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Health System Reform
Ministry of Public Health
Lebanon

The Problem

Lebanon was ravaged by a devastating civil war that lasted from 1975 till 1992, leaving a severely weakened public health system, compensated by a strong high- technology unregulated private health sector. Attempts at reforming the health system started since 1998, but were halted by the very volatile political situation, and repeated crisis situations and security instability. At the beginning of the second millennium, more than 50 % of the population of 4 million had no insurance, and had to rely out of pocket payment) for accessing health care. Similarly, the poor had to rely on the disorganized Primary Health Care (PHC) services provided mostly by the thriving religious and politically affiliated NGOs. In addition, the MOPH had only around 300 beds available in its 12 out of the 26 operational public hospitals, most of which were poorly equipped and understaffed. The remaining hospital services were purchased by the MOPH from the private sector (which had a total capacity of 1,200 beds available in 147 hospitals), with poor control on quality and cost of care provided in these hospitals.
The national health accounts analysis undertaken during the year 1997estimated that public health expenditure as percent of GDP was 2.24, and public expenditures on health as percent of total expenditure was 10.5 and the share of out of pocket payment for receiving health care was around 59%. At the same time the national health indicators were suboptimal, with significant discrepancies among regions across the country. The above situation presented pressing issues of equity, quality and efficiency that had to be addressed to improve the overall performance of the health system and subsequently improve population health status. The situation was aggravated by the additional burden on the health system that resulted from the July 2006 crisis.

Solution and Key Benefits

 What is the initiative about? (the solution)
In 2006, the MOPH reoriented the National Health Reform Plan using the post July 2006 war recovery phase as a leverage to implement the following interventions:
i. Reinforce the public hospitals system: the 26 public hospitals were rehabilitated, equipped and adequately staffed, and operated under the law of autonomy which allows the hospital administration a degree of flexibility in management and fund raising;
ii. Revise the contracting modalities with the private hospitals for specific inpatient services at specified rates , and with the NGOs affiliated PHC centers for specific package of services;
iii. Revamp the Public PHC sector; the national public PHC network was expanded in terms of number to reach 147 PHC centers by end of 2010, distribution covering all Qada across the country and a health care package introducing new services such as mental health and referral to secondary and tertiary care.
iv. Establishing a quality improvement program for health care delivery: the MOPH introduced the accreditation system at the hospitals and PHC levels
The key benefits include:
a. With the expansion of the Public hospital system both in terms of number and geographic distribution, the MOPH depended progressively less on the private sector to respond to the hospitalization needs of the poor, thus tertiary care access was improved especially for the poor. The public hospitals share of inpatients went up from 18.3% in 2006 to 27.3% in 2007;
b. the financial burden on the MOPH for hospital care was alleviated, and the financial risk shifted down to the hospital management level. In fact, despite an increased utilization of the public hospitals, the MOPH made savings in the total budget allocated or hospital care, while the public hospitals were responsible for complementing required financial resources through the law of autonomy;
c. the out of pocket expenditures decreased from over 60% in 1998 to 44% in 2007 , since access to subsidized public health care services (hospital and PHC level) has improved;
d. the culture of quality of health care delivered at the Hospital and PHC levels was introduced and implemented;
e. the MOPH strengthened its leadership role and governance functions and has remained stable during the period 2006 -2010;
f. the contracting process for services in the private sector and NGO sector became more transparent and efficient
The main health system improvements are summarized in Table 1 below
Table 1 Comparison of selected Health system indicators in Lebanon
Year GDP $ (mil) THE $ mil %GDP 0n Health % OOP from THE GDP $ PC THE $ PC OOP $ PC
1995 11719 1250 10.7 55.3 3357 358 198
1996 13690 1467 10.7 55.3 3838 411 227
1997 15595 1804 11.6 56.3 4301 498 280
1998 16910 1975 11.7 59.6 4604 538 320
1999 17009 1894 11.1 58.1 4573 509 296
2000 16822 1829 10.9 56.0 4459 485 272
2001 17179 1818 10.6 52.4 4482 474 249
2002 18693 1752 9.4 50.6 4795 449 228
2003 19802 1761 8.9 46.9 4994 444 208
2004 21465 1809 8.4 42.4 5329 449 191
2005 21558 1832 8.5 41.8 5282 449 187
2006 22136 2017 9.1 42.8 5365 489 209
2007 24731 2183 8.8 42.9 5942 525 225
2008 28660 2510 8.8 39.9 6834 599 239
GDP – Gross Domestic Product; THE – Total Health Expenditure; OOP - |Out of Pocket Expenditure; PC – Per Capita; $ - US Dollars

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
The National Health Sector reform was initially proposed by the WHO and supported by the World Bank. From 2006 onwards the reform process has been ably led by the Minister of Health seconded by the Director General and the Ministry's team along with a group of health system experts with the support of the WHO. The MOPH has successfully implemented the proposed reforms by providing the needed stewardship that has brought together the main stakeholders to agree to these reforms despite several political, technical, organization and financial challenges. The main stakeholders included in the reform process are the Order of Physicians, the Syndicate of private hospitals, the Order of Pharmacists, the Syndicate of Drug importers, the Order of Nurses, the national NGOs (collective des ONG and Forum des ONG), the academic institutions, and the UN agencies involved in Health and Development.
Note is made that while the cabinet of ministers was suspended due to the withdrawal of a number of ministers, the Minister of Health insisted on ensuring proper and continued work at the MOPH with special emphasis on the initiatives under the health system reform

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The main strategies used to implement the reform were based on the pre existing efforts in terms of health system reform, and the urge to restore the proper functioning of the health system in the areas most affected by the July 2006 crisis. Accordingly, the strategies adopted included:
i. Reinforcing the public hospitals system:
o rehabilitating all the public hospitals , equipping them and staffing them, by issuing necessary decrees to implement the law of autonomy ,
o revising the financial contribution of the government to ensure more equity and efficiency
ii. Revision of the contractual modalities with the private hospitals
o updating of the reimbursement schemes
o standardizing the contractual agreement form
o introducing the financial performance audit
iii. Revamping the PHC system:
o expansion of the public PHC network supported by the MOPH ,
o piloting new partnerships such as the ministry of Interior and Municipalities
o standardizing the contractual agreement based on a well defined package of services
iv. Establishing a quality monitoring system for health care delivery:
o updating the Hospital Accreditation system,
o piloting the PHC accreditation system
o introducing the hospital performance indicators

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
The initial national Health Sector reform plan developed in 1997-1998 was revised in 2006, and reoriented to address the urgent needs of the overburdened health system after the July 2006 war. In the Paris International Donors Meeting organized in November 2006, Lebanon proposed the key components of the health strategic reform that are summarized follows:
(i) initiating a recovery program for the communities affected by the conflict;
(ii) strengthening PHC services with an emphasis on new quality standards and improved information systems for monitoring;
(iii) a public hospital expansion program; and (iv) undertaking health insurance reforms to increase the efficiency and transparency of public sector spending with the aim of working toward the phased integration of the public health insurance schemes.
As part of the recovery activities aimed at restoring the operational capacity of the health care delivery system in the areas most affected by the July 2006 crisis, the rehabilitation and operationalization of the 26 public hospitals was launched in early 2007 and completed by 2010, the rehabilitation of PHC centers damaged by the July war was completed by 2008, the hospital performance improvement initiative was launched in 2007, the “visa system” for hospital admission and reimbursement by the MOPH was refined in 2007, the expansion of the PHC network was started in 2008, the accreditation system for hospitals was revised and updated in 2008-2010 ( to be in effect by mid 2011), the contractual agreements with hospitals and PHC centers/NGOs were revised in 2009,the establishment of public health units at the district level was initiated around mid 2009 and completed by mid 2010, the satellite drug dispensing centers were established in 2009, the pilot phase of the accreditation of PHC was launched in 2009 and completed by the end of 2010, the referral system from PHC to public hospitals was piloted in 2009-2010, the electronic medications card was introduced at PHC network in 2009.
In view of the above, it is observed that the MOPH succeeded in:
• Establishing partnership with the various stakeholders: the private/NGO/ public mix is reinforced as well as public /public collaboration and coordination. All decisions pertaining to improve this partnership and ensure quality and cost effective care was reached by consensus among the various stakeholders with the MOPH providing the necessary leadership. Key initiatives implemented by various partners included:
o the chronic medications program which is implemented by the YMCA,
o hospital performance improvement which is implemented by academic institutions;
o PHC accreditation in partnership with academic institutions and professional societies;
o PHC service delivery in partnership with concerned ministries (ministry of interior and municipalities, ministry of social affairs)
• Progressing towards “decentralization” of care: the law of autonomy is applied in all public hospitals, the distribution of public hospitals and PHC centers affiliated to the MOPH network is widened to cover all districts, the main drug warehouse has satellite centers in every district, creating the Public health Units in every district/Mohafaza
• Reinforcing the regulatory function of the MOPH: the contractual agreements with the hospitals are revised according to the flat rate, the admission and reimbursement is based on the “visa system”, the contractual agreements with the PHC are standardized, the accreditation is mandatory for all hospitals and used as a pre requisite for subcontracting them for specific health services, cancer protocols are developed, a computerized Drug dispensing system for selected diseases( cancer, hemophilia, HIV/AIDS..) is established.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
Perhaps the most important obstacle was the political instability that the country went through over the past 6 years. In fact the period 2005- 2010 witnessed several political assassinations; prolonged and draining sit ins; paralysis of the cabinet of ministers; tense parliamentary, municipal and presidential elections; and localized but severe internal armed clashes, which greatly affected the decision making process at the national level, especially when it came to issuing required regulations and budget allocations.
The MOPH team was not discouraged by lack of conducive and supportive environment, and succeeded in mobilizing the communities and stakeholders and was able to convince all political factions that Health is a main common good that concerns all , and hence should not be jeopardized due to prevailing political differences. Accordingly, the MOPH engaged in strengthening partnership with all concerned stakeholders, and proceeded with consensus building on the main related issues.
Another obstacle was the availability of qualified and well trained human resources at the MOPH to implement the main initiatives and monitor them, a fact that was aggravated by the brain drain and the decision to freeze all recruitment in the public sector. The MOPH relied on the technical backup of WHO and the academic sector, outsourced national experts, and finally obtained special permission from the cabinet of Ministers to recruit specialized staff
The availability of necessary funds to implement the planned initiatives was an additional challenge. The MOPH prepared strategy papers and developed projects and initiatives that were funded by International agencies (WHO, other |UN agencies, the Italian Cooperation) , the Recovery fund as well as through bilateral donations ( Governments of Turkey, Kuwait, Qatar, Iran)
The initial resistance of certain stakeholders such as the National Social Security Fund (NSSF), the Ministry of Finance, the private sector and NGOs to introduce certain norms and regulations required for improvement of access, quality and efficiency. This was overcome by using evidence based advocacy, obtained through national surveys that included, among others, the National Household Expenditure and Utilization Survey, National Health Accounts, Demographic and Health Survey; reporting system development; automation of key departments and selected programs in the MOPH.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The MOPH used primarily its financial resources from the government allocated budget, that was complemented through the Recovery Fund, the bilateral donations and international NGOs projects, in addition to the biennial cooperation plan implemented by WHO and other UN agencies concerned with health issues.
No less important were the non-financial resources – that included the human, physical, information and intellectual that were harnessed by the MOPH leadership, which subsequently contributed to the success of these reforms.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The initiative is sustainable since it relies essentially on MOPH funds, and the various interventions are already institutionalized. The outsourcing of required special expertise is readily available in view of the solid partnership established with the private and academic sectors, and the significant number of highly qualified experts and well known pioneering academic institutions. The initiative is also transferable since it is well documented, tested and proved to be effective.
The reforms have the commitment of all stakeholders who have agreed to support their implementation under the leadership of the MOPH and are backed up by the required decrees and laws to so that it could not be easily reversed. All these make the reforms more sustainable and possibly replicable.
The effort and initiative of the MOPH Lebanon over the period 2006-10 to improve the equity, efficiency and quality of health services in Lebanon has been recently acknowledged in the World Health Report 2010 on Health System Financing: The Path to Universal Coverage, Lebanon has been cited as a model for middle income countries for improving health coverage and reducing out of pocket expenditure on health.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
The main lessons learned include:
• Crisis can be a leverage and an opportunity for development: the recovery period constituted a unique opportunity to reinforce the health system, address its pre-existing weaknesses, and mobilize the international community and national stakeholders;
• Committed and continued leadership of the MOPH is critical for the design, implementation and monitoring of effective and successful health care reforms. These reforms are as political as technical and require the MOPH, as in the case of Lebanon, to be politically astute and technically sound;
• Partnership with the stakeholders strengthens the health initiatives and provides a platform for development and improvement of equity and efficiency. The collaboration of the private/NGO sector was a significant factor in the success of the initiatives. The input of the academic sector was instrumental in the design, monitoring and evaluation of the initiatives;
• Advocacy is a strong tool if supported by evidence. The evidence used by the MOPH allowed for the smooth flow of funds and consensus on conflicting health issues;
• Political instability does not always mean paralysis of the health system: in fact, many of the initiatives were launched and developed during periods of severe political and security turmoil.

Contact Information

Institution Name:   Ministry of Public Health
Institution Type:   Government Agency  
Contact Person:   Dr. Mohamad Jawad Khalifeh
Title:   Minister of Public Health  
Telephone/ Fax:   +961 1 615716/7
Institution's / Project's Website:   +961 1 615020
E-mail:   ministeroffice@public-health.gov.lb  
Address:   Museum area, Mansour Buildging, 8th floor
Postal Code:  
City:   Beirut
State/Province:  
Country:   Lebanon

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