Many column inches have been dedicated to the Syrian conflict and the resultant refugee crisis, the impact of which has been particularly felt in neighboring countries like Lebanon. Less acknowledged but deserving of recognition is the shocking reality that Lebanon’s healthcare system has performed with surprising efficacy in coping with this crisis. The much-maligned and historically weak system, in the course of the last seven years, has proven its resilience, and has even expanded previously underpowered capacities.
The resilience of the Lebanese healthcare system has been highlighted in recent research. A paper on The Collaborative Governance of Lebanon’s Health Sector was released in May 2018, the product of a partnership between the World Health Organization, the American University of Beirut (AUB), and the Ministry of Public Health (MoPH). It found that “Lebanon’s health sector has shown remarkable progress over the past twenty years,” and that Lebanese achievements in the mobilization of health resources “went well beyond what could have been expected given the country’s recent history and geopolitical environment.”
Two years earlier, an academic study examined the performance of the Lebanese healthcare system during two peak crisis years after Syrian refugee inflows in mid-2012 intensified to previously unimaginable levels. Reviewing the responses of the healthcare system in the years 2013 and 2014, the study concluded “that the Lebanese health system was resilient, as its institutions sustained their performance during the crisis and even improved.” The authors of this study, both Lebanese and international experts, took as their definition of resilience in healthcare the “capacity of a health system to absorb internal and external shocks, and maintain functional health institutions while sustaining achievements.”
Walid Ammar, the director general at the MoPH and an AUB professor, was a co-author of this study. He confirmed to Executive in July that since the publication of this research at the end of 2016, things have kept moving in the same direction: “From the publication of this paper until now, all [health] institutions, private and public, are still functioning, and our indicators in Lebanon are still improving.”
He points out that the last years had functioned as a genuine stress test of the national health system, and thus were all the more indicative of its resilience. “If you can predict something and make a plan to deal with it, this is part of your planning capacity to meet challenges that you expected. Resilience is when something occurs that is not predictable, and this is what happened with the Syrian refugees,” Ammar says.
In seeking to assess the Lebanese health system for its overall quality and for its resilience in the face of the refugee crisis, it should be noted that all of the academic evaluations of the system mentioned thus far have relied on collaboration or co-authorship with interested stakeholders, the MoPH’s Ammar above all. But despite the skepticism that will likely be triggered by this rare national success story, the proof is in the pudding.
The success narrative becomes more convincing when one is presented with the evidence and testimonies of the institutions and people who are in the thick of managing healthcare for refugees, such as the United Nations High Commission for Refugees (UNHCR) and non-governmental organizations (NGOs) focused on health.
According to UNHCR Public Health Officer Jakob Anhem, the organization’s record of the medical health needs of Syrian refugees is based on UNHCR surveys that are presented in the Vulnerability Assessment of Syrian Refugees in Lebanon (VASyR) annual report. “The trend on the numbers of refugees who need medical services and the number who are able to obtain them is relative stable,” Anhem tells Executive.
He explains that in 2017 the number of refugees in Lebanon who said that they needed and were able to receive medical help in terms of primary health care (PHC) improved to 89 percent, from 84 percent in 2016. Numbers were “slightly lower” for secondary healthcare, he adds, but four out of five refugees said they had access to hospital care when they needed it.
The improvements in the Lebanese health system are corroborated by Fondation Merieux, a French, healthcare-focused NGO. “The evolution of the crisis and response in Lebanon is not comparable to other countries because of its length and specificities. The healthcare system here is in [an] adaptation process. Relative to where it was, it sought to address issues as they emerged, with the funding they had. There is international coordination and also a very good push to strengthen the national NGO network. It is a good thing to see this evolution,” says Josette Najjar-Pellet, the foundation’s Lebanon representative.
According to Najjar-Pellet, Fondation Merieux is mainly active on the side of capacity building. Its missions include researching and fighting infectious diseases, building systemic access to diagnostics, and knowledge and information sharing.
Highlighting that the Lebanese healthcare system has thus far been able to avoid epidemics in the refugee and vulnerable Lebanese population, Najjar-Pellet confirms the important role that strengthening the PHC network played after the onset of the Syrian refugee crisis. She tells Executive that analyzing the factors behind this control of serious outbreaks and avoidance of epidemics is a complex undertaking; she also cites the resilience of the system and the resilience of healthcare workers in Lebanon. “When observing this crisis from the perspective of someone coming from outside, and also as a Lebanese who had left the country and has come back, you cannot say anything but that only a country like Lebanon could have supported this situation and remained peaceful,” she says.
The comments by persons and institutions that are once-removed stakeholders in the Lebanese health system support the notion that Lebanese hospitals and PHC centers—dispensaries run by non-governmental organizations and charities, as well as those owned and operated by the Ministry of Social Affairs—have been able to deal effectively with the demands placed on them throughout the protracted crisis, which now spans more than six years of extensive and intensive needs. Moreover, the ability of Syrian refugees in Lebanon to access hospital care is not correlated with their legal status; according to UNHCR assessments, the barrier in accessing secondary healthcare is cost—the same barrier that locals must overcome in accessing hospital care.
Throughout the crisis, the capacities of the Lebanese PHC network continued to improve and the country’s healthcare networks were additionally boosted by growing collaboration between non-governmental organizations in Lebanon and international civil society. The PHC network grew out of a state of disorganization from its founding in the mid-1990s, having been designed by the MoPH to be the cornerstone of a health system that would focus on assisting the poorest Lebanese. Through effective collaboration with local NGOs, the MoPH’s network grew from 29 PHC facilities at the time of its establishment in 1996, to 85 facilities in 2005—a number that has almost tripled to 220 centers by the time of this writing.
Moreover, according to Hala Abou Farhat, associate public health officer in the UNHCR Inter-Agency Coordination Unit, there now is a sizeable and increasingly stable network of international and national organizations involved in UNHCR-coordinated aid efforts, including about 50 organizations that have indicated their interest in receiving funding under the Lebanon Crisis Response Plan (LCRP). “Many of [these organizations] work in health or are interested to expand their existing health services to the refugee population in Lebanon. They are interested to appeal for funds and interested to liaise with donors, but in 2017, out of all organizations, 31 partners received funds,” she explains.
Abou Farhat says that this group of NGOs is dependable and consistent. “The network has become more or less stable in size. In every year, we hear of new partner NGOs, but the traditional partners are the ones that have been working for the past four to five years consistently,” she says.
This increasing stability contributes to continuity and to the development of healthcare provision to extremely vulnerable population groups. Abou Farhat says that the MoPH-NGO collaboration has also produced other benefits, including the formalization of the PHC accreditation program, and investments in training and capacity building. She notes, however, that such improvements may not be highly visible in short-term comparisons, between periods spanning from a few months to a year.
“I would say that the system has improved a lot over the years. It has evolved greatly and the MoPH has been at the forefront of this development,” she says. Regarding collaboration with NGOs, she notes that “the MoPH has a very different mentality from other ministries, by acknowledging that it is the partnerships with NGOs that allow them to work.” Between the lines of such evaluations, listeners might think they detect unspoken messages that the Lebanese healthcare system is still vulnerable to influence by partisan interests and non-optimal political approaches, but that its ability to overcome such restraints is advanced compared to that of other institutions.
Many of the problems that persist in the area of refugee health care mirror the issues that afflict the Lebanese population, but with added severity. For both populations, cost is the main barrier. Anhem explains that the UNHCR has had to make tough decisions regarding hospital care for Syrian refugees: “We have been forced to prioritize when we set up the program of health services for specialized hospital care,” he says. “We decided to prioritize deliveries, i.e. obstetric care, and [the treatment of] urgent life-threatening conditions or conditions that might lead to disability. In the case of some conditions that are life-threatening, like renal failure, or cancer, where long-term expensive treatment is required, it was decided that we cannot support this. So, we had to ask the international community and other NGOs to step in with funding.”
In practice, this means that for the current year, UNHCR made an appeal for $67 million for healthcare funding in Lebanon. Of this funding appeal, which would contribute to the total required budget for 2018, “$18 million is currently funded, which leaves the total gap at $49 million,” UNHCR spokesperson Lisa Abou Khaled told Executive in early July. Moreover, when the funding gap is further qualified according to what is urgently needed to cover minimal assistance levels to ensure access to life-saving hospital care until the end of December, the need, according to Abou Khaled, is for $28 million.
Taking into account the time dimension of the process to acquire donor funding, the outlook for 2018 is not very dissimilar to the previous year, when funding needs were met to 80 percent, Anhem explains. But the process sounds at the very least like an exercise in stress induction. “It is my impression that we are biting our nails every year and wonder if we will need to make severe cuts to our programs by September, but by the year’s end, we have always been able to provide a decent level of care,” he says.
As Abou Farhat points out, however, this appeal does not cover all of the health needs seen by the community of NGOs. “We need to be mindful that UNHCR does not cover everything. From an interagency perspective, things look a bit different, because the total amount we have requested for 2018 is $290 million, out of which $193 million is requested for secondary healthcare and $94 for primary healthcare. [This total] includes [the $67 million budgeted under] UNHCR but also accounts for dialysis, cancer treatments, and other conditions which are not covered by UNHCR,” she says. A further $2 million is budgeted for improving outbreaking control and $500,000 for improving youth health. While there are different population groups included in this funding appeal, the bulk is requested for Syrian refugees, whose healthcare needs are seriously underfunded, she adds.
The resilience of Lebanon’s healthcare system is a narrative with two intertwined strands. One strand tells a story of healthcare assets owned by diverse stakeholders, from private, for-profit enterprises to non-profits to the public sector, which have performed for both the Lebanese and the Syrian refugee population at a surprisingly high level. The second strand of the narrative reveals that the system is still marred by special interests and imbalances, the most important of which is that the total financial requirements far exceed the available means for delivering the required healthcare to all needy people, of whatever nationality, in Lebanon. This nevertheless makes the performance and resilience of the existing healthcare system ever more surprising, in its efforts to provide care for Lebanese poor and refugees alike.