By Fadi El-Jardali
BEIRUT – A massive protest movement has swept across Lebanon. The immediate trigger was a proposed tax on gasoline, tobacco, and some social-media platforms, including WhatsApp. But the ground for unrest was fertile, owing to vast and growing economic, social, environmental, and health disparities, which the next government – led by an as-yet-unnamed prime minister – must commit to addressing. If Lebanon’s leaders are to meet protesters’ demands for greater equity and social justice, they must begin with far-reaching reforms to the public-health system.
To be sure, Lebanon’s leaders have failed its people in myriad ways. Through a combination of corruption and incompetence, they have steadily depleted the country’s resources – Lebanon’s debt-to-GDP ratio is among the world’s highest – and allowed a waste-management crisis to grow. Civil wars, invasions, and other crises have hastened the economy’s decline, contributing to a steady rise in unemployment and skyrocketing inequality.
But health may be the most fundamental inequality; after all, public health lies at the foundation of economic prosperity and social justice. And while Lebanon’s health system has improved in terms of access and quality in recent years, existing governance, financing, and delivery arrangements leave many behind.
As it stands, roughly half of Lebanon’s population has no form of health insurance coverage. This makes them eligible for secondary- and tertiary-care coverage, with the Ministry of Public Health covering treatment at public hospitals or even private ones, where the cost of services is capped at a predetermined level.
But the ministry lacks a well-delineated coverage mandate, and it struggles to control patient flows across various levels of the health-care system, with only a limited capacity to direct the uninsured to public hospitals. Moreover, the ministry’s expenditures on care are unpredictable, not least because private hospitals may petition it after the fact for treatment prices above the cap.
Yet the burden on the ministry is only growing heavier, because it is responsible for the care of a large proportion of Lebanon’s growing elderly population (aged 65 and up), who are projected to account for 21% of the total by 2050, from 7.3% today. Since formal-sector workers lose their health coverage when they reach the retirement age of 64, and there is no universal pension program for the elderly, up to 50% of this group may have no health insurance at all. (Informal workers do even worse in terms of social security benefits.)
Administrative hurdles, political clientelism, confessional/religious-based favoritism, and demands for out-of-pocket and informal payments further exacerbate health inequities. Out-of-pocket spending on health in Lebanon is high – 36.5% of total costs – and lower-income households pay a disproportionate share. People with disabilities – some 10-15% of Lebanon’s population – are among the most vulnerable; their full health-care needs are only rarely met.
Worse, Lebanon’s health-care system focuses mainly on treating injuries and illnesses, with less than 10% of public health expenditure allocated to preventive and primary care. Yet non-communicable diseases such as heart disease, cancer, and diabetes, for which many risk factors are controllable, cause some 90% of deaths in Lebanon.
The first step toward reform is a mentality change. Health is not exclusively a medical issue; it must be viewed as part of a complex social, economic, and policy ecosystem. This means recognizing how political and social power affect health outcomes. It also means addressing environmental risks to public health (such as air pollution and poor waste management) and updating social-protection schemes (such as for disability or unemployment benefits) to support health-care coverage. In order to maximize the likelihood that policies and programs will achieve their objectives, sufficient and appropriate evidence must be at the heart of decision-making processes.
Such reforms will offer the next government an opportunity to reimagine the relationship between the people and the state. The protests have provided a powerful reminder that ordinary citizens are critical agents of change. Reforms must reflect that, with strong public participation helping to ensure that the health system – and public policy more generally – is responsive to citizens’ needs.
At the same time, policymakers should introduce mechanisms to strengthen accountability at all levels of the health system. Lebanon is beset by corruption, and the health sector is no exception: provider absenteeism, demands for informal payments, embezzlement of public funds, tampering with medical bills, and unethical or unregulated interactions with representatives of pharmaceutical companies are rampant.
Reform efforts should promote far greater transparency at the top, say, by requiring the results of regular performance and financial audits to be made public. They should also aim to strengthen social accountability, for example, through community oversight boards, civil-society watchdogs, participatory budgeting and planning, citizen scorecards, and quality media.
Lebanon’s new government has an opportunity to lay the foundations for a more stable, equitable, and prosperous future. To succeed, it will need strong and consistent public support. Reimagining the health system would go a long way toward securing it.
El-Jardali is Professor and Chair at the Health Management and Policy Department and Founder and Director of the Knowledge to Policy (K2P) Center at the American University of Beirut in Lebanon.
Frontpage September 3, 2019