Can Lebanon conjure a public health phoenix from the ashes?BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38996.466678.68 (Published 19 October 2006) Cite this as: BMJ 2006;333:848
- 1 Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El Solh, Beirut, Lebanon
- 2International NGO Training and Research Centre, Oxford OX2 6RZ
- Correspondence to: A-M Sibai
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.
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.
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 interests None declared.