The last century heralded a dramatic upsurge in healthcare costs in Lebanon. An aging population, the transformation of acute diseases to chronic ones and the innovation gap in pharmaceutical drug discovery despite increased funding for research have all contributed to the ‘healthcare cost crisis’. Lebanon is particularly vulnerable to this crisis given its unstable and unregulated environment.

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

The reality of coverage

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

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

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

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

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

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

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

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

Between rising air pollution, contaminated food, and indoor smoking, cancer in Lebanon is becoming  more common and more expensive. While consolidated numbers do not exist, there are some good signposts that point to the direction we are heading. 

MedNet, a leading third-party administrator (TPA) of medical insurance services in Lebanon, offers perhaps the best possible view of the industry. Sarkis el-Zein, vice president of actuarial and reinsurance services at GlobeMed, a unit of MedNet, says that the company serves some 250,000 people in Lebanon, and that its figures cover more than 15 medical insurance providers, including self-insured schemes, mutual societies, and commercial insurance companies. 

Adjusted for inflation, the annual cost of cancer treatment per MedNet member has doubled from 1995 to 2010, while cancer now also has a heavy share of overall healthcare costs for MedNet clients. “Out of each five dollars you are paying, one dollar goes to cancer. This is very significant,” said Zein. 

By his estimates, the share in the Lebanese population that receives some form of healthcare benefits via any provider is about 70 percent. But the coverage blanket for financing treatments of cancer in Lebanon is a badly sown quilt of part overlapping, part contradictory social contracts that originate from a vague mixture of private sector and public sector medical care formulas. 

The insurance net

The National Social Security Fund (NSSF) is the primary — though overly bureaucratic and financially dysfunctional — safety net for Lebanese citizens. It has been augmented in the dispensation of medical care payments by the services of the Ministry of Public Health (MoPH), especially for costly treatments and chronic ailments, such as cancer. According to Zein, even the MoPH cannot provide information on what share of treatment costs their beneficiaries have to pay “because each hospital sets a different share. It is chaotic.”

The country has more than 50 insurance companies that form one part of the provider scene. The other part comprises mutual societies, cooperatives and self-financed insurance schemes of large public sector employers, such as civil servants and branches of security and military forces, or private sector entities such as banks or professional syndicates.  

According to a World Health Organization report, there are an estimated 500,000 owners of health policies issued by insurance companies. This includes people who are entitled to NSSF medical benefits but have bought private insurance to cover the 15 percent portion of treatment costs that the NSSF, as a rule, does not pay. 

What is, and is not, covered

Holders of medical policies from insurance companies using MedNet as a TPA are covered for financial costs of cancer treatment as they are for all other diseases, Zein said. Some 89 percent of owners of individual and family medical policies have “guaranteed renewability” (GR) and policies do not impose financial limits on annual or lifetime coverage, with the exception of a 720-day cap on overnight stays in a hospital during the life of the insurance contract.

Insurance companies holding ownership stakes in MedNet, namely Axa Middle East and Libano-Suisse, market their health insurance products as providing “unlimited financial coverage” and GR from the first day for persons under 46 who buy the in-hospital policy.

However, a view into the market of health policies offered by Lebanese insurance companies overall shows a picture of “many different contracts and different conditions,” said Salim Yared, general manager of Sloop Insurance brokerage and former president of the Lebanese Insurance Brokers Syndicate. 

Several companies that outline the terms of their medical plans on their websites state coverage ceilings. Whereas ceilings on covered in-hospital costs are frequently cited in similar ranges from $50,000 to $200,000, depending on the class of service, the information is anything but straightforward. Some ceilings are described as “per case” or “per medical case” or “per case per year.” Other companies ask prospective clients to call them or use entirely nondescript terminology such as “insured amount” or “hospitalization expenses up to x.” 

While the paucity of online medical policy marketing by Lebanese insurers speaks to the fact that the local health insurance market is not web savvy, the more important cautionary note is that all such ceilings require clearer and more detailed definitions. A small textual difference between contracts can mean that a chronic disease under ‘Contract A’ will be covered without financial cut off; under ‘Contract B’, it will not be covered beyond $100,000 in hospitalization costs in the current year but will be covered to the same ceiling in the following year, provided that the contract includes GR; ‘Contract C’, even with GR, may limit the $100,000 amount to the lifetime of the contract and will not pay another dime beyond the guaranteed amount. 

The central dilemma is that no standard contracts for health insurance exist in the Lebanese market. Whereas providers have agreed on sample contracts with reference characters for most insurance lines, discussions of a model document for medical policies were abandoned years ago due to irreconcilable views among companies, according to an industry executive who spoke off the record. 

No standards or standardization

Medical insurance contracts are not standardized and providers use a very wide range of policy forms that differ from one company to the next, confirmed Paula Abdel Massih, the head of the medical committee at Lebanon’s insurance collective Association des Compagnies d’Assurances au Liban (ACAL).    

Different contract conditions usually translate into different policy pricing. This is problematic for individual buyers because their focus on price often trumps choosing a policy that actually fulfills their needs. As some Lebanese insurance companies do not specify upfront the risks for policyholders, such as if and when the coverage would actually cut off during treatment of a chronic condition such as cancer, insurance policy holders all too often find out about stress points in their contracts only when they need their insurance most badly. 

On the side of limiting their risks, Lebanese insurance companies uniformly demand that prospective clients disclose medical conditions that have been diagnosed or treated previously. Insurers may decline inclusion of those conditions in a new contract and will refuse payment of claims on recurring diseases where policyholders have falsely stated to have no pre-existing condition in their coverage application.

Zein acknowledged that disputes due to allegedly false statements or treatments also exist in the client base of MedNet, but he described the numbers as “very low” without giving a specific count. This speaks to the question of insurance disputes and arbitration where some mechanisms are in place but transparency regarding the frequency and targets of complaints leaves much to be desired. 

Once upon a time, about 1998, an insurance commissioner at the Lebanese Ministry of Economy and Trade (MoET) said she wanted to introduce a white book on insurance companies, where consumers can see which providers have a track record of high client satisfaction and low rates of complaints and disputes. As with many fairy tale endings in the Lebanese Republic, the commissioner soon moved to another country. 

The current website of the insurance control commission hosts a helpful (Arabic) text on rules for insurance arbitration at the MoET, called article 48. Among the ideas Economy and Trade Minister Nicolas Nahas circulated this year are plans to elevate Lebanon’s capacity on insurance arbitration to regional leadership. That may prove difficult.    

When premiums jump

Besides disputes over coverage exclusions and payment cutoffs, another risk for the insured is that while the GR component of insurance policies provides security on continuous coverage for individual and family policy owners, it does not guarantee affordability over time. Besides premiums adjustments because of cyclical cost increases in the health care sector, the annual renewal schedules of premiums mean that the insured have to pay more when they enter a higher age group. In one example where Capital Insurance Co made its premiums schedule visible online, the premiums of an individual in first, second, and third hospitalization classes would jump by 20, 30 and 35 percent, respectively, once they moved from the 56-to-60-year-old age group to the 61-to-65 bracket.  

Premium costs and age-related increases of premiums for the privately insured are not set on a social need basis but on actuarial indicators. “If I see that the whole individual and family portfolio needs a rate adjustment by 15 percent, we adjust the rates by 15 percent for all members. We do not single out those that have diseases,” Zein said.

Buyers beware

While the bulk of Lebanese insurance companies offer contracts that neither cover all imaginable health risks nor meet societal needs of specific income and age groups, the companies will generally promise tangible and clearly quantified benefits and provide accordingly, or even a bit better. But some providers promise less. According to Sloop’s Yared, some insurers write exclusions of cancer and cardiovascular diseases into their contracts, with the reasoning that the MoPH is assuming responsibility for the treatment of Lebanese citizens.  

Insurance companies that put exclusions on cancer treatment into their contracts do not actually sell them at a discount, but rather bet on the sales talks and the lack of diligence by policy buyers to get away with evading risks they should provide for. The reason why customers let themselves be talked into buying questionable policies is insufficient diligence. “People have a blurry image of what they are buying,” Yared said. 

Compliance of policy contracts with best practices is not enforced by the government or under any self-regulatory initiative, meaning that it is up to the customers to verify that their policies provide for their needs. The problem is that insurance buyers rely mainly on the word of the sales person and trust in what they want to believe rather than what the contract says. Also in Zein’s experience, “people do not read their policies.” 

But when it comes to insurance claims, here is where the buck stops. If claimants think they are covered because they failed to read their policy, Zein proffers: “That is their problem.” 

On the occasion of Mother’s Day last month, the Ministry of Public Health (MoPH) launched a campaign to encourage Lebanese women to check for cervical cancer. Easily treatable when detected early, cervical cancer affects the uterus and is the third most common cancer among women worldwide. In the United States however, the disease is much less prevalent due to the well-established practice of annual pap smear tests; an example showing the importance of awareness and early detection campaigns. 

According to the World Health Organization, the global burden of cancer can be reduced and controlled by implementing three strategies: prevention, early detection, and “managing” patients with cancer. The latter however, is a complicated and extremely costly affair as cancer requires a lengthy multidisciplinary treatment — often a combination of surgery, chemo and radiotherapy. Hospitals need to invest millions in the latest technology and patients need to cough up tens of thousands of dollars per treatment per year. 

“Suppose you got an inheritance and decide to invest $100 million in a medical center,” said Professor Marwan Ghosn, head of the Hematology and Oncology Department at the St. Joseph University’s Faculty of Medicine. “A noble initiative, of course, but do not think you will make any money,” he asks rhetorically. 

He explained that, in Lebanon, there are challenges for hospitals related to how they get paid for their services, where most bills are covered by either the MoPH or the National Social Security Fund (NSSF), with a smaller number covered by private insurers.  

“In general, the MoPH pays years late, while the NSSF pays years late with cuts,” said Ghosn. “These days even private insurance companies pay late and will bargain for a package deal.”

He noted that payments suffice to keep management and doctors in a job, but hardly to invest in the latest medical equipment. 

Finding the funds

Nearly all hospitals in Lebanon are facing financing shortfalls. The result is that many are  inking alliances with foreign hospitals, while philanthropy is also on the increase, said Ghosn: “We never saw much philanthropy in Lebanon, but these days it is common practice.” 

One medical institution familiar with sponsorship and fundraising is the Children’s Cancer Center Lebanon (CCCL). “We operate on an annual budget of some $12 million, some 80 percent of which is generated through fund raising, which varies from corporate funding and sponsoring of a single patient to our annual gala dinner the proceeds of which go to the center,” said CCCL General Manager Hana Chaar Choueib. “The remaining 20 percent comes in the ‘normal’ way by means of the MoPH, the NSSF, and private insurance companies.”   

Affiliated with the St. Jude Children’s Research Hospital in Memphis, the CCCL opened its doors in 2002 and has since treated a total of some 800 patients below the age of fifteen. Every year the CCCL accepts some 70 to 80 new patients, yet on average it treats some 250 patients a year, as the treatment of leukemia takes some 2.5 to 3 years to complete. About a third of pediatric oncology cases in Lebanon concerns leukemia. 

According to Choueib, the average cost of treating a child with cancer amounts to some $50,000 per year. More complicated and rarer cases however, such as bone marrow transplants and lymph salvage, cost up to $250,000 a year. “We particularly depend on third party generosity as it is our policy to accept children without discrimination,” said Choueib. “No parent should be worried about what and how to pay. They should only worry about the health of their child.”

Affiliated with Johns Hopkins International, the Clemenceau Medical Center (CMC) is arguably one of the few Lebanese hospitals that need not rely on sponsoring and fund raising to make ends meet. Currently, the hospital is set to invest $35 million in a special cancer center. 

“The lion’s share of the $35 million dollar budget is to be spent on medical equipment. Our objective is to offer all the latest technologies under one roof to avoid people traveling from hospital to hospital, or even abroad,” said CMC’s chief executive Dr. Mounes Kalaawi. “We aim to attract patients to Lebanon.” 

Progress at a price

Delete the cliché image of a doctor with stethoscope. Enter that of an engineer behind a computer screen handling a mouse. Today, even in the operating theater a single robot and controller can do what a dozen people did a decade ago. The technological revolution in the medical world however, comes with a hefty price tag and newly improved models and machines enter the market almost every year. 

“We have pretty much replaced all imaging equipment since the CMC first opened its doors in 2006,” said Kalaawi. 

Medical imaging has come a long way since scientists first detected the X-ray in 1895. Today, a hospital also uses computerized tomography (CT) scans, a combination of X-rays taken from different angles with which a computer produces a cross-sectional image. Magnetic resonance imaging (MRI) is a technique used in radiology to create images of organs and the body’s internal structures, while a positron emission tomography (PET) scanner is a nuclear imaging device producing a three-dimensional image of the internal body. 

Yet progress has its price. While you can buy a simple X-ray machine for a few thousand dollars, a CT scanner costs over $100,000 and a medium-sized MRI scanner and PET scanner cost some $1.5 million and $2.5 million, respectively. And that is not all. 

“In order to produce the radioactive material needed for a PET scanner, you need a lab and a cyclotron, which cost some $1.2 million and $2 million respectively,” said Wassim Boustany, sales manager at General Medical Equipment (GME), the authorized distributor of General Electric Healthcare in Lebanon. “There is only one such system at the Mount Lebanon Hospital, yet that is enough to provide the whole country.”

A complete oncology center furthermore needs two linear accelerators and bunkers (to avoid radiation spreading) for the radiotherapy unit. Total cost: some $4 million. Until recently, an analog mammogram system cost some $50,000 to $60,000. These days however, there is a digital variety on the market that is more precise with less radiation. Cost: some $350,000. 

“From a personal experience I can say that most Lebanese hospitals used to be financially healthy, would make a profit even,” said Boustany. “Yet today some cannot even pay for maintenance cost and spare parts, as the end user simply cannot pay for the technological advancements. A PET scan costs about $1,000 in Lebanon. In the US it can amount up to $10,000.”

Nevertheless, there is generally no shortage of equipment in Lebanon. For example, the country has five of the latest PET/CT scanners, while GME is currently installing a combined PET/MRI device at Rizk Hospital, of which there are only 10 in the entire world. 

Medication’s massive costs 

“The cost of cancer treatment is determined by three components: the cost of medical equipment, the cost of medication and doctors and hospital fees,” said Ghosn who is also head of the CMC’s Hematology and Oncology Division. “In the diagnostic phase the patient pays mainly for the equipment. In the treatment phase, he or she mainly pays for medication. The new generation of chemotherapy drugs, for example, may cost some $4,000 to $6,000 per session, while in all stages the patient pays but a few hundred dollars on hospital and doctor’s fees.”

His view was confirmed by Rahif Jalloul, president of the Lebanese Society of Medical Oncology. “A six-month breast cancer treatment on average costs some $50,000, some $30,000 of which is spent on drugs,” he said. “The average patient would spend some $3,000 to $4,000 on X-rays and biopsies and, if needed, some $2,000 to $3,000 on surgery. In addition, a patient needs six sessions of medication [one every three weeks], which may cost up to $8,000 per session and I would not be surprised if one session soon costs $9,000 to $10,000. Radio therapy, if needed, costs some $5,000.” 

Surgery, chemo and radiotherapy are the most common ways of treating cancer. Radiotherapy uses radiation to control or kill malignant cells. While it may prove a cure for some tumors, it is mostly used in combination with chemotherapy to prevent tumor growth or recurrence after surgery. Chemotherapy refers to the use of a cocktail of chemicals aimed at destroying cancer cells. 

There are currently some 250 identified cancers and 50 commonly used chemotherapy drugs in the $1 trillion dollar industry. Last year, Hoffman-La Roche (Roche) spent 8 billion Swiss francs ($8.75 billion), or 22 percent of its global turnover, on research and development. According to a company brochure, it takes an average of $1 billion, 7 million work hours, 423 researchers and 6,587 experiments to produce one drug. The company then earns back such astronomical investments by being able to exclusively market the drug under patent. 

“Research and innovation are at the heart of what we do,” said Abed Rahman Sabra, Lebanon Country Manager of Swiss pharmaceutical giant Hoffman-La Roche (Roche). “A certain minimum has to be set or else we will not be able to sustain our practices. You should know that we have hundreds of molecules under investigation, of which one or two will eventually make it to the market.”

Patented drugs generally enjoy a monopoly for 15 to 20 years, after which they can be produced by anyone. Yet often companies file patent upon patent in an attempt to extend the life of a drug patent and stop or delay generic drugs from entering the market. 

As a result, as Matthew Herper wrote in Forbes last November, generic companies are constantly suing to invalidate extra patents, while brand name drug makers sue to keep generic versions off the market. “In theory, we pay more for branded drugs to finance the massive research needed to develop them,” he wrote. “But long battles over dozens of patents can simply distract pharmaceutical companies from their job: making new medicines.”

One such legal battle, which recently took place in India, could have global repercussions. On March 12, the Indian Controller General of Patents Designs and Trademarks ruled that the anti-cancer drug Nexavar was so beyond reach of ordinary Indians that he decided to sign a compulsory licensing order. 

The German pharmaceutical giant Bayer that produces the drug had set a price of 280,000 Indian rupees or $5,448, which meant an Indian civil servant would have to work more than 3 years to pay for one month’s dosage of the drug. Based on the ruling, Indian firm Natco Pharma will now produce the drug for $172, while paying Bayer a 6 percent royalty on sales. 

The case is already starting to shake the pharmaceutical industry. A few days after the ruling, Tuygan Goeker, head of Middle East and Asian markets at Hoffman-La Roche announced it would cut the prices of two cancer drugs, Herceptin and MabThera, starting in 2013. The wholesale price of the two drugs is currently $3,000 and $4,500, respectively.

Looking ahead

While the advancements in medical technology and chemotherapy drugs have led to improved cancer treatment and a cure rate of some 50 percent, the cost of battling cancer and other diseases is imposing an ever-higher burden on society as a whole. Between 2008 and 2010, the MoPH’s annual drugs bill increased 73 percent to more than $60 million, most of which was due to ever more expensive cancer drugs.

In order to effectively deal with cancer, more emphasis needs to be placed on prevention and early detection. Measures such as an affordable check-up for cervical cancer, the annual breast cancer awareness campaign, and the announced ban on smoking are thereby but a start. 

“To start with, eat less meat, avoid the intake of high-energy food and drinks, avoid food colorants, avoid smoked foods and eat more fresh fruits and vegetables,” said Dr. Jamil Halabi, Secretary General at the Lebanese Cancer Society. “And in the near future we must, for example, discuss the use of pesticides and insecticides.”

The bottom line is that without a fundamental change in the way our society operates, the number of cancer patients will only rise, and the costs of their care with it.

Childhood cure rate at risk

This year the Children’s Cancer Center Lebanon (CCCL) celebrates its 10-year-jubilee, and the institute has every reason to celebrate. “The cancer rate among Lebanese children has remained more or less stable since the 1960s, yet their survival rate for cancer has increased exponentially,” said Dr. Samar Muwakkit, associate professor of Pediatrics at the American University of Beirut and a leading doctor at CCCL. 

Childhood cancer is not a common disease. Every year, less than 280 of Lebanon’s some 2 million inhabitants below the age of 15 are diagnosed with the disease. The most common childhood cancer is leukemia (one third), followed by brain tumors and lymphoma.

In the early 1960s, the survival rate of childhood cancer was a mere 20 percent, while 10 years ago 53 percent of Lebanese patients survived the ordeal. Today, the CCCL has achieved a cure rate of some 88 percent. Interestingly, it has largely managed to do so using the same drugs that were used in the 1960s.

“We achieved our cure rate by remaining extremely disciplined on protocol, constantly evaluating each dose and each patient, thus gradually advancing,” said Muwakkit. “It shows that, at least in treating leukemia, new technology and new, more expensive drugs are not necessarily the way forward. You do not always need to invest to advance.”

One might think that adult oncology (and the pharmaceutical industry) could learn something from its pediatric counterpart, yet some caution is necessary. “Firstly, cancer in children is easier to treat, as they are stronger and healthier than adults and react better on chemo therapy,” said Muwakkit. “Secondly, what is true for leukemia is not necessarily the case for solid tumors, which concerns the vast majority of cancers among adults.”

Today CCCL’s impressive cure-rates are under threat as a supply of the injectable, preservative-free drug imported from the US is fast running out. First developed in 1956, methotrexate is regarded as a lifesaver for children with Acute Lymphoblastic Leukemia (ALL), the most common childhood leukemia.

The acute cause of the shortage is that one of the largest producers of the drug, Ben Venue Laboratories, stopped production in late 2011 due to quality concerns. A more fundamental cause however, is the fact that a total of only five pharmaceutical companies in the US produce the drug and in February reports emerged that only a few weeks of supply were left.

Pharmaceutical companies make little profit on generic drugs like methotrexate, which costs $1.58 per vial. Compare that to the $6,000 paid for a single injection of the latest (patented) chemotherapy drugs. The issue of shortage in generic drugs has prompted US President Barack Obama to sign an executive order strengthening the FDA’s power to predict and tackle shortages of prescription drugs and halt overcharging in times of scarcity. On February 20, the US Food and Drug Administration announced the immediate availability of relief supplies of methotrexate and also agreed with another manufacturer, Hospira, to immediately distribute 31,000 vials of the drug, which would meet nationwide demand for about a month. As for Lebanon and the rest of the world, the cost of curing childhood cancer may soon become a burden the youngest among us will have to bear even more.

Cancer rates in Lebanon are rising and the illness has, or will, touch the lives of virtually everyone in the country. They are a lucky few that do not have a friend or family member that has had to tackle the disease. However, as treatments and awareness improve, people are increasingly coming to realize that cancer is not necessarily a death sentence, but is in a great number of cases a treatable disease like most others. 

As the discussion moves from awkward whispers to confident debate there is a need to look at the role of the state in this national affliction. For thousands of cancer patients every year the treasury is the purse from which their treatments are purchased. However, a combination of weak government, pernicious corporate influence and slack policy are impeding the state from fulfilling its obligations. 

Over the years a system of laws has been enacted that obligates the government to provide coverage for a number of “catastrophic” illnesses, the term the government uses on the basis of the financial burden of their treatment. The original ailments to fall in this category were dialysis and open-heart surgery, but as the net of state support has widened, cancer treatment has entered into this fold of government activity. 

In theory, the state is now committed to providing support for the costs of cancer treatment for anyone who does not have a third party payer. Dr. Rahif Jalloul, president of the Lebanese Society of Medical Oncology, has recently compiled a data analysis of trends among cancer patients in Lebanon and he calculates that some 45 percent of cancer patients go to the ministry of health to fund their treatment, around 35 percent are funded from social security and the remainder are covered by professional or governmental cooperatives, or private insurance. 

Even in cases where patients have a third party payer they can turn to the Ministry of Public Health (MoPH) for assistance if the cost of their treatment exceeds the limit of their coverage. In addition to having to cover 100 percent of the cost of chemotherapy treatment, Dr. Walid Ammar, director general of the ministry of public health, says, “The government covers 95 percent of costs for public hospitals and 85 percent in private hospitals, and we have a wavering system for the very poor who get 100 percent… What’s more, we cover radiotherapy when it is necessary.”

A disease in the dark

There is a general consensus that the incidence of cancer is on the rise in the country, but making an accurate assessment of the situation has been hindered by a lack of coherent and comprehensive data. In 2002 the national cancer registry (NCR) was launched in a collaboration between the MoPH and the World Health Organization (WHO), but was hampered by financial, bureaucratic and political impasses. In 2005 the NCR was relaunched as an institution of the MoPH. “The [national] cancer registry is your eyes. Without your eyes you don’t know what to do,” says Michel Daher, professor of clinical surgery at the University of Balamand and president of the Lebanese cancer society.  

However, the nation’s vision has been somewhat obscured by the reluctance of hospitals to cooperate with the ministry. 

“We are in a country where every hospital thinks they are an empire by themselves,” says Salim Adib, professor of epidemiology and public health at the University of Saint Joseph, and a key player in the development of the registry. “We can pretend to demand [data] but in reality we are just asking because we can’t force them.” 

Dr. Ammar at the MoPH admits that initially there were big gaps in the statistics because physicians did not want to cooperate. However, by combining the figures with records kept at the central drug distribution center in the Karantina district of Beirut, the ministry has been able to build a more detailed assessment of the situation, even if it is far from an exact science. 

Between 1998 and 2004 there was a sharp rise in the age-standardized rates of cancer in Lebanon, with an increase of around 60 percent in reported cases. According to Professor Marwan Ghosn, head of the hematology and oncology department within the faculty of medicine at the University of Saint Joseph, one of the main reasons behind the rising incidence of cancer in Lebanon is the nation’s aging population. However, he also warns that the figures should be interpreted with some caution. 

“We think there is a real increase in the numbers but the data does not represent the real increase,” he reasons, on the basis that with improved detection and data collection systems the increases are exaggerated. 

According to Ghosn, the cancers most prevalent in Lebanon — such as breast, lung, prostate and colorectal — reflect trends seen in the developed world (see chart). Between 7,000 to 8,000 new cancer cases are recorded every year in Lebanon, meaning there is an annual incidence rate of between 175 and 200 cases per every 100,000 people. Ghosn says this falls roughly between what is common in the developed world — 400 to 500 recorded cases per 100,000 people — and the lower rates in the developing world — of around 100 cases per 100,000 people.

The growing incidence of cancer in Lebanon is stretching the government’s ability to provide the coverage it is mandated to offer. This reality is compounded by the inexorable rise in the cost of newer and more advanced treatments.

From 2008 to 2010 the MoPH bill for drugs rose from LL52.5 trillion ($35 million) to LL91 trillion ($60.6 million), an increase of some 73 percent in just two years, the lion’s share of which is swallowed up to pay for cancer treatments. Of all MoPH spending on drugs in 2007 (the most recent figure published by the MoPH), 63.6 percent was for cancer treatments, and a source within the MoPH told Executive that data from the Karantina dispensing center suggest that proportion is now likely to exceed 80 percent. 

Doctor deals with Big Pharma 

“It is not sustainable,” concedes the MoPH’s Dr. Ammar. “We have major problems with some physicians who are prescribing drugs which are very, very expensive and they are putting pressure on the Ministry of Health to purchase them. We know that the pharmaceutical firms are behind them.”

To have the director general accusing the pharmaceutical companies of actively lobbying and influencing physicians’ prescriptions is a damning reflection of the profession in Lebanon. Whilst a number of the doctors interviewed for this report denied this was the case, one senior oncologist told Executive, on condition of anonymity that, “Some doctors have got into a position of a conflict of interest whereby they have been co-opted by pharmaceutical companies to buy the more expensive medicines.”

Under the current system there is a “gentlemen’s agreement” between the doctors, pharmaceutical companies and the government, but the concern is that economic prejudices are too often overriding ethical imperatives. By Dr. Ammar’s own admission, “I can’t enforce [the agreement].”

With regards to which drugs can be administered in Lebanon, the government is the standard setting authority. 

A registration board under the MoPH — including members from the order of physicians, the order of pharmacists and the universities — must give the green light to any drug before it can legally enter the Lebanese market. However, beyond this stage the government has virtually no control over what physicians are prescribing on their tab. 

“The political aspect is that the government likes to be generous and there is a political commitment to cover the expensive drugs for the population for which they don’t have the resources,” explains Dr. Ammar.  

There is no coherent system within the ministry to direct what drugs are being prescribed for what cancers at their different stages of development. 

“They are buying more expensive products that are not more effective on the collective level, and there are no standards to say lets move from drug A to drug B,” says Dr. Adib of Saint Joseph. “We don’t have any standard operation approaches to doing things so it is whoever shouts the loudest that gets the money.” 

Dr. Ammar at the ministry glumly agrees: “The health authority should have the authority to say ‘no’, but it doesn’t. The authorities in Lebanon do not actually have enough authority.” He cites an example whereby the ministry agreed to cover a prescription for the drug Gleevec at $4,000 a box, whilst “It wasn’t even being covered by the national [social] security in France.”

The impacts of excessive expense 

There are two major consequences of this crippling expenditure on drugs. The first is a tragic reality encountered by many cancer patients when the stocks of the drugs they need run out and the government has no more money to buy the necessary medication. 

“We give until it is gone, and when it is gone it is gone,” complains Dr. Adib. “So if you are sick in the second half of the year the chances are you won’t be able to get your medication from the drug dispensing center.” 

At the ministry Dr. Ammar admitted that this was sometimes the case and that come the end of the year he simply does not have the money to keep the medication stocks replenished. Unlucky patients who get ill at the wrong time are forced to shop on the market themselves, where they may or may not find the medication they need let alone afford it.

In the second strain of the medication tab is that the government is unable to dedicate a sufficient amount of resources to prevention and early detection. 

“Of course it is much more cost effective to invest in early detection and prevention — this is where we need to spend our money,” says Dr. Amaar, before adding, “If there is a politician and there is someone saying I am dying I need such and such a drug, yet on the other hand you have the director general telling him ‘please don’t put your money there and put it somewhere more cost affective and after a few years you will get results.’ He will not listen to me. He will listen to the patient who is crying.”

It is stated in the ‘Country Cooperation Strategy for WHO and Lebanon 2010 to 2015’ that, “The current financing structure, with the fragmentation of public funds, tends to focus more on curative care and gives relatively less focus to areas such as disease prevention and public health management in primary care.”

The killer of women

Of all the forms of the disease, breast cancer kills more women than any other, and Lebanon ranks fifth in the world on the basis of the age standardized death rate for the disease. As such there has been a concerted effort to develop the infrastructure, practice and awareness for early detection in screening for breast cancer. The 2010 statistics from the MoPH show that 38.3 percent of cancer cases among women were breast cancer. Based on data accumulated since the early 1990s there are now national guidelines for women over the age of 20 to have a clinical breast examination performed by a physician every three years, and annually after the age of 40. In a 2008 study, a sample of 2653 women aged 35 or over, 77.7 percent said they had a clinical breast exam in the last 12 months. 

“[The guidelines] are being implemented more and more,” says Dr. Adib, who is a member of the Breast Cancer National Task Force. “It has all been voluntary but increasingly there is more and more use of mammography as a screening tool.” 

In most cases the government will only provide support in funding a mammography if it is prescribed as a diagnosis tool. However, for the month of October, breast cancer month, the MoPH works in conjunction with the nearly one hundred centers that offer mammographies to ensure the price is kept below LL40,000 ($26.7), whereas it would normally cost around LL150,000 ($100) or more.

However, Dr. Jalloul acknowledges that the country is not reaching its targets: “You have to push people to do this screening. We notice last year only around 10,000 did the screening and yet there are around 800,000 [susceptible] women. We are not hitting the target. We should have around 50 percent of our active females doing this mammography every year. Now it is closer to 10 percent.” 

Less than the minimum

While the government now plays a minimal role in either prevention or early detection of cancers, Dr. Adib frets that in the future the ministry will be able to do less and not more in this area: “We are not going to be starting anything new in our current financial situation. We are all aware that if you invest in prevention it will give a return on investment but there is not the money there in the first place.”    

One area where the government hopes to bring about a change in both culture and practice, while freeing up resources, is within palliative care. As defined by the WHO, palliative care “focuses on improving the quality of life and relieving suffering in patients with progressive chronic illnesses,” in other words, those cases where the illness will almost certainly be fatal. The understanding and provision of this kind of care remains very limited in Lebanon and its development has been identified as a priority for the WHO throughout the whole of the Eastern Mediterranean.

The reasons for the near non-existence of palliative care in Lebanon are several. “Lebanese patients and their families don’t like the idea of palliative care because they have misconceptions about it,” says Dr. Ghosn. “This is important because it means a lot of patients are not really aware of their real diagnosis or their real prognosis. You may have a very advanced cancer case where the patient believes he is going to be cured.”

Further to this, the MoPH’s Dr. Ammar argues there is a problem within the medical establishment itself: “The physicians don’t have the right training. They are trained to prescribe drugs. They are trained to prolong the life as much as they can, but they are not trained to look at the quality of life, at the dignity of the patient.” 

Once again he points the finger at the pharmaceutical firms for influencing physicians’ decisions with “their bullshit evidence” to prescribe prolonged and often very costly treatments when patients should have moved onto palliative care, even if cheaper generic drugs do exist [see page 34].

In May 2011 the MoPH launched the National Committee on Palliative Care and the ministry’s Dr. Ammar says development of policy in this field is essential.  

“We are working on making [palliative care] drugs more easily available,” he said. “Then to make reimbursement mechanisms for this kind of care, which currently does not exist, and thirdly to create awareness among physicians and the population at large.”

The Lebanese Cancer Society’s Dr. Daher argues that the reasons for developing palliative care are not just moral or clinical, but that there is also a financial rationale. 

“Now you have a patient with advanced cancer so why spend thousands on every session of costly treatment?” he asks. “This is the way to ensure better quality of life, with less expense under the coverage of the government… [The savings] can be spent on prevention campaigns of screening campaigns. This is where you need to spend money.” 

That the Lebanese government at least strives to provide coverage for the fundamental treatments of cancer patients is perhaps commendable. But as Dr. Adib warns, “There is no holistic strategy.  We are working on a case-by-case basis.” Consequently, and by the admission of the director general of the MoPH, under the current system the government will not be able to continue fulfilling its mandate.  

A ballooning bill for expensive drugs, lax oversight of which treatments to fund and a political unwillingness to tackle thorny issues of what the government can realistically offer have left the MoPH functioning as little more than a drug dispensing counter, and a failing one at that.

Cancer is everyone’s disease. At some point or another it enters nearly every home society. It can devastate patients and their families, not just emotionally, but financially as well.  It also lays a heavy burden on the government which bears a significant amount of the treatment costs. But research shows that the disease does not have to be so chilling, if  prevention were maximized. According to the World Health Organization (WHO), 30 percent of cancers are highly preventable through lifestyle choices relating to diet and avoidance of toxins. Common cancers like breast, colorectal and even lymphomas in children actually have high cure rates, if caught early. 

The most recent breakdown in figures regarding cancer in Lebanon are from 2007, something that in itself shows how little the government acts to stay on top of the problem. The most common cancer among women is breast cancer and for men it is lung cancer, both of which mirror global trends. But factors known to cause cancer such as environmental carcinogens have all been on the rise, not to mention smoking rates. Thus, it’s little wonder that since figures began to be compiled in 2002, official cancer rates have increased around 5 percent every year.  

If an ounce of prevention is better than a pound of cure then we are on the heavier side of the problem. A lack of policy to push preventative measures means the focus is on the provision of medicine, while more often than not, cancer is diagnosed at an advanced stage. A nation-wide survey conducted by the health ministry in 2007 showed that only 12 percent of women in Beirut had had a mammography in the past year, though the ministry has been campaigning to increase awareness for more than 10 years, while offering a cut in the price of mammograms.

Cervical cancer in women, mostly caused by the HPV virus, is a leading cause of death in low-income countries, even though it is highly preventable. In Lebanon, estimates show there are up to 270 cases annually, but only 10 percent of women have annual pap smear tests at their gynecologists’ clinic, and (although there are no official figures) even less are thought to have been vaccinated for HPV infection. 

What is even more alarming is that some cancers affect different groups in a much higher proportion compared to figures from the United States and Europe. Breast cancer among young women under 40 years old is higher in Lebanon than in western countries, though it is partly due to the high proportion of young people compared to demographics in other countries.

Indeed, many fear a higher risk of developing cancer in Lebanon because of a number of factors within concentrated urban areas, such as war residue, pollution, toxins, low-quality diesel fuel toxins, forest fires, poor urban planning, contaminated food products and toxic pesticides used on farms. Though no figures directly correlate pollution levels to cancer rates in Lebanon, pollution levels exceeded the norms set by the World Health Organization, with many of the contaminants being carcinogens. 

Little has been achieved in terms of curbing this pollution. Thus, costs related to treating cancer patients, both for government and insurance companies, will also rise. While two-thirds of the population is covered by health insurance from employers, the National Social Security Fund or through private insurance companies, that leaves the financial fate of around a third of the population at the mercy of government, whose financial resources often run short.

After the shock of being diagnosed with cancer, patients have to run the gauntlet of choosing between treatment options, or lack of options, at various and sometimes competing hospitals. Even if one is insured, there are also ample cases where private coverage will not keep the cost of combating the ‘Big C’ at bay. 

This Executive special report helps untangle the complex web of costs and treatments, reveals strategic operations and financial data from hospitals and insurers, and offers in-depth testimonials and exclusive insights to sort the truth from fiction in relation to cancer treatment in Lebanon.