Despite the ongoing insecurity climate and socio-political instability for decades, the Lebanese healthcare system has been able to sustain achievements among which, controlling and preventing outbreaks, ensuring universal accessibility to essential quality care, decreasing out of pocket expenditures and lowering of maternal and child mortality (achievement of MDGs 4 and 5)[1]. Five years into the Syrian crisis, the Lebanese health system is still showing considerable resilience, despite the unprecedented increase of demand and strain on the healthcare system. The continuous focus on non-emergency reforms in the health sector shows that progress in achieving strategic goals has been maintained against all odds. It is, hence, noteworthy to look at the main historical stages of the health system development following the 1975-1989 civil war.
 
The after civil-war years of the 90s represented a period of assessment and planning, while setting basic administrative systems and reorganizing the MOPH. During this period, important studies were conducted including the Households’ Health Utilization and Expenditures Survey, the PAPFAM and PAPChild surveys, the National Health Accounts and many others. This endeavor led to identifying problems and setting priorities, of which:

On the other hand, the political system based on power-sharing among political forces and distribution of benefits on a confessional basis, resulted in a widespread practice of favoritism and clientelism in government institutions. This required a professional response paying particular attention to improving governance while focusing on:

The 2000-2010 denoted the era of innovative institutional arrangements, through the involvement of all stakeholders in the execution of the national strategy and programmes implementation. The post 2000 period brought meaningful achievements, such as:

Since 2010, studies have been consistently providing evidence on the significant positive impact of health reform policies, and tangible achievements became more and more recognized.

In the WHO World Health Report 2010, the case of Lebanon was documented as a success story in how to decrease total health spending in % of GDP by lowering, mainly, out of pocket spending, while at the same time improving health indicators. This validates the sound health policy of strengthening PHC and rationalizing the cost of hospital services, while promoting the MOPH regulatory capacity. 
 
 
Box 4.2. Lebanon’s reforms: improving health system efficiency, increasing coverage and lowering out-of-pocket spending[3]
In 1998 Lebanon spent 12.4% of its GDP on health, more than any other country in the Eastern Mediterranean Region. Out-of-pocket payments, at 60% of total health spending, were also among the highest in the region, constituting a significant obstacle to low-income people. Since then, a series of reforms has been implemented by the Ministry of Health to improve equity and efficiency.
The key components of this reform have been: a revamping of the public-sector primary-care network; improving quality in public hospitals; and improving the rational use of medical technologies and medicines. The latter has included increasing the use of quality-assured generic medicines. The Ministry of Health has also sought to strengthen its leadership and governance functions through a national regulatory authority for health and biomedical technology, an accreditation system for all hospitals, and contracting with private hospitals for specific inpatient services at specified prices. It now has a database that it uses to monitor service provision in public and private health facilities.
Improved quality of services in the public sector, at both the primary and tertiary levels, has resulted in increased utilization, particularly among the poor. Being a more significant provider of services, the Ministry of Health is now better able to negotiate rates for the services it buys from private hospitals and can use the database to track the unit costs of various hospital services.
Utilization of preventive, promotive and curative services, particularly among the poor, has improved since 1998, as have health outcomes. Reduced spending on medicines, combined with other efficiency gains, means that health spending as a share of GDP has fallen from 12.4% to 8.4%. Out-of-pocket spending as a share of total health spending fell from 60% to 44%, increasing the levels of financial risk protection.
                                                                                                                                 Date: 11/26/2010  | WHO Report 2010 on Health Care Financing

 
By 2013, The World Health Statistics listed Lebanon among the only 45 countries in the world to have reached MDG 4 (reducing child mortality by a two thirds), and among the only 16 countries in the world to have achieved MDG 5 (reducing maternal mortality by 75 percent)[4]. In addition, Lebanon became well rated in terms of cost-effectiveness. According to the article published in 2014 by the Economist Intelligence Unit Healthcare, "Health outcomes and cost: a 166-country comparison", Lebanon is ranked 32 in the second tier (out of six) in health outcomes, directly following Denmark and preceding the United States. Astonishingly, the cost per health outcome point in Lebanon is $8 USD while, for slightly better outcomes, Denmark is at $73.2 USD per health outcome point and for slightly lower outcomes, the US is at $107.8 USD per outcome point. This evidence proves first, that the Lebanese healthcare system ranks well in terms of outcomes internationally, and second that healthcare is not expensive in Lebanon when compared to countries with similar health outcomes[5].
Furthermore, the World Economic Forum[6] published the Global Competitiveness Report 2016-2017, which confirmed the good performance of the health system in Lebanon, ranked 34 with a score of 6.8 out of a maximum of 7, despite the adverse conditions of other sectors including the social and economic determinants for health, as shown in the same report. The “Bloomberg 2017 Healthiest Country Index” reconfirmed, once again, the high ranking of the Lebanese health system showing Lebanon as the healthiest country in the Arab world. Recently the “Health Care and Quality Index”[7] published in the Lancet in May 2018 puts Lebanon in position 33 with an index of 86 (score of 0-100) among 195 countries and territories. This study highlights Lebanon as one of the three states that showed the most progress for high-middle-SDI countries. More recently Lebanon ranked 23rd for healthcare efficiency according to “Bloomberg’s Healthcare Efficiency Index”[8].
As a recognition, Professor Walid Ammar, Director General of Health, was awarded the renowned Shousha Foundation Prize by WHO for “his significant contribution to public health in Lebanon, in particular in the areas of primary health care and health policy, and for his efforts in translating research and evidence into policy, programmes and practice, and for bringing together a range of stakeholders to chart a vision for the welfare, rights and health care in an open network model of governance”[9].
In his address in the awarding ceremony Dr. Ammar stated: “If I should attribute progress to one single characteristic of the health system, I would say: innovative governance. The most difficult leadership is that of getting things done by a multitude of stakeholders with different agendas, interests, and beliefs. The Lebanese society is plural and diverse by its different confessions and political groups, a strong private-for-profit sector and an active civil society with powerful NGOs. Considering the very limited resources and weak authority of the public sector, the challenge is how to make all these partners work together to achieve national health goals. The answer is to find a non-hierarchical governance structure, that replaces control and command leadership, by a collaborative leadership to achieve common goals through an open networking type of governance”. Dr. Ammar paid tribute to the dedicated MOPH team, and to “people who collaborated with the Ministry of Health to make progress. These are health professionals working in different institutional settings, guided by science, professional ethics and human values. Those actors in public and private sectors, despite the depressing political climate and unfavorable working conditions, are contributing to alleviate pain, reduce morbidity and mortality, improve quality of life and promote social progress”.



[1]“World Health Statistics,” World Health Organization, 2013
[2] https://www.moph.gov.lb/en/Pages/9/1269/strategic-plans#/en/view/1279/health-reform-in-lebanon
[3] Health systems financing: the path to universal coverage. World health report 2010. http://www.who.int/whr/2010/en/
[4]“World Health Statistics,” World Health Organization, 2013
[5] Health outcomes and cost: A 166-country comparison,” The Economist Intelligence Unit, 2014.
[6] The Global Competitiveness Report 2016–2017. World Economic Forum. https://www.weforum.org/reports/the-global-competitiveness-report-2016-2017-1/
[7] Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016- The Lancet, May 2018
[8] Bloomberg’s Healthcare Efficiency Index, September 2018.
[9] Regional Committee for the Eastern Mediterranean, WHO, Sixty-third session. EM/RC63/INF.DOC.7Rev.1, September 2016.