Dr. Roger Sfeir is one of Lebanon’s leading cardiovascular surgeons and has been a key advisor on national healthcare reforms. International bodies such as the World Bank and United Nations Development Program have sought his expertise for a number of studies. Executive sat with him to discuss recent developments in the sector and the problems that continue to beset healthcare in the country.
Is there an over-reliance on private sector financing for healthcare in Lebanon?
Provision of healthcare is nearly 90 percent private and the expenditures mainly go to these centers, so yes, it is skewed to the private sector.
What are the implications of that?
Well, we need to look at the financing, from where the money comes. Before 1998, the public hospitals were incredibly inefficient so in that year a law was passed called the Law of Autonomy of Public Hospitals, where they changed the legal structure of these hospitals.
So instead of being directly managed by the Ministry of Public Health (MoPH), each hospital had a board and a general manager under the supervision of the ministry, but it was supposed to operate like a private hospital, with its own budget. Its income would come from billing the government for the patients it serves.
Has the law been successful?
Not really.
Why not?
When this law was written, we were aware that as long as the manager and the board were appointed by the politicians then the same problems would occur again. As the law is written, the boards and managers are appointed by the MoPH, so they are not free of political interference. I believe now around 15 to 20 percent of the overall healthcare budget goes to public hospitals whereas it was around 10 percent back then.
Within healthcare in Lebanon, are there sufficient quality control measures?
Before the major effort to restructure the healthcare sector back in 1998, there wasn’t anything called quality control by the government in the hospitals. We wanted something like the joint commission in the United States, but we ended up doing what is called the accreditation of hospitals, whereby a committee from the MoPH comes and checks the hospital including everything from the infrastructure to the nursing to the management.
How rigorous is the process?
It is working, but not very well. This is because of how it is being implemented. The problem is that the hospitals are audited by one of four companies selected by the ministry. [It is a situation] where the companies may give wrong results.
How?
[Laughs.] Well, if you know or have relations with the people who own the [ratings] company, then they can give better grades. With these contacts, they can help the hospital get an accreditation when maybe they shouldn’t. The way the system is built is not foolproof to prevent abuse.
How would you assess the balance of primary to secondary and tertiary healthcare spending?
There is too little [spending] on primary healthcare and preventative medicine. There has been an effort by the MoPH and [its] director general to improve the primary healthcare centers and put more effort into improving preventative medicine, because the dollar you put there can save you 10 further down the line. Private institutions can’t do this because it is not profitable.
How coherent and comprehensive is the data available for the sector?
There was lot of money put into a 1998 study for restructuring the sector. Part of this was to collect data in what is called the national health account, and it gave some alarming findings. For example, it found that total healthcare expenditure was 12.3 percent of gross domestic product, which was second only to the US. [Between] 2004 and 2005, it found it went down to around 9 percent. But we really have to take these figures with a large pinch of salt. There is [a possibility] for errors or even gross errors in the collection of this data.
How efficient is the pooling of resources and data within the sector?
Healthcare information is very important for the steward of the system, and this should be the MoPH. Now the ministry is a lot of things. It is the steward, it drafts the laws, implements the laws, treats patients and pays for the patients. All these should be split and divided. There should be checks and balances.
These proposals have been put forward many times but have not been implemented. Why not?
The ministry should be the steward for the system, put down the regulations and have a center for the collection of data. The one that owns the hospitals should be another entity, and the one that collects and pays the money should be the national healthcare fund. The government has not been able to implement these policies even though they were approved by the Council of Ministers [Lebanon’s Cabinet] way back in 1999.
Why not?
There is no political will. If you want to take from the National Social Security Fund (NSSF) the power of paying for the hospitals, then they will not be happy, and the same for the MoPH. If you want to create a national health fund, this will take from the MoPH and the NSSF. Neither of them will allow it.
How would you assess the efficacy and equity of the mix of payments from the public health ministry, insurers, NSSF and professional associations?
It is both inefficient and inequitable. The most inefficient way to pay for healthcare is out of pocket, and yet it amounts to around 60 percent of all healthcare spend here. This also leads to inequality. If you are poor and don’t have insurance, you can’t afford to pay out of pocket so you go without. We need more prepaid systems.
The NSSF is in a bad state of affairs. What could be done to make it more sustainable?
The sickness fund portion of the NSSF used to have more money in the bank, but year after year you see the money available going down because the losses are more and more. It has passed zero and it is now losing billions of lira every year. Another set fund was created a few years ago for those people that are not insured. Who chose to join? The elderly who have no social security — and they are very sick, so within a couple of years the fund ran out of money. The government pays into the regular fund, but they have not been paying their share because they say there is a lot of theft and abuse of the system. The NSSF is going to remain in deficit unless there is a major change made, which I don’t see happening in the coming years.
What is the state of care for the elderly and palliative care in Lebanon?
I think one of the worst aspects of our healthcare system is that there is no proper adequate care for our elderly, either in terms of healthcare or nursing homes. Nothing. There are hospitals that have long-term contracts with the government for the elderly, but they are really paid minimal amounts per day. Not enough to pay the electricity. This is [a failure] of the system. Once you stop working at 65, your insurance stops and your health coverage stops and you get paid your social security, which [runs out] in one year. After that you have no medical coverage, so many of the elderly are left uncovered.
