- En
- Fr
- عربي
The lebanese healthcare system: is there any place for reforms?
The lebanese healthcare system: is there any place for reforms?
Introduction
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(1).
After the civil war, it was normal to expect a collapse of the country’s health sector. However, contrary to what most people expected, this system has shown remarkable resilience and improvement. This has been seen in health outcomes, health care productivity and performance, and in healthcare governance(2).
Many indicators of health outcomes have improved considerably. Between 2000 and 2020, 5.1 years were added to life expectancy at birth to reach 79, outperforming other countries in the region(3). For example, life expectancy at birth in Turkey was 70 years in the year 2000 and reached almost 78 in the year 2020, while Jordan was a bit below 72 in 2000 and reached almost 75 in the year 2020. Child mortality in 2020 stands at 6% and maternal mortality decreased to reach 23 per 100,000 live births by the year 2009. However, this increased to reach 29 by the year 2017 due to the inflow of the Syrian refugees(4). It now stands at 8.7 per 100,000 births for the Lebanese and at 27.7 for the refugee resident populations.
As for performance in health, in a study published in the Economist in 2014, Lebanon ranks 31st out of 166 countries in the Economist Intelligence Unit comparison of health outcomes, just after Denmark and just before the USA(5). Lebanon is graded the healthiest Arab country in the Bloomberg 2017 Global Health Index, ranking between Czech Republic and the USA(6). It is 34th out of 137 countries for the health sub-index in the World Economic Forum’s global competitiveness report(7), with health performing relatively better than other national sectors relevant to competitiveness. Lebanon’s Health Care Access and Quality Index (HCAQ Index) ranks 31st out of 195 countries and regions, on par with Portugal and Estonia(8).
According to Bloomberg, Lebanon ranked number 22nd in the World for Healthcare Efficiency just behind Sweden.
As for the allocation of resources to the health sector, Lebanon was in a fairly good place with 8.65% of its GDP going to healthcare in 2018. To put this number into perspective, the European Union (EU) allocated 9.92 of its GDP to healthcare and the Middle East and North Africa allocated 5.52%, Jordan 7.58%, UAE 4.28% and Turkey 4.34%(9).
Healthcare sector in crisis
These numbers are great, but the actual state of the Lebanese healthcare sector is not all well at all.
The Lebanese healthcare sector has been receiving many blows during the last couple of 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.
Lebanon’s healthcare system is rapidly collapsing as the country grapples with one of the worst crises in the world since the beginning of the 20th century after Chile in 1920 and Spain in 1930.
As a result of the Lebanese economic crisis, which began in 2019, many small to moderate healthcare institutions have faced the looming threat of potential bankruptcy. Later on, with the continuous financial strain, even the bigger tertiary medical centers had to succumb to such dire circumstances and adopt harsh measures to stay afloat(10). Some of these institutions went as far as to lay-off a considerable number of hospital staff and to close some of the hospital wards that were operating at suboptimal capacity(11).
As we are witnessing, dwindling supplies of fuel and medicine mean that the Lebanese healthcare system may on the brink of collapse, unless fast and proper measures are taken to mitigate the repercussions of such demise.
According to Médecins sans Frontières, the economic crisis has not only destroyed people’s purchasing power and led to unprecedented inflation, but it has also choked off the importation of fuel to the country. Hospitals have been experiencing daily power outages that last for hours because of cuts in the national electricity grid, and shortages of diesel fuel for their backup generators. Lebanon is also experiencing a shortage of basic drugs and medication across distributors and pharmacies, most of which cannot be produced or made available locally(12).
Medical care is becoming so costly that people are not able to afford private medical care and large proportion of the population is seeking humanitarian assistance to access healthcare services.
Moreover, many highly qualified physicians and nurses opted to leave Lebanon for better opportunities abroad as a result of pay cuts that were later accompanied by a depreciation of the national currency, as the Lebanese Pound lost approximately 90% of its value(13).
It is of prominent importance for every stakeholder in this field to start planning for the aftermath of this crisis and try in every possible way to mitigate these unfortunate events that have struck this sector.
A thorough analysis of the needs and identification of the major gaps of the healthcare sector is critically needed. After that, a healthcare strategic planner would do, there should be a rank-ordering of the gaps by order of importance and urgency (availability and accessibility should be also take into consideration) for us to have a clear view of the path on which we are about to embark.
It is important to note that although Lebanon is receiving vital support from the international community, the proper allocation of funding and resources is still not efficient, which affects the equity in the services provided.
This vital sector should resume its functions as soon as possible, especially with the hospital services, be it public and private, while taking into account the huge deficiency in the healthcare workers after the crisis.
Finally, with an unstable political and socioeconomic environment, it is becoming very crucial to build a solid culture of collaboration and trust between the different stakeholders in this sector in order to shape a unified vision of Lebanon’s future healthcare system.
The greek model
The Greek healthcare system was stunted between a highly fragmented social health insurance and a national health service model. In 2008, Greece suffered major consequences from the global financial crisis.
Since the 1980s, Greece had a working universal health coverage system, though incomplete. The private provision had an expanding share, especially from out-of-pocket payments as private health insurance remained very low.
The Greek healthcare system is characterized by the coexistence of the National Health System (NHS), compulsory social insurance, and a strong voluntary private healthcare system(14).
In health politics and policy in Greece, three reform efforts are of crucial importance: a) the introduction of a universal national health system in the early 1980s; b) a failed attempt to revive reform momentum for completing the shift towards a national health system in the early 2000s; and c) a crisis-driven reform under the bailout program(15).
In response the Greek government took the following steps:
It introduced e-governance tools and attempted to make the public procurement system more transparent and efficient; these were among the most important cost-containment measures.
It increased pharmaceutical co-payments from 10 to 25%. Also, it introduced a 15% co-payment for diagnostic and laboratory testing in contracted centers. This scheme took into consideration low-income and vulnerable individuals and families and exempted them from these co-payments.
It established a drug-pricing observatory and a preference pricing system, setting the rates on the basis of the average price of the three lowest-priced markets in the EU.
It introduced, in 2010, an entrance fee for outpatient care and a fee for every hospital admission, in 2014, then it cancelled them in 2015. However, in 2012, it mandated that patients should pay 30% of the total cost when they receive treatment in private hospitals and contracted clinics.
The government installed a centralized decision-making and control process over the range of service provision and resource allocation methods. It also established the centralization of the procurement of medical supplies and devices in order to reduce less-than-optimal outcomes and enhance transparency(16).
The Greek government passed legislation adding a further layer of primary services (the Local Units of Primary Care) with their role as gate-keepers to the system, thus strengthening primary prevention and health promotion activities.
Regarding secondary health providers, the Greek government initiated a plan to re-configure this sector aiming to contain costs and rationalize structure and governance. The plan was to combine hospitals into fewer units under common administration. Equally, it rearranged the clinics and functional beds. The government also focused on efficiency improvement. This was done by taking measures such as double-entry accounting system for costing services, all-day functioning of hospitals, the extension of working hours of outpatients’ offices and the revision of emergency and on-call duty(17).
It is important to mention that what helped exacerbating inequalities in care were the informal payments being a major component of out-of-pocket payments and keeping private spending high. It was equally difficult to attract physicians to local primary care.
To summarize, the Greek healthcare system aimed to tackle inequalities in coverage and access by unification and standardization of health insurance. It opted for a systematic allocation of resources across the country on the basis of need, drawing upon demographic, socio-economic and epidemiological data has hardly been in place. It is important to note that the Greek government has received substantial help from the EU (almost USD 320 billion), making the reform trajectory relatively easier(18).
Miltary healthcare strategy
The Military Healthcare (MHC) has also faced many problems during the COVID-19 pandemic, the August 4th explosion and the economic crisis. Therefore, what were the crisis management strategies and mitigation plans devised by the military to alleviate them?
This section will begin with an overview of the MHC, and then the central military laboratories’ testing capabilities and their rapid adaptation to the increasing number of patients as well as the special strategies necessary to continue a steady and consistent workflow. Next, it will address hospitalization issues, in the central military hospital and in different civilian hospitals. It will also shed some light on the various strategies in the aftermath of the Beirut blast, its impact on performance, and the additional burden it generated. The economic crisis will then be discussed and the contingency plans and measures the military healthcare has devised. Finally, a summary of learned lessons for future crises.
The MHC covers almost 10% of the Lebanese population and caters for active military personnel as well as veterans and their families. It is located in Badaro, Beirut with 5 regional military healthcare centers in the 5 governorates as well as 35 dispensaries scattered all over the Lebanese territory.
It comprises several departments such as the Military Hospital, the Central Military Laboratories, Central Military Pharmacy, Procurement department, Hospitalization and others.
The MCH operates on different levels. At the level of grand strategy, a crisis was always anticipated, assets harnessed, people aligned, resources allocated, and our role as military healthcare clearly defined. Our goals were determined and set to sustain medically the army and the beneficiaries in time of war and peace. Going down the ladder, at the level of operations, judgments were made as to the most appropriate form of execution in the light of the prevailing conditions and this is achieved on the departments level. Finally, at the level of tactics, units will attempt to push forward the goals of the operations in their specific circumstances. This is what the MHC tried (and continue to try) to execute through this period.
The pandemic
The Central Military Laboratories
These laboratories began their preparation for the pandemic in later January 2020, prior to the first document case of COVID-19 in Lebanon, which was recorded February 21st, 2020. The pandemic strategy took into consideration personnel, society, culture, economics, logistics, administration, technology, operations, geography, uncertainty, and time. At the beginning of the pandemic, there was no need to perform PCR testing in the military because the numbers were low. Tests were outsourced to Rafic Hariri General Hospital. Fully operational capabilities regarding testing began by the end of March with centralized testing in Beirut. Later on, the decentralization of the sampling with the establishment of 4 regional centers was opted for, where patients have their swab taken and then sent to the central laboratories to be tested.
Facing a pandemic is not only about money and resources, but also about adaptive ideas and strategies. In this regard, all the lab technicians were divided into two groups, each covering one week (the other week in home confinement) to prevent suspension of operations when and if a group is infected by the virus. When this did, in fact, happen with the COVID-19 team, they were sent to their homes with the alternate team taking their place until full recovery. The work in the molecular department was continuous without interruption and with the results being delivered within 24 hours, even in peak days, where the number of swabs exceeded 2500.
Another main pillar in the central military laboratories is the blood bank department. It is one of the biggest in Lebanon, in terms of output per center, with more than 100 donors a day. The blood bank has the advantage of 24/7 readiness due to its systematic blood withdrawal from the different military brigades and regiments. Therefore, a strategic stock is always available with the ability to rapidly replenish used stock on order.
Hospitalization
Regarding the hospitalization strategy, the military healthcare adopted a centralized decision-making process with the establishment of a call center. The center was established one year before the pandemic broke out and, hence, the staff was well-acquainted with the system. Every COVID-19 patient would call the center, which would launch a search to identify available hospital beds all over Lebanon. It was no easy process, sometimes patients needed to be transferred all the way from Baalbek in Beqaa to Nabatieh in the south as all contracted hospitals were linked to the military healthcare via the call center. In some cases, COVID-19 patients would go directly to the hospital and the hospital would contact the call-center to obtain approval to admit the patient. If no places were available, the patient would be directed by the call center to a hospital with available beds. However, the transportation process was no easy task for either the MHC or the patients. Many times patients would spend all their hospitalization potentially hundreds of kilometers away from their homes.
In addition, in every hospital, the medical controllers, spread all over the civilian hospitals, followed up with each admitted patient closely and, therefore, real-time tracking was established. In this context, no patients were denied access to hospitalization or treatment.
Another significant side of strategy is not only the active strategy, but mitigation strategies to avoid further exacerbating crises.
This was the primary interest of the Lebanese Armed Forces (LAF). All these measures held as a primary goal, maintaining LAF readiness to perform its core mission: preserving security all over the country. The death rate from COVID was 1 per thousand (per active military personnel).
In the central military hospital, fever clinics were established in all 5 regional centers, diagnoses were made and swab samples collected. For the Military Hospital, it has rapidly undergone a massive enlargement of its Intensive Care Units (ICUs) from 13 beds to 23 beds along with the provision of a field hospital turned completely into ICU. It also acquired a part of the Lebanese-Canadian hospital (46 beds). Therefore, the strategy was that every COVID-19 ICU patient would go into the military hospital and the other patients would be catered for in civilian hospitals. In many cases, due to the shortage of critical drugs for COVID-19 patients, the MHC provided the civilian hospitals with these drugs because it had foreseen a fairly large reserve in the beginning of the pandemic.
Vaccination
The vaccination of the LAF healthcare workers began in February 2021. The vaccination of the LAF personnel began in March 2021, with the vaccination plan already in place. Eighty percent of military personnel were vaccinated (with two doses) with an average of 15,000 doses per month. Of note, are also those patients who had previously contracted the virus and who were still not eligible for the vaccination. These numbers were attainable thanks to the timely implementation of comprehensive software conceived before the vaccination process was implemented.
Beirut blast
The explosion of August 4th also took its toll on military healthcare as well as all surrounding hospitals. The central military hospital attended to military personnel, civilians, and foreigners.
Almost 250 patients injured were treated (the LAF had its share of deaths as well). The military readiness was easily noticeable with more than 60 emergency professionals showing up for duty within one hour.
The blood bank was ready with a baseline of 80 blood units, increased within hours to reach 120 (which was much more than what was needed). Large numbers of blood units were sent to the hospitals treating the wounded. It is also worthy to note that the PCR professionals were summoned at night to perform the tests to the international delegations coming to help (all other centers wanted at least 24 hours to deliver the results).
Economic crisis
Further darkening the overall state of the country is the brewing economic crisis. The army, as a core part of the Lebanese society, has been affected in this crisis too. Of course, the depreciation of the national currency had a serious effect on the personnel. It’s a well-known fact that the pay has been severely cut, which no longer translates to a sustainable salary anymore. This is, indeed, a matter of national security. It is only normal that the military healthcare was also affected. In sync with our modus operandi, the MHC had already a strategic stock of life-saving drugs and reagents for dialysis and essential medical equipment, such as cardiac stents. In the laboratories, there was also a strategic stock for vital tests (COVID-19 and blood units). Yet, one cannot ignore some shortages, as was seen everywhere else due to difficulties of foreign currency transfers.
Downsizing
In the middle of this quagmire, the MHC was able to practically face it. Several measures were taken, starting with decreasing the number of dispensaries and allocating their resources. Spending rationalization processes were accentuated; from pre-approval for the operations and audits after discharge to the renovation of the Operating Room (OR) department and the acquisition of 4 ORs and 25 beds in Rafic Hariri General Hospital that helped in the drastic reduction of costs. Lab tests and diagnostic imagining were also reduced (knowing that there is always a tendency to abuse when the procedure is free of charge), and more constraints were put on the quantity and prescription eligibility of tests. Moreover, the number of admission was reduced by 25% due to the temporary halt of the cold-cases and unnecessary medical procedures.
Donations
In addition, part of the international donations went to the military hospital, which contributed to alleviate the economic burden. This was the pillar in the decision taken by the Military Healthcare, which was to increase 70% the tariffs remunerated to the hospitals. This decision was first of its kind in Lebanon because the MHC’s main objective is not to deny any beneficiary from his or her healthcare right, keeping in mind that the vast majority of patients could not afford to pay the difference required by the hospitals due to the depreciation of the currency.
On another level, it is important to note the wide range of aid offered to the LAF from nations and individuals because of the national consensus that the Army is the backbone of the country.
The Army command has never spared any effort to materialize those aids in short and long-term provisions for the personnel (subsistence rations, collective transportation, convenient working shifts, etc.). It is only fair to say that the morale of the soldiers is still high relatively to the crisis we are experiencing. It is clearly shown in the execution of missions (which can be seen very recently in Baalbeck) and especially in the MHC where we were affected as was the overall healthcare sector.
This brings us to the conclusion that the true value of an organization cannot be measured by the success it has achieved based on a set of arbitrary metrics over arbitrary time frames. The true value of an organization is measured by the desire its people have to contribute to that organization’s ability to keep succeeding, not just during the time they are there, but well beyond their own tenure. In retrospect, it is of a foremost importance to assess our successes and failures in order to be ready for future events.
Contrary to the common thinking, centralization was vital in these crises. That was due to the small area of Lebanon and the relatively ease of movement across the country, but it is a decision to be taken after a thorough examination of the situation from every aspect (geography, transportation, even culture…). It is also important to know when to decentralize as was done with the swabbing but not in the testing procedures. Likewise, planning is essential in the LAF, and as the saying goes “failing to plan is planning to fail”. If one thinks that planning is enough, one should think again. Planning without clear communication, realistic goals setting, execution, and, most importantly, rapid adaptation to circumstances is merely words on paper and it’s a well-known truth that real life events do not pan out as planned. These different crises have uncovered the importance of time saved from anticipated planning. The readiness of the LAF has paid off also, especially during and in the aftermath of the explosion and throughout the entire pandemic. It is also important to state the prominence of the rapid execution of plans.
In short, there is a difference between a group of people who work together and a group of people who trust each other. That was one of our greatest assets in the military. In a group of people who simply work together, relationships are mostly transactional, based on a mutual desire to get things done. That also works for the LAF, we want to get things done too, but those things do not add up to a trusting team. In order to achieve trust, there have to be positive relationships, good judgment (also known as expertise) and consistency.
The COVID-19 pandemic has taught the whole healthcare system many lessons; mainly that sustaining our way of life requires deep changes in the way we interact with the natural world, the way we think about prevention, and the way we respond to global health emergencies. Cooperation on every level from municipal to national is mandatory and yet hard to achieve due to our individualistic culture. Then again, it is motivating to strive for excellence, whereas striving for perfection is demoralizing.
Conclusion
In order to approach the transitional phase of the health sector in Lebanon and how to alleviate bad outcomes and embark on health reform trajectory, several measures should be taken, both on the short and the long term.
In order to properly devise solutions and recommendations we should have a solid grasp of our current situation and the reality we are facing. Next, we should address our consumerist behavior vis-à-vis healthcare and why it is imperative to change. Then, we can begin to lay down the proper ground work of the tough choices we will have to make in order to cushion the shocks at the end of the transitional phase. And finally, the roadmap to a better health sector in Lebanon will become clearer while emphasizing the rapid execution of the plan.
The Lebanese healthcare system, as we said earlier, is facing its worst crisis on every imaginable level. Shortage in personnel, drugs and equipment is widespread. We are looking at an incomplete development of a national health system beset by inequalities in coverage and funding. Economic and political crises provide windows of opportunities for major reforms. However, for this to happen there needs to be an alignment between three components: actors, institutions, and ideas. Namely, there needs to be problem recognition by actors, willingness, and ability to act by the institutions and, of course, availability of ideas (Kingdon, 1995). One point to add here, our health system is dominated by the private sector, which is geared towards hospital-based curative care rather than primary and preventive health care.
As healthcare demands are highly inelastic, big chunks of household income have been drained to this sector. Noting that in the available literature, a threshold of 10 to 15% of household monthly income spent on out-of-pocket healthcare payments is considered to be a catastrophic and impoverishing cost for households (see Xu et al.,2007)(19).
The Economic and Social Commission for Western Asia (ESCWA) published a policy paper in September 2021 in which it estimated that 82% of the Lebanese population lives in multidimensional poverty(20).
According to the WHO, “Equity is the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality.” That being said, it is easy to translate this definition onto the Lebanese society and healthcare sector. The latter is packed with unfair access to health among the citizens causing them to spend a larger proportion of their expenditures on health.
“Health equity is achieved when everyone can attain their full potential for health and well-being”, according to the WHO. Access to medicines, health insurance, and medical services are the three most vital factors used to determine poverty levels. And according to the aforementioned report, 55% of the Lebanese population does not have any health coverage, putting additional heavy strains on the MOPH. To put that into very simple terms, the Lebanese Healthcare Sector is subject to the most aggressive blow in its history regarding health equity.
Now, to have a clear vision for healthcare reform, we must first come clean with ourselves. We benefited from a system that was all-inclusive, technologically advanced and practically free of charge. Every stakeholder made profits and paid almost no taxes. Control measures were lenient from governmental authorities and the reimbursement policies are far from perfect. Adding to that, tax evasion and abuses are rampant. As we are witnessing, this poorly organized system failed at the first challenge. As bad as it is, we do not have the luxury of time to point fingers. We should acknowledge that we are at the end of the profligacy era.
Despite an impressive track record, the road remains bumpy and the transformation will not be easy, especially that the MOPH is facing factors beyond its realm of control, as Lebanon faces one political crisis after another. Challenges related to the Syrian refugees are just one example; another is pandemic threats, such as COVID-19 and other catastrophes like the Beirut blast with repercussions lasting until this day. One should note, though, that the Ministry has been able to meet these challenges and overcome them even with its limited resources.
Recommendations
The fields of reform are many. We should prioritize low cost with high impact solutions. As you know, we have more than 8 independent healthcare guarantors, each working with their own agendas, rules and regulations with almost no coordination between each other. We have almost no guidelines and no effective medical audit and when we do have audit, it is not always up to the professional levels. To add insult to injury, the rapid devaluation of the currency and the crippling debt crisis took its toll on the sector.
Moving on, we lack external audit, detrimental at least in the first phase to have a clear view of our abuses and wrongdoings. We are also short on trust and unity, two major pillars in our endeavor, for without them we will never have the inclusion of all the stakeholders. This inclusion will pave the way for innovations despite budgetary constraints.
So, where do we go from here? To begin with, we all know the importance of healthcare data in every path we decide to take in this transitional phase. It will provide support on value-based pricing and enable informed cost-benefit analysis.
Then, we should look at the unification of health funds, the standardization of contributions and the equalization of the benefits packages. We can begin with the consolidation of the security agencies healthcare under the military healthcare umbrella, so we will end up having two kinds of payers: one military and one civilian.
Next, it is imperative to set the MOPH free; meaning that the ministry should no longer be a payer but a regulatory stakeholder. Instead, we should consider the implementation of the mandatory participation to the NSSF and eliminating the civil servants cooperative. In doing so, large numbers of experienced personnel will be released, thus, increasing the control capabilities and reducing the abuses. Here we can think about TPA’s (third party administration); they can really enhance the efficiency of the healthcare guarantors at this stage.
Now regarding reimbursement, there is much room for improvement in this area. In pharmaceuticals, we know that the sum of reimbursement of drugs is very high compared to the total invoices of the drugs imported to and manufactured in Lebanon. The reimbursement strategy should be revised as well in term of putting a cap on the percentage of the drug reimbursed. It is becoming more urgent by the day the need to achieve a national self-sufficiency in the drug sector or at least as sufficient as we can get. To do that, it is imperative to have high-level cooperation and coordination between all stakeholders. It is of a national interest to improve the access to medicines for the totality of the population.
This is on one hand, on the other hand we should address abuses in medical interventions (laminectomy, C-section, orthopedic surgery, etc.) and the abuse of lab exams and medical imaging. Here the role of health technology assessment (HTA) is pivotal. Moreover, significantly important is a plan to overhaul primary care because it was neglected and largely provided by the private sector. Not to mention, there is the need to a more balanced distribution of health infrastructure and personnel.
Now, the pooling of health guarantors indicates a move towards centralization, while the assignment of control over primary care is a move towards decentralization; and this duality is very important. In the MHC there is ample experience in this strategy and the lessons learned are many. For example: guidelines are implemented directly, there are no interferences, and also a general IT system is instigated so abuses are easily controlled. Not only that, hospital admissions approval is centralized and we do tenders for all medications and medical supplies. In this predicament, the number of dispensaries was decreased and their resources were allocated, and spending rationalization processes were accentuated from pre-approval for the operations to audits of medical bills after discharge.
To summarize, the pooling of resources, rationalizing funding like the establishment of a single payer, the shift from retrospective reimbursement for secondary health service provision to a case-mix payment, would definitely lead considerable improvements in the healthcare system.
Rationalizing health expenditures should be a prerequisite to support these efforts.
The MOPH has to take drastic measures to contain costs based on robust information systems, scientific parameters introduced in concert with the stakeholders who recognized again their relevance and their merit to health care institutions and programs. In addition, the new standard for public-private partnership is performance contracting and special attention should be given to revise the price structure of pharmaceuticals that constitute a major component of health care expenditures whether to the Treasury or the households.
It is important to mention that reforms and cuts driven by austerity, like cost-containment and control measure shifting the cost to patients, will cast doubt on attaining the “universal” goal of reforming healthcare. In order to go through these reforms, we should always keep in mind the importance of the evidence-based policy making, good governance, and a culture of openness and transparency.
REFERENCES
1- Wim Van Lerberghe, Abdelhaye Mechbal, Nabil Kronfol, The Collaborative Governance of Lebanon’s Health Sector, p.9.
2- Ammar W, Kdouh O, Hammoud R, et al. Health system resilience: Lebanon and the Syrian refugee crisis. J Glob Health; 6. DOI:10.7189/jogh.06.020704.
3- The World Bank. Life expectancy at birth, total (years) | Data. https://data.worldbank.org/indicator/ SP.DYN.LE00.IN?locations=LB (accessed Nov 30, 2017).
4- Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2014; 384: 980–1004.
5- Nicholls A, Pannelay. Health Outcomes and Cost: a 166 country comparison. 2014. https://stateofreform.com/wp-content/uploads/2015/11/Healthcare-outcomes-index-2014.pdf.
6- Bloomberg.com. Italy’s Struggling Economy Has World’s Healthiest People. Bloomberg.com. 2017; published online March 20. https://www.bloomberg.com/news/articles/2017-03-20/italy-s-strugglingeconomy- has-world-s-healthiest-people (accessed Nov 22, 2017).
7- World Economic Forum. The Global Competitiveness Report 2016–2017. World Econ. Forum. https://www.weforum.org/reports/the-global-competitiveness-report-2016-2017-1/ (accessed Nov 18, 2017).
8- Fullman N, Yearwood J, Abay SM, et al. Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016. The Lancet DOI:10.1016/S0140-6736(18)30994-2.
9- https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=LB
10- Major Beirut medical centre lays off hundreds as crisis bites . (2020). Accessed: August 22, 2020: https://www.reuters.com/article/us-lebanon-crisis-aub-idUSKCN24I2GW.
11- Loulwa Farha, Joseph Abi Jaoude, Lebanese Healthcare System: How Will the Aftermath Look?
12- https://www.msf.org/healthcare-system-lebanon-crumbles-amidst-political-and-economic-crisis
13- Loulwa Farha, Joseph Abi Jaoude, Lebanese Healthcare System: How Will the Aftermath Look?
14- Nikos Maniadakis, 2008, Overview of Healthcare System in Greece, http://healthmanagement.org
15- Petmesidou Maria, Challenges to Healthcare Reform in Crisis-Hit Greece
16- Petmesidou Maria, Challenges to Healthcare Reform in Crisis-Hit Greece
17- Idem.
18- Amadeo Kimberly, Greek Debt Crisis Explained, the balance, May 2020.
19- Ke Xu et al. Health Aff (Millwood). Protecting Households from Catastrophic Health Spending, Jul-Aug 2007.
20- Economic and Social Commission for Western Asia (ESCWA). Multidimensional poverty in Lebanon (2019-2021): Painful reality and uncertain prospects. http://www. https://www.unescwa.org/sites/default/files/news/docs/21-00634-_multidimentional_poverty_in_lebanon_-policy_brief_-_en.pdf
نظام الرعاية الصحية في لبنان: هل هناك مكان للإصلاحات؟
المقدم الصيدلي حبيب عبده
شهد قطاع الصحة في لبنان تقدمًا ملحوظًا على مدى العشرين عامًا الماضية. ساهمت العديد من العوامل الاقتصادية والاجتماعية والثقافية في هذا التقدم .في نهاية المطاف، يقاس نجاح أي إدارة صحية بعدة مؤشرات: أولًا، قدرة نظامها الصحي على الارتقاء إلى مستوى توقعات المجتمع من أجل تحسين الصحة؛ ثانيًا، من خلال مرونتها في مواجهة التحديات الجديدة؛ وثالثًا، من خلال كفاءتها في الاستفادة القصوى من الموارد التي يمكن لمجتمعها تعبئتها من أجل الصحة.
تجدر الإشارة إلى أن لبنان احتل المرتبة ٢٢ في العالم من حيث كفاءة الرعاية الصحية بعد السويد.
خلال العامَين الماضيَين، تلقّى القطاع الصحي في لبنان العديد من الضربات مما أثر في طبيعته وجودة تقديم الرعاية الصحية، وهذا بسبب تعرّض البلاد إلى واحدة من أسوأ الأزمات في العالم منذ بداية القرن العشرين. فقد أصبحت الرعاية الطبية مكلفة للغاية لدرجةٍ أن المواطن أصبح غير قادر على تحمّل تكاليف الرعاية الطبية الخاصة، وإن نسبة كبيرة من السكان تسعى إلى الحصول على المساعدة الإنسانية للوصول إلى خدمات الرعاية الصحية. وباتالي، هناك حاجة ماسة إلى تحليل شامل للاحتياجات وتحديد الثغرات الرئيسة في قطاع الرعاية الصحية.
هناك عدة دروس مستقاة من الدول التي مرّت بأزماتٍ مماثلة كاليونان التي اتّخذت خطوات كثيرة لمواجهة الأزمة الصحية أبرزها إصدار الحكومة اليونانية تشريعات تضيف طبقة أخرى من الخدمات الأولية (الوحدات المحلية للرعاية الأولية) مع دورها كحراس بوابة للنظام (Gate-keeping)، وبالتالي تعزيز الوقاية الأولية.
كما أن الطبابة العسكرية واجهت العديد من المشكلات أيضًا خلال جائحة كورونا وانفجار ٤ آب والأزمة الاقتصادية، من خلال وضع استراتيجيات محددة وتنفيذها لتأمين استمرار التغطية الصحية للمستفيدين كافة. هذه الاسترتيجيات شملت تأمين الاستشفاء والفحوصات المخبرية والأدوية والمعدات الطبية واللقاحات لجميع المرضى، وترشيد الإنفاق لتأمين استمرارية هذا المرفق الحيوي.
من أجل مقاربة المرحلة الانتقالية للقطاع الصحي في لبنان وكيفية التخفيف من النتائج السيئة والشروع في مسار الإصلاح الصحي، ينبغي اتخاذ عدة تدابير على المدى القصير والطويل.
على الرغم من السجل الحافل بالإنجازات، إلا أن الطريق لا يزال وعرًا والتحول لن يكون سهلًا، لا سيما أن وزارة الصحة العامة تواجه عوامل خارج نطاق سيطرتها، حيث يواجه لبنان أزمة سياسية تلو الأخرى.
إن مجالات الإصلاح كثيرة من النظر بإعادة هيكلة القطاع إلى تطبيق إجراءات خاصة بترشيد الإنفاق والتخصيص المناسب للموارد. ومن أجل المضي في هذه الإصلاحات، يجب أن يكون التركيز دائمًا على أهمية صنع السياسات القائمة على الأدلة، والحكم الرشيد، وثقافة الانفتاح والشفافية.