Navigating Access to Healthcare in Lebanon: The Political Economy of Health across Conflict, Revolution and Applicability

Just weeks after the eruption of the uprising in Lebanon, also known as the October 17 Revolution, the medical suppliers who provide equipment for both public and private hospitals said that they were unable to import medical equipment due to the shortage of US dollars and the absence of government regulations that would prevent banks from arbitrarily restricting money transfers outside the country. The private hospitals carried out an unprecedented “warning strike” to sound the alarm about the shortages they were facing and to urge government officials to pay them the funds they owed them.[1] Shortly, the Central Bank of Lebanon issued a decision which guaranteed the provision of 50 percent of the US dollars medical suppliers need for imports at the official rate, leaving them to obtain the remaining 50 percent at the market rate.

As access to healthcare in Lebanon remains subject to multiple layers of politics, economy, sectarian interests and political objectives, similar to many of Lebanon’s institutions and policies, the health sector remains independent of any form of meritocratic or inclusive practices. When tackling the issue of the political economy of health in Lebanon, academics and researchers alike often encounter two fundamental areas in which the findings are rooted: state structure and institutions of sectarian political parties. The ideological hegemony of sectarianism does not infiltrate the access to healthcare exclusively, but rather influences Lebanon’s “system” as a whole, with intersections among various governmental agencies and institutions hindering the effectiveness of the other. Moreover, fragmented policies in the health sector do not even carry over from one administration to the next.

Findings the Global Health Institute at the American University of Beirut derived from key informant interviews conducted with various experts, officials and academics in Lebanon have concluded the realization that Lebanon does not have a national policy on healthcare, but rather operates navigating through pieced-together policies and directives amid sectarian and political constraints.

The current demographic and conflict-based challenges Lebanon faces, and has faced since the Lebanese Civil War, have rendered the system which “covers the most vulnerable Lebanese” not only ineffective, but also exclusive. Coupled with Lebanon’s recent outbreak of political protests demanding transparency and reform, Lebanon’s public administration, its ministries and its local politicians face the ever-conflicting and difficult task of attempting to render policy, budget, reform and ramifications upon the Lebanese general public tailored to the revolutionaries’ demands and needs.

With Lebanon currently lacking the funds and resources for its health sector to accommodate developments and challenges, as well as the sharp decrease in aid from the international community, Lebanon’s health sector is faced with a harsh reality of having to consistently resort to post-hoc policies rather than preparing and adopting other universal models contextually and preventatively –  a reality that will not only no longer work in a post-revolutionary era, but further escalate into a health crisis should this era not account for Lebanon’s most vulnerable both inclusively and comprehensively.

The fundamental hindrances, short-comings, as well as the overall lack of preparation and political will which shape Lebanon’s health sector shed light upon the sectarian interests, the “right to seek care”, as well as the socio-economic and political determinants which affect the health system in the country as a whole. The healthcare sector continues to find itself at a crossroad between its technical capacity and the overall political will of the serving elites amid developments and intersections between global health and political and economic realities.

With Lebanon currently enduring its own political and economic obstacles and uncertainties amid is 2019-2020 uprising, health trends have taken a back seat to pressing matters related to the country’s overall stability while the international health scene is consistently in development across both political and economic realms.

Although Lebanon “adheres” to multiple international mechanisms, treaties and frameworks, as well as allows these international agencies to operate within its borders, the ramifications of this into the policies actually adopted and applied is still scarce. Lebanon’s national healthcare and social security remain similar to all government agencies across the country. According to interviews conducted by the Global Health Institute (GHI) at AUB, they are “partisan” instead of constructively political, and simply do not elevate themselves to take part in a global framework which would assist their overall aim and future benefits.

In January 2020, following months of political gridlock, Lebanon finally managed to form a new government, and gain the Parliament’s vote of confidence. Now settled, the new government, which is comprised of technical experts agreed upon by major political parties, are tasked with this inheritance, and the healthcare system is one of the country’s major escalating crises. The government, tasked with finding solutions to the numerous pressing issues facing the country, amid tackling rampant corruption, is anticipated to be moving toward reform for good governance particularly as Lebanon continues to look abroad for aid and investments in order to deal with its public debt and dwindling currency. More recently, an ill-equipped Ministry of Public Health in Lebanon is currently tasked with the spread of Coronavirus – with Lebanon’s Cabinet attempting to make its way through a multi-layered crises in Lebanon.

The Lebanese civil war had an overwhelmingly negative impact on the public health care system. The state facilities were in their majority destroyed, looted or deserted. Staff and medical personnel found difficulty in reaching work. To provide care to the traumatized population, the Government relied on the private sector. Whereas before the war, in 1970, only 10% of the Ministry budget was spent on the care of patients in private facilities, that proportion escalated to a staggering 80% in the late 1990s. According to Dr. Nabil Kronfol, Founder and President of the Lebanese Healthcare Management Association, of all the sectors in the economy, none has flourished as much as the private health sector during the two decades following the Civil War.

Amid political unrest and staggering economic declines, Human Rights Watch has reported that Lebanon’s medical practitioners and public officials have been warning that hospitals may soon not be able to provide patients with mandatory surgeries and urgent medical care due to a financial crisis. This crisis in particular stemming from the government’s failure to reimburse private and public hospitals, including funds owed by the National Social Security Fund and military health funds. The aforementioned making it difficult to pay staff and purchase medical supplies. Additionally, a dollar shortage has restricted the import of vital goods and led banks to curtail credit lines.

The case of Lebanon’s health sector is highly fundamental in understanding healthcare in the MENA region – where health sector reform efforts are progressively converging on a combination of a public/private mix in the financing and provision of health services. The most vital lessons which can be learned are the need for the Ministry of Public Health to be the integral player in a pluralistic/sectarian system, particularly in defining the areas of public and private sector operation based on a needs assessment, and having the capability to monitor and regulate the private sector. In the absence of a policy framework and of a regulation capacity, there is a major risk that health systems based on public and private participation will not produce the desired health outcomes, nor provide health services that are comprehensive, equitable, efficient and of high standards.

The truth of the matter is that Lebanon has yet to grasp the delicate reality surrounding the applicability of a healthcare solution within its borders. And this is mainly due to the fact that the global health agenda flows from the convergence of unprecedented changes and events in international relations. And comprehending this convergence communicates that global health’s rise emerges from factors that reshaped the manner through which States, INGOs, and non-State actors approach and incorporate health into their foreign policy, diplomatic, and governance agendas – and this reality is quite far away in Lebanon especially in a converging post-revolutionary period as Lebanon continues in its struggle to place itself within the international community under the international governing bodies strategically, and within the global health system alike.

“This work was funded by the UK Research and Innovation GCRF RESEARCH FOR HEALTH IN CONFLICT (R4HC-MENA); developing capability, partnerships and research in the Middle and Near East (MENA) ES/P010962/1.”

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Editorial Credit(s)

Marianna Karakoulaki

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