Lebanon Health Profile 2012

Strengthening planning, monitoring and quality assurance capacity of MOH to meet the needs and priorities of health care in Lebanon: Under this major heading lies, firstly, the health care infrastructure and resource planning under what is called the “Carte Sanitaire” project. For that purpose, a committee was established in 1999 having for one of its major activities the working on legalizing the Carte Sanitaire in the Council of Ministers as the main resource for planning and prioritizing the provisionof health care services in the country. The second measure was the cost containment through rationalization of the MOH expenditures on health care in private and public  autonomous hospitals. In that respect, the reimbursement of private hospitals forrendered services shifted from the fee-for-service mechanism to the more cost-contained and quality assuring mechanism of flat rate reimbursement, which was introduced gradually, and currently it involves all surgical procedures. In addition, the separation of physician fees in hospital bills was also enacted. The third measure was the establishment of the interconnecting database in what was known primarily as the Visa Billing project and its Interconnecting Data Base (IDB) counterpart. Under and around that goal lies, and at a national information level, a decision on establishing a beneficiaries database which was issued by the Council of Ministers in January 2001.This database would allow all public funding agencies to interconnect and be connected to the central portal set at the MOH. For this purpose, not only demographic and health information should be linked, but also the in-patient and out-patient authorization and billing forms are to be unified. In addition, An inter-ministerial committee and an associated technical committee was established in August 2003 to follow-up on the standardization of the medical procedures among all public funding agencies, including the MOH.
Improving Service delivery: The renaissance of the public sector has for major  component the rehabilitation of the public hospitals as well as the strengthening of the Primary Health Care network. For that purpose, working on four front line referral public hospitals was completed as far as medical supplies and civil works are concerned. In addition, strengthening the Primary Health Care activities and improvement of the role of district health services was established with the help and support of the NGO community, resulting in achieving a proper management and initiation of a predefined package of PHC services. For that purpose, an NGO evaluation study was conducted to see for the fulfillment of that activity. Through the PHC network, programs such as the essential drugs program for the chronically ill funded by the YMCA, and the emergency transportati on program implemented by the Red Cross proliferated.
Quality Assurance: As part of its quality assurance policy of hospital care, and in order to achieve a better control over the supply of hospital beds, the first national hospital accreditation survey was conducted, in 2001-2002; and currently a second round of accreditation is underway. At the level of controlling  the supply of human resources, the MOH is currently subsidizing nursing training programs in two prominent universities in the country, to outweigh the oversupply of physicians since the former cannot be controlled in view of a highly proliferating private sector and foreign university graduates, pumping high number of MD graduates. As part of the control over Health care financing, the first National Health Account survey was conducted in 1998. A second round of NHA is to be initiated for the year 2003 as soon as the administrative and resource measures are cleared.
To ensure the sustainability of the reform components after the HSRP ends, the institutionalization of the staff working on the components was achieved by two ministerial decrees considering the creation of two units within the MOH that should integrate the staff within the personnel of the Ministry after approval from the Civil
Service Board, which is the official body responsible for employment in the public sector. At a national level, the MOH has also participated in the General Data Dissemination System (GDDS), which is a World Bank initiative in collaboration with the Central bank of Lebanon. The mission that was sent in December 2002 had for purpose to assess the statistical system in the country and its capacities in order to establish a multi-sectoral
database including population and health statistics.

Modern, for-profit
In the health sector, the principal providers of for-profit services are private hospitals, clinics and some health centers delivering outpatient services like radiology and laboratory tests. So far, establishing a private hospital is not based on the needs for medical services but rather for political considerations. The law that should govern the planning of health service provision and needs assessment, and hence the establishing of new hospitals, is not endorsed yet. This is the Health care mapping or the Carte Sanitaire project. Once established however, a new hospital has to follow certain guidelines for construction and operation. Previously, the classification of the hospitals as U, A, B, C or D followed certain guidelines as to their hostelry and medical services, and teaching facilities. Currently, though the common terminology used stands for classification, the accreditation system newly introduced in 2001-2002 has taken the lead. To be accredited, a hospital has to meet two categories of requirements, the basic standards and the accreditation standards. While the basic standards tackle conditions of administration laws, building and construction, in addition to the medical equipments and staffing; the accreditation standards, however, have for interest the quality of services offered in a sustainable and cost contained way. A hospital is usually headed by a Chief Executive Officer (CEO) who is the general manager, affiliated to him/her a board of trustees, and beneath lay the different departments. The departments’ terminology might differ from a hospital to another, but the basic structure of anesthesia, emergency services, pediatrics, surgery, obstetrics, laboratory, nursing, pharmacy, radiology and medical audit remains the universal. Basically, all hospitals render services to all citizens provided they pay the full fee for service rendered, or the remaining of the bill had there been a third party payer as a public or private funding agency. Relation of the private sector providers with public funding agencies occurs, for most services, through local authorities in the geographical area to which the hospital belongs. Certain services, like open heart surgeries and kidney dialysis, still need interference of authorities at the central level.

Modern, not-for-profit
The majority of the not-for-profit health care institutions belongs to Non-Governmental Organizations; and are primarily, if not always, health care centers, though certain nursing homes and rehabilitation institutions might cross the line. The work of NGOs in Lebanon started as early as the year 1860. In 1909, the law of formation of an NGO, or what was previously called Organizations for Public Benefits, stated that, “it is a group of individuals sharing information and efforts towards a common non profitable goal”. Their primary interest was the orphans and the elderly, in view of their religious motives and affiliation. With the burst of the civil war in 1975, with all the social, political and economic recession, and the crippling of the governmental institutions, most NGOs assumed the role of the service provider and the local government, in some cases, with all what that role necessitates of creative solutions to the emerging problems. With the end of the war in 1990, NGOs were faced with new responsibilities, shifting their role to the social and economic development with the limited resources that prevailed after the long years of war. Though no permission for foundation is required, the liability of an NGO stands for The Ministry of Interior, which is the sole governmental body that needs to be informed when a new NGO is established. Even though, some NGOs have religious affiliations, but the financial aspect relies mainly on donations and grants, both local and international, giving the NGO the sole responsibility of management and fair distribution of resources, especially so for drugs and health services in general. In some health centers, some exemplar fees for drugs or certain services are taken to help for operational costs, without forming a burden on the beneficiaries, or for profitable money generation.
Traditional The only traditional services in Lebanon stand for traditional birth attendants (TBA). Though their status is illegal, and they receive no formal training, the National Perinatal Study showed that in remote and underserved areas (as in the Akkar sample) some 9.6% of deliveries are attended to by a “Matron” (more defined as an “old woman”).

Public/private interactions (Institutional)
At the institutional level, two major pictures of interaction between the public and the private sector prevail. From one part there is the public sector being the major financing agent for services rendered in the private sector. 64% of the income of private hospitals comes from the public financing, with 30% coming from the MOH alone. Nevertheless, the public sector has no access to complete data from the private sector due to the fragmentation of the system and the weak regulation capabilities of the sector, from one ide, and the lack of transparency of the private sector from the other. But then again, the major aspirations put on the unification of the public systems of financing and the  formation of a public TPA, might solve a big chunk of the problems between the two sectors.
The other picture stands for the services provided through the private sector under direct supervision and cooperation of the public sector, namely the Primary Health Care delivery centers. There exist now 81 PHC centers, 18 of which are public and run by the MOH (14) or the Ministry of Social Affairs (3); with 63 private centers (50 of which are for NGOs, and 13 run by the MOH in collaboration with local municipalities, with one run by municipality). Governmental hospitals that were once fully owned and organized through the MOH are now still public but separate, administratively and financially, except for a lump sum of money allocated initially for operational costs.

Public/private interactions (Individual),
Most medical doctors if not all of them have private clinics. And, whenever the specialty permits, all MDs have contracts with hospitals and/or health centers. Medical doctors and other paramedical staff that are employees in the public sector might contract with private facilities (Hospitals or health centers), provided they execute their activities outside their official employment time. Private doctors, though, will not choose to contract with public health facilities except for voluntary or charity purposes, whenever it applies; and that’s because of the very minimal, sometimes absent, fees for consultation whenever a non-for-profit heath care center is concerned. Any planned changes to private sector organization. Players in the health care field are many in Lebanon. The roles range from regulating, to providing, passing through financing. The MOH acts as a sector regulator through allocation of funds to cover hospital beds in the private sector in addition to managing and controlling appropriate quality of care. It is thus acting as a financing agent in the private sector. In addition, through regulating the accreditation, previously classification, system of private hospitals, it is now acting as the regulator for assuring basic and technology-based guidelines for quality services. On the other hand, and through PHC centers and dispensaries, the MOH acts as a direct service provider insuring primary and promotive care at a reasonable cost and increasingly covering additional territories in the country. The body that’s playing the role of the financing source is the Ministry of Finance through setting governmental budgets. The provision of the healthcare in the country wouldn’t have been possible without the continuous cooperation and support of the Orders of Specialties (Physicians, Pharmacists, Nurses, etc.), as well as the Syndicate of Private Hospitals and a wide network of Non Governmental Organizations, through the provision of quality services and allocation of resources; both financial and technical; as well as through insuring a sociopolitical environment for access to care.