Dr walid ammar harvard 2015

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Health System Resilience Amidst
Political Instability
The case of Lebanon
Harvard Kennedy School
Sept. 2015
Walid Ammar MD, Ph.D.

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The case of Lebanon
This presentation is not meant to introduce the health system in
Lebanon as a model to follow in normal circumstances.
It does not pretend either that the system has been able to
satisfy all needs of the Syrian refugees, who are still facing
obstacles to access certain hospital services. No country could
reasonably be expected to cater for needs of a massive influx of
refugees, increasing suddenly its population by one third.
The purpose of this presentation is to show how the health care
system in Lebanon has been able to absorb recurring pressures
and shocks, particularly the recent Syrian Crisis, and to sustain
its functions and achievements, and even improve some. Hence
challenging certain well established concepts and paradigms in
relation to health system’s performance.
Walid Ammar, MD.; Ph.D. - 2015

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 The political system in Lebanon
 Characteristics of the health system
 Political instability context with
focus on the recent syrian crisis
 Resilience indicators
 Factors behind resilience
The case of Lebanon

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The Political System
Lebanon is a small country of 10452 km2, and a population
of 4 million inhabitants including 400000 Palestinian
refugees (2010).
The political system is described as parliamentarian
democratic. In fact the regime is an oligarchy established on
power sharing based on religious affiliation (18 sects).
The health system operates in a context of free market
economy with a strong tradition of laissez-faire. The
economy is service-oriented (76%), mainly banking and
tourism.
In 2013, Nominal GDP was 47.2 billion USD at current
prices, and a GDP per capita of 11,324 USD.

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Sectarianism and Distorted
Accountability
 Governing political parties have an interest in
keeping the government weak and using their
own channels to provide services.
 Mechanisms to hold parties accountable, such
as elections, are perverted by sectarian
considerations.
 External financial and political support to
political groups diverts accountability to
regional powers, where coalitions are mostly
based on confessionnel loyalties.

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Health Coverage in Lebanon
6 Public Funds
Private Insurance (& Mutual Funds) 12%
Almost half of the population, has no formal
insurance, and is entitled to the coverage of the
Ministry of Public Health (MOPH).
Social Security Fund 28%
Civil Servants Cooperative 5%
4 Military Schemes 9%

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MOPH Coverage
 As the insurer of last resort, the MOPH covers
hospital care and expensive treatments i.e what may
constitute a catastrophic spending for households
(ensuring accessibility while protecting households
from impoverishment).
 The MOPH does not reimburse ambulatory care. It
provides, however, an alternative for the poor by
subsidizing a comprehensive package of PHC
services through a wide network of PHC centers.

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Strong Private Sector
 Overwhelming Private provider:
75% of hospitals beds
90% of ambulatory care facilities
 Oversupply and supplier induced demand:
- Physicians 32 per 10000 (average of 13 in EMR).
- CT Scan machines 26 per million (15 in Canada).

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Weak Government
Complex and lengthy decision making
processes at both legislative and executive
levels.
Lack of MOPH authority, incapacity to
enforce laws for both political and
institutional reasons.

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Fragmentation
 Overlapping & gaps in coverage
 Weakens the bargaining power of public funds
 Hinders planning and regulation, inability to see the
whole picture
 Risk pooling issues
 Provision Fragmentation: Public / private. No formal
referral system through different levels of health care.

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Failed Reform Attempts
Restructuring the MOPH
Control of Supply / Carte Sanitaire
Unifying Public Funds & Expanding
the SS coverage

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 Civil war 1975-1999
 Wars with Israel 1982, 1993, 1996, 2006
 Armed conflicts at the borders with Syria
since 2011
 Social tension and confessionnel disputes
 Paralysis of political institutions
Political Instability Context

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The influx of Syrian refugees started in 2011
1,500,000 Syrian refugees
52,000 Palestinian Refugees from Syria
40,000 Lebanese residents in Syria
1,000,000 host community members directly
affected by the Syrian crisis
The equivalent % of refugees to the French population would be
20,000,000 refugees. The EU (500 million) considers itself in a state
of crisis for an influx of less than 100,000 syrian refugees.
The Impact of the Syrian Crisis

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The WB in collaboration with UN, EU, IMF
conducted a study quantifying the impact and
stabilization needs of Lebanon. It was
estimated at 7 billion USD. (Lebanon, Economic
and Social Impact Assessment of the Syrian Conflict.
September, 2013)
The current estimate is at 10 billion USD
only a total of 1.6 billion USD
transferred from 2011 till 2014
The Impact of the Syrian Crisis

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Health System Resilience
Capacity to absorb pressures and shocks, to prevent or
contain outbreaks, to maintain its institutions
functional and sustain achievements.
In terms of Inputs:
Human resources - Production
- Retention problems
Financial resources - MOPH budget and public spending
- Disbursement delays
- Deficient financial assistance from the
international community.
In terms of Process:
Operationality of Public and Private institutions
Governance, financing and provision functions of the health system: level
of functionality

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Health System Resilience
In terms of Outputs and outcomes :
 No discrimination between Lebanese and non-
Lebanese at the PHC level. This is unfortunately
not the case in hospital care.
 Evidence shows that provided services have
been steadily increasing in both PHC and
hospital care.
 Major outbreaks were controlled (measles, hep.
A) or prevented (Polio, leishmaniasis, cholera…)
 MDGs 4 & 5 achieved

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Out Of Pocket
In a context of increased demand for health care (older population
and higher prevalence of NCDs) and high cost of medical
technology:
Imposed fees and co-payment may hinder the
accessibility of the poor to health services.
Health spendings may become catastrophic for the near
poor and push them under the poverty line.
The MOPH strategy focused on reducing OOP (mainly by
improving accessibility to PHC) from 60% of THE in the 90’s,
(spent mostly on private ambulatory services) to less than 40%.

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National Health Accounts
summary statistics (USD)
1998 2005 2012
Total population estimate 4,005,000 3,870,000 4,104,000
Total health expenditure 1,987,808,565 1,741,671,128 3,083,009,900
Per capita expenditure 496 450 751
Total GDP 16,200,000,000 21,499,834,163 42,985,074,627
Health expenditure as % GDP 12.4 8.1 7.2
Percent GOL budget allocated to MOPH 6.6 5.9 3.4
Sources of funds (%)
Public 18.22 28.98 31.14
Private 79.84 70.99 68.39
Households 70.65 (OOP 60%) 59.82 (OOP 44%) 53.02 (OOP 37%)
Employers 9.19 11.17 15.37
NGO 1.94 0.03 0.47

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MDGs related health
indicators
1990 1995 2000 2004 2013*
IMR (per 1000 live births) 35 33 27 16.1 8
<5 MR (per 1000 live births) 43 40 35 18.3 9
Births attended by skilled health
personnel (%)
45 89 98.2
Maternal Mortality Ratio (per 100,000) 300 130 104 86.3 16
MMR 2008 LEB 26 (World Statistics Report Sept. 2010), >5MR (2009) 10‰ (MICS 3, 2011)
* World Health Statistics
Maternal deaths among refugees are proportionally close to those of the Lebanese and are
included in the 2013 national MMR of 16, compared to 2010 MMR in Syria of 70 per 100000

Health Reform in Lebanon: A success story in the
"WHO Report 2010 on Health Care Financing"

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Outcomes versus Health
Spending
Health spending per head in 2012, nominal US$
Sources: The Economist Intelligence Unit; World Health Organization

www.eiu.com/healthcare
Top tier by outcomes: Coping with ageing ( 28 countries)
Tier two by outcomes: The rise of non-communicable Diseases
22

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? how to deal
at the same time with:
 Strong private sector.
 Weak Government.
 Fragmented health system.
 MOPH lack of authority.
 Increasing demand.
 MOPH shortage in human and financial resources.
 A chronic context of political instability.
 Acute crisis of massive influx of Syrian refugees
and their distribution all over the country.

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Weak Regulation VS
Flexibility
 Legislation loopholes offer room for manoeuver.
 Capacity to adapt and innovate.
 Soft Regulation through contracting, in the framework
of Public-Private partnership.
 Results based monitoring and accountability (to bypass
resource consuming procedural control).
 Financing as a leverage for enforcing regulations
(MOPH financing is a consequence of unaccomplished
Social Security coverage).

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Fragmentation VS
Diversity
Mitigating fragmentation while benefiting
from the advantages of diversity.
Diversity:
 Of sources of funding: balance between
taxes, contributions and OOP.
 Of Institutions with different problems at
different times.
 Of Interveners at different levels of provision.

26
Participation as a Principle of
Good Governance
Opportunities
 Formal participation frameworks (provided for by law).
 Active Civil Society and a strong NGO sector.
 Professional Orders legally representing different professions.
 Long history of contracting with the private sector.
Challenges
 Absence of strong and credible consumer associations.
 Patients’ associations are very few and weak (sometimes
manipulated).
 Disfunctioning national accountability mechanisms.
 Centralized public administration (MOPH).

27
Engaging NGOs and
Municipalities
After 17 years of civil war, the MOPH decided to capitalize
on the NGOs resources and created the National PHC
Network. MOPH-NGOs Relationship formalized by
contractual agreements. Municipalities included as partners.
Policy Level: Steering representative Committee
Tripartite contracting agreements
Legal framework based on common understanding. (explicit
commitment to a comprehensive package of services and
quality of care, performance based financing). Outcome based
contracting (soft responsive regulation).
Consumer empowerment
Provide information on patient rights & Patient satisfaction
surveys.

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Give weight to the consumer voice vis-à-vis the
provider
Patient satisfaction linked to payment
Election of municipality council members
Accountability at the polls
Accountability of the health center to the NGO
Organizational accountability
Accountability of the NGO to the MOPH
accountability through contracting
Accountability in PHC

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Hospital Care
Accountability Framework
Performance based financing
Case-mix and output indicators
Accreditation
Patients reporting on:
- Perception of quality of care
- Extra payment imposed by provider
- Responsiveness of provider to patient’s non
medical expectations
Contracting as a tool to improve quality and to meet
patient’s expectations.

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Concepts & Paradigms
Should multiplicity of financing and provision still be
considered as detrimental? Or should we benefit from
diversity to promote competition, complementarity
and mutual support?
What about oversupply of physicians, hospital beds
and high tech equipment? And the capacity to absorb
an increased demand of a “flourishing medical
tourism” or resulting from high influx of refugees!?

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Should we rely more on legislation to regulate the health
sector considering the Lebanese context and to what
extent? VS developing negotiation skills and institutional
capacity for contracting as a soft and flexible tool for
regulation?
Should refugees be concentrated in camps to be well
controlled (by a strong government) and to facilitate
delivery of services? or should they be left spreading all
over the country, which helps distributing their burden
over numerous communities and health providers?
Concepts & Paradigms

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Political Dimensions
 Take strength from science to face the perverting
“power” of confessionalism.
 Health is a uniting cause which helps overcome the
hatred of “the other”, and break the vertical division of
society and the vertical allegiance to sectarian parties.
 Create new accountability frameworks to palliate the
deficient existing mechanisms.
 Enhance decentralization and community involvement.
 Overcome the lack of authority and resources
 Capitalize on existing resources (NGOs, Municipalities, Private
Sector)
 Create soft tools rather than coercive legislations
 Use financing as leverage for change
 Performance contracting and results based management

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Conclusion
Behind system’s weaknesses there
are strengths that most often are the
other side of the same coin.
It is all about system dynamics within
a specific context… and definitely a
matter of governance.

Dr walid ammar harvard 2015

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Dr walid ammar harvard 2015