dr walid ammar harvard 2015

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Health System Resilience Amidst Political Instability

The case of LebanonHarvard Kennedy School

Sept. 2015

Walid Ammar MD, Ph.D.

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The case of LebanonThis 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 SystemLebanon 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 beds90% 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 GovernmentComplex 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 refugees52,000 Palestinian Refugees from Syria40,000 Lebanese residents in Syria1,000,000 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 USDonly a total of 1.6 billion USD

transferred from 2011 till 2014Walid Ammar, MD.; Ph.D. - 2014

The Impact of the Syrian Crisis

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Health System ResilienceCapacity 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 problemsFinancial 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 ResilienceIn 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 achievedWalid Ammar, MD.; Ph.D. - 2014

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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 9Births 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"

http://www.google.com.lb/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=&url=http://www.who.int/whr/2010/en/&ei=cl9tVb3KLIWisAHMpoP4Cw&bvm=bv.94455598,d.bGg&psig=AFQjCNERk-BfTqTlWSNL5Q9Pf9b3nbl8Ow&ust=1433317619144084

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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


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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 DiversityMitigating 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.


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Participation as a Principle of Good GovernanceOpportunities 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).


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Engaging NGOs and MunicipalitiesAfter 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 agreementsLegal 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 empowermentProvide 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 paymentElection of municipality council members

Accountability at the pollsAccountability of the health center to the NGO

Organizational accountabilityAccountability of the NGO to the MOPH

accountability through contracting


Accountability in PHC

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Hospital Care Accountability Framework

Performance based financingCase-mix and output indicatorsAccreditationPatients 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 & ParadigmsShould 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

Healthcare