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HOSPITALIZATION in LEBANONProgress of PUBLIC HOSPITALS

Antoine ROMANOSUNRWA Workshop

23/6/2011

• Health Indicators (Figures and Facts)• Hospital care (Private/Public)• Health system(Medical Professions/Health facilities)• Health coverage (Public funds)• Hospitalization Rate• Public hospitals (History and progress)• SWOT Analysis• RHUH (FIGURES)• Towards HEALTH CARD

HOSPITALIZATION IN LEBANON ROLE OF THE MOPH

Global Core Objectives of a Health Care System

• Universal access to all citizens• Effective care for better health outcomes• Efficient use of resources• High quality services• Responsiveness to patient concerns

Selected health indicators of LEBANON 2005-2009

Unit 2005 2006 2007 2008 2009

Total GDP

Billions LBP

32.945 33.917 37.926 45.346 52.650

Allocated to MPH from total Gov.

budget

% 3.6 3.12 3.05 3.26 2.7

Annual Budget MPH Billions

LBP360.3 348.8 361.6 373.9 439.7

Annual Budget MPH per

capita

USD 63.3 60.1 61.1 62.1 73.3

National health

Exp./Capita

USD 460

NHE as %GDP

% 8.3

Public Spending on the Social Sectors

Social Ministry of entity

Ministry’s Budget Total Public Spending

LBP Billion % of Government

Budget

LBP Billion

% of Government

Budget

Education 922.86 8.24% 1147.86 10.25%

Health 346.94 3.11% 593 5.30%Social Affairs

96.92 0.87% 96.92 0.87%

Total 1,366.72 12.22% 2,993.63 26.74%

Source: Ministry of Finance 2007

PUBLIC HOSPITAL

• Contracts with financing agencies (MOPH)• Hospitalized uninsured patients pays 5% of the bill in

comparison to 15% paid in private hospital ,the MOPH reimburses 85%

• The public hospital prices are thus 10%lower than those of private hospitals

• Public hospital is strictly not allowed to select patients nor to impose extra fees

• MOPH does not provide any preferential treatment to P.H and respects the patients freedom in choosing the physician and the hospital

PRIVATE HOSPITAL

• Development was relatively less affected by civil disturbances and continued to grow both in number and capacity

• Represent 90%of the total N. beds in the 1990’s• The percentage decreased later with the opening of

new public hospitals to 75%• Hospitals owned by physicians and philanthropic or

religious congregations (association of private hospitals )

• This pre-existing oversupply ,induced a greater demand and use of in-patients health services

Distribution of private hospitals according to bed capacity by MOHAFAZAT2007

MOHAFAZAT Less than 100 BEDS

100-200 BEDS

More than 200 BEDS

TOTAL

BEIRUT 15 4 4 23

MOUNT LEB 43 12 1 56

NORTH LEB 24 3 1 28

SOUTH LEB 21 2 1 24

NABATIEH 9 0 0 9

BEKAA 23 5 0 28

TOTAL 135 26 7 168

Distribution of MOPH contracted hospitals and allocated budget by MOHAFAZAT

Hosp % 2000 2002 2007 CEILING/ year

Million LBP

% Allocation

BEIRUT 23 13.7 22 8 11 28.248 13.4

MOUNT L 56 33.3 50 23 43 61.885 29.4

NORTH L 28 16.7 22 17 25 45.547 21.6

SOUTH L 24 14.3 19 11 15 30.904 14.7

Nabatieh 9 5.4 4 5 9 10.921 5.2

BEKAA 28 16.7 23 12 22 33.151 15.7

TOTAL 168 100 140 76 125 210.657 100

Amount Categories No. of Bills

No. of Bills (%)

Cost Cost (%)

< 500.000 45.093 25.51 % 15.948.713.175 6.99 %

Between 500001 & 1000000 63.139 35.71 % 46.055.179.208 20.2 %

Between 1000001 & 1500000 34.284 19.39 % 42.276.216.653 18.54 %

Between 1500001 & 2000000 11.912 6.74 % 20.557.670.241 9.02 %

Between 2000001 & 3000000 10.417 5.89 % 25.315.425.850 11.1%

Between 3000001 & 4000000 4.059 2.30 % 13.870.003.361 6.08 %

Between 4000001 & 5000000 2.524 1.43 % 11.346.203.658 4.98 %

> 5,000,000 5.360 3.03 % 52.651.075.949 23.09 %

Grand Total 176.788 100 % 228.020.488.094 100 %

Repartition of Hosp. cost by bill (LBP)

Patients Repartition by age /Cost /MOPH

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

0- 0-5 Years

1- > 5- 10Y

ears

2- > 10- 15Y

ears

3- > 15 – 20Y

ears

4- > 20 – 25Y

ears

5- > 25 – 35Y

ears

6- > 35 – 45Y

ears

7- > 45 – 55Y

ears

8- > 55 – 65Y

ears

9- > 65 Years

ND

Cost(%)

Count(%)

Number of Visas issued between private and public hospitals 2008

7726

40294

36044

31503

27530

8638

15976

7543

15339

10486

4465

12965

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

بيروت جبل لبنان الشمال البقاع الجنوب النبطية

المحافظة

خاصحكومي

Medical professions and Health Facilities

Manpower and physical resources Indicators per 10.000 population

2005 2006 2007 2008 2009 2010

Physicians 27.4 28.4 28.5 35.4

Dentists 10.1 9.8 10.9 13.3

Pharmacists 11.5 13.8 12.1 12.2

Nursing and Midwifery

16.1 13.2 17.9 22.2

Hospital beds

36 36 35 34.5

Occupancy rate /HospitalsOccupancy rate /Hospitals

Source: Ministry of Health

52%45%

37%

53%54%56%58%60%64%65%65%68%

72%80% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

OECDBah

rain

WBG

KuwaitSau

di Arab

iaSyr

iaTunisi

aJo

rdan

OmanLeb

anon Ira

nAlge

riaUAE

Moro

ccoEgy

pt

New technologiesMohafazat Population CT Scan RMI Open Heart

CentersBEYROUTH 416.000 13 12 6

BEKAA 504.000 23 4 3

MOUNT LEB 1.600.000 36 13 7

NABATIEH 236.000 4 0 0

NORTH LEB 820.000 15 3 3

SOUTH LEB 428.000 13 6 3

TOTAL 4.004.000 104 38 22

New technologies

DIALYSIS 36

Linear Accelerator 8

PET- SCAN 2

Comparison between LEBANON and FRANCE

(Yearly hospitalization cost )IndicatorLEBANON FRANCE

POPULATION4 MILLIONS60 MILLIONS

Yearly hospitalization cost

(USD)600.000.00073.200.000.000

Yearly hospitalization cost /Capita)USD (1501220

Hospital syndicate2005

Comparison (total exp. on health/GDP)2004

Country GDP Spending per person

$Lebanon 10.5% 469

USA 10.9% 4270

Switzerland 10.9% 3857

Germany 10.8% 2697

France 9.4% 2288

UK 7.5% 1675

Hospital coverage

• In 2007 ,the household survey(CAS) provided the number of people who don’t have any type of medical coverage across all age of groups

• These individuals are considered to be eligible population for the MPH services coverage

MOPH Coverage in numbersYear N of

admissionsN of patients

admittedRatio Total

Hospitalization Cost

(Billions LBP)

Average Cost

/Admission(USD)

2008 218.000 158.000 1.37 213 650

2009 226.000 169.000 1.33 220 650

2010 230.000 173.000 1.32 245 710(Increment of 8.5%)

Coverage by Insurers

05

101520253035404550

MPH CNSS Army Private CSC ISF

44

30

7.6 7.5 6.33.8

MOPH coverage in numbers

• Average number of patients treated over the last 5 years :185.000/Year

• Average number of Admissions over the last 5 years :225.000/Year

• Rate of Admissions to Hospital:11%

Government’s Health ServicesThe Major Providers

Financing Body # of People Eligible Government Budget for

Health Coverage

(L.L)

MOH 1,761,758 301,591,500

Army & Security 564,459 187,274,500

NSSF 1,200,000 482,770,000

COOP 252,739 87,050,000

Government’s Health ServicesHospitalization

Financing Body Hospitalization Expenditures (L.L)

MOH 250,000,000

Army & Security 115,147,500

NSSF 279,060,000

COOP 40,600,000

Percent hospital utilization among eligible by Gender ,2009

• The prevalence of medical conditions among those eligible reaches 12.9 %

• The pattern of service utilization for females probably follows delivery services in younger age groups

• The utilization for both genders increases with age as the proportion of working population

• And hence the medical coverage which is largely related to the professional status , decreases

Gender Percentage

Male 11.6

Female 14.2

Hospitalization RATE (%)2005

MOPH NSSF CSC ARMY SF(ISF,GSF,

SSF)

TOTAL

11.3 23 12.5 22.9 30.5 16.6

The evolution of MPH subsidized admissions in public and private hospitals between 2005-2009

Private hospitals % Public hospitals %

2005 85.89 14.11

2006 81.68 18.32

2007 72.73 27.27

2008 69.44 30.56

2009 70.44 29.56

The evolution of MPH subsidized admissions in public and private hospitals between 2005-2009

85.89 81.68

74.73 69.44 70.44

14.11 18.3227.27

30.56 29.56

Governmental hospitals/VS Public Institutions: Definition

► Public institutions :Listing 1

► Governmental hospitals :Listing 2

► Public institutions: Data by region

► Public institutions :Current functioning status

► Public institutions : Mission & discussion

► Public institutions : Infrastructure & its problems

► Privilege of Public institutions over private hospitals

► MOH contributions to Public institutions

►Swot Analysis

► Public institutions :A new era to come or improve : Discussion

Governmental hospitals v/s public institutions : Definition

Governmental hospitals v/s Public institution

Gov. Hospital Public institution

Human resources

MOH ●Directly by the Board of Directors upon demands & in coordination with Council*Civil service board (Law 583/2004)

Financing Directly by MOH ● Financial autonomy (self budgeting )● Collections from third payers

Supervising &

Management

Designated manager

by MOH

● Board of Directors ● General manager ● Supervision by MOH via representative at the Board

Equipments MOH ● MOH● Direct purchasing

Provisions MOH ● Direct purchasing & bid

PUBLIC INSTITUTION HOSPITAL : DEFINITION & MISSIONAutonomous Organizations

• Administrative Autonomy• Financial Autonomy• Moral personality• Under the tutelle (Supervision )of the

Ministry of Public Health

PUBLIC INSTITUTION HOSPITAL : DEFINITION & MISSION

►Governmental Public institution

► Offers health services (treatment & preventive )

●Without discrimination

● At High quality

● At Low cost

► Complementary with private sector

► Cooperation with all Health Partners (Universities, insurance…)

GOVERNEMENTAL PUBLIC HOSPITALS : LISTING 1

Bekaa Nabatieh North Lebanon Beirut Mt Lebanon South lebanon

► Zahleh ► Nabatieh ► Tannourine ► RHUH ► Dahr el Bachek ► Saida

► Rachaya ► Marjayoun ► Halba ► Karanti ► Baabda ► Jezzine

► k.Kanafar ► Mais el Jabal ► Sir Dinnieh ► Sibline ► Saksakieh►Baalbeck

► Bint Jbeil ► Ehden ►Kartaba►Hermel

► Hasbaya ► Tripoli ► Bouar

►Tibnine ► Becharreh ►Chahhar el gharby

► Orange Nassau

LISTING 1

South Lebanon

BeirutMt Lebanon

North Lebanon

NabatiehBekaa

326765

GOVERNMENTAL HOSPITALS NOT YET PUBLIC INSTITUTION : LISTING 2

► Tyr

GOVERNEMENTAL HOSPITALS :LISTING 1 + LISTING 2

GRAND TOTAL

►Number of hospitals= 37

► Number of beds = 2635

GOVERNEMENTAL HOSPITALS :LISTING 1 + LISTING 2

GRAND TOTAL ►Number hospitals= 37

► Number of beds = 2635

Governmental Hospitals

Governmental/public Institutions

NEW HOSPITALS

N= 1TYR

N= 29N=7 Damour,sarafand,

Shebaa, Barty ,Mayfouk,Kana,

Aley

► Public institutions: Data by region

PUBLIC INSTITUTION HOSPITALS:DATA(BY REGION)

BEKAA DATE OF AUTONOMY

NUMBER OF BEDS

NUMBER BOARD OF

DIRECTORS

NUMBER OF EMPLOYEES

Zahleh 1998 150 5 330

Rashaya 2000 45 3 99

Baalbeck 2005 100 5 220

Hermel 2005 100 5 220

Kherbet Kanafar

2005 25 3 55

NABATIEH DATE OF AUTONO

MY

NUMBER OF BEDS

NUMBER BOARD OF

DIRECTORS

NUMBER OF EMPLOYEES

Nabatieh 1997 100 5 220

Marjayoun 2001 50 3 110

Mais el Jabal 2002 100 5 220

Bint Jbeil 2002 100 5 220

Hasbaya 2003 40 3 88

Tibnine 2005 70 3 154


North DATE OF AUTONOMY

NUMBER OF BEDS

NUMBER BOARD OF

DIRECTORS

NUMBER OF EMPLOYEES

Tannourine 1999 50 3 110

Halba 1999 45 3 99

Sir dinnieh 2000 45 3 99

Becharreh 2003 20 3 44

Ehden 2002 12 3 26

Tripoli 2002 150 5 330

Orange nassau

2003 30 3 66


Mt Lebanon

DATE OF AUTONOMY

NUMBER OF BEDS

NUMBER BOARD OF

DIRECTORS

NUMBER OF EMPLOYEES

Dahr bachek 1999 100 9 220

Baabda 2000 100 9 220

Sibline 2003 100 5 220

Bouar 2005 100 5 220

Chahhal el Gharby

2005 70 3 154

Kartaba 2005 10 3 22


South Lebanon

DATE OF AUTONOMY

NUMBER OF BEDS

NUMBER BOARD OF

DIRECTORS

NUMBER OF

EMPLOYEES

Saida 2000 150 5 330

Jezzine 2005 40 3 88

Saksakieh 2005 20 3 44


Beirut DATE OF AUTONOMY

NUMBER OF BEDS

NUMBER BOARD OF

DIRECTORS

NUMBER OF EMPLOYEES

University Beirut

1999 540 9 1188

Karantina 2000 150 5 330


PUBLIC INSTITUTION HOSPITALS:DATA (BY REGION)

Number of BEDS

REGION

420BEKAA

460NABATIEH

352North LEBANON

480Mount LEBANON

210South LEBANON

690BEYROUTH

► Public institutions :Current functioning status

PUBLIC INSTITUTIONS HOSPITALS : CURRENT STATUS

FULL ACTIVITY PARTIAL ACTIVITY/Health Center

NO ACTIVITY *Under Rehabilitation

N= 22 N=3 N=4

RHUH- Karantina /Chahhar el Gharby-Dahr el Bachek-Baabda-Bouar-Sibline/Rachaya-Zahle-Baalbeck- Hermel/Saida/Sir dinnieh-Tannourine-Halba- Tripoli-Becharreh/-Bint Jbail-Hasbaya –Mais el Jabal-Nabatieh-Marjeyoun

KartabaEhdenJezzine

Saksakieh-Khorbet kanafarOrange Nassau

Tibnine

51

Mohafazat

Visa System/Hosp. in Public hospitals

200520062007Beyrouth4,5291101612,224

Mount Lebanon4,10743035,947

North5,71169359,808

Bekaa2,52528916,268

South4583592,429

Nabatieh8,289820410,971

Total25,619 (14%)33,708 (18%)47,649 (26.5%)*Total

Public+ Private181,605183,997180,158*Number of Public

Hospitals141921DATA/Visa System – Source :Years2005-2006-2007

*Visa system2007till end of OctoberVisa system2007till end of October

► Public institutions : Mission & discussion

GOVERNEMENTAL HOSPITAL : A PUBLIC INSTITUTION ITS MISSION

►Provide health care with the highest quality possible at the lowest cost

Question 1: What care? :

Discussion 1: Preventive v/s primary care v/s tertiary care

DISCUSSION 1: PARAMETERS TO CONSIDER

●Orientation of the Board of directors

● Geographical demands

● Funding resources

● In house capabilities

● Human resources

● Overall directives & orientation of MOH

► Public institutions : Infrastructure & its problems

PUBLIC INSTITUTION HOSPITAL:INFRASTRUCTURE

MOHMOH

BOARD●Administrative independence

●Financial independence

LAW

BYLAWS

HUMAN RESOURCES

MISSION ACCOMPLISHED ?

PUBLIC INSTITUTION HOSPITAL:INFRASTRUCTURE

Question 2: Infrastructure v/s UNDERMINING structure

Discussion 2 : ●Rigid law not allowing flexibility● Historical political dependance of the MOH● Painful & lengthy procedure for recrutement● Employement heritage due to civil war ● Financial independence v/s dependence of MOH ● Disbursement alike private hospitals ?

► Privilege of Public institutions over private hospitals

PUBLIC INSTITUION HOSPITALS:RELATIONSHIP WITH “PARTNERS ”

HOSPITAL

Ministry of Health

Ministery of finance

Social security National office

Other third party payers ●Financial control office(Court of AUDIT) ● Civil Service Board

Universities

Question 3 : Similar relationship as with private hospitals?

Development &Reconstruction Council

DISCUSSION 3: PARAMETERS TO CONSIDER TO PRIVILEGE PUBLIC INSTITUTIONS HOSPITALS

●“Shortcut” system to speed up financial process & budgeting

●Encourage Public insurance towards Governmental hospitals ?BUT within the mission of the hospital

●Liberalize investment of the hospital assets ?

●Concept of complementarities with private hospitals

● Patient’s part is 5 % v/s 15 % in private hospitals *● MOH contributions to governemental hospitals*● More independence by modifying law = Decret 5559/2001*

* Done or in process

► MOH contributions to Public institutions

MOH CONTRIBUTION TO PUBLIC INSTITUTIONS HOSPITALS

REGION YR 2003(Billions)

YR 2004(Billions)

YR 2005(Billions)

TOTAL(Billions)

BEIRUT 13,O85 9.2 22.285

SOUTH 10.2 0.9 11

Mt LEBANON 3.8 0.55 2.5 6.85

BEKAA 3.5 3.5

North 8.3 5.35 13.65

57,285Grand Total =

MOPH Itemized budget for the past three years

2007(‘000LBP) 2008(‘000LBP) 2009(‘000LBP)

Hospitalization in private sector

250.000.000 256.000.000 305.000.000

Public hospitals 15.000.000 15.000.000 12.000.000

Total MOPH budget

361.631.670 373.917.225 439.747.598

MOPH Itemized budget for the past three years

• While the total government budget has increased

• The MOPH budget has decreased to less than 3% of total gov. budget

• 72% goes for hospitalization coverage in public and private sector

• 15% for drug procurement (66 BillionsLBP/2009)

Visas for patients admitted at the expense of MOPH 2009

PRIVATE 159377

PUBLIC 66870

TOTAL 226247Issued to 136993

patients

Visas for patients admitted at the expense of MOPH 2009

PRIVATE 159377 70%

PUBLIC 66870 30 %

TOTAL 226247Issued to 136993

patients

Ratio Coverage in Numbers

MOHAFAZAT PRIVATE % PUBLIC %

BEIRUT and NABATIEH 30 70

NORTH L and BEKAA 70 30

MOUNT L and SOUTH L 80 20

FIGURES and FACTS

• In places where there are active public hospitals ,the number of admissions issued to the public sector exceed that for the private sector

• Examining Visas issued over the months during the year 2009 shows that they range from 20.000 to 24.000 Visa /month

FIGURES and FACTS

• Improving quality services in public hospital to the extent that admissions are being increased

• Considering the active number of beds that is originally lesser than the private sector ,the occupancy of public hospitals seems to have reached saturation

• The ratio of public to private admissions revolves around 30/70 for the 2 consecutive years 2008 and 2009

• Regional services (Health Decentralization)

Rehabilitation of Public Hospitals.Contracts by CDR for Health system from1/1/1992 au 31/12/2004 ,

millions US Dollars

260 Millions US Dollars

Situational analysis (SWOT)

STRENGTHS WEAKNESSES

OPPORTUNITIES THREATS

Situational analysis (SWOT)STRENGTHS

• New model of management (Public hospitals)• Competency with private sector• Infrastructure/Buildings/ Equipments• Specialized Human Resources (Employment

policies)• Hospitalization coverage (Contracts with public and

private Funds)• Mission of the public hospital (None- profit ?)

WEAKNESSES

• Human Resources (Lack of some specialties)

• Relationship with MOPH/Heavy burden of administrative procedure

• Rigidity of laws and regulations

• Salaries and wages policy (in comparison with private hospitals)

• Political Interferences with the board and directors

OPPORTUNITIES

• Economical situation/oblige citizens to run towards public hospitals

• MOPH support (Performance appraisal…Training programs…)

• International Agreements (Loans, new equipments…)

• Information technology• Agreements with Universities( Public/private)• Increase of demands and needs

THREATS

• Private sector notoriety (Hospitals/ physicians…)• Decision making in private hospitals• Advanced technology• Specialized human resources• Employment policies (OFFER/DEMAND)• Same hospitalization coverage type (Public/Private)• Public hospitals geographical distribution

► Public institutions :A new era to come or improve : Discussion

PUBLIC INSTITUTION HOSPITALS :A NEW ERA TO COME ?

Question 4: Is it possible ?

Discussion 4 : YES but /WHY/ HOW

Directives of the MOH:

► Improving quality :Better delivery ? Medical protocols + specialized units = Cooperation with foreign institutions

●Japanese delegation for improvement *● AUH with University Hospital Bir Hassan *● Lebanese University with Baabda,Dahr *

bachek & University Hospital

► Centralize overhead at least regionally Decreasingcost

► Improving MOH Central committee supervising gov .hospitals*(Already present decree 11807 Jan 30st 2004)

A NEW ERA TO COME or BE IMPROVED ? HOW


*


► Partnership with academic institutions on Some issues such as training for MD and RN’s

► Simplify the financial process = Quicker reimbursementLess penalties

► Handling protocols + medical charts + complementarities within the governement hospitals + Mission of every hospital :

Creation of a central council composed of Presidents of the Board and MOH representatives

► More organised inhouse work = Infrastructure of the hospital *External financial audit *

American University with University hospital Bir HassanLebanese University with Baabda & Dahr el Bachek *



►Improving quality of care :

●Accreditation already in place ● Medical Committees as per LOP

● Central committee supervision

►Improving the mechanisms of drug delivery:

● Pilot study for a model for chemotherapy treatment

● Place for generic medication ????

*


HOSPITALIZATION IN RHUH 2008

TotalAdmissions 19945

100913 daysAve. LOS 5.1d

General 15485 96007 days

Day Chemotherapy 4460 4906 days

Average Census 263 / 305 Occupancy: 86%

MOH : 73% NSSF : 13% Other : 14%

NUMBER OF PATIENTS BY MOHAFAZAT /RHUH 2008

HEALTH CARD

PRIMARY HEALTH PRIMARY HEALTH CARECARE

SERVICESSERVICES

HOSPITALIZATIOHOSPITALIZATION SERVICESN SERVICES PRIMARY

HEALTHCARE CENTER

DISTRICT PUBLIC HOSPITAL

CENTRAL PUBLIC HOSPITALC

PRIVATE HOSPITAL(

CHALLENGES• Health Decentralization• Hospitalization Cost containment• Towards Alternative hospitalization(Community care)• Enhancing home care• Central purchasing• Relation with local authorities and NGO’s

• Primary health care• Geriatric medicine / Mental health• Emergency services • Referral system

THANK YOU

hospitalization in lebanon progress of public hospitals · pdf filehospitalization in lebanon...

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