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?
There is no doubt that our health system is more fragile than it was. 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. We brought a lot of generics into the country, and we have been advocating for the use of generics. 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?
We have been working with the private insurance [industry] on several different schemes, 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.