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EducationOverviewSpecial Report

A categorical imperative to not abandon the future

by Thomas Schellen June 9, 2023
written by Thomas Schellen

Public goods are numerous. In the face of extreme perils, public goods exist to guarantee the very survival of a society. External and internal guardian institutions against invading powers, catastrophes and crime exist today in form of defense, the justice and police system, and fire brigades, but also in form of agencies for environmental protection, preservation of biodiversity and climate. They are safeguards that facilitate the survival of societies in present and future. As such, they benefit all and must be designed to be non-exclusionary by their reach and coverage. But they are not created equal. 

During a century of external peace, the public good of defense capabilities is less prominent. In a stable society with persistently low crime rates, police and prisons might become lower priorities, especially if other societal threat factors are intensifying. Established public goods of external and internal security may thus be overshadowed by new societal worries when for example simultaneous increases in population and economic activity are eroding environmental integrity, climate, biodiversity, global coexistence and social cohesion – until the moment when international tensions and internal social divergence burst again onto the scene. 

twitter]Education and health are universal concerns of the human species [/twitter]and in this sense less sensitive than other public goods to societies’ shifting priorities. However, they are subject to shifts of individual and collective priorities and perceptions. The perception of personal health is in part human self-perception informed by personal choice, individual folly, and cultural bias. But overall, measurable indicators and impartial science plays an ever-increasing role in our approaches to health. Education is a matter of projecting societal experience forward in time, imperfectly sourcing future productive contributions of a wide variety and anticipating impending societal needs, such as jobs. 

In being directed at a child and youth as formal education, the education system reflects in a significant part societal needs and priorities, to which it seeks to match the new member with tools of measurement and statistics. It significantly also is a matter of family perception where the dreams and biases of the parents are influenced by the biases of their parents, frequently going back all the way to various philosophical speculations of the so-called axial age that a more educated human being will have a better life for herself and at the same time contribute to a superior community with ever-growing quality of living. 

In this sense, education has presented itself with the underlying communities’ historic consent as a moral imperative aimed at reaching a communally-relevant quality of life that delivers on such ethereal human wants as happiness, honor, respect, benevolence, political honesty, sustainable development, peace, and love. Such are dreams of education – or, in the worst case, vain and expensive hopes. 

A weakening system’s disintegration

The current state of the Lebanese education system appears to have fallen from a popular utopian dream into a pit of depressiveness. Having disintegrated financially and sharply degraded in its capacities over the past four years, the education system’s internal divisions, which have been unabated since the country’s economic and societal reconstruction phase in the 1990s, seem to have descended further into a disorder where few learners achieve and the majority is left behind. In its genesis, this classical tragedy of education in Lebanon – where extraordinary efforts result in the opposite of the desired outcome – can be described in numbers that date back to the days when the country was still absorbed in its delusion of a stable currency and sustainable model for business and society. 

In one puzzling set of data, the ratio of pupils to primary school teacher in Lebanon was for a long time one of the lowest in the region and among upper middle-income countries. Compared with global averages that improved haltingly from over 28 to about 23 pupils per teacher in the course of five decades between 1970 and the mid-2010s, the value for Lebanon fluctuated – as per available data – between 12 and 17 pupils per teacher. By such data, and also by qualitative evidence such as the local tradition of Teacher’s Day, this society has over many years impressed as a positive outlier against several international peer groups in its cherishment of teachers.  

By another measuring stick, however, namely in terms of spending on education, the Lebanese state can be classified as spendthrift to the point of suspicion of non-sustainability in the short and the long term. A 2021 paper by World Bank staff claimed that “the government of Lebanon spends $1.2 billion on education (less than 2 percent of GDP).” Surprisingly, however, another World Bank paper by the title Lebanon Education Public Expenditure Review 2017 (LEPER) – which is referenced in the Foundations for Building Borward Better (FBFB) document of late 2032 – cites the same figure of about $1.2 billion in annual public spend on education but associates it with “approximately 2.45 percent of GDP and 6.4 percent of total public expenditure.” 

It is said in the FBFB report that the public expenditure on education in Lebanon dropped to less than 2 percent of GDP in 2020 but a data series for the 11 years from 2005 to 2015 cited in the Public Expenditure 2017 Review shows that public education expenditure through the Ministry of Education and Higher Education (MEHE) moved somewhat erratically between 1.6 percent and 2.4 percent per year, to which one has to note that Lebanon experienced significant fluctuations in its GDP growth rate over the period. In a vaguely correlated trend line, MEHE budgets as percentage of total public expenditure vacillated over the same period between a high of 7.7 percent in 2005 and a low of 5.2 percent in 2008 for an average of about 6.3 percent over the period. It further has to be noted that Lebanese households were estimated to have spent $1.5 billion annually – another tranche of GDP that would have the total public and private country spend on education trending well above the lower bound of the 4 to 6 percent share of GDP range that has been recommended in context of the United Nations’ sustainable development goals (SDGs). 

By time of this writing in 2023 however, assessment of Lebanese education expenditure has been massively impacted by the continuing economic crisis, and it must further be taken into consideration that data on population, GDP, and private and public expenditures in view of purchase power losses, rising economic informality, wild currency fluctuations and uncontrollable price inflation are presently even more tenuous than in the previous decade. The fiscal misery nonetheless suggests that Lebanon will over the first half of the 2020s – and possibly far longer than that – be allocating significantly less to education in percentage terms of GDP than the 4 to 6 percent range that was recommended as means toward achieving SDG4 by a World Education Forum in 2015.

Missing education targets

Named the Incheon Declaration after the Korean city where the forum was held, the event’s concluding statement advised that countries provide 12 years of free public education and urged them to adhere “to the international and regional benchmarks of allocating efficiently at least 4 to 6 percent of GDP and/or at least 15 to 20 percent of total public expenditure to education.” World Education Forums were organized as global-level initiatives in 2000 (Dakar, Senegal) related to the Millennium Development Goals, and in Incheon, Korea, in 2015 related to the SDGs. UN agencies and the World Bank were the organizing entity. 

However, for discussing mores, modes and models of education for the future, it is hardly self-evident that primacy of public education and state finance is optimally tailored to all rapidly evolving education mandates such as remote learning in a digital future and lifelong learning on individual level. Moreover, in hindsight of a world that has experienced an unprecedented education crisis in the pandemic years of 2020 and 2021 (which was an education-related observation of “Our Common Agenda”, a September 2021 UN event and report whose top recommendations included the renewal of the social contract and the protection of global public goods), the Incheon Declaration’s context was programmatic. It was not necessarily immune to tinges of top-down, pro-state policy orientation – one article in the declaration took a decidedly pro-state position in insisting that education is a public good “with the state as main duty bearer in protecting and fulfilling the right to education.”

Moreover, on the scale of Lebanon, the World Bank’s LEPER of 2017 noted that “higher educational attainment corresponds to higher earnings in the labor market” and that education investments consequently deliver “high returns” to Lebanese households. It cannot be disputed that the majority of society was embracing a high share of private education finance in an outlier country such as Lebanon, given that the extraordinary tripartite education system of public, private, and not-for-profit private provision was delivering results in form of annual cohorts of graduates. This is also expressed in enrolment numbers at private education providers up to the level of tertiary education, embraced by society during the post-conflict reconstruction period and into the 2010s. 

However, a diminishing performance against education benchmarks, long-standing deficiencies in qualifications and inefficiencies in allocation of teachers, and a frighteningly high degree of education inequity are indisputable factors in reviewing of the trajectory of the Lebanese education system in the years before the pandemic and financial and economic and policy crises. 

“Learning outcomes in international assessments are low and have been declining for the past decade,” notes the World Bank FBFB paper of 2021, which in its executive summary prominently references the World Bank’s Human Capital Index in suggesting that children born today would, on average, at adulthood reach not more than 52 percent of their productivity potential. The paper further cites decade-long declines in results of assessments such as the Trends in International and Science Study (TIMSS) and below-average performance of Lebanese students in the Programme for International Student Assessment (PISA) where test results revealed worryingly vast distances between scores for best and worst performing schools. 

A set of long-term outlook speculations by the World Bank’s Human Capital Project – which constructed and published its first Human Capital Index (HCI) at the end of the 2010s – drew on education outcome measurements such as PISA and TIMMS in allocating an unexpectedly low HCI ranking to Lebanon in its assessment of a newly born Lebanese child’s capacity to achieve optimum economic productivity by age 18. 

Although any such multi-decade prediction of human productivity by necessity will be heavily programmatic, be unable to account for influences that go beyond a small number of increasingly tenuous data projections, and be co-dependent on unknowable factors that are impossible to quantify for impacts upon national and global economic dimensions, the low HCI ranking of Lebanon – dating to the time when the roots of the long crisis period were still hidden – is yet another urgent alarm signal for education and health institutions and policy makers in the country. The human economic resource is perceived as a rare national treasure, often named in analyses and public speeches as the country’s most significant asset.  

With regards to education opportunities, the 2021 FBFB paper admonishes as the first statement of its medium-to-long term reform recommendations that “the Lebanese education sector is highly inequitable.” This is consistent with the 2017 LEPER observation that “inequity associated with socio-economic status exists in terms of access to quality private and public schools.”

This high inequity has negative implications for an efficient labor supply and for the ability and effectiveness of the Lebanese education system. In this context, also the pupil to teacher ratio, which on the face of it looks like an advantage of the Lebanese system, has a very dark side. According to the LEPER report, the salary cost in the Lebanese education system was above that of many developed economies and the utilization of teachers per student “low and inefficient by international standards”. Partial explanations for the discrepancy between teacher numbers and learning outcomes according to the report were firstly that a significant portion of the teaching cadre are working in administrative roles rather than in the classroom and secondly that some rural schools have a full complement of teachers for comparatively few students. 

Additional indicators for the – prior to the economic crisis – inefficient Lebanese education system’s need for reform and development were cited across international reports in wide mismatches of graduates’ qualifications and labor market needs. School system brick and mortar infrastructures showed regional differences in quality, which in turn were reflected in student performances. 

In terms of teacher pay, training, motivation and performance, by international comparison high salary entitlements of some teachers and weak qualification levels of others, stood in contrast to the lack of training, incentive, and performance evaluation systems. According to several reports also in need of addressing were the lack of regulatory frameworks, need of curriculum reform, absent governance and quality control. 

To draw a concluding impression of all this, the high number of reform proposals and remedial recommendations that have been published since the 2000s, including many proposals for curriculum reform and delivery system reform, is juxtaposed with very little evidence of effective systemic changes.

The education system of Lebanon has performed better than many expected when confronted with unexpected challenges such as the influx of Syrian refugee children in 2012 and 2013 and with the lockdowns and Covid-19 challenges in 2020. Yet, the many calls for structural reform seem to have gone in one ear and out the other. The brokenness of the education system in the 2020 to 2023 period is in this sense the pinnacle in a cycle of education system shocks and crises. In this downward spiral, reform needs discovered in the 2000s were exacerbated by the very high impact that the Syrian refugee crisis had on schools in Lebanon and forced into a yet more severe state of shock by the pandemic and collapse of livelihoods. 

Beacons of betterment 

This picture taken on March 28, 2022 shows a view of Mufti Hassan Khaled School in Lebanon’s capital, which was restored as part of a UNESCO project to rehabilitate 280 educational buildings damaged by the 2020 Beirut port blast. – Lebanon is grappling with an education “emergency,” said Maysoun Chehab of the UN education and culture body (UNESCO), as years of economic collapse weigh heavily on students and teachers. Chehab spoke on the sidelines of an event on March 28 celebrating the completion of the $35 million UNESCO project. The explosion caused by haphazardly stored fertiliser at the port killed more than 200 people, disrupted the education of at least 85,000 youths and sparked international outcry. (Photo by ANWAR AMRO / AFP)

Going forward, structural education reform plans without political and financial viability can hardly be expected to deliver during the latter stages of the systemic crisis what they did not deliver in earlier stages. While the inequities and problems on the systemic level must be expected to increase in most aspects of the education system, attempts to confront the problems can perhaps draw energy from a look at solutions. 

One beacon of hope for development has been erected by the thought and strategy leaders at top universities, which are addressing the challenges they face with the support of their networks that reach around the globe (see their comment pieces in the Dec/Jan issue of Executive). However, the top educational institutions, although deeply woven into the social and economic fabric of this country, need a functional education system to stand upon. 

On that side of the education equation, with only the faintest traces of trust in the state as guardian and provider of this public good being visible in society, the risk of a further spike in inequity and privatization of education in Lebanon has to be considered. Viable solutions might not reach to the scale and scope of strategic reform but momentum of change to the better might be found through meaningful steps on the ground while not abandoning the state as stakeholder. 

An extant party to the education development issue that can be viewed through this bifocal lens, is the United Nations International Children’s Emergency Fund, known by its acronym UNICEF. The organization has according to Ettie Higgins, UNICEF deputy representative, been present in Lebanon since the middle of the 20th century but has achieved a huge leap of impact in the context of the Syrian refugee crisis of the 2010s when it helped addressing the emergency needs of children. 

Support mechanisms for children that the organization has initiated in context of Lebanon’s education crisis include a fund by name of transition resilience education fund (TREF), which according to Higgins allows for the direct payment to the public sector, to schools, and to teachers for the work that they have been doing, as soon as the delivery of services to students is verified. Support of the formal education system accounts for a huge chunk of the organization’s budget in Lebanon. “UNICEF really sees the job that the public sector does for education as irreplaceable,” Higgins tells Executive.

Other current programs coordinated by UNICEF comprise a project to create as many as 100 community centers in coordination with about a dozen NGOs that will deliver an integrated package of education, child protection, and youth services. There also is an innovative “school bridging program” to children who have been out of school for one year or more. The program, which is currently in its pilot phase, is designed for collaboration with private schools in providing learners with “multiple flexible pathways” to improve their societal and economic productivity. 

“We focus our integrated interventions where we have a high number of children out of school and where we have high pockets of vulnerability, regardless of nationality,” Higgins describes the strategy behind programs that are currently being rolled out. Addressing needs of children, including the debacle of Lebanon’s education system, at the points of greatest vulnerability appears to be deeply ingrained into the institutional DNA of UNICEF whose acronym still reflects that the intergovernmental organization was originally tasked to act as emergency fund. 

Another strand in the UNICEF DNA is collaboration with state institutions.  “Working with the public education system remains our primary logic. We are not an NGO. When we come into a country, we are coming on the invitation of the government and our primary focus and mandate is on supporting the public system,” Higgins emphasizes. 

“When we speak with donors and design programs, we want to make them as multi-year and flexible as possible. This allows us to plan ahead so that we don’t start the school year and run out of money and have children lose out on their education. We also do a lot of awareness raising because the important thing about education is that it is not just education but also a protective environment,” she explains and concludes: “The scale of challenges for education in the country are so acute that it requires for all stakeholders to come together and try to jointly mobilize resources to do better programs that give children better results in their education.” 

June 9, 2023 0 comments
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AnalysisEducationSpecial Report

An education system in peril

by Rouba Bou Khzam June 9, 2023
written by Rouba Bou Khzam

Education is the cornerstone of a nation’s progress, and it is often touted as a powerful tool for achieving equality and social mobility. However, in today’s Lebanon, the situation is quite different. The country is facing a widening inequality in educational opportunities, threatening the future of its youth and its development prospects.

“I want to learn and succeed in life, but how can I when the resources and opportunities are not available to me? Education should not be a luxury for the privileged few, but a right for all,” Rajaa Sharafeddine says, an eighteen-year-old student at Al Amir Shakib Arslan Secondary School in Verdun, Beirut. Around this time of the year, she would normally be thinking about her exams, graduation, and future choices, she tells Executive in late March, laconically adding that her education is now being disrupted for the fourth year in a row – first owing to the Covid-19 pandemic and lockdowns, and more recently because of economic school closures and teacher strikes.  

Sharafeddine’s comment highlights the reality of many students in Lebanon, attempting to gain an education amid a deteriorating system. In January, an estimated one million children were out of school, according to international organization Save the Children. In 2021, following pandemic-related measures and the declining economy, more than 737,000 children of Lebanese, Syrian and Palestinian descent were out of school, the United Nations High Commissioner for Refugees (UNHCR) said.

One of the main barriers to education access has been the proliferation of widespread strikes among teachers at both public and private schools, resulting in temporary school closures up and down the country, as staff demand better wages and working conditions. As these strikes are ongoing, while wealthy families can afford to provide their children with alternative educational resources like private tutoring, for lower-class families the disruption will only serve to exacerbate the gap between the rich and the poor; perpetuating a cycle of poverty and limiting opportunities for social mobility.

Education in Lebanon has long been a point of pride for the country due to its history, diverse culture, and Westernized schooling system. However, in recent years, there has been a growing concern about the widening gap between the education opportunities available to students in private and public schools. This inequality has been exacerbated by several factors such as economic disparity, social exclusion, and political instability. According to the World Bank, in the 2020-2021 academic year, approximately 55,000 students moved from private to public schools. 

Educator and sociologist Sanaa Hassan explains to Executive the dynamics of the public and private education systems in Lebanon. “Private schools in Lebanon are typically run by for-profit entities and charge tuition fees that can be prohibitively expensive for many families. On the other hand, public schools are generally run by the government and are meant to provide education to all children regardless of their socioeconomic background.”

Despite having the same curriculum set by the Ministry of Education, Hassan emphasizes that private schools have a distinct advantage due to their ability to invest in better resources and infrastructure. “Private schools have access to modern technology, more textbooks, and teaching materials. They also have better facilities such as libraries, laboratories, and sports facilities. Public schools, on the other hand, may lack some of these resources and facilities due to a lack of funding,” she adds. 

Hassan also highlights the role of socioeconomic status in amplifying this inequality. She says that private schools are usually filled with children from wealthy families while government schools have diverse populations. “This can affect the learning experience of students, as those from wealthier families may have had access to more resources and support before entering school.” She further lists factors which impact the quality of education, such as class size. However, she also notes as a counterfactual that the dedication and expertise of the teacher is of higher significance than the number of children in a class.

Madeline Khoury, a former French teacher at Sagesse High School in Jdeideh, suggests that the issue with education in Lebanon does not simply come down to disparities between public and private schooling but rather an outmoded approach to education. “Both systems suffer from the limitations of an outdated curriculum and a lack of sufficient teacher training,” Khoury says. For her, an updated approach to teaching, with learning methods that prioritize the development of higher-order thinking skills, is overdue in the Lebanese school system.

“Teaching is a noble profession that requires continuous learning and development, but unfortunately, many teachers in Lebanon are not adequately prepared to meet the complex demands of modern classroom,” Khoury says. Without sufficient training, teachers may struggle to engage students, manage behavior, and create a safe and supportive learning environment. As a result, many students miss out on opportunities to reach their full potential, and teachers may become frustrated and burn out. [inlinetweet prefix=”” tweeter=”” suffix=””]Khoury recommends investment in teacher training programs in Lebanon to improve skillsets.[/inlinetweet]

Teacher strikes, vocational barriers, and exclusion of refugee learners 

“I’ve been at home for the past three months, not learning anything, because of the ongoing teacher’s strike. It’s frustrating to see my education being put on hold because of a conflict that I have no control over,” Sharafeddine says.

“I feel like we are being left behind while other students in private schools are moving forward. It’s not fair that we are forced to stay at home without an education while they are able to go to school and learn everything they need to succeed. We all deserve the same opportunities and resources to reach our full potential.”

Throughout this year, public schools have suffered from intermittent closures as teachers demand higher wages and stipends. The demand varies from basic education to secondary education, university education, and technical education.

Vocational or technical education is an area where financial restraints translate into pertinent difficulties for technical schools. Dany Maroun is an accounting and finance teacher and guidance and employment officer at Edde Technical School in Jounieh, an educational institution that offers vocational and technical training programs. “[Technical schools] rely heavily on specialized equipment and facilities for their training programs. We would sometimes pay from our pocket to make our students have enough equipment and [so they] can enjoy learning, but now we can’t afford to do this anymore,” he tells Executive. 

With the depreciation of the Lebanese pound, [inlinetweet prefix=”” tweeter=”” suffix=””]Maroun’s monthly salary has fallen to the equivalent of less than $200, down from $3,000[/inlinetweet] before the crisis. He has been struggling to keep up with fuel costs to power the generator and heaters during the winter months. 

The teachers’ hardships are having a ripple effect on the quality of education. “How can we ask the teacher to give his time and effort and raise generations when he is unable to support himself?” Maroun says. “And all the time [the teacher] thinks about what he will do besides education so that he can live the whole month without going hungry. Today, I’m like the majority that thinks of leaving, and whenever I get a chance abroad, I will not think twice [about going]. Between humiliation and leaving, the choice is clear to everyone.”

Since the start of Syria’s civil war, over 1.5 million Syrians have relocated to Lebanon, but only around 950,000 people are registered with UNHCR. Refugee education in Lebanon is impeded by various factors at a smaller scale, mostly related to financial constraints, in addition to transportation expenses, economic instability, the absence of legal documents and differences in curriculum. According to a 2021 report from Human Rights Watch, an estimated 29 percent of Syrian children are out of school due to arbitrary rejection by Lebanese schools. 

The teacher strikes have also impacted refugee education. As morning classes for Lebanese students ceased, so too did the afternoon classes attended by refugee children. Education Ministry officials recently commented that the closure of the afternoon classes was due to “equality” concerns, as it was unacceptable for Lebanese children to miss school while others did not.

More challenges and the will to change

“Imagine being a student and not being able to take an exam because we don’t have the supplies to administer it. And it’s not just exams. We don’t have proper electricity in some of the classrooms, so we’re teaching in the dark. How can we expect students to learn in these conditions?” asks Basel Saleh, a professor of philosophy at the Lebanese University. 

[inlinetweet prefix=”” tweeter=”” suffix=””]Lebanese University (LU) is the only public university in Lebanon, and it plays a critical role in providing higher education opportunities for low-income families. [/inlinetweet]But such opportunities are at threat as the university faces challenges from political interference, financial difficulties, lack of resources, and declining academic standards. It has spurred a decrease in enrollment, protests, strikes, and a wider decrease in the quality of education. 

Saleh tells Executive that the university is undergoing several problems resulting from the economic crisis. According to him, these problems extend from “unequipped buildings to the scarcity of papers and other necessary supplies, in addition to the demands of full-time contracted university professors, all of which is threatening the academic year and the fate of its students.” He notes, however, that the troubles of Lebanon’s public university have preexisted the economic crisis, lamenting that the government has been disregarding “the demands of academics for a long time, even prior to 2019.”

According to Saleh, 80 percent of the professors at LU are not registered as full-time employees, which means they are excluded from welfare benefits like health insurance, while their monthly paychecks are currently paid biyearly. He explains how this further lowers the commitments that society can expect from those entrusted with teaching at LU. “If you don’t have professors who are employed full-time, you cannot compel them to participate in administrative meetings. Additionally, if they don’t receive social and financial stability, they may have to take on multiple jobs which could lead to increased stress and potentially compromise the quality of education,” Saleh says, even as he notes his own choice of staying in Lebanon and embracing the challenges while his family has emigrated in pursuit of better opportunities.  

Despite the many facets of the Lebanese education dilemma, decoding its needs and pointing to possible solutions is no deep enigma to committed educators who have decided that the vital public good of education is in urgent need of resuscitation. As an educational sociologist and president of the Lebanese Association for Educational Studies, Suzanne Abdul-Reda recommends several key actions to help close the gap in education opportunities and create a more equitable and just society in Lebanon, beginning with governmental investments in the sector. “This investment should focus on improving the quality of education and increasing access to educational resources, such as textbooks, technology, and libraries,” she says. “The government should also provide financial assistance to families who cannot afford the cost of education, including tuition fees, transportation, and school supplies. This will ensure that all children have access to a quality education regardless of their family’s financial situation.”

In her view, schools in Lebanon must adopt policies and programs that promote equity in education. “This includes providing extra support to students who are at risk of falling behind, such as those who come from low-income families, those who speak a language other than Arabic at home, or those who have special educational needs. Schools should also promote diversity and inclusivity by celebrating the cultural differences of their students and providing a safe and welcoming environment for all,” she says. 

The desire to create a world where education is a right for all has motivated Abdul-Reda and a group of experts to act towards this goal. In April 2022 they founded an educational consultancy called SCOPE that provides services to empower and equip communities, schools, and NGOs working in both formal and informal educational settings. “We act through evolutionist paradigm of governance based on wholeness, trust, free information, worker autonomy, self-management, critical peer relationships, shared values, valorization of diversity and continuous learning,” Abdul-Reda says. 

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CommentEducationSpecial Report

The State of Arabic Literacy: Schools and Online Arabic Learning

by Nisrine EL Makkouk June 9, 2023
written by Nisrine EL Makkouk

Every one of you reading this today can understand this simple sentence. However, almost two thirds (59 percent) of children in the Arab world are in ‘learning poverty’—which means they cannot read and understand an age-appropriate text in Arabic by the age of 10. This is a problem for schools and parents across the Arab world, including in high income countries in the Gulf. With two thirds of the Middle East and North Africa’s (MENA) 50 million children in learning poverty, this is an urgent problem that is holding back our region’s development and progress. To succeed in solving this problem, any solution must find ways to  (1) modernize outdated teaching practices, (2) close the gap between Modern Standard and spoken Arabic and (3) leverage technology.

How do we translate that to respond to the existing needs of schools in the MENA region? Students need Arabic content that is relevant to their interests and life. They need to feel engaged in the language learning process and they need to feel that they can achieve and that success is within their reach. Meanwhile, teachers are scrambling to find the tools and resources to help them improve how teaching and learning happens. Kamkalima provides support to Arabic teachers in schools across MENA to empower existing curricula with engaging digital content, assessment and insights to drive continuous improvement in learning. We come to schools with the conviction that technology can be effective in assisting learning and improving student outcomes, especially when it is spearheaded by teachers.  

The Pandemic Imposes Change  

Schools are “late bloomers” in opening up to technology. In the 1920s and 30s, television and later radio were thought to largely replace textbooks in the future. In the mid-80s, the forefather of artificial intelligence, himself an educator, forecasted that the computer would emerge as a key instructional tool. Yet, schools remained hesitant in the integration of technology, until a global pandemic made it imperative.

The Covid-19 pandemic forced 1.4 billion school students out of classrooms and forced schools and teachers to find immediate remote learning solutions. School closures have been substantial– an average of 115 days in lower-middle-income countries according to UNESCO. And just as substantial has been the students’ learning loss. Children have lost up to two years of formal learning. Many are experiencing a regression in their educational advancement. World Bank experts have warned that the biggest side effect of the pandemic will be children’s lost learning, which is estimated at $17 trillion contruction in lifetime earnings for students currently in school.

Reports also show children’s resilience dwindling and a negative impact on mental health. We noticed this in students’ writings.  Our AI models run sentiment analysis on students’ writings to help teachers to gauge how students feel about certain topics, processes, and learning experiences. The sentiment analysis automatically clusters student writing and detects sentiment polarity into positive (+1), negative (-1) and neutral (0). Negative sentiments in student writing surged during the Covid-19 lockdown possibly indicating the impact of the global pandemic on student wellbeing.  This technology allowed us to respond quickly by introducing targeted content around Covid-19 awareness, prevention, and coping including content around mental health.

The Scramble for Solutions 

[inlinetweet prefix=”” tweeter=”” suffix=””]Demand for digital solutions exploded with the pandemic as schools scrambled for education technology. [/inlinetweet]Three hurdles would stand in the way:

Identifying the right tools: not all edtech is created equal. Technology to improve teaching and learning – which is at the heart of education – is certainly more challenging to adopt than technology to manage timetables and payment gateways. It is more challenging because it requires a paradigm shift from a teacher-centric approach to a student-centric approach. The promise of education technology lies in extending the teachers’ abilities – not replacing them – while helping them to implement and facilitate student-centric learning. What we need to see is learning that is supported by technology, not mechanically mediated by it. Technology will never replace teachers, but teachers who use technology will probably replace those who don’t.

Teacher Readiness: Teacher capacity is the wind beneath the wings of successful integration of education technology, and schools need to prioritize professional development programmes. Capacity building cannot be seen as an extra, something that teachers have to make time for on their own or spend on individually. Digital literacy is a must. Every teacher today needs the knowledge, skills, and attitudes to support effective hybrid models of teaching and learning.

Change takes time: It is easy to forget that change takes time when we live in the era of fast food, drive-thrus, diet pills, and instant messages. Change at the school level is imperative for education to remain relevant. Students change, jobs change, and the skills required for success change. Technology can now help teachers gain deeper insights into student learning and teach more effectively. With the advancements in data science, teachers can now gain deeper insight into student learning, better understand learning gaps and match learning resources and activities to student’s needs. 

Schools are beginning to change. Schools that would never have considered an online meeting three years ago are now comfortable with the idea. Teacher training sessions that could only be delivered in person to a few teachers in a single school are now delivered remotely as well as in person, synchronously and asynchronously, to support hundreds of teachers across the Arab World.

Championing Schools in Lebanon 

Ukrainian boy Danylo Titkov takes online Ukrainian studies in his room in Vienna, Austria on September 2, 2022. – After months of anguish and hesitation, the Titkov family — who fled to Vienna from Ukraine just after Russia invaded — have finally decided to stay. AFP is following the refugee family from Irpin, one of the suburbs of Kyiv that saw the worst of the fighting in the early weeks of the war, over the course of the first year of their new life in a land where a quarter of the population are immigrants. (Photo by JOE KLAMAR / AFP) / TO GO WITH AFP STORY BY ANNE BEADE – TO GO WITH AFP STORY by Anne BEADE

As we know, the education sector has not been exempt to the country’s breakdown amid the economic crisis. It has created huge challenges for schooling; from remote learning experiences, to shortages in resources, to teacher migration and children dropping out. The crisis has also led to a decline in the quality of education, with many teachers leaving the profession due to low salaries and poor working conditions. As a result, students in Lebanon are facing increasing difficulties in accessing quality education, which could have long-term impacts on their future prospects.

In 2020-21, students in Lebanon lost more than 5.5 months or 22 weeks of school, equivalent to ⅔ of an academic year, according to UNESCO, with some reports estimating over 1.2 million school-aged children in Lebanon did not receive proper education that year. Meanwhile, during that same year, Kamkalima witnessed 133,000 educational activities from teachers and students in Lebanon. Edtech solutions are not a replacement for school; however, they can provide learning continuity  as well as contribute to maintaining a sense of normalcy for students and teachers struggling to cope with frequent disruptions and challenging circumstances. 

However, in order to harness the power of technology equitably for all learners, we need “all hands on board” and we need to work together. [inlinetweet prefix=”” tweeter=”” suffix=””]We invite the educational community to continue to pilot and evaluate the use of digital technologies[/inlinetweet], such as Kamkalima, among others in challenging contexts like Lebanon, adding to the bank of knowledge about digital education. All stakeholders must prioritize investing in teacher’s digital skills and their readiness to use digital alternatives to promote remote learning. The Lebanese government’s role in providing sustainable infrastructure for electricity and connectivity must be a priority. 

As Kamkalima, we continue to support learning recovery in Lebanon in more ways than one. Between 2019-22, we have supported over 24,000 teachers and students in public and private schools across the country with free access to quality tools and resources. In addition, our entreprise supports young Lebanese university students with multiple work-based learning opportunities, including training and internships. Over the past few years, we have hosted more than 30 young people in fields of technology, languages, design, psychology, business and communication arts, helping 65 percent of them to successfully transition into employment in Lebanon and abroad.

The 2021 joint-report by the World Bank, UNICEF and UNESCO ‘The State of the Global Education Crisis: A Path to Recovery’ showed that in low- and middle-income countries, like Lebanon, the share of children living in Learning Poverty – already high before the pandemic – could potentially reach 70 percent given the long school closures and the ineffectiveness of remote learning to ensure full learning continuity during school closures.  

We always like to evaluate what we do in the hope that we learn and improve. In September 2022, at the end of a three month internship, Kamkalima asked our youngest colleagues to reflect on their learning experience. For Dana, an MA Student in Comparative Literature, “learning about concepts like ‘inquiry- mindedness’ and ‘social-emotional learning’ has been invaluable.” Aya Catherina Elias feels she was able to “take a glimpse into the future,” by working on real-life projects that build on theoretical concepts learnt in class: “I can see what it’s like to be a researcher and practitioner in my field (psychology).”  Youmna and Nour are aspiring female data scientists who consider that the most important thing they learnt was to challenge themselves and believe in their capacity.

In the midst of challenging times in Lebanon, we continue to find hope in each other.

Nisrine El Makkouk is the co-founder and chief strategy officer of Kamkalima

June 9, 2023 0 comments
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FeatureHealthcareSpecial Report

A checkup on the beating heart of healthcare

by Thomas Schellen May 3, 2023
written by Thomas Schellen

The growing impoverishment among the population means the availability of affordable healthcare has become an essential aspect of meeting basic needs today. Primary healthcare centers have emerged as an option for Lebanese struggling to access now unaffordable public or private HOSPITAL CARE. Executive visited two major centers, the Karagheusian Primary Healthcare Center and the St. John the Baptist Community Health Center, to hear about their operations.

It is a crisp spring morning. Life is awakening on the streets of Bourj Hammoud. The sun strafes the rooftops of the countless low-rise apartment buildings that huddle cheek to jowl along alleys in the densely populated town, which is an integral part of the Beirut conurbation. While shops start opening along streets that are often barely wide enough for a small truck, life is already bustling at the Karagheusian Primary Healthcare Center (PHC), an unassuming complex of four buildings tucked away in a side street near the Beirut river.

The odd journalist and even a visiting delegation from an international funder organization coming here this morning (independently from each other) are immersed in a steady stream of visitors to the Karagheusian PHC. They are locals and resident refugees seeking relief from toothaches and eye problems, mothers looking to have their children vaccinated, persons in need of medications for their chronic ailments; they are the sick, weary and the suffering of many backgrounds and communities who have made Bourj Hammoud their home and live mostly in walking distance.

“We have a multi-disciplinary team of healthcare workers, both full-time staff and physicians who work with us half-time or part-time in such a way that 30 clinics in our 500 square-meter compound are ready to receive patients throughout the day, so that our center is able to welcome 700 patients per day. This is our philosophy: we are here to provide healthcare services for all. We believe that primary healthcare should be attainable, accessible, affordable, sustainable, and continuous for all, without discrimination,” says Serop Ohanian, the center’s director.

While I have splurged 200,000 Lebanese pounds or the equivalent of about $2, on a ten-minute taxi ride coming here this morning, and whereas nearby shops – advertising apparel such as $4 skirts, $5 belts, and $6 tops – visibly seek to cater to consumers with very modest purses, those with even tighter purse strings are served at the Karagheusian for a consultation fee ranging from an amount as symbolic as 30,000 Lebanese pounds to at most 200,000 Lebanese pounds for some advanced services. The fees for the standard PHC offerings represent a meaningful sacrifice to patients here and according to Ohanian are still a barrier to too many, even as in spring of 2023, 30,000 Lebanese pounds is just a few dimes for people who have access to livable amounts of veritable cash.

That the poor and needy are present in all types of societies is a historic truism. [inlinetweet prefix=”” tweeter=”” suffix=””]The flows of the ailing never cease in Lebanon and elsewhere, but the Lebanese residents’ needs for affordable healthcare have quadrupled[/inlinetweet] when comparing present beneficiary numbers to those of 2019. More than reflecting the Covid-19 pandemic and the economic crisis, however, the rapid growth in needs commenced with the arrival of refugees from Syria around 2012. The number of beneficiaries at this PHC has exploded tenfold in the space of a decade, increasing from around 20,000 in 2013 to some 200,000 visits in 2022.

It is not in the least coincidental that the affordable provision of services at a long-standing charitable organization in Bourj Hamoud is done under a partnership of stakeholders, which includes the Ministry of Public Health, foreign donors and international NGOs, as well as the Karagheusian organization in its position as a local NGO.

According to Ohanian, the government’s growing enthusiasm for primary healthcare objectives such as disease prevention and health promotion in recent years has led to more and more synergies and partnerships between the public sector and local NGOs which have been delivering charitable works in Lebanon since the 1960s and 70s. “There is a commitment by the government to create synergies and there is a commitment from iNGOs to keep primary healthcare functioning as the best way possible,” he says.

Encased in this narrative of new synergies of social and charitable stakeholders, there is, however, a connotation of the persistent human inability to address predictable human needs without first having had to witness the impact of reiterated human decision errors. Explaining that the roots of the Karagheusian organization, which operates PHCs in Lebanon and Armenia, link back to both the early 20th century refugee experience of the Armenian people and to one Armenian family’s tragedy of losing a teenage son in the ‘Spanish flu’ pandemic, Ohanian says that “as an organization we have tasted the meaning of pandemic, and the meaning of refugees, and today, after 100 years, the history is unfortunately repeating itself. We are still seeing refugee crises and still seeing pandemics.”

May 3, 2023 0 comments
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AnalysisHealthcareSpecial Report

Lebanon’s fight against infectious diseases

by Rouba Bou Khzam May 3, 2023
written by Rouba Bou Khzam

Lebanon has been historically renowned for its healthcare system; Lebanese physicians have staffed hospitals in the Middle East and North Africa (MENA) region, while travelers have flocked to Beirut for medical tourism. For years, high class facilities and training among the country’s university medical centers enabled international standards to prevail and created a trusting and respected environment. This applied to both Lebanon’s public and private hospitals and was also demonstrable through their performance during various infectious disease challenges.

Lebanon has experienced several infectious diseases including influenza, tuberculosis, hepatitis A, typhoid fever. The most recent global health pandemic, Covid-19, saw Rafic Hariri University Hospital (RHUH) at the forefront of the country’s fight against the infectious disease. With the public healthcare system overseen by the Ministry of Public Health (MoPH), the country’s coronavirus response initially centered on state healthcare. RHUH is the largest mental health facility, and has not been without its problems: material and logistical issues, poor maintenance, and unsatisfied staff. Yet despite these setbacks, during the pandemic it transformed into the leading public hospital in the fight against the disease. Though, it should be noted that Lebanon’s healthcare system is dominated by the private sector: the country has 157 private hospitals and only 29 public hospitals, according to the MoPH. The public healthcare system is funded by the government and provides free or low-cost healthcare services, while private healthcare is often expensive, making it inaccessible to many people, particularly those who are uninsured or have low incomes. 

Lebanon’s fight against Covid-19 began with the MoPH’s operational plan which was implemented in March 2020, a few weeks after the first recording of a positive test detected in a woman who had travelled from Iran, where an outbreak was flourishing. As the government sought to contain just a handful of positive cases, restrictive measures were rapidly introduced. Universities, schools, nightclubs, bars, restaurants were ordered shut, and then in a dramatic move, the country’s land, sea, and air borders were closed and there was an implementation of a state of emergency. Citizens who had corona-like symptoms; headaches, sore throats, or fevers, were told to stay at home and avoid mingling with others. Severe cases were to be treated in hospitals. During that period, [inlinetweet prefix=”” tweeter=”” suffix=””]the government’s quick reflex in implementing containment measures was widely lauded.[/inlinetweet]

Government Responsibility

Led by now caretaker Health Minister Firass Abiad, RHUH played a vital role in caring for coronavirus patients and leading the crisis response. As a 430-bed public hospital, RHUH needed to step up to the challenge and ensure its services could meet those most in need. A collaboration with the World Health Organization (WHO) boosted its services, thanks to the provision of technical support and training to staff, as well as through medical supplies, including personal protective equipment, and creating public awareness campaigns. Despite this external support, the hospital, alongside other public hospitals, was suffering from the country’s dollar shortage – a ramification of the economic crisis – which was hindering the ability to import medical supplies.

Human Rights Watch (HRW) reported in March 2020 that the government had only paid 40 percent of the dues owed to RHUH from the previous year and was yet to make any payments for 2020. Public hospitals in the north of Lebanon also said they had not received all their reimbursements from the government. Private hospitals, though not at the full mercy of the state, were not exempt from dealing with it. The government owed private hospitals an estimated $1.3 billion worth of unpaid bills since 2011, HRW noted in the same report. The financial imbalance meant the hospitals were struggling to maintain quality services just as the pandemic took hold.

In fact, this precarity was just the start of a long decline in the quality of the health sector. One of the major impacts of the economic crisis has been the dearth of drugs. Despite the government’s subsidy policy, basic painkiller tablets to cancer medication have been at times impossible to source. There have been widespread reports of patients and their families scrambling to find alternative sources for drugs; reaching out over social media, scouring the black market, or asking friends and relatives abroad. These stories epitomized the broken state of the health sector: a population left with no alternative but to resort to private initiatives to meet needs.

With this in mind, Lebanon’s ability to address infectious diseases like Covid-19, as well as cholera, tuberculosis, typhoid or hepatitis A, is dependent on state finances or the involvement of external aid. This was tested last October, when cholera, an acute diarrheal bacterial illness, was detected in Lebanon for the first time since 1993. It was considered a major regression in public health and was believed to have crossed the border from Syria, where an outbreak was underway. Cases were quickly identified in Akkar, the Bekaa valley and the Baalbek-Hermel regions, mainly in Syrian refugee camps, where living conditions are squalid and access to clean water is not guaranteed for the many thousands of families living there.

Like the coronavirus, the cholera outbreak was another instance of the country’s reliance on external organizations, such as the WHO. Due to the WHO’s involvement, the cholera outbreak was able to be monitored and controlled, and vaccines were brought in by the WHO and distributed among refugee communities. But such measures have been simply band-aid responses, and health experts have warned that without a thorough reform of Lebanon’s water system and improved sanitary measures, there remains a risk of future disease outbreaks. The crisis also highlighted that [inlinetweet prefix=”” tweeter=”” suffix=””]without this external support, the government alone would struggle to contain the disease.[/inlinetweet]

Dr Aline Mouchaham, a specialist in regenerative medicine, says disease outbreaks could become more common: “The lack of adequate funding and resources has resulted in a shortage of medical supplies, equipment and testing kits,” she tells Executive. Mouchaham also says that disease outbreaks are likely to occur in areas where there is conflict, inadequate waste-water management, contaminated water, and accumulations of garbage. These conditions are often prevalent among Lebanon’s poorer communities, who live in overcrowded and unsanitary conditions, which can increase the chance of infections spreading rapidly, she says. The situation is worsened by the lack of access to health services for these communities. “It is not surprising that Lebanon experienced a cholera outbreak when large numbers of displaced individuals lack access to clean water, proper hygiene, and healthcare,” Mouchaham says.

The blind spot: the lack of scientific research

Patients infected in an outbreak of Vibrio cholera receive treatment in a mosque hall converted into a field hospital in the town of Bebnine in the Akkar district in north Lebanon on October 26, 2022. (Photo by Ibrahim CHALHOUB / AFP)

“It is disheartening and astonishing to witness individuals prioritizing their personal beliefs over scientific evidence and expertise, especially in times of crisis,” Dr Tamara El Zein, the secretary general of the National Council for Scientific Research, tells Executive. El Zein points out that the lack of awareness and access to reliable information about diseases can have significant implications for public health. In the context of infectious diseases, this can lead to delays in diagnosis and treatment, and ultimately contribute to the spread of disease. 

“For example, during the Covid-19 pandemic, there were concerns about the accuracy of information being disseminated on TV and social media, which may have contributed to confusion and mistrust among the population,” El Zein says. The debate in Lebanon about the Covid-19 vaccine, which was warped by fake news and disinformation campaigns, highlighted a broader issue in public health about the importance of access to safe and reliable information. “Some people believe that vaccines can cause harm or are part of a larger conspiracy to control the population,” El Zein says, before adding: “However, these beliefs are not supported by scientific evidence, and it is important to look at the history of infectious diseases in Lebanon and the lessons learned from past experiences.”  El Zein touches upon a concern for the MOPH to tackle public misinformation and the need to place greater resources on awareness and information campaigns.

Past disease outbreaks in Lebanon have surfaced from a variety of factors, including poor vaccination coverage, inadequate health infrastructure, and a lack of importance placed on vaccination and disease prevention. “Without a connection between scientific research and society, individuals are limited in their ability to educate themselves about the advancements in science, particularly with regards to vaccines and their benefits,” El Zein says.  

Prioritizing scientific research that matches the challenges is essential, according to El Zein. More targeted and impactful research can lead to the development of expertise and knowledge in specific areas. “For example, Lebanon now is facing a high incidence of cancer cases; it would be more beneficial to invest in research that focuses on cancer treatment rather than research on artificial intelligence,” El Zein says, noting how research can have a direct benefit to the population’s wellbeing.

Strengthening the scientific culture in Lebanon can have a positive impact on the status of the public health system. For example, through the promotion of science education and “encouraging scientific inquiry and supporting research institutions.” This can be achieved through partnerships between academia, industry, and government, as well as promoting interdisciplinary collaboration, El Zein says. In addition, supporting development of research infrastructure and increasing funding for research can enable the scientific community to address the challenges posed by infectious diseases. “By prioritizing scientific research and promoting a culture of evidence-based decision-making, Lebanon can better protect its citizens from infectious diseases and build resilience against health threats,” El Zein says. 

Community efforts

The Covid-19 pandemic brought to light the importance of community awareness, engagement and response in public health campaigns in responding to infectious diseases. Taking recent infections as examples, one of the main drivers of cholera and coronavirus’ rapid spread was the lack of communication and awareness among the population. “This is a reminder that [inlinetweet prefix=”” tweeter=”” suffix=””]we need to be ready to respond to outbreaks at all times, [/inlinetweet]and that means investing in things like clean water and adequate healthcare facilities,” Mouchaham says.  

Regarding community engagement, Mouchaham notes: “It involves educating the public, clarifying any doubts or misunderstandings, and engaging community leaders and organizations in response.” Individuals must also do their part by practicing good hygiene, wearing masks, and social distancing. Infectious diseases can be spread easily and quickly, and each person has a role to play in preventing their spread. If individuals take responsibility for their own health and wellbeing, it can ultimately help to reduce the burden on the healthcare system.  “Outbreaks can be stressful and challenging but is important to remain focused on the goal of protecting public health and working together to overcome the challenges,” Mouchaham says.  

May 3, 2023 0 comments
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CommentHealthcareSpecial Report

Private health care at risk: challenges and solutions

by Roula Gharios Zahar May 3, 2023
written by Roula Gharios Zahar

According to several international studies published by the World Health Organization and Bloomberg, Lebanon’s healthcare was ranked in the top tier class among healthcare systems in the world in both 2015 and 2017. To illustrate this point, the Lebanese living abroad prefer to be treated in Lebanese private hospitals as the quality of care is comparable to high international standards and waiting times to perform procedures are close to zero (it is even several months in some developed countries such as France, Canada and the UK).

Thanks to its high ratio of qualified physicians, private investment, hence the availability of the latest treatments and medical equipment, Lebanon was able to score extremely well in all major international health indicators such as life expectancy, maternal and infant mortality, and disease control. This situation was key in addressing the Covid-19 pandemic which was relatively well managed in Lebanon. For these reasons, the consequences of the economic crisis took longer to impact the healthcare system.

The 2020/21 subsidization policy of the Central Bank provided short-lived relief, though it was an expensive policy for the government and caused shortages, imbalances, and the hoarding and smuggling of medication. Today, the Lebanese health sector remains among the top performers in the country in terms of quality medical care and the availability of services, although it is facing serious threats. 

Hospitals, patients out-of-pocket

In Lebanon, a large portion of the population historically has been covered by employers of the private sector, while the other portion is covered by the government and individuals. As all public services (including the National Social Security Fund) have not adequately adjusted their payments since the Lebanese pound’s decline, most Lebanese are left with practically no medical coverage. The absence of the NSSF and governmental co-payment coverage, along with the soaring costs of hospitalization, is resulting in substantial out-of-pocket payments for hospital services, exams, and medication, jeopardizing the access to care for the poor, the very ill, and uninsured population. Along with this financial coverage issue, the sector witnessed shortages in medication due to the unintended consequences of the subsidization policy of the central bank. The high cost of oncology drugs and the partial lifting of subsidies in 2021 has left countless cancer patients without treatment and dialysis patients with the terrible prospect of having no access to care.

Along with financing problems and medication shortages, another serious threat to the healthcare system is the brain drain, as physicians and nurses are departing “en masse” towards better-paid jobs and better living and working conditions abroad.

Private-sector healthcare providers nevertheless have been innovative in circumventing the consequences of the crisis. Better salaries and job flexibility – such as the ability to partially work abroad – have been offered to healthcare workers. Prices have been revised to adapt to the high costs. Solar panels have been installed to reduce energy costs. Mergers and acquisitions have also been trending in the sector. Cash flow has improved by the de facto reduction in payment delays resulting from cash transactions. By the end of 2021, the private insurance companies converted their prices into US dollars and had obtained substantial discounts from hospitals, allowing them to gain important market share and provide coverage to middle- and upper-class populations.

At Mount Lebanon Hospital University Medical Center, there has been a massive brain drain. Since 2019, 120 physicians and about 150 nurses have left. The hospital has been fighting to avoid shortages in life saving medication, which it did at a high cost (by direct imports and high inventory which ultimately resulted in expired products being discarded). For the past two years, chemotherapy drugs have been unavailable for numerous patients and remain so today.

In order[inlinetweet prefix=”” tweeter=”” suffix=””] to retain our existing staff, salaries have been offered in US dollars,[/inlinetweet] alongside medical insurance and schedule flexibility. The hospital has also had to reduce the number of beds by 20 percent, down from 250. Another catastrophic issue that we are facing is the unaffordable costs of dialysis sessions, which cost hospitals $60 per session and are currently reimbursed at 2.5 million Lebanese pounds (equivalent to $25 per session). Several attempts have been made to increase the prices and index them to the dollar and improve the payment delays to prevent further losses, but negotiations are stalling and payments are pending since the beginning of 2023. The official reason is that the NSSF board is not meeting to renew the budget. Dialysis patients are extremely vulnerable and cannot skip any of their sessions and are in an absolutely devastating situation. 

The hospital is looking for an alternative financing scheme through private insurances, international franchising projects and diversification into paramedical activity lines, in a hope to overcome these challenges.

Alternative insurance schemes

Several initiatives are being studied by an expert group at RDCL – the Lebanese Business Leaders Association – health GPA committee, whereby the private sector is proposing a project that conceives complementary, employer-sponsored, mandatory private insurance for the employees of the private sector with proper governance. 

Despite these efforts, the challenges resulting from the Lebanese pound devaluation and the slow pace of change in prices of healthcare services is putting pressure on hospital costs. The increasing cost of fuel, supplies, maintenance, and salaries, along with shortages in medication, and shortages in qualified healthcare workers are creating worrisome challenges. In such precarious conditions, hospitals will no longer retain competent healthcare professionals, be able to pay maintenance fees, or update their equipment.

This will cause a contraction in the sector, leading hospitals to reduce the number of beds or even to close while avoiding any additional investment in equipment. The aggregate offer for healthcare services will decline, driving costs higher and reducing quality. We will end up with the waiting queues that the Canadian, British or French experience. This is a serious threat to the population and will foremost affect vulnerable groups, but also citizens’ ability to work, produce and grow. It may well induce social unrest. 

Several  objectives should therefore be envisaged for the long-term sustainability of the system:

1- Guaranteeing access to basic healthcare for most of the Lebanese population – in an optimized and equitable manner – without having them endure financial hardship;

2- Ensuring medication availability and access throughout the country;

3- Providing a healthcare workforce retention strategy to prevent further losses of human resources;

4- Supporting and upgrading the healthcare system’s infrastructure to ensure continuous quality care.

The Lebanese health sector deservedly has been described as a flagship in the region. Before it is too late, this vital sector should be rescued from the claws of the financial and economic crisis.

Roula Gharios Zahar is co-founder and deputy general director of Mount Lebanon Hospital

May 3, 2023 0 comments
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HealthcareQ&ASpecial Report

A glimpse into the future of public health?

by Thomas Schellen May 3, 2023
written by Thomas Schellen

At the nexus of the Lebanese health system with its numerous components and competing private stakeholders, and as a historic refuge of last resort for those in desperate need of medical services, the Ministry of Public Health (MoPH) represents both all that is excellent and all that has been deplored in the narrative of the people’s experience with medical treatment, care, and prevention. At the conceptual core of the ministry’s – and the entire health system’s – future today towers the National Health Strategy: Vision 2030. To fathom its promise, Executive sat down for an in-depth interview with Dr. Firass Abiad, the caretaker Minister of Public Health.

E  The National Health Strategy Vision 2030, along with many goals, makes a strong case in presenting past achievements of the Lebanese healthcare system, demonstrated in improved health indicators in the years up until 2020, but also reveals numbers related to shocks suffered by the system in recent years. For example, the Vision 2030 document states that “excess mortality rates of 15.4 percent in 2020 and 34.4 percent in 2021 were recorded mostly due to non-Covid 19 related illnesses.” Did this excess mortality rate already reflect the economic crisis in its asperity?

Probably. It is very clear that starting with the financial crisis in 2019, patients faced many limitations to access [of health services]. We had already seen this at Rafic Hariri [governmental hospital] where we were noticing more late presentations among patients that were coming to the emergency room. The second thing we noticed was [an increase in] the average size of the tumors we were operating on. The reason for that also was probably that people were going to the emergency room later in their disease. Especially early in the crisis, patients had almost no access to their money and access to care became a problem. This is reflected in many of the numbers that we have seen.

E  Do you assess this high excess mortality as a problem for years to come or do you expect it to recede again?

[inlinetweet prefix=”” tweeter=”” suffix=””]There is no doubt that our health system is more fragile than it was. [/inlinetweet]But we are seeing that the health system is still coping in different respects. With all this crisis, it is amazing that the health system is still standing on its feet. But we are witnessing that people have less and less financial protection of health and have to pay more and more out of pocket for their healthcare.

That means that especially the most vulnerable will have limitations in access to care; and this is worrying because it might be reflected in excess mortality.

E  Universal health coverage is a declared target of Vision 2030. But was it not so that a form of universal health coverage was present before the crisis?

The health packages available [back then] were such that the Lebanese had a lot of access to advanced care, whether at the hospital level or at the level of innovative medication. What was unfortunate was that there were areas where people were covered less, especially when it comes to secondary care and also to primary care. The vast majority of the Lebanese were not enrolled in primary healthcare centers or had a primary healthcare physician. If they got sick, they would directly go to a specialist. We know that this is much more expensive than [care is] in a system that has set up a primary healthcare (PHC) network. This is why one of the major points in the national strategy is that we need to shift more to a PHC-based health system, and we are talking about preventive care and primary care more than about innovative medicines and hospitalization.

E  How many primary healthcare centers are currently under the supervision of the MOPH?

It has gone up to just above 270.

E  I was told at one PHC that the number of annual visits has increased to over 200,000 from about 49,000 a few years ago. Is this a typical rate of increase for the PHC system as a whole?

Yes, it has tripled or almost quadrupled in most of the entire system.

E  Are there plans to further expand the PHC network?

What we are working on is sustainable financing for the PHC. We are very weary of expanding the network without proper financing that will allow us to have sustainability.

E  A central financial insufficiency of the healthcare system in general seems to be that funding is today largely dependent on the international community and donors.

That is correct, and especially so in PHC. The primary healthcare program is heavily supported by the international donors. This is welcome but it is unsustainable. Therefore, we have been working on a transition where Lebanon is able to put more support within the PHC system.

E  Is there a figure on how much annual financial support has reached the PHC system from all the diverse international donors and funders?

We believe that it is anywhere between $70 to $100 million annually. [Taking into account the global situation], it is clear that there are other crises, donor fatigue, and other priorities that prohibit expecting this to continue in the long term. That is why as the Lebanese government, we want to move more and more into supporting [our PHC system].

E  The Vision 2030 document speaks of integrating “WHO building blocks”, “essential public health functions” and frameworks of six or seven health system components, or perhaps what one could call distinct systemic pillars that compose a well-functioning health system. Would you please explain what the frameworks refer to and how they rank in priority?

I like to put them as five areas as I like to combine the financing and governance. Thus to me, the five pillars are financing and governance as one pillar; then the second pillar of the health services delivery, which moves more towards having the primary healthcare program as the cornerstone; the third is the health security, which is reflected more in the public health functions at the ministry, such as emergency preparedness, the central public health laboratory, and quality control. The fourth pillar is the healthcare workforce, which we believe is going to be the biggest challenge in moving forward, and the fifth one is the digital transformation.

E  Is this characterization of a health system coming from the World Health Organization (WHO) and could it therefore be interpreted as mental framework that was superimposed as an international theoretical model on the Lebanese National Health Strategy?

The WHO was part of the process. This [National Heath Strategy] was a document that we wrote together between us and the WHO, and our vision on the future of health in the country is very much aligned. But it is not just a WHO document. It is important that this is a document that is fully endorsed by the ministry and fully owned by the ministry. The ministry had several active participants in the process of coming up with this document.

E  You noted that the component with the greatest challenge going forward is likely to be the human capital pillar. Which pillar would you say will be least problematic?

I think all of them are challenging, simply because we are working in a resource-poor environment. One of the things about systems in health is the word “interdependence.” Each one of these pillars depends on the other and has an impact on the other. For me, it is not anyone of these pillars that is easier than the others, but I think that the human capital is always going to be a big challenge, simply because it is a universal challenge and not just a Lebanese challenge. We are unfortunately seeing an attrition of the human capital in health [everywhere] and this makes it even harder for Lebanon to address. Especially within the current circumstances, we are seeing a lot of people who want to move out [of Lebanon].

E  If one looks at some incongruences in the health system that are not directly covered in the five structural components of Vision 2030, one of the issues flagged in the document were supply-side driven, exaggerated expectations by patients. Are you still facing strong patient demands for branded import medicines that carry higher costs than the equivalent generic medications?

This is the issue of supply-induced demand, which is one of the areas which we are addressing in our drug policy. We have moved forward quite well in that direction of better managing our drug bill. If you look at our bill for [medical] drugs, Lebanon used to spend almost $370 per capita before the crisis. That is almost as high, if not higher than the average in OECD countries. Denmark, for example, spends $380 [annually per capita] in average on medications. This [sending pattern] is obviously something that could not be continued after the financial crisis. However, despite the fact that we could bring our drug bill down, when considering that Lebanon is now a low-middle income country, it is still higher than what is expected. The way we have worked around our drug bill was first concerning generics. [inlinetweet prefix=”” tweeter=”” suffix=””]We brought a lot of generics into the country, and we have been advocating for the use of generics.[/inlinetweet] I think also that people have become very price sensitive and [shifting to generics] is something that resonated well with the people. The second was that we introduced protocols and guidelines for the use of innovative medications. This has also helped us control how much we pay for those medications. Finally, we have been working very hard on supporting our local pharmaceutical industry. We have seen their market share – in the products that they produce – move from almost 20 percent to 75 percent.

E  On the flipside of the equation, are the domestically produced generics getting enough acceptance and respect in the population?

Gradually, they are; the proof is that their market share has increased. Clearly, people are buying those medications. Knowing that the other [imported brand medications] are available, I think that [generics] are being well received as people are trying these medications. These are some of the opportunities that are lying in the crisis.

E  Is there a number on the current per-capita spend on medications?

Our estimate is that it is almost $170 per capita per year now, and our importation bill is down by 50 percent.

E  Does that mean that our lower importation bill of medication is not an indicator that the availability of medication is lower by the same degree?

Especially when it comes to most of our chronic diseases, patients are able to find their medications. I [note that] shortages of medication are now being seen all over the world because of problems of interruption of logistics and other reasons. In Lebanon, we have been able to address many of the shortages that we have had previously, and from where I can see it, the situation is better.

E  The Vision 2030 document mentions several committees and funds to be established, such as a health financing and coordination committee, a health insurance authority, a Health Crisis Response and Recovery Fund and a Health Crisis and Recovery Council. What is that Health Crisis and Recovery Council about?

This is part of the first pillar, which is governance and finance. All of this stems from the fact that if you look at the way in which we governed health expenditure in the past there was a lot of fragmentation. What we wanted to achieve in this difficult time was create a more participatory decision making to allow everyone to have ownership and understand what we are doing. That was why there is a lot of talk about the Council and about bringing people together.

E  From the perspective of universal health coverage versus the idea of universal health insurance, how much would it cost annually to have universal health coverage in something like two years from now?

Let us compare this with [the situation in] some countries around us. In Turkey, the expenditure per capita was around $370 and they were providing universal health coverage. At the same time, Lebanon was spending around $680 per capita, and we were not providing universal health coverage. This attests to a lot of inefficiencies in the expenditure. The crisis that we are passing through is an opportunity for us to address those inefficiencies. The challenge is how we can work around those inefficiencies without limiting access, especially to the vulnerable for whom access to care is becoming much more difficult.

E  Leaders in the private insurance industry told me of plans for gradually filling the gaps in affordable access, beginning from filling the gap between health costs and the offerings of the NSSF. How do you view such concepts?

[inlinetweet prefix=”” tweeter=”” suffix=””]We have been working with the private insurance [industry] on several different schemes,[/inlinetweet] some of them relating to private healthcare and some to insurance, whether a complementary insurance or introduction of micro-insurance schemes that we are seeing in other countries that are in the same position as Lebanon. It would be interesting to see if we could agree on some of those.

E  Do you have any models in mind that are successful in other countries that you think Lebanon could emulate?

There are several models, but the issue is that there is no universal model that everyone is following. Each country is creating a model that is customized to its needs and to its resources. The problem with Lebanon is that we are a country that is in rapid transition, which we have not finished. This makes it more difficult to create stable programs, because of the day-to-day changes in the situation.

E  Among the many levels of transition, how could the human capital at the MoPH transition into a situation with enough supply of qualified employees and civil servants?

We have been working on this with some of our international partners, but it requires a lot of development funding. Unfortunately, in the current situation, not much funding is allocated to development. Most of the allocations that are made are going to humanitarian support. This has affected our ability to build capacity or do task shifting and other things that we wanted to do. We hope that now, with the introduction of our strategy that makes visible to everyone what we want to do, international partners can come and help us with these things.

E  By how much has the staff at the MoPH decreased if one were to compare the levels at the end of March 2023 with those at the end of March 2018?

It is very difficult to say. If you are talking about the MoPH itself, I would say around 20 percent. But if you look at the government hospitals, the number might be even higher than that.

E  Does a 20 percent contraction in public health staffing at MoPH or government hospitals signify a severe attrition of human resources?

Twenty percent might not sound like a lot, but if you look at many of those who left, they tend to be the people with the higher skills. Thus I think that the impact of those who have left is much larger than what the number would suggest.

E  One of the intrinsic problems in the Lebanese political governance system, which also appears to affect the MoPH, is that ministerial chairs have been more of hot seats than places where you can develop a strategy over the long term. Is this a problematic factor for the new National Health Strategy?

[In most countries] ministers come with their mandates, but a lot of the longer-term work is done by the [senior ministry officials] and civil servants. Lebanon has been an exception, especially post-Taif, where a lot of the problem was with the ministers who not always were people coming with the right background to take a certain sector forward. Irrespective [of that], about your point regarding the hot seat, I think that with the crisis, that seat is extremely hot at the moment. I would also say that within the crisis lies an opportunity for change and that is why [we have] the National Health Strategy.

E  You have been described to me by industry leaders, and have even been portrayed by some media colleagues, as very clean, performance oriented, and competent. Did you have to take a crash course in politics in order to be the minister?

In politics? I took a crash course in public management when I managed Rafic Hariri Hospital for six years. Managing within the public sector has its own challenges, which is something you do not see in private sector management. I think that the time I spent managing Rafic Hariri University Hospital, which is the largest public hospital in Lebanon, during different crises, including the Covid crisis, were good preparations for the job I am doing now.

E  You wrote in your introduction to Vision 2030 that a “high-level political will” will be needed for passing this strategy into legislation. Is there enough political will on the horizon?

At the end of the day, it is in their interest even for politicians for the population to receive health services. From that aspect, I don’t think that there is political will not to provide services. The question is if there is a political will to make the required sacrifices. For example, when we talk about unification of public guarantors, each public guarantor is obviously a fiefdom and when you talk about unification of this, there are many political interests that have to be sacrificed. Also, when we talk about efficiencies, that will affect employment, performance, and a lot of the contracts that are in place. All of this will require some kind of political support. But what is important is that without those reforms, the system will stay broke. The clear message of the health strategy is that it is not an optional strategy. It is a mandatory way forward, especially within the context of low resources.

May 3, 2023 0 comments
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HealthcareOverviewSpecial Report

Market solutions for public goods

by Thomas Schellen May 3, 2023
written by Thomas Schellen

The proverbial Lebanese entrepreneur is nothing if not agile and adaptive. She or he is a dealmaker par excellence and almost genetically primed to spot opportunities and seek to exploit them. Rules and processes are guidelines more than legal and cultural straitjackets that hold our archetypical entrepreneurs back from the pursuit of business and profit. Thus, whether you encounter them as a theoretical model of behavior or in real life, Lebanese entrepreneurs exemplify keen business senses similarly to any entrepreneur around the world, but just a little more so.

By contrast, the stereotypical setting of the public sector is institutional, inherently cautious and beholden to legal precedents, policy making entitlements and bureaucratic stipulations. When compared with the private sector’s hunger for immediate gain, it moves at a snail pace. The Lebanese public sector, which in addition to the globally common public sector inertia, is infested from bottom to top with partisan identities and competing interests and has managed to make public administrations of other countries look like racehorses.

Despite their many divergent aspects, public and private are today understood to be indispensable partners in systemically important economic systems – including the management of public goods. But is the traditional Lebanese entrepreneurial mold conducive to the creation of good partnerships with a public sector that is still far from formulating a constructive national political will? The question is increasingly critical for a health system whose previous formulas of fragmentation, inefficiency, overlap, and competition by multiple self-interested stakeholders has proven invalid.

The question seems today increasingly relevant even in health concerns that are found on the periphery of a universal care model. Jad Rizk is a seasoned Lebanese entrepreneur who has spotted a problem in the wider health system that he sees as a profitable opportunity. “I am developing a high-end retirement home,” he tells Executive.

Utilizing an existing $5 million hotel property, his plan is to invest $4 million into a refurbishment and expansion that will yield in the first phase 70 rooms for single or double residency of retirement-age Lebanese who will have access to nurses, medical care and a wide range of social amenities, all in-house. The project is planned in three phases, the first of which is the conversion of the existing hotel for opening around the first quarter of 2024 under the name ‘SK Retirement Life-Style Suites’. In later phases, the facility will add 60 rooms and then again 40 chalet-style apartments.

Partnership with a home care services company, the part-time contracting of doctors and other medical staff, and agreements with insurance companies, are either existing or being explored, Rizk says. Conversely, other than obtaining necessary state permits, the one thing that he would not do is venture into collaboration with the state for providing elderly care. “Anything that has to do with the government? Of course not,” he exclaims, pointing to many bad experiences his business ventures have had in dealing with the public sector.

With price tags of up to $1,800 per month for a couple’s full-service residency, the addressable market for the project is both affluent and narrow. “What we are trying to do for expatriates is provide an alternative to ‘warehousing’ old people, or putting them in places to die there,” Rizk says, arguing that this care offering for their senior family members would at the same time liberate the diaspora members of feelings of guilt, and give them an investment opportunity towards their own future care needs.

Having worked on the project since the second half of last year, Rizk goes on to say how he conducted market studies among his prime target group of Lebanese expatriates (in the Gulf region and elsewhere) and received 70 percent positive responses from diaspora Lebanese who are eager to find care facilities for elder family members, many of whom have been deprived by the Lebanese economic crisis of their social interactions and mobility. Undeniably, Rizk has an entrepreneurial market solution to a problem involving the public good of health.

A towering need

From the perspectives of several social and economic business leaders to whom Executive mentioned the project, comments were that such a project may indeed be economically interesting. However, they also noted – some of them in addition to voicing fundamental concerns about retirement homes as often flawed businesses and imperfect societal alternatives to functioning family units – that a high-end retirement home project at this time does not meet a major societal need in Lebanon. Yet the fact that a niche market for luxury retirement homes is seen as interesting by 70 percent of expatriates polled for their responses to such a proposition, illustrates how market logic can work and mobilize investments for a private sector project. This is even at a time when the imperative of broader social safety is still languishing far below the threshold of an inclusive net with mandatory and inclusive coverage of health needs of residents of all ages.

However, this once again illuminates the social distortion factor of market logic that one can see as an historic impediment of the Lebanese health system. As private operators from the start of the post-conflict reconstruction time in the 1990s latched onto earnings opportunities in medical provision, [inlinetweet prefix=”” tweeter=”” suffix=””]it can be argued that the increase in private sector offerings was a mixed blessing.[/inlinetweet] New medical offerings of private clinics and hospitals were accompanied by accommodation options of different room categories whereby non-medical services enabled private hospital administrations to level charges that only the affluent could pay. Specialized treatments or innovative procedures, machine-intensive diagnostics using the most sophisticated scanners, and branded drug recommendations with a bias toward expensive imported medications all contributed their share to the boosting of health expenses to developed-world levels approaching nearly 9 percent of GDP by the mid-2000s. This was even as the high out-of-pocket contributions and the fragmentation of medical care packages in the first two decades of this century presumably dampened some moral-hazard factors seen in health systems with broad entitlements to care.

Today, as it is undeniable that trust in the Lebanese state’s political readiness for delivering reforms and urgently needed services is exceedingly scarce and doubtful alongside the pernicious total vacuity of political promises during all stages of the economic crisis, several strong factors are pointing to the importance of redrawing partnership paradigms for public, private, and community collaborations. This is especially relevant regarding society’s public goods, of which health is as weighty for the short-to-long term fate of Lebanese society as education is for the long-to-short term.

Global principles and local specificities both come into play as factors here. To summarize them in a short list, one global factor in support of an intensive discourse of public-private and public-private-community partnerships (PPP and PPCP) in the health sector, is the maturing of the principle of PPP from lessons learned worldwide. From failed and successful partnerships over the past few decades, a local collateral benefit of that factor is that PPP has wide support among local health system stakeholders and reform advocates.

Another weighty pro-partnership argument is that unstructured past coexistence of public and private health approaches – in many ways the opposite of an ordered, transparent, and contractual PPP approach – has cost Lebanese society, due to health system inefficiencies and public-private dichotomies in the provision of public goods over the past 30 years. A financial argument further along this line of reasoning is that investments with a PPP approach open new access to finance options, whereas financing of the National Health Strategy through anything but inclusive, innovative and transparent methods or unsustainable betting on concessionary loans and grant pledges by international development finance institutions and foreign governments, appear today as solid as betting a trillion lira on a roulette payout at the Casino du Liban.

Lastly, the perhaps most compelling practical argument from a macro-social policy perspective for the pursuit of public-private partnerships for Lebanon’s public goods is that[inlinetweet prefix=”” tweeter=”” suffix=””] this country’s private sector is forever racing ahead of the public sector [/inlinetweet]in improving its productivity and performance, with the ongoing resurgence of health and pharmaceutical manufacture being a perfect example.

Private stories of excellence

Arwan received WHO accreditiation  and provides WHO-compliant facilities

The Lebanese pharma producers could meet a high portion of local drug needs during the crisis, ramping up their market shares. “Before the crisis, Lebanese pharma manufacturers used to cover only about 8 percent of the [domestic] market. Now we are around 40 percent of the entire market, but we do not produce everything. If you take the pie of what we are producing as Lebanese manufacturers, we are covering around 80 percent of the market demand for the products that we produce,” says Ruwayda Dham, Ph.D., vice-president and managing director of pharmaceutical manufacturer Arwan Pharmaceutical Industries and board member of the Syndicate of Pharmaceutical Industries in Lebanon (SPIL). According to her, the coverage ratio of local pharmaceutical needs with local production more than doubled from 34 percent in the years before the economic crisis.

Dham emphasizes that meeting the needs of the local market is something that all member companies in the pharma manufacturers’ syndicate are committed to do. While profitability concerns and frustration with delayed or broken state promises are motivating them to look at export markets, manufacturers have a moral stake in their home market and also have invested too much into building their positions in Lebanon for them to cede their hard-won market shares to manufacturers of generics from lower-cost production countries. “[inlinetweet prefix=”” tweeter=”” suffix=””]We will not leave what we have established here up for others to grab. [/inlinetweet]We never export at the expense of the needs in the local market. All of the SPIL companies have committed to the priority of satisfying the local market,” Dham tells Executive.

The numbers she provides on the increasing role of domestic pharma manufacturers are the same as the ones cited in the National Health Strategy: Vision 2030 document. On the distribution side of the pharmaceuticals supply chain, they are also corroborated by non-profit partners in the health system. Lina Traboulsi and Guita Abou Haidar, the quality assurance pharmacist and chief pharmacist supervising the central drug warehouse of the Order of Malta’s (OML) primary healthcare (PHC) network, confirm that most drugs in the warehouse – which do not include injectable drugs nor oncological and psychotropic ones – are sourced from local manufacturers. “Of the drugs that we procure from the local market, 80 percent are produced by local manufacturers. But we have products that we receive as donations from abroad, which used to constitute a good portion of our stock,” Traboulsi says.

Their commitment to satisfy the Lebanese pharmaceutical needs as much as possible does not mean, however, that a pharmaceutical manufacturer such as Arwan is resting on their laurels of their recently improved domestic market share and exports-shy orientation of the past few years, which actually meant that some products incurred losses because of cash flow issues and price divergences rooted in the huge volatility of the Lebanese pound.

For the current year, the company’s expectation is to operate without losses and aggressively pursue export earnings. “Our plan for 2023 is to sell 55 percent of our products in Lebanon and 45 in exports,” Dham says, emphasizing that in addition to the growing interest in Arwan’s product range of injectable drugs by hospital clients in the Arab region as well as African and Eastern European markets, investors have shown interest in the company.

While the market positions and production capacities of pharmaceutical manufacturers are improving gradually, there is, however, also no doubt that the pharmaceutical needs of Lebanese patients remain under-served and require more local supply. According to Abou Haidar and Traboulsi, the drug warehouse they are managing serves the needs of OML’s national network of PHC centers. OML primary care distributed 1.7 million units of medication in 2022 and the need is still growing, while the supply is not always keeping pace. “With the increasing number of beneficiaries and the increasing demand, the rotation of our stock is very fast,” the pharmacists say, adding that the OML network’s projected need for medical drugs this year is much higher when compared last year.

They also say that the predominance of locally manufactured drugs in their stock is a reversal of a previous pattern under which until mid-2022 in-kind pharmaceutical donations coming from abroad accounted for up to 70 percent of the stock at the warehouse. The shift to locally produced drugs correlates positively with both the improved value chain position of local pharma companies and with an attitude change among Lebanese patients who now welcome any medication. However, it also reflects the shifting priorities of European donors in the face of other crises, such as the Ukraine-Russia war, and budget restraints on the side of international NGOs. The drug supply for primary healthcare beneficiaries around Lebanon is further complicated by temporary disruptions in the provision of some essential medications by the Ministry of Public Health (MoPH).

Out of the funding abyss

Nabil Khairallah, a dentist at Order of Malta’s Primary Healthcare Center

To progress on the financial management side from today’s health system which is in every respect – from the supply of drugs to the securing of funds for generators at primary and tertiary healthcare providers – dependent on international donors’ good will and hard cash will require integrated solutions for to cover costs through a new public-private insurance partnership, explains Elie Nasnas, a long-standing leader in the private insurance sector of Lebanon.

[inlinetweet prefix=”” tweeter=”” suffix=””]According to Nasnas, coverage of health insurance needs is part of an economic and social revival plan[/inlinetweet] for the Lebanese economy that is being prepared by the economic associations of Lebanon. “We need to regulate all the existing schemes of healthcare provision, such as charities and primary healthcare centers by long-standing NGOs and make this into a scheme that will align for all the citizens,” he tells Executive.

He concedes that universal health coverage containing an element of basic, ideally mandatory, health insurance is an ambitious vision under the circumstances. It would have to be achieved in a stepwise approach, which he suggests can commence by addressing gaps between the medical coverage provided by the National Social Security Fund (NSSF) to enrolled Lebanese employees and the actual payments required by hospitals. “Today the offerings of social security are very low compared to what hospitals are asking. Our view is that the private sector needs to fill the gap in order to ensure the access to healthcare for the maximum number of Lebanese citizens,” he says, adding that increasing numbers of employers – driven by concerns over employee productivity and retention – are keen on securing such insurance covers for their employees.

Under the initial concept of such an insurance that would augment the NSSF scheme, all employers should have been obligated to acquire for their employee’s health insurance covers with dynamic tariffs and benefits that are determined by what the NSSF provides. However, Nasnas admits that discussions have already shown that institution of a mandatory cover under a new law would be very difficult and likely not be approved by lawmakers.

Noting that concerns over an extension of any mandatory scheme to public sector employees have been presented as a barrier but opining that the rule could be limited to private sector employees, he reasons that costs per insured employee would be lowered significantly under a mandatory cover of basic health insurance for a large swathe of the population. “We have to keep in mind the situation today where employees are forced to tell their employers that they cannot pay a hospital bill of a few thousand dollars. However, if the costs are mutualized for all employees, the cost per policy will be much lower. And once the scheme is compulsory, there will be no anti-selection. This is the principle of it,” Nasnas says.

After filling the gap to NSSF coverage with an insurance solution that works with a correct price and very narrow margin, and demonstrating the scheme’s success, insurers and public health authorities could proceed to tackle the challenge of universal health coverage equitably with a basic insurance component, Nasnas advises. “Lebanon is receiving aid from donors for the health sector. Our view here is that the government should not be a risk taker. It has to offer access to healthcare to all citizens but with a cap in financing, so as to run no future budget deficits.”

In his view, it would be possible to achieve this risk mitigation by dedicating aid funds into giving people access to private health insurance at very low rates in form of a low-cost basic product with add-on options for more extensive needs that the insured could buy as top-up covers. “The public-private partnership would be in regulating all this under a regulatory authority that includes numerous stakeholders, NSSF, hospitals, the MoPH, insurance companies, and also representatives of the stakeholders, the insured,” Nasnas enthuses.

This endeavor, according to Nasnas, is on the agenda of public and private sector stakeholders today and would involve the entire qualified insurance sector as a private stakeholder, but under a tight regime of accountability and transparency with participation of stakeholders from the international community who might be willing to help the Lebanese government in financing health coverage: “If we are very transparent and if the donors have a seat on the board of the regulatory and supervisory institutions, proving that there is no abuse or whatever.”

As the entire project in his estimation would hinge on international funding and require convincing donors, he cannot predict if international funding and donor support would suffice to move Lebanon into socially equitable universal health care but acknowledges that the prerequisite will be a public-private partnership of trust and transparency. “The solution is definitely a public private partnership,” he says, concluding that “the crux of the matter is a change of mindset. The main change of mindset will be to have transparency. If we can succeed in this, it would be a first experience to be duplicated in other areas of PPP.”

The wider problem of health

Arwan’s local production more than doubled from 34 percent in the years before the economic crisis

The idea of building sustainable partnerships in health is daunting in the global context. The sheer multiplicity of stakeholders in health will make it more complicated to reach any standard partnership platform anywhere. The prospect of reaching the respective United Nations sustainable development goal, SDG3, “To ensure healthy lives and promote well-being for all at all ages” – is today tainted by detriments such as health cost inflation, losses of social cohesion, global increases in income and wealth inequality, and ever-sharper divergence in political convictions and approaches to defining what constitutes a natural, dignified, good and healthy life.

On the front of medical innovations, unsolved ethical challenges, and divergent quality of life experiences within societies and between countries, humanity in 2023 continues to face risks of exponentially increased, different health speeds between tech dreams of eternal life harbored by some super-wealthy and the fates of an estimated 8 billion humans. Most humans are immersed on one hand in the reality of recurrent infectious disease risks for the highly populated countries with specters of epidemics and pandemics, and on the other hand in the hardly less worrying presence of non-communicable lifestyle diseases and chronic illnesses that accompany the progressively higher age profiles and sedentary urban modes of post-industrial denizens in more and more countries.

In the bottom line of health system developments of the past 38 months since the alarm signals of the Covid-19 pandemic shook up everyday life of the Lebanese people, it is to be expected that distortions and dichotomies in the health system will not diminish in the near term. [inlinetweet prefix=”” tweeter=”” suffix=””]The MoPH-owned strategy for the national health system contains important insights [/inlinetweet]into the system’s past and present successes and weaknesses, but it has in itself a fundamental deficiency when measured against two essential components of any viable strategy: a clearly sourced budget and an executable timeline.

From the organizational challenges to a rebuilding of basic and advanced insurance for the resident population at large, to operational pressures experienced by private hospitals (see comment page 42) to the reduction in the number of pharmacies – reported in the National Health Strategy as over 15 percent at some point before 2023; Executive’s attempt in vain to conduct an interview with the Order of Pharmacists in Lebanon for a current assessment of this segment in the health system – the challenges on private sector stakeholders in the health system must be expected to linger, especially if political barriers to systemic health solutions fail to be removed.

Wins of new and well-structured partnerships in health cannot be sustainable without sound contractual, governance, and finance underpinnings that bind together the multiplicity of stakeholders in health. This is despite the current hopeful signs in provision of mental health services (see ‘Last Word’), and of astonishing progress by health system stakeholders as diverse as the pharmaceutical manufacturers and non-profit organizations that operate PHC networks. Some of the latter have evolved into meeting needs for non-PHC supplied medical solutions such as dental prostheses, with the daring (and to some almost cheesy) promise to give the Lebanese people, and at least their beneficiaries, back their smiles.

May 3, 2023 0 comments
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Leaders

Public goods and their ubiquity

by Executive Editors May 3, 2023
written by Executive Editors

It is desirable for a polity to agree on a social contract as that is what “we” as a society manage collectively. If there is further agreement that the “we” means that both (public) state and market (private) will be acting in the shared interest of stakeholders from the smallest to the largest, the – somewhat intangible – concept of the social contract and the practical process of public-private-partnership can converge. It hopefully also becomes both economically evident and morally paramount to this polity that the social contract as management of public goods needs to be 100 percent inclusive and can best be applied universally through informal and formal contractual relationships. 

Since the middle of the past century, economists have defined public goods as goods that are accessible to every member of a society. These defined as such goods are thought to be economically non-excludable, meaning that it is too expensive or technically impossible to keep some members of society from accessing them. Herein lies the justification for a society to oblige those who can to contribute to financing them, and the challenge of having some members of society or outsiders taking advantage without contributing economically. They are also thought to be non-rivalrous because the use by one member of society does not diminish or disallow the access of another member. 

Public goods have been commonly associated with the state as their coordinating entity and baseline provider. But the social contract of the digital age and knowledge society seems more complicated than that when it comes to the creation, sustenance, and management of public goods. 

Through technological inventions with universal utility for a society and benefits beyond its borders, like the hammer, the wheel, the light bulb and the radio, unknown individuals and well-known individuals can create and have created public goods – not precluding that they also harvest a private gain from their successful inventiveness. Similarly, one must surmise that markets can produce and promulgate public goods, as the contrapuntal forces of human nature and competitive pressures on small and large enterprises lead them to deliver goods and technologies that vastly expand the public utility of their innovations (examples the lighthouse, VoIP telephony, virtual conferencing and online work from home, or internet knowledge resources such as crowd-sourced encyclopedias). 

As old as time

Before economists declared them, market participants have been co-creating or contributing to public goods for millennia (for one 20th century lighthouse-as-public-goods debate, it would have been fascinating to see if the Phoenician and Greek travel writers of antiquity harbored economic opinions regarding the public-goods implications of the Alexandria lighthouse as one of the seven wonders of their world, but, alas, this angle was forsaken). More current economic insights suggest that market participants are increasingly outputting public goods in the contexts of information societies and digital economies.

As much as aficionados of such intellectual discourses have been held in thrall by almost a century of debates of academic economists over the properties and characteristics of public goods, merit goods, common goods, quasi-public goods and, lately, global public goods, the discourse on the need for public goods in Lebanon may quite safely assume several things.

For one thing, stakeholders seeking the reform of the Lebanese system can assume that erudite discourses on the nature of public goods will neither sway the minds of local policy influencers nor contaminate the decision-making processes of political bodies in Beirut. 

Secondly, the truth is undeniable that public goods have to be protected by a vigilant state and virtuous civil society against private excesses of greed but public goods also have to be protected by private stakeholders against the corruption of public servants and the exhaustion or failures of civil society altruism. For opinionated evidence, just ask a Lebanese if this country’s political and economic systems are impervious to corruption.

A sad further reality in the public-goods question of this country is that strategy papers and (more or less accurately) data-driven discourses on the need to reinvent the education and health systems are desperate bets on reforms to be realized over the next four or five years – but without any budgetary certainty, secured manpower or leadership, and any sign of political will to reform anything. 

But shockingly, and with even greater certainty, [inlinetweet prefix=”” tweeter=”” suffix=””]it has to be expected that in the coming months more lives will be lost due to insufficient access to healthcare[/inlinetweet] and [inlinetweet prefix=”” tweeter=”” suffix=””]more futures will be stunted as youth’s education journeys are turned into lost years. [/inlinetweet]

In this context then, instead of proving ephemeral and elusive in the way of political promises, the social contract need for a new Lebanon aligns with the meme demanding unity of word and deed. The latter meme is ubiquitous across cultures and has been verbalized in many nuanced ways, for example in Confucius’ statement that a gentleman (junzi, individual embodying five constant virtues) first enacts what he preaches and only then follows up with explanations. 

For a solutions-centric national discourse on public goods or, in a spiritually inclined and ethically informed sense, universal goods of education and healthcare that are today in disastrous undersupply in Lebanon, the observation bears repeating that public goods are produced by ethically oriented stakeholders with a variety of public, private, and civil society competencies and authentic motivations for the greater good. Under this perspective, Executive has witnessed, among an ocean of deficiencies in the broken health and education systems, very encouraging signals coming from primary healthcare and from informal education, from partnerships involving local NGOs and international donors, and also from the top tier of tertiary education leaders in Lebanon. 

For the improved management of public goods in a future Lebanon, one would wish for partnerships that reflect the global public-private partnership (PPP) lessons of the last 40 years and are cognizant of the winning trends of the 21st century, that are well structured and transparent, contractual and reliable, results-oriented and governed according to the best principles of accountability. Concepts of unilateral state dominance over public goods should be abandoned in favor of developing new and better public-private and public-private-community partnership formulas. 

But the most impactful message – both in the sense of unity of word and deed and in the sense of effective and practical responses to need – is any small, even informal but effective, partnership and joint stakeholder solution that brings health back to patients and provides education access to students – today, not after a reform plan is politically approved and secured with finance. 

May 3, 2023 0 comments
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Last Word

Mental health at a crossroad

by Joseph el-Khoury May 3, 2023
written by Joseph el-Khoury

Unfortunately, mental healthcare has never been a priority for Lebanon’s public or private sectors. The responsibility for this essential service has largely been outsourced to benevolent organizations and funded through meager subsidies. Psychiatric institutions have managed to survive primarily out of necessity, rather than adequate resources. Privately, the field remains under-resourced in terms of workforce and facilities. There are around 70 psychiatrists available to provide hospital-based psychiatric care, and the number has dwindled due to the crisis. Over 30 percent of these doctors were seeking relocation abroad in part or in full, according to a 2021 survey by the Lebanese Psychiatric Society which indicated that most are unlikely to return unless there is a radical change in the country’s situation. Psychiatric nursing, which has always been a weak element in the care system, struggles to recruit and retain professionals, with many being lured away by opportunities in the Gulf Cooperation Council, Europe, and the United States. However, the situation is slightly better for psychologists. With 800 now licensed by the newly established Lebanese Order of Psychologists their numbers are higher, and their influence has grown in recent decades. Despite the significant number of professionals relocating, those who remain have risen to the challenge and filled the gap at least when it comes to generic interventions. 

It is worth noting that Lebanon used to be a destination for individuals in the region seeking specialized psychiatric care. Many local institutions developed a solid reputation for inpatient hospitalization of the most common psychiatric conditions and addiction disorders. However, this role has all but disappeared in the current crisis. On a positive note, no other country in the region has replaced Lebanon in this area of healthcare, and there is an opportunity for the country to regain its prominence with the right investment in facilities, training, and marketing.

A Regional reputation

Academically, major institutions in Lebanon have managed to maintain their standards and produce consistent output despite the crisis. Health departments at the American University of Beirut, Saint Joseph University, and Balamand University, as well as the Lebanese University among others, are recognized internationally. However, the patients are more likely to benefit in the short to medium run from aligning academic output and clinical priorities. This includes finalizing and implementing mental health legislation, shifting first level interventions to the primary care sector, developing appropriate community services for severe mental disorders, advocating for insurance coverage, updating and rationalizing public provision of services or subsidization of treatments to the most vulnerable and needy. 

The proliferation of non-governmental organizations (NGO) locally has served to move the mental health cause higher on the public agenda. Lebanon continues to lead the way at the regional level in terms of harm reduction services with the only nationwide opiate substitution treatment (for people with substance dependence) in the Arab world, and a network of services targeting vulnerable populations. The endorsement of a highly visible hotline for those in need from local NGO Embrace by the National Mental Health Program and the Ministry of Public Health has contributed to local and global interest in funding mental health projects. In parallel, the protracted Syrian refugee crisis, now in its 12th year, has also played a part in developing specialist services serving refugees and host communities alike in areas that had been previously deprived. The tragedy of the Beirut blast was another occasion to highlight the public health importance of trauma and its complications. Yet, sustainability and upscaling remain an inherent challenge to these models. 

 The relative reduction in social stigma and increase in demand for care should be a catalyst for investment from the private sector, backed by a mixed funding model. While Lebanon remains far from political stability, the adaptability of its resident population mixed with the resilient loyalty of its expatriates to its healthcare sector means that waiting for an ideal ecosystem is not essential. What we need is the vision, the leadership and the stamina.  

May 3, 2023 0 comments
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Since its first edition emerged on the newsstands in 1999, Executive Magazine has been dedicated to providing its readers with the most up-to-date local and regional business news. Executive is a monthly business magazine that offers readers in-depth analyses on the Lebanese world of commerce, covering all the major sectors – from banking, finance, and insurance to technology, tourism, hospitality, media, and retail.

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