Healthcare in Lebanon

The following article about healthcare in Lebanon appeared in the British Medical Journal (BMJ) in 2006. It summarizes the development of the sector since independence in 1943 and goes over some of its prominent characteristics today.

Overall, the article shows how Lebanon is an example of a developing healthcare system. It is far ahead of some very primitive systems that are unfortunately still prevalent in many countries around the world; but at the same time, despite the availability of technological advances (32 cardiac catheterization centers offering the second highest rate of catheterizations in the world is no small feat for country of 10,000 square kilometers), it is not able to provide the same high level of care to which citizens in developed countries have access.

The authors delineate the main causes--"a system dominated by private providers with little interest in the needs of people who are poor or have long term disabilities or chronic illnesses"--and outline the need for a reform "moving away from high tech care and focusing on providing expanded access to primary care and community health centres for the poor and uninsured populations in the more remote regions."

Unfortunately, and particularly in light of increasing globalization and privatization, many countries around the world are in the same predicament: Resources may be available but are poorly allocated, and there is no clear overall strategy for healthcare. And although the debate is not quite the same in the US, it is not hard to see some similarities between the two situations. As the healthcare providers of the 21st century, it behooves us to learn more about this; for, in the era of such incredible medical advances as artificial hearts and intrauterine fetal surgeries, it is a shame not to ensure that as many people as possible have access to primary healthcare across the globe.

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BMJ 2006;333:848 (21 October), doi:10.1136/bmj.38996.466678.68

Analysis and comment

Can Lebanon conjure a public health phoenix from the ashes?

Abla-Mehio Sibai, associate professor¹, Kasturi Sen, director of research²

¹ Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El Solh, Beirut, Lebanon, ² International NGO Training and Research Centre, Oxford OX2 6RZ

Correspondence to: A-M Sibai ansibai@aub.edu.lb

The recent bombing of Lebanon has destroyed much of the health infrastructure. The challenge now is to establish a focus on primary care and public health services

Lebanon is currently struggling with the aftermath of the most devastating conflict in its history. Israel's bombardment over the 34 day war that started on 12 July has crushed the economic, social, and health infrastructure of Lebanon, a small country with less than 4 million population. The south, where the population was already disadvantaged, was worst affected. Two government hospitals were completely destroyed along with many health and social centres. Over one million people, about a quarter of the population, were displaced. The Higher Relief Council put the overall death toll at 1183, nearly all of them civilians; over 5000 were wounded, mostly women and children. Acute crises, such as loss of clean water and electricity, destruction of road networks, and overcrowding with thousands of homeless families living in tents are exacerbated by an underlying chronic fundamental lack of resources.

Before the war Lebanon had one of the highest gross domestic products in the region ($4045 (£2150; 3195) per head), with 12% spent on health (table).¹ However, because of a system dominated by private providers with little interest in the needs of people who are poor or have long term disabilities or chronic illnesses, health provision in the south was already inadequate. We describe how healthcare provision developed and argue that the postwar climate ought to compel the government to reconsider the prevailing market led structure.

Table: Lebanon's healthcare statistics1 Value Total health care expenditure ($) 2bn Per capita health expenditure ($) 500 Gross domestic product (GDP) ($) 16.2bn % of GDP spent on health 12.3 % government budget allocated to health 6.6 Source of funds (%): Public 18 Households 70 Employers 10 Donors 2

Development of health services

After independence in 1943, Lebanon briefly built up some public health provision, under the rubric of national social development programmes. The state built a network of district and rural hospitals that operated within a referral system but focused on serving the underprivileged. Patients were required to prove hardship in order to be admitted for care. This legacy of stigma associated with public provision remains today.

The frequent civil wars, Israeli incursions, occupation, and bombing that ravaged the country from 1975 until 1991 weakened the institutional and financial capacity of the government, and the Ministry of Public Health and its allied services almost totally disintegrated.² As a result, the country had no clear health policy, no means to implement it, no information database to work from, and no health workers—the classic profile of a country at war.³ The public sector shrank dramatically in quantity and quality. The few public health programmes available, such as vaccinations and healthcare for mothers and children, were driven by donors and pushed further into the hands of local and international non-governmental organisations. The number of public hospital beds fell from 1870 (in 1975) to fewer than 700 (from 26% to 10% of the total) by 1991.⁴ More than 56% of private sector bed capacity was created during this time, much of this expansion focusing on high cost curative care.⁴

This period also witnessed a rapid expansion of non-governmental, not for profit health centres and dispensaries. International non-governmental organisations increased service coverage throughout the country from 28 to 171 services.⁴ Small non-governmental organisations also multiplied, working in underserved rural and urban communities. A study in the late 1990s showed, for example, 56 organisations working solely on disability and rehabilitation.⁵

After 1991, government provision became limited to some secondary and tertiary care for civil servants plus some targeting of the most disadvantaged groups. But since most public hospitals had been either destroyed or closed, the state had to buy services from private hospitals.⁶ The private sector continued to expand and became the main secondary and tertiary provider, with primary care largely relegated to non-governmental organisations. Modern diagnostic techniques, equipment, and high technology services proliferated disproportionately to the size of the population. For example, the number of facilities offering cardiac catheterisation rose from 10 in 1994 to 32 in 2002, and the rate of these procedures (72 per 10 000 population) was the second highest in the world.⁷

One effect was to create health services that were led by private for-profit provision with supplier induced demand.⁸ This process has been difficult to reverse because of vested interests embedded in the political and economic structure of health provision. Powerful syndicates, professional associations such as the Orders of Physicians and Pharmacists, and the predominance of confessional political parties have helped maintain the primacy of private providers.

The health sector in Lebanon is now widely recognised to be facing a major crisis, with inefficient services of uneven quality and large inequality in distribution and access to care despite high cost and substantial public funding.⁴ The 1999 national household expenditure survey showed that low income households spent a much higher share of their incomes on health services than the wealthy (20% for households with less than $200 income per month and 8% for households with over $5000 income).⁸

Public health funding

Only 49.5% of the population report having any insurance.⁸ The remaining 50.5% with no insurance represents the most vulnerable population, such as the unemployed, seasonal workers, women who work in the home, and older people. The ministry acts as the insurer of last resort since, in theory, it finances the hospital costs for any citizen whatever their income or assets, who are not covered by insurance. However, the nature and organisation of health services means that as much as 84% of health expenditure goes on curative care, with hardly any support for preventive public health activities.⁸

Given the separation between financing and the provision of health care, the loss of control by state agencies is almost inevitable. This kind of problem typifies a market led and emerging corporate healthcare system, where private profits rely on public subsidy. The endemic problems are fragmentation, high costs, overuse of drugs and high tech interventions, high administrative charges, lack of continuity of care, and low priority for prevention and health promotion. The gross inequities and cost of the system, benefiting political allegiances, has no place in a country in which the population has been economically, socially, and psychologically undermined.

An opportunity moving forward

As Lebanon moves to meet the needs of its population from the most recent war it has an opportunity to challenge its predominantly market led health system and begin anew, with a vision for radical change. The healthcare system in Lebanon was always fragile, but the underlying vulnerability of the population, especially in the south of the country, has aggravated the effects of the war. Their vulnerability is likely to be magnified because most people living in the war torn areas have also lost their livelihoods.

Any government planning of health services should follow the lead of local non-governmental organisations. This means moving away from high tech care and focusing on providing expanded access to primary care and community health centres for the poor and uninsured populations in the more remote regions.

Expanding public coverage through partnership with trusted local providers and civil society groups that existed before the war needs to be a priority. Similarly, donors and international non-governmental organisations providing emergency relief in Lebanon should work closely with community based providers and locally managed health clinics to rebuild and plan for longer term care. Working in partnership with local communities will help expand affordable health care coverage, encourage retention of the workforce, promote resiliency and begin a healing process to a hugely traumatised and dispossessed population.

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Contributors and sources: A-MS has studied and reported widely on population health issues, in particular the disadvantaged (disabled and older adults) and has interest on the overuse of high-tech interventions. She conceptualised and drafted the first version of the paper. KS has undertaken multicentre studies on behalf of the European Commission in south Asia and the Middle East for the past decade intended to enhance collaboration between scientists in Europe and countries of the south on issues of equity and access to health care. She contributed to the several revisions made to the paper. Both authors are responsible for the final version of the manuscript.

Competing interest: None declared.

References

1. Ammar W, Azzam O, Khoury R, Fakha H, Mattar C, Halabi M, et al. Lebanon national health accounts 1998. Beirut: Ministry of Public Health in Lebanon, World Health Organization, and World Bank, 2000.
2. Kronfol NM, Bashshur R. Lebanon's health care policy: a case study in the evolution of a health system under stress. J Public Health Policy 1989;10: 377-96.[CrossRef][Medline]
3. Van Lerberghe W, Ammar W, el Rashidi R, Sales A, Mechbal A. Reform follows failure. I. Unregulated private care in Lebanon. Health Policy Plan 1997;12: 296-311.[Abstract/Free Full Text]
4. Mechbel A. Health care reform in Lebanon: research for reform. In: Nitayarumphong S, ed. Health Care Reform at the Frontiers of Research and Policy Decisions. Bangkok: Ministry of Public Health, 1997: 120-40.
5. Sen K, Sibai A-M. The impact of traumatic injury related disability on families and the state among adults in Lebanon and elderly people in the Occupied Territories. EEC - IC18CT 96 0036-INCO-Dc framework, 1999 (unpublished report).
6. Harik J. The public and social services of the Lebanese militias. Vol 14. Oxford: Centre for Lebanese Studies, 1994.
7. Sibai A-M, Refaat M, Rizk R, Saab R, Saab W, Sabbagh M, et al. The use and overuse of coronary angiography in Lebanon. BMJ (Middle East) 2004;11: 6-17.
8. Ammar W. Health system and reform in Lebanon. Beirut: Enterprise Universitaire d'Etudes et de Publication, 2003.

Osteoporosis

The municipality of Zawtar el-Charkieh, a village in South Lebanon, has been collaborating with AUB's FHS on a number of projects to help improve the quality of life of its inhabitants. The mayor, who has been tremendously involved in these projects, is currently interested in screening the population for osteoporosis. We assisted by writing a report about guidelines and cost-effectiveness of screening. Lebanon is actually one of very few countries in the world to have a database for the FRAX tool, an online calculator for global risk assessment of fracture risk that can be used independently of BMD results (available at http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=21). AUB's FHS had already conducted a health needs assessment of Zawtar that was very helpful. As it turns out, "to test or not to test" is a question that does not always have an easy answer--particularly in the setting of limited resources. We were also ready to lead an awareness session on osteoporosis, complete with a PowerPoint presentation--only to find out that the municipality had already organized two in the past year!

Just so our efforts don't go completely to waste, here is a slide from the PowerPoint presentation (in Arabic!):



To find out more about AUB's activities with Zawtar el-Charkieh, you can go to: http://fhs.aub.edu.lb/outreach_practice_training/unit/community_services/zec_about.html

Oum El Nour

We have been driving for over an hour. After battling our way through Beirut’s morning traffic, we slowly wind our way into the surrounding mountains. Hidden deep within (but yet managing to overlook the Mediterranean) is the Oum El Nour center. “No pictures of the building” I am quickly told when I pull out my digital camera. This, of course, is to protect patient privacy.

Although there are few recent studies in Lebanon, the WHO estimates a prevalence of approximately 0.2% for opiate abuse, 0.1% for cocaine abuse and 2.5% for alcohol abuse [1]. Oum El Nour (which means Mother of Light in Arabic) is one of a few inpatient rehabilitation facilities in the country.

We arrive with our AUB contact and are promptly introduced to one of the directors. As usual, we are stunned by how friendly and open everyone is towards a group of random American strangers. Average stays range from 15 to 18 months here and both men and women are offered care free of charge. The center is partly funded by the Lebanese Ministry of Health but also relies heavily on private benefactors.

The men’s center is home to 60 men, most of them polysubstance abusers including IV heroin. Patients are initially evaluated by a GP on admission and tested for HIV and hepatitis. If necessary, they are referred to outpatient psychiatrists in addition to seeing the therapists and counselors at the center. The use of methadone or buprenorphine is not legal in Lebanon and instead a strict abstinence policy is implemented.

“The difference in Lebanon,” the director explains, “is the presence of family as an integral part of the rehabilitation process.” The addict here is rarely homeless and usually lives within a busy household. “But what about the few who are homeless?” I ask, recalling the patients with substance abuse that I’ve treated over the last few years. To this I am met with largely blank stares and, after a somewhat prolonged pause, our friend from AUB answers, “it is very very rare. We may live within a tent, but we do so with our family”.

After detox and an initial isolation phase, relatives are brought in quickly and considerable time is spent with therapists working on family relations. The director believes this emphasis accounts for the extremely high rate of program completion (45%). Although long-term success rates are unknown, the AUB school of public health is busy collecting this data. In the meantime, patients are happy to receive another chance within the peaceful confines of Oum El Nour.

[1] http://www.emro.who.int/mnh/drugs_countryprofiles_leb.htm

Jordan!

We spent the weekend on a short trip to Petra, the site of an ancient Nabatean city a few hours south of Amman. We had originally hoped to drive to Jordan, making our way through Syria, but obtaining entry visas remains a challenge for US passport holders. We instead flew into Amman. Enjoy the photos. The last one is of the Roman Theater in Amman.

The Bedouin Health Project

Dumou', 16, is engaged to a distant cousin of hers. Fully veiled, she welcomes us with a shy smile into the small, decrepit apartment she shares with her father, his two wives, and their ten children. With all the mannerisms of a young teenager, she giggles when a sensitive subject is broached and glows when she realizes she is being addressed as an adult, before carefully volunteering her opinion on anything from women's health and pregnancy to domestic violence and early marriage.

Manal, in her 30s, has already taken her youngest daughter, born with a congenital retinopathy, to see several of the leading ophthalmologists in the region. Her son, who walks into the large and newly renovated family home sporting his newest jeans, is getting ready to go to college, which will give Manal more time to dedicate to the women's organization she helped found. Wearing sports gear, she effusively discusses the problems of access to healthcare as she describes the many medical conditions--high blood pressure, diabetes, heart failure--that her acquaintances suffer from, before reminding us that she has completed First Aid training and has been to visit many health professionals in different parts of the country. As we get ready to leave, she too, as Dumou' had done earlier, rushes to offer us food and drinks--although instead of Pepsi and chocolate wafers, she brings us tea and coffee in Chinaware along with home baked goods made with coconut.

These two women are Bedouins living in Lebanon. Both were selected by the Bedouin leaders as potential candidates to be Community Health Volunteers (CHV), as part of the Bedouin Health Project spearheaded by researchers at AUB's Faculty of Health Sciences in collaboration with the Ford Foundation and Oxford University. Between 50,000 and 75,000 Bedouins live in Lebanon, the majority of whom migrated from the Golan Heights after losing access to pastoral lands following the 1967 Six Day War. Today, most have settled in the fertile Beqa’a Valley. Those who are not Lebanese citizens have to buy private insurance or pay out-of-pocket for any healthcare expenditure they incur. The problem is not access to healthcare per se: Bedouins do seek medical care, particularly when dealing with pregnancy; however, they are overall reluctant to do so as their care is hindered by discriminatory practices on the part of providers and cultural norms that limit the women's comfort level while interacting with physicians. Surveys conducted by AUB additionally suggest that there is also an "overmedicalization" of health services with little or no focus on preventative care.

In an effort to minimize some of these barriers, the Bedouin Health Project is training CHVs to work as facilitators and mediators between the Bedouin women and the primary care centers in the Beqa'a region. Additionally, these women will receive training in children's and women's health in the hopes that they may serve as resources for the local communities when and where more specialized care is not available. The project is also involved in building local providers' cultural competency toward Bedouin attitudes and practices. While fraught with obstacles--most of the women selected by the tribe leaders are barely 18 and most of the providers, already overworked, are not particularly interested in training sessions on cultural awareness, the project has been enthusiastically received by the Bedouins, who see it as a first step toward their becoming more empowered in dictating their own healthcare

Tobacco control law press conference

Last week, AUB's Faculty of Health Sciences (FHS) held a press conference to announce its position statement regarding a proposed tobacco control draft law currently under discussion in the Lebanese Parliament.

Smoking remains a major public health problem in Lebanon, with a prevalence of close to 50% among the general population. A recent survey looking at students aged 12 to 16 in Beirut and Mount Lebanon found that 10.5% currently smoke cigarettes and 29.6% currently smoke narguileh (hookah). The latter, which is popular in the region as a recreational activity, has in fact been found to be just as harmful as (if not more harmful than) cigarette smoking. Despite having ratified the WHO Framework Convention on Tobacco Control in December 2005, Lebanon continues to have weak tobacco control policies, and the tobacco industry continues to hold a strong lobby: Many hospitals and schools are not smoke-free; tobacco advertising is rampant; and there are no restrictions on who can buy cigarettes, with a pack selling for less than a dollar. While discussions regarding the proposed law have generated some interest (a Facebook group named "Ban indoor smoking in public places in Lebanon" now boasts more than 15,000 members), overall the issue has not seen much light (and, in fact, an opposing Facebook group has sprung up: "NO to 'Ban indoor smoking in Lebanon'" with a little more than 100 members).

Widely attended by members of the public, the media, and the government, the press conference featured academicians from FHS and AUB's Faculty of Medicine, as well as government officials and representatives from NGOs. All of them strongly emphasized the need to adopt strong provisions in any tobacco control law. Their arguments focused not just on the health benefits but also on economic considerations including references to how stringent tobacco control laws would not harm tourism, the restaurant industry, or tobacco farmers. Many handouts--mostly in Arabic, but also in English and French--were distributed.

The position statement presented by FHS advocates the implementation of three main measures:
1) A total ban on tobacco smoking in indoor public areas;
2) A total ban on advertising tobacco products; and
3) The inclusion of large pictorial health warnings on tobacco products, covering at least 40% of two large surfaces of the pack with rotating messages every six months.

The current draft law proposes to have designated smoking and non-smoking zones in public areas, which studies have repeatedly shown to be ineffective in reducing the harm of second hand smoke. To demonstrate this, an experiment was conducted at the end of the conference in which the room was divided into a "smoking" and a "non-smoking" area: A machine located on the "smoking" side was used to smoke a number of cigarettes, and within eight minutes, the levels of ultrafine pollutant particles became equal on both sides of the room.

http://www.aub.edu.lb/news-images/103583-13

BGUH (part deux)

We spent another day at Beirut Government University Hospital, and had the opportunity to meet with the medical director and attend morning report.

Just as in the US, a significant percentage of Lebanese have private insurance, but the uninsured and the underinsured populations remain significant. The government insurance scheme does not cover outpatient care. There are discounted clinics (including at BGUH) where physician visits are more affordable, but patients are limited in their ability to pay for bloodwork or imaging tests. They are building new outpatient clinics at BGUH but the director told us that there is still no funding for ongoing patient care.

Many patients come to the ED for admission because they cant afford routine outpatient care. Furthermore, private hospitals severely limit their capacity to admit underinsured patients by limiting the available beds in the hospital. One of the hospitals we visited earlier reportedly has only 10 beds out of over 400 reserved for patients with the government insurance plan. Underinsured patients at private hospitals either wait for days in the ED for beds to become available or get transferred to the government hospitals.

BGUH is a modern tertiary-care hospital with an ICU, cardiac catheterization lab, PICU, etc. Its 400 beds are always at capacity, making it many times busier than the next largest government hospital. In spite of excellent facilities, the hospital is chronically underfunded, often without enough money for blood tests or radiologic studies, and loses 15-20 million USD annually. Government funds are often distributed based on political needs rather than medical needs with monies going to outlying regions of the country to show governmental support for those districts.

The morning report was mostly remarkable for how similar it was to our own. The case was an elderly man presenting with painless jaundice and weight loss who was being evaluated for likely pancreatic cancer. The discussion was identical to one we might have at Columbia including choosing appropriate blood tests and imaging modalities. Perhaps one difference was the greater emphasis on concepts of efficiency and cost-effectiveness. The patient had pre-renal azotemia and the initial debate was whether an abdominal ultrasound or a CT with contrast would be the preferred study based on safety, utility, and cost. Later we learned that the patient had undergone a non-contrast abdominal CT at an outside hospital a few months ago that was reportedly unremarkable. Now the thought was whether the additional time and expense of an MRI would be beneficial.

A nurse interrupted the presentation with a printed sheet of paper. This was the daily report of which tests had been approved by the government insurance for that day. Of the 15 items, perhaps one third to half had been rejected, including things as simple as a TSH assay. Cancer markers for a patient with a known mass were denied, as was a brain MRI for an individual with persistently altered mental status with negative workup including two unremarkable CSF examinations. The residents regularly spend hours speaking with the insurance companies to get these tests covered.

For our case, the team had decided on the MR scan, but we found out from the daily report that day that the request for his MRI abdomen was approved, but the MRCP was denied.