60 CDR October 2014

Public Health1 - Overview of the HealthSector

The Lebanese health system is mainlyoriented toward curative care(treatment) and witnesses a rapidgrowth in the number of privatehospitals and high-tech medicalcenters.

The government has made significantefforts to strengthen the capacities ofits institutions and promote the publichealth sector and its role in providinghealth services. However, the privatesector still accounts for over 90% ofhospital beds and the bulk ofhealthcare infrastructure with a 17%of hospitalization rate that depends onmedical insurance coverage.Also,most emergency services areeither provided by the private sectoror by private clinics, and most of theprimary health care services areprovided by health centers run byNGO’s. Only 5% of the public healthsector expenditures are allocated forprimary health care services.

Due to the lucrative nature of healthservices, the health sector favored thelarge, high-income cities at theexpense of poor communities, where8% of Lebanese households livebelow the poverty line. Somethingthat led to a disproportionate access tohealth services and treatments.

However, the Ministry of PublicHealth (MoH) -being the last resortfor covering the treatment fees ofnon-insured citizens and supportingthe primary health services through anetwork of primary health centers incollaboration with NGO’s - has

largely contributed to theimprovement of access to treatmentby the disadvantaged, which led to anincrease in life expectancy to 74 yearsand a decrease in infant mortality rateto 5.1 per 1000,despite regionaldisparities and the uneven provisionof health services.

Several initiatives were launched inorder to improve the management andquality of health services, inparticular the classification ofhospitals and the establishment ofadvanced primary health centers.Initiatives also included the publichospitals autonomy law, the projecton Child and Maternal Health in theAkkar region, the establishment of theControl Program for Tuberculosis, theNational Program against AIDS, andthe National Program for Non-Contagious Diseases etc. Efforts werealso made to set up and implementprograms about health awareness andmedical staff training in the privateand the public sectors.

Attempts to improve healthinformation systems were also made,including several national studies(household spending study and healthaccounts study).

Studies have shown that the overallspending of the Treasury through theMinistry’s budget and its share ofinsurance spending, as well as thebudget of other insurance funds,including those for state employeesand military treatments, do not exceed20% of total spending on health. Thebudget of the MoH does not exceed3% of the government’s budget.

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61CDR October 2014 Social Infrastructure

Six government health funds

cover around 38% of the

population, while 8% are covered

by private insurance companies.

As for the remaining 54% of the

population, it is the MoH that

covers their high-cost hospital and

pharmaceuticalservices.

Scattered funding and the lack of

control over the private market

seriously impede MoH and public

insurance funds from purchasing

health services at a good price

from the public sector.

Medication bills in 2005

constituted 30% of total health

expenditure. Actually, the use of

the primary health care network is

extremely low, and it seems to be

motivated by the availability offree medications. This clearlyindicates that current expenditureis ineffective, since the majority ofhealth revenues for funding issecured through prevention andprimary care, instead of treatment.

However, MoH is planning tointroduce performance assessmentfor primary health care centers.Attempts to implement themandatory transfer system, fromhealth centers to hospitals, havebeen made. MoH spends 68% of its budget onhospitalizations and medicationswhich constitute half of the bill,but the major source of healthfunding remains family budgets,constituting 44% of overall healthspending. This poses a heavy

burden on low-income families.Expenditure on health servicesand goods constitutes an average14% of family budgets. However,this percentage varies between20% for the poorest families and8% for high-income families.

Concerning the health reform, theself-evident question is: will thecurrent health expenditure remainthe same?The main points adopted by MoHfor the sector’s reform, in order tocontrol health expenditure, provideefficient and even health services,reduce the burden on families,control the increase in consumptionand reduce medication prices whileensuring quality services andboosting primary health careservicesat a reasonable costlie in

Qarantina Public Hospital

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accomplishing the following goals:

• Rationalize the public expendituresby consolidating the multipleinsurance coverage funds.

• Improving the performance ofthe health system in all regionsthrough a better allotment of theresources of both the public andthe private health sectors, inaddition to providing sustainabledevelopment of the healthcoverage system

• Increasing the Ministry’scapacity to control healthservices quality and rationalizethe Lebanese health sectorfinancing, to cutback the cost ofhealthcare in proportion to GDP.

• Improving the provision ofhealth services, especiallyprimary health care, which is thecornerstone for improving healthlevels for citizens, to provide itas an alternative for servicesprovided by the private sector,including checkups,medications, and tests, to beaffordable to low-incomecitizens.

• Audit the quality ofpharmaceutical products anddecrease the medication bill.

• Promoting and developing acomprehensive strategy for thehealth sector, with the publicsector contributing to healthfunding.

2- The main achievements ofthe (1992-2013) period

Health sector policy studies andtechnical assistance:

Several important studies dealingwith health policy have been

completed namely the following:• The study aiming at establishingthe "Health Map System”.• Hospital accreditation study

(Phases I and II) for theclassification of hospitals inLebanon, based on standards andnorms set by MoH.

• Setting the medical protocolrelated to most surgicalprocedures paid by MoH inprivate and public hospitals.

• Hospital autonomy study (phaseI), covering the formation ofautonomous management boardsfor public hospitals. The hospitalautonomy law is implemented atthe financial and administrativelevels in all new hospitals.

The most significantachievements made by theMinistry as part of its adoptedstrategies were:- Creating a new management

system for MoH that meetscurrent demands, pendingdrafting a bill.

- Creating a unified database forbeneficiaries of health coveragefrom all insurance funds, whichhelped put an end to duplicity in

public services.- Establishing a primary

healthcare network incooperation with the privatesector which providedcomprehensive services tocitizens, especially in theneediest areas.

- MoH reexamined the medicationregistration system, adding newstandards, such as requiringanalysis certificates frominternationally recognizedlaboratories. It also adopted newguidelines in pricing medication.

- Carrying out many trainingcourses and drafting remedialprotocols, which led to raisingthe level of primary healthcareservices.

- Working towards adopting thehealth card which is now asymbol of the efficiency andfairness of the health system.\

- Strengthening the primary healthcare through the expansion ofthe network of primary healthcare centers: Twenty eight (28)health care centers wereconstructed and completed in allLebanese regions. These projects

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were financed by several donorsamong which:

• A grant by the Kuwaitigovernment, through whicheight (8) health centers wereestablished.

• A grant by Prince Al Waleed BinTalal, through which eight (8)health centers were established.

• A loan from the World Bank,through which eight (8) healthcenters were rehabilitated andequipped.

• The Lebanese governmentrehabilitated three health centers;the supply of necessaryequipmentwas funded partiallyby the Italian government.

• Providing hospitalizationservices to all Lebanese regions.

• Works for Beirut GovernmentalUniversity Hospital (BGUH)were completed (540 beds), four(4) new public hospitals werealso completed and are now inactual operation in the followingregions: Nabatieh (75 beds),Tannourine (40 beds), Rachayya(40 beds) and Sir al Diniyeh (40beds). These hospitals are in fulloperation now.

• Moreover, rehabilitation worksof Tibnine GovernmentalHospital (75 beds), Jezzinehospital (40 beds), HasbayaHospital (40 beds), andMarjeyoun GovernmentalHospital (40 beds) have beencompleted.

• Construction works of three (3)new public hospitals have alsobeen completed: Halba hospital(75 beds), Sibline Hospital (75

beds) and Hermel hospital (75beds).

• Expansion and rehabilitationworks of four (4) governmentalhospitals have been completedwithin the framework of thehealth sector rehabilitationproject. These are: Tripoli,Baalbek, Shahhar el Gharbi andDahr el Basheq hospitals.

• Zahlé Hospital: (125 beds):works inZahlé Hospital wereachieved through a grantprovided by the Kingdom ofSaudi Arabia and the IslamicDevelopment Bank (IDB).

• Saida Hospital (125 beds): worksinSaida Hospital were completedowing to a grant provided by theKingdom of Saudi Arabia andIDB.

• KeserwaneHospital (75 beds):construction works and majorequipment installation, financedby OPEC Development Fundand IDB, were completed. Theremaining equipment installationwill be funded by the IDB.

• BintJbeil GovernmentalHospital:The State of Qatarpledged to implement theBintJbeil GovernmentalHospitalproject. The equipmentoperation started in April 2008and ended in April 2009.

Moreover, a dispensary was

established and equipped in

Batroun, financed by Prime

Minister Saad el Hariri.

- Finalization of Phase II ofJezzine Governmental Hospital(40 beds): rehabilitation worksstarted in February 2006.Equipment installation startedin October 2009 and ended inJuly 2011. The hospital iscurrently being equipped withan intensive care unit.

- Keserwane GovernmentalHospital: A tender was releasedfor the procurement of (3) lotsof medical equipment forKeserwane Governmenthospital through a grant by IDBand OPEC. Installation of thefirst lot of equipment started inJanuary 2008. Installation of allthree lots was achieved in July

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2010. - Specialized hospital in the

treatment of war and accidentcausalities in Sidon: A hospitalspecialized in the treatment ofwar and accident casualties(US$ 20 million)wereestablished in Sidon, financedby a grant from the Turkishgovernment. Works started inAugust 2009 andended inFebruary 2011. The Turkishparty was in charge of theproject implementation.

• Becharreh GovernmentalHospital:The CDR rehabilitatedand equipped theBecharehGovernmental hospital througha grant provided by theKingdom of Saudi Arabia.Works began in June 2008 andended in May 2011.

• Rehabilitation and provision ofequipment toTibnineGovernmental Hospital (75beds): Rehabilitation works,financed in the form of a grantprovided by the Belgiangovernment, began in February2009 and ended in June 2011.Procurement and installation ofequipment started in April 2009and ended in June 2011, andwere financed by IDB.

• A field hospital of 40 bedswasconstructed and equipped inMinieh with a grant from theKuwaiti Red Crescent. Worksstarted in November 2009 andended in July 2011.

• The rehabilitation of OrangeNassau Governmental hospital,financed by a grant from KSA,has started in May 2009 andwas completed in April 2012.

• In coordination with MoH, two

feasibility studies wereconducted for the constructionand equipment of twogovernmental hospitals, one inSarafand and one in Sour, and athird feasibility study for therehabilitation and provision ofequipment to the KarantinaGovernmental Hospital. Therelevant studies started inMarch 2010 and werecompleted in mid-2011.

• Labweh Health Center:Construction works ofLabwehHealth Center werecompleted by the end ofSeptember 2007. Equipmentinstallation started in December2010 and endedin April 2011.

3 - Progress, during 2013, in

contracts awarded before

2013:

• The construction of a new

building for the MoH:

In coordination with MoH, theconstruction of a new building,more suited to the Ministry’s roleof controlling the LebaneseHealth sector planning, began, inits first phase, in September 2010and ended in September 2011.Works for the second phasebegan in May 2012 and ended inMay 2012, with completionexpected in May 2015.

- Rehabilitation ofKherbetKanafar DevelopedHealth Center and SaidaMedical Center

- The rehabilitation of SaidaMedical Center and part ofKherbetKanafar DevelopedHealth Center is co-financed bythe Lebanese and the Belgiangovernments. Works started in

January 2011 and ended inApril 2013. The 2 centers werefully equipped and works wereconcluded in September 2013.

- Construction of a hospital in

Deir El Qamar and provision

of its materials and supplies:

A study has been developed toconstruct and equip a hospital inDeir el Qamar. The CDR iscurrently in the process ofreleasing tenders for worksexecution. Works are expected tokick off in July 2014. At a laterstage, funds will be raised tocover the expenses of materialsand supplies.

- The rehabilitation of Baabdagovernment hospital: Therehabilitation and equipmentprocess of Baabda governmenthospital was financed by theIDB. Works started in February2012 and ended in June 2013

- Equipment installation isunderway at the Rmeich HealthCenter, and is financed by theIDB

The main studies underpreparation are: the nationalnursing training program whichcovers a study for developinginstitutional activities through thetraining of nurses, and theestablishment of a nationalnursing authority; and the healthsector reform study aiming atimproving the primary healthsystem to be adopted by MoH.4 - The main contractsawarded in 2013:

• Procurement and provision ofequipment and supplies to Sidonand KherbetKanafarmedicalcenters.The project started inApril 2013 and was achieved in

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September 2013.

• A study to build and equip apublic hospital in Sarafand andTyr, and a study to upgradethepublic hospital in Karantina.

5 - The main projects underpreparation for the (2014-2016) period

• Rehabilitation and equipment

of Baabda hospital (125 beds):

the rehabilitation of the secondpart of Baabda hospital, financedin the form of a grant providedby the Italian Government, willstart as soon as the donorapproves the tender document.Works arescheduled for August2014 and are expected to finishwithin one year.The medicalequipment, procured with fundsgranted by the AFD and theLebanese Universitywill be

installed as soon as rehabilitationworks are finalized.

• Rehabilitation of Karantina

hospital: a detailed studyhasbeen launchedto transform theKarantina Hospital to a publichospital with a specialized ChildCare Division, according to adecision taken by MoH.Rehabilitation and equipmentworks are scheduled forFebruary 2014 and are expectedtoend in September 2017.

• The CDR is currently workingon rehabilitating and equippingtwo stories in a building annexedto Bechareh GovernmentalHospital. Work is expected tobegin on September 2013 andend after one year.

• Tripoli, Tannourine and Sir al

Diniyeh Hospitals:

CDR has prepared a study for

theadditional rehabilitationandprovision of equipment to theabove-mentioned hospitals, aswell as six other governmentalhospitals that were established bythe CDR. Works are expected tostart as soon as the necessaryfunding is secured.

• Sour Governmental Hospital:

CDR hasprepared the studyfor tothe construction and equipment ofa new Hospital in Sour(75 beds),after conducting a feasibility studyfor the project.

• Sarafand Governmental

Hospital:

Following the feasibility studyconcerning the construction andequipment of SarafandGovernmental Hospital, CDR hasstarted the study related to itsconstruction and equipment.Works are scheduled for August

Expected completion

Starting Source of Funding

Value (US$)

Project

Seplember 2013

April 2013 Greece Government

41,500

August 2017

August 2014

The Lebanese Government

435,600

August 2013 January 2013 The Lebanese Government

541,200

The main contracts awarded in 2013

Equipping Saida and Khorbet Anafar Medical centers

Supervision for the execution of Tyre government Hospital

Study for the execution of a new Government Hospital in Carantina

Social Infrastructure 67CDR October 2014

2014 and are expected to last 3

years.

• Equipment of the radiology and

lab divisions in Orange Nassau

Hospital by a grant offered by

the Kuwaiti Development Fund.

• Construction, rehabilitation and

equipment of Health Centers in

Saksakieh, Khelwat, Jbaa,

Booday, Terbol, Damour,

Ghobeiri, Qana, Ghazeer and

Aamchit, funded by IDB.

• The creation of a blood bank in

the Rafik Hariri Governmental

Hospital is being studied and

will potentially be financed by

IDB.

• CDR is coordinating the

preparation for the construction

of a governmental hospital in

Mayfouqin the Caza of Jbeilwith

the MoH, with promised funding

from the Saudi Fund. CDR has

started preparing the study

concerning the construction and

equipment of this hospital.

• CDR is currently working to

secure the necessary funding for

the establishment of two

governmental hospitals, in the

city of Aley, and in the towns of

Deir El-Qamar and Berti.

Expected completion

Starting Source of Funding

Value (US$)

Project

August 2015 August 2014 Italy (grant)

Saudi Development

Fund

4,000,000

August 2017

August 2014

IDB

IDB

9,000,000

August 2017

August 2014

10,500,000

The main projects under preparation for the (2014-2015) period

Rehabilitation of Baabda Governmental Hospital – part IIConstruction and equipment of Sarafand Governmental HospitalConstruction and equipment of Sour Governmental Hospital

July 2017July 2014

12,300,000Construction and equipment of a hospital in Mayfouq

Lebanese Government

July 2016July 20146,000,000Construction and equipment of a governmental hospital in Deir El-Qamar

IDB September 2014

September 2017

7,000,000Rehabilitation of Qarantina Hospital