In Lebanon, one in four people suffer from mental illness in their lifetime, according to non-profit mental health NGO Embrace. Mental health refers to the condition of a person’s emotional or psychological well-being, in the same way that physical health refers to the condition of their body. Although the public discussion around mental health in Lebanon has been increasing in recent years, a strong societal taboo surrounding the issue still lingers. Combatting this stigma in Lebanese society is now a mission of both governmental and non-governmental organizations (NGOs). There has been a recent increase in the number of NGOs advocating on mental health issues, as well as in the number of practicing psychologists, psychiatrists, and other mental health professionals, according to a 2015 World Health Organization (WHO) report on mental health in Lebanon.
How the government deals with the mental health of its citizens is one factor that influences how society views mental illness. “If [the government] recognizes that these people need help, it changes the public’s perception [of mental health for the better],” says Omar Dewachi, a physician and assistant professor of Anthropology, Social Medicine, and Global Health at the American University of Beirut (AUB). Shifting the public perception of mental health is important because neglecting mental illness can—in addition to other potential ramifications—negatively affect society’s productivity. When people suffer from untreated psychiatric disorders it can limit their ability to work, and, without adequate state assistance, the burden of care will often fall on family members. These caregivers, in turn, will be less productive and will often suffer a hit to their own mental well-being. The negative impact of untreated mental illness on a society’s productivity can be used as a counterargument to the economic logic of not covering mental health expenses. In Lebanon, as in other countries worldwide, there is insufficient awareness of the importance of mental health and a dearth of good, free healthcare services geared toward those with mental illnesses. Given the reticence of profit-driven private insurance companies to cover mental health treatment and the government’s lack of budgetary allocation for mental health, the burden falls on non-governmental and international organizations.
Lebanese private insurance companies do not provide coverage for the treatment of mental illnesses. Pascale Abou Nader, head of the Medical Claims Department at insurance company Libano-Suisse, says that private insurance companies do not cover the potential psychiatric care-related expenses of their clients due to the long-held belief that “mental illness is not a real illness.”
In Abou Nader’s opinion, all private insurance companies would fight against the implementation of a law requiring that there be no mental illness-related exclusions in individual health insurance policies. However, the private sector is involved in one scheme concerning mental illness. An insurance package offered to big corporations covers the full supplementary cost of all of the treatments that are partially paid for by the NSSF. Since the NSSF pays for 90 percent of the treatment for mental illnesses, private insurance companies in this particular package are beholden to pay the remaining 10 percent.
In practice, however, Libano-Suisse has yet to deal with a case of an employee covered by the “Delta NSSF” insurance who has claimed the supplementary 10 percent coverage for treatment of a mental illness, even though clients regularly use this particular insurance for other physical ailments. It is statistically unlikely that none of these employees has ever been treated for a mental illness, so Abou Nader speculates that it is likely employees do not ask for this coverage either because they are unaware that the company’s insurance policy covers it or because they have internalized the stigma surrounding mental health issues. In other words, the societal cost is perceived to be higher than the economic cost and individuals would thus rather pay the supplementary cost themselves rather than claim it on their insurance.
It is also worth mentioning that psychiatric disorders are treated differently from the usual exclusions stipulated by private insurers, such as cancer, chronic diseases, and pre-existing conditions. The Insurance Control Commission (ICC), a body in the Ministry of Economy and Trade, implemented a ministerial decision (No. 109) in May that required insurance companies to cover chronic diseases, pre-existing conditions, and cancer, and to offer guaranteed lifelong renewability of individual healthcare insurance if the client gets sick six months after they have entered the contract. This policy does not, however, include psychiatric illnesses, with some minor exceptions.
These exceptions come with very strict limitations. First, consultations, tests, and medications are never covered, and hospitalization is covered only for those with schizophrenia and bipolar disorder, and only for 30 days. Hospitalizations due to attempted suicide, self-inflicted injury, or substance abuse are not covered because these afflictions are described as “caused by the individual,” Abou Nader says. The issue here is that because of the lack of physical proof and the intangible nature of such illnesses, a medical diagnosis is not seen as justified. Dewachi suggests that one of the reasons for insurance companies’ reticence to cover psychiatric-related costs is that they “are afraid of the fact that there are very blurry lines between what is really an illness and what isn’t, because there are no real diagnostic tools, such as CT scans and blood tests for mental illnesses.”
Stigma aside, the associated costs also prompt insurance companies to exclude mental illnesses from their coverage. As Abou Nader explains, including psychiatric treatment in insurance policies would be very expensive for these companies, because psychiatric treatments are continuous and often last a lifetime. Such an inclusion would thus entail an unwelcome financial burden on these profit-oriented groups. And, unlike in the case of chronic physical illness, the lack of legal obligation to cover these treatments means that insurers have no motivation to do so.
The NSSF is under the supervision of the Ministry of Labor, and decisions concerning changes in insurance policies require the ministry’s approval. “When we go to the Council of Ministers with proposals, it happens through the Ministry of Labor,” explains Mohamad Karaki, director general of the NSSF. The social security fund insures Lebanese employees in three categories: sickness and maternity care, family allowances, and end-of-service indemnities.
Employers from all economic sectors are required by law to enroll their employees in the NSSF. The NSSF covers mental illness-related expenses under the umbrella of sickness and maternity care. Unlike private insurance companies, its policy covers cases of attempted suicide, self-injury, and substance abuse, among others. Mental illness is treated in the same way as physical illnesses, with no special or specific policies or exclusions.
The NSSF’s general policy for all illnesses, whether mental or physical, is that there are no fixed budgets or limitations. Therefore, there is no specific budget directed toward mental health. Given that the institution does not produce statistics on insurance usage, it is impossible to know how many people make use of this coverage, or to determine, roughly, how many suffer from and receive treatment for mental illness. The lack of information means that it is not possible to calculate the social and monetary ratio between physical and mental illnesses.
However, the director general believes that even if there were official statistics, the taboo around mental illness in Lebanon would lead to popular misrepresentations of the country’s mental health landscape. Karaki believes that many people who need treatment for mental health problems do not seek it, and their illness therefore has no impact on the NSSF. This inaction, he says, might be either because of a fear of social repercussions or due to a lack of awareness about mental health and available psychiatric care. According to Karaki, just as in the private sector, “there are no official requirements [on the NSSF] coming from the government and the Ministry of Public Health (MoPH).” Requiring both the public and private sector to cover mental health could be transformative, in ensuring increased access to good, free treatment for mental illness and a lessening of the social stigma around it.
The Ministry of Public Health
The goal of the MoPH is to provide free, universally accessible, high-quality health services to those who are not insured by either the private sector or the NSSF. In an effort to improve the state of mental health in Lebanon, the ministry in 2014 put in place a National Mental Health Program (NMHP). The NMHP aims to raise awareness about the importance of mental health through yearly campaigns designed to reduce the societal stigma around the issue. It also offers training for various professionals (general practitioners, nurses, social workers, etc.) in primary healthcare centers (PHCs) and provides medical attention to people who need it, not only via PHCs but also via specialized community mental health centers and inpatient facilities.
The NMHP put in place a five-year strategy for 2015 to 2020 aiming to lead the reform of mental health care in the country and develop a country-wide system at both the preventive and the curative levels. The NMHP has a collaborative governance model, meaning that it works with different actors to accomplish its goals. First, it cooperates with other public institutions, such as the Ministry of Education and the Ministry of Social Affairs. Second, it interacts with civil society, as can be seen in its collaboration with Embrace. In addition, international organizations such as the WHO, UNICEF, and the International Medical Corps (IMC) are financial partners in the program and provide some technical support.
These partnerships are very helpful in achieving the NMHP’s goals, especially since the MoPH does not allocate a budget to the program. There is one stakeholder, however, that the NMHP has yet to reach: private insurance companies. The program aims to ensure the full coverage of mental health-related expenses by these companies. “We cannot punitively make them do it, but we can discuss together potential schemes that can be integrated. It is something we are preparing at the moment,” says Nour Kik, policy and advocacy coordinator at the NMHP.
Because of the lack of fixed funding, some of the planned year-by-year goals of the NMHP have not been met on schedule. Nevertheless, Kik notes that, “it is still important to have a roadmap in order to know our priorities.” The program relies on opportunities arising to sign agreements with different partners funding a particular project. On the curative level, the NMHP is progressively introducing mental health treatment at PHCs and is also developing community-based mental health care facilities. They train non-specialized staff such as nurses, social workers, and family doctors who are already present in the PHCs to manage these issues and conduct outreach activities. Nevertheless, the government’s actions are undoubtedly limited because of a lack of stable funding and their resulting dependency on civil society to conduct anti-stigmatization campaigns, as well as to help provide free healthcare for the mentally ill.
Lebanon’s two most prominent nonprofits for mental health, Embrace and the Institute for Development Research Advocacy and Applied Care (IDRAAC), work to compensate for the government’s deprioritization of mental health. They also make it their mission to encourage the public sector to take action. “The public sector should do more when it comes to raising awareness and IAPT [Increased Access to Psychological Treatment] by training more people. They need to create dispensaries that people can easily access,” says
Aimee Karam, a clinical psychologist, member of IDRAAC, and president of the Lebanese Psychological Association (LPA). There are currently initiatives in place to reach out to policy makers and advocate for mental health care as a basic human right, via lobbying and the drafting of laws. Embrace’s website also mentions their aim to support the policies of the NMHP. The NGO participated in a dialogue to put in place a national policy “securing access to quality mental health services in primary health care in Lebanon.” It also collaborated with the MoPH, the National Committee for Ethics, and IDRAAC to draft a mental health law to submit to Parliament for the protection of persons with mental illnesses.
In Lebanon, the latest legislation decree concerning mental health dates back to 1983. Despite efforts by different associations to provoke discussions and drive policy making initiatives, no new policy has been implemented by Parliament to ameliorate and regulate the way mental health is treated both medically and socially for over thirty years.
In other words, NGOs have taken on the responsibility of bridging the gap between the needs of society and the shortcomings of different public institutions when it comes to mental health.