the desired outcomes.
Healthcare professionals’ associations
Professional associations, such as medical and nursing associations, represented the interests of healthcare professionals and contributed to the development of policies and guidelines.
They played a crucial role in shaping the reforms and ensuring they were aligned with the needs and expectations of healthcare professionals.
Academic institutions and research organizations
Academic institutions and research organizations were instrumental in providing evidence-based insights and conducting research to inform the development and implementation of the reforms.
Their expertise and contributions helped shape the reforms and ensure they were grounded in scientific knowledge.
Insurance companies
Insurance companies played a vital role in expanding health insurance coverage as part of the reforms.
They developed and implemented insurance schemes to ensure that a larger portion of the population had access to healthcare services, regardless of their socio-economic status.
Conclusion
Lebanon is resolute in its commitment to building a healthier future for its citizens.
The challenges that confronted the healthcare system post-civil war have catalyzed a transformative process, where stakeholders are reimagining every facet of healthcare delivery, financing, and regulation.
The road to reform might be complex, but it is undoubtedly marked with unwavering determination to foster positive change.
