Developing the ideal at home

Marwan Ghosn is professor and chairman of the hematology-oncology department at Saint-Joseph University's Faculty of Medicine
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The last century heralded a dramatic upsurge in healthcare costs in Lebanon. An aging population, the transformation of acute diseases to chronic ones and the innovation gap in pharmaceutical drug discovery despite increased funding for research have all contributed to the ‘healthcare cost crisis’. Lebanon is particularly vulnerable to this crisis given its unstable and unregulated environment.

On paper, the Lebanese healthcare system is comparable to the French one.   In theory, it guarantees equity in the distribution of healthcare services, ensuring access to essential services, irrespective of people’s ability to pay for them. But this is Lebanon, and to list all the pitfalls between what healthcare is and what it should be would be a monumental undertaking. If we are to attempt to close this gap, the systemic supply, demand and coverage issues outlined in this article must be addressed. 

The reality of coverage

The majority of Lebanese citizens are covered by a number of healthcare services: the National Social Security Fund (NSSF), the Cooperative, the Army and Security Forces, mutual funds or government-managed health insurance systems. Only a minority are covered by a private insurance system. Gainful employment is the basis of the funding and benefits the social security system. Thus, retired people, for example, who are elderly and more prone to chronic diseases, are not eligible for medical insurance through the national social security fund, laying a huge burden on the government and youth alike. 

When including indemnity pay, some 20 percent of the gross salary of the working population is deducted to fund the social security system, which is managed by the labor ministry. Yet there is no contribution from the population provided to the health ministry, which pays the bill for all those uncovered citizens. As such, the system is inherently unsustainable and widespread reports of a lack of publicly funded medicines or treatment remain the norm and not the exception. As long as this continues to be the case, accessibility to healthcare will be threatened and patients may be priced out of the market. 

When it comes to reimbursement, the process is anything but unified, suffering from chronic delays and, in some cases, significant out of pocket payments by the patient. As a result, the tenet that healthcare services should be provided irrespective of the ability to pay is threatened. The variability and lack of clarity in the insurance programs, both reimbursement and procedure, is also a source of continuous tension and lack of efficiency.

As medical staff and patients, we cope with a regular inability to ensure the continuity of care due to unpredictable payment limitations and cost ceilings set on a case-by-case basis, which is hardly a characteristic of a functioning healthcare market. 

Among the unique features of the healthcare market is the fact that provider and patient both constitute the demand element of the market, whereby a patient’s sickness and the prescription of their medical provider make up the total monetary demand. Providers are put in a position where they may inflate healthcare costs if not properly monitored by a regulatory process that maintains a high level of ethics, with clear and strict requirements and timelines. 

The multitude of products on the market offers a range of choices to healthcare providers and patients alike and ostensibly creates a competitive environment for better pricing and quality.  However, the efficacy of the registration process is often in doubt, prompting patients and physicians to reply unduly on pricey name-brands to ensure quality. 

Even with these issues resolved, we would need to recognize that the major part of our priorities are still channeled towards curing cancer rather than preventing it. Curing cancer, like any disease, always costs more in the long run than prevention. A culture of preventive healthcare and early screening is needed on every level. Perhaps most importantly, the role of family physicians, especially in remote areas, and development of systems ensuring continuity of care and intermediate care facilities, will be crucial. 

Many questions will only be answered with time, such as which system is ideal, how to finance it, what the priorities are, who the gatekeeper is, and if the public is willing to follow an escalating tax scheme. There is no one ideal system, but the one we create needs to both fulfill our mounting needs and take into account the reality that we are not France — the solution  cannot simply be imported, but must rather be created here at home.