I- Universal Health Coverage and the Lebanese Dilemma
Achieving Universal Health Coverage (UHC) is a main goal of the National Health Strategy, and is based on the principles of justice, equity, poverty reduction and the rational use of resources. It requires financing or providing preventive and curative quality health care for all, to satisfy each one’s needs against affordable contributions, whereas alleviating the financial burden, as much as possible, on households, especially the poor, remains a main objective of UHC.
The purpose of Universal Health coverage is to ensure universal accessibility to services that address population health needs and country health priorities with adequate quality, without incurring households financial ruin. This implies reaching a consensus over two major policy decisions: 1st defining a benefit package, and 2nd, setting an acceptable level of financial burden on households, more specifically the OOP bearable level by income category. Starting up from scratch, the benefit package would include essential health services such as PHC, and the government would cover as much health interventions as its budget allows, by beginning with the most cost effective ones such as immunization, TB treatment and prenatal care. Thus the population would expect regular upgrading of the system and would welcome incorporating progressively more advanced services such as renal dialysis, treatment for cancer, and sophisticated surgeries. The dilemma of the health system in Lebanon is the current existence of a universal coverage for tertiary care and sophisticated treatments such as open heart and joint replacement surgeries and expensive cancer patent drugs, whereas, paradoxically, prevention and PHC services are not universally covered.
Therefore, while the population is looking up for more and more technologically advanced interventions, the public opinion would not be particularly enthusiastic about enhancing the coverage of essential services such as introducing new vaccines to the immunization calendar, mental health and safe motherhood care. Consequently, politicians would not venture a UHC plan that may disappoint their voters.
Nevertheless, technically, the main issue for achieving UHC in Lebanon remains the accessibility to a comprehensive package of PHC services including promotive, preventive and palliative care in addition to early diagnosis and early treatment.
II- Scaling-up PHC and reducing OOP as a Strategic Direction
The 1998 National Health Accounts revealed that Total Health Expenditures (THE) represented 12.3% of GDP of which 60% were Out-Of-Pocket (OOP) payments. There is no doubt that oversupply in addition to focusing on financing curative care, and the poor quality of preventive and primary health care at that time, have contributed to over consumption of expensive diagnostics and treatments provided by the private for profit sector.
The success of the MOPH in decreasing the THE to 8.3% of the GDP mainly by decreasing the OOP to reach 44% of THE, confirms the pertinence of reorienting its strategy towards PHC, especially that rationalization of households health expenditure was associated with an increased utilization of health services along with quality improvement. This was consolidated by a positive overall impact documented by a significant improvement in health indicators. Nevertheless, the OOP is still considered relatively high which requires moving further along the same strategic direction towards achieving UHC.
In addition, and since the MOPH covers only In-patient services and expensive treatments without ambulatory services, the development of a wide network of PHC centers providing quality services, that are accepted as an alternative for the private outpatient care, becomes a must to ensure universal accessibility to PHC.
III- The Cost of ensuring financial fairness through Universal Health Coverage
Calculating the cost of exempting the poorest and decreasing the contribution of the less poor, necessitates defining those categories and calculating their health spending. The current distribution of THE by source of health financing is as follows:
43% of THE are Out-of-pocket spending
27% of THE are General Government Spending. These include the totality of the MOPH budget, 25% of the NSSF spending, and health care budget items of the remaining public funds.
28% of THE are prepayments that include private insurance premiums and NSSF employees and employers contributions.
According to the Household Living Conditions Survey of 2004-2005, the OOP spending is distributed by income categories as follows: 30% paid by households with a monthly income lower than 650 thousand LBP; 30% by households earning between 650 thousand and 1,200,000; and finally the income category of more than 1,200,000, contribute the remaining 40% of the total OOP spending on health. Knowing that a significant proportion of the latest category spending is on supplementary and luxury goods and services like food supplements, cosmetics and plastic surgeries.
The target for achieving equity in health financing and alleviating poverty would be set as to achieve complete exemption of the poorest from any payment, and decrease the health spending of the less poor by half.
Considering that Total Health Expenditures (THE) represent around 7.41% of GDP and OOP spending 43% of THE, then OOP amounts to 3.19% of GDP. This is distributed over the three aggregated categories of income respectively 0.957%, 0.957%, 1.276%. Accordingly, the amount that needs to be alleviated from the households burdens amounts to 1.4355% of GDP (0.957%+0.957%/2).
If we consider the 2009 GDP of 53,000 Billion LBP; the estimated reduction of OOP would be around 760 Billion LBP. However, this does not mean that the cost incurred by the government needs to be as mush. From our experience, the cost born by the government for providing PHC and public secondary health services is equivalent to almost the third of the cost incurred by the individuals when purchasing themselves the services directly from the private sector. Accordingly, the estimated cost of the project would be around 250 Billion LBP which corresponds to increasing by 24% of total government spending on health in 2009. This estimate assumes good adherence to the set rules, particularly the respect of the referral system between the PHC centers and governmental hospitals, and the prescription of generic drugs. This might be ambitious to achieve in short term, nevertheless, the cost of the first stage of the project concerning the universal accessibility to essential services is perfectly affordable under current circumstances as shown in section VI.
IV- Primary Health Care: The MOPH-NGOs-Municipalities partnership
Primary Health Care services have proved to achieve significant outcomes compared with the modest resources they need. In addition, the contractual relationship of the MOPH with NGOs have contributed to streamlining PHC services provided by NGOs and to rationalizing the spending through shifting more funds towards promotion and prevention. This relationship is based, on one hand on the centers’ commitment to improve the health status of the community by providing a comprehensive package of PHC services according to WHO’s definition; And, on the other hand, the MOPH provision of free-of-charge vaccines and essential drugs in addition to setting quality standards and clinical protocols, as well as ensuring the required training of NGOs Staff. What distinguishes this relationship is the MOPH in-kind contributions (replacing the conventional fee-for-service reimbursement), against centers' commitment to achieve better health outcomes. This mechanism avoids incentives for over consumption and encourage tailoring interventions according to community’s needs. This relationship constituted a more effective alternative compared to traditional financial subsidies provided by other Ministries to NGOs, whereby the government has not been able to control spending or even evaluate the results of its investment. By their nature, the MOPH contributions, whether related to its normative role or to the supply of vaccines and generic drugs, cannot serve but the intended purpose of the contract. On the other hand, the involvement of Municipalities as third parties enhances community participation in orienting, managing, and evaluating PHC services.
Strengthening the network of primary health care centers, and linking them to government hospitals through a referral system, is a key pillar of the national health strategy. This network is covering gradually all cities, neighborhoods and villages, benefiting from a geographic information system indicating the groups of habitats that are to be included.
Achieving Universal Health Coverage in Lebanon requires the adoption of government financing modalities linked to community enrollment of citizens providing them foremost access to preventive services, early diagnosis and early treatment, which will reflect positively, not only on the health status and budget of households, but also on public health and total health expenditure.
V- Community health coverage to ensure universal accessibility to a basic benefit package
This is a decentralized coverage design consisting of the following:
