Characteristics and challenges of the health sector response in Lebanon

By Frank Tyler

Frank Tyler was Senior Public Health Coordinator in the Inter-agency Coordination Unit, UNHCR Lebanon from January to October 2014. He is a humanitarian and public health specialist with over twenty years’ experience implementing relief programmes. Areas of expertise include public health, disaster management, disaster risk reduction, and training design and delivery.

Many thanks to all Lebanon health sector stakeholders that contributed to the Lebanon health chapters of the Multi Sector Needs Analysis (MSNA) and the regional resilience and response plan, which in part are summarised and referenced throughout. 

A Multi Sector Needs Assessment (MSNA) was conducted in 2014 by a team of UN agencies and NGOs and the findings shared by sectors in the form of chapters. The MSNA team aimed to provide an objective overview of the available data and Sector Working Group (SWG) views. It involved identification of information needs, secondary data collation, data categorisation, together with consultation with sector working groups. This article shares some of the key observations and recommendations emerging from this review which are documented in the MSNA Health Chapter¹. It also draws on findings from a subsequent health access and utilisation survey by UNHCR in July 2014².

The context 

During the past two and a half years, Lebanon has experienced an unprecedented influx of refugees from Syria numbering over 1 million and projected to rise to 1.5 million. As of March 2014, Lebanon reached its 2050 projected population figure (4.6 million) and this will continue to increase over the next year. The population surge has put severe strain on finite resources, the already over stretched public services and the capacities of authorities at central and local levels. This strain is keenly felt in the health sector. The World Bank estimates that USD 1.5 billion (3.4% of Lebanon‘s GDP) will be needed to restore services to pre-crisis levels, of which USD 177 million is for health services alone. The Ministry of Social Affairs (MoSA) and Ministry of Public Health (MoPH) report an average 40% increase in the use of their services with ranges of between 20-60% across the country.

The Lebanese healthcare system is dominated by the private sector which is geared towards hospital-based curative care (48% of total public health expenditure) rather than primary and preventive health measures.  The refugee crisis has exposed the fragile nature of the pre-existing public health system where 50% of the Lebanese population have no formal health insurance, are exposed to very high health care expenditures and lack basic means of social protection such as pensions and unemployment insurance. A struggle over access to public services that has seen a 40% increase in use (MoSA), is a key driver of increased tensions between host communities and the refugee population. Lebanese without private medical insurance rely upon the MoPH and the National Social Security Fund to reimburse a portion of their medical bills. Those on low incomes must often choose between paying for health and for other necessities including food.  According to the World Bank, the Lebanese social security systems, including health, are “weak, fragmented and poorly targeted”.  

Challenges in coordination

The political landscape in Lebanon is dynamic. The unstable administration and the political divides in the Lebanese government meant there was a lack of an effective, rapid and strategic response to the refugee crisis. This vacuum with regard to the responsibilities and accountabilities of government actors, particularly at national level, resulted in the municipalities playing a greater role in responding to and coordinating the crisis. There is no national administrative or legal framework for the management of refugee affairs and the response to the refugee crisis must be coordinated across a number of Ministries. The central authority is weak, and with refugees scattered across the country, all activities on their behalf have to be carefully negotiated with local religious leaders and municipal representatives.  Communities across Lebanon are largely confessional based and the same groups fighting each other within Syria are also present in Lebanon. All humanitarian efforts therefore have to carefully navigate a complicated web of often competing political agendas so as to ensure the real and perceived impartiality of the humanitarian response to ensure access and security of staff.  The predominance of the private healthcare sector provides a unique situation compared to other humanitarian situations and hampers effective coordination of health services for refugee populations. 

Under these circumstances, the UN System and the international community involved in the humanitarian response established a mechanism to support government efforts in ensuring basic access to protection and assistance to the increasing number of Syrian refugees in Lebanon. UNHCR, in line with its mandated responsibilities, is the designated UN lead agency for the response to the Syrian refugee crisis and is ultimately accountable for the well-being of the refugees. UNHCR supports the Government in addressing existing gaps, and plays a lead role in coordinating the response to the Syrian crisis with other UN agencies, NGO partners, donors and local stakeholders³.  

The UNHCR Mission in Lebanon was in operation with approximately 70 staff at the beginning of the Syrian crisis in May 2011, mainly catering for Iraqi and Sudanese refugees. Entering its fourth year in the Syrian crisis, UNHCR now have more than 600 staff throughout Lebanon supporting 1,154,580 registered refugees and almost as many vulnerable host populations. The UNHCR co-leads the health sector response with WHO. The health sector facilitates planning and strategy development, undertakes health assessments and analysis of needs, coordinates programme implementation, provides direct monitoring, evaluation and reporting, and provides advocacy and resource mobilisation for refugees and host communities.

Health service provision

UNHCR’s public health approach is based on a primary healthcare strategy. The Lebanese government and UNHCR in collaboration with partners provide healthcare services to Syrian refugees in Lebanon. In the highly privatised/fee charging health system context, refugees can receive care for free or at a subsidised cost at designated facilities across the country. Services covered by UNHCR and partners are summarised in Box 1. In addition, some health partners provide free access for Syrians to primary health care services. 

The country has more than 950 dispensaries (offering limited services) and primary healthcare (PHC) centres (providing a range of services of variable quality). The MoPH has chosen 193 PHC centres to establish a primary healthcare network, of which more than 70% belong to non-governmental organisations (NGOs); many were established pre-crisis to fill shortfalls in the public health system. Less than 10% belong to the public sector (MoPH or MoSA).  Public secondary and tertiary healthcare institutions in Lebanon are semi-autonomous and referral care is expensive⁴.Not all adhere strictly to the MOPH flat rate for hospital care. To harmonise access to secondary healthcare and manage costs, UNHCR has put in place referral guidelines in Lebanon⁵. 

Heath sector issues of relevance to nutrition

In terms of nutrition and health, key considerations are communicable disease (linked to a potential acute malnutrition risk), the prevalence and incidence of nutrition-related non-communicable disease (NCDs) (nutritional factors related to aetiology and/or management), reproductive health (influencing neonatal nutrition status and feeding modality), and access to primary health care services (support on breastfeeding, infant and young child feeding).  Also healthcare costs may impact on household expenditure on food.

Health information and data

Sources of health data are summarised in Box 2. There are significant information gaps on health; the MSNA in March 2013 noted gaps in real time/up to date data for specific geographical areas (reporting is done on a national level with a time-lag of a few months), limited information on the prevalence and severity of health conditions such as NCDs and mental health issues across target groups, lack of information on utilisation rates of hospitals and response capacity in terms of quality of health serves, availability of medications, and lack of data on how social determinants of health (e.g. education, shelter housing ) are linked to the health status. Recommendations on health emerging from the MSNA included:

• To strengthen disease surveillance (EWARN), and the Health Information Monitoring Systems of UNHCR and the MoPH. 
• To establish a national population based health survey. This could be an expanded version of the UNHCR household assessment and utilization survey to provide a health and wellbeing profile of Syrian refugees and vulnerable host communities. This is planned for January 2015.

Communicable diseases

The top five communicable diseases/conditions are viral hepatitis A, mumps, dysentery, measles, and typhoid (EWARN system, October 2014)⁶. To date, and to the credit of the humanitarian effort, disease outbreaks have been largely prevented. However, measles and increased risk of epidemics such polio, and waterborne diseases remain. Data on immunisation and coverage rates in Lebanon prior to the crisis is of variable quality. Access to vaccination services have improved but vaccination coverage for measles and polio remains lower than the herd immunity threshold needed (90%)⁷. Deteriorating WASH conditions in informal settlements pose serious health risks for the spread of communicable diseases⁸. According to the UNHCR HIS annual survey 2013 (preliminary annual health report), consultations for acute illness were the primary reason for accessing healthcare, accounting for 74% of clinic visits. The same survey found that approximately 38% of visits for 33 acute illnesses were by children younger than five years (19% of population). Assessments in Beirut and its suburbs have found that 65% of Syrian refugee patients suffer acute illness, the most common being respiratory tract infections and skin infections⁹. The health needs among elderly Syrian refugees are particularly acute with limited access to care and medications¹⁰. 

Non-communicable diseases 

The demographic and disease profile of Syrian refugees is that of a middle-income country, characterised by a high proportion of chronic or non-communicable diseases (e.g. diabetes, cancer, cardiovascular and respiratory disease). Pre-crisis, 45% of all deaths in Syria were attributed to cardiovascular diseases (CVDs)¹¹, half of 45–65 year old women had hypertension, and 15% of older men and women had ischemic heart disease. Type II diabetes was common (15% prevalence)¹². In Lebanon, in line with rising population numbers, the incidence of various NCDs (cardiovascular, diabetes and hypertension) has risen; amongst older refugees, the prevalence of chronic diseases such as hypertension, diabetes, and cardiovascular diseases is high¹³. 

A UNHCR survey in July 2014 found that 14.6% of households had at least one chronic condition amongst ≥18 years¹⁴. The proportion varied by age, increasing from 4.5% among 18 to 29 year olds to 46.6% for household members who were 60 years or older. The main reported chronic conditions were hypertension (25.4%), diabetes (17.6%), other cardiovascular disease (19.7%), lung disease (10.3%) and ischaemic heart disease (6.2%).  

Health care access 

A UNHCR household health access and utilisation (HAUS) telephone survey of 560 refugee households was conducted in July 2014¹⁵. It found an estimated 12.1% of refugees needed health care services in the month before the survey and a majority (73.2%) were able to seek care mostly through a government-affiliated PHC facility (24.9%), private facilities (21.9%), NGO-operated PHC centres (15.2%), government hospitals (8.3%), traditional or religious healer (2.3%) and mobile clinics (0.2%).   However, over half (56.1%) of Syrian refugees with chronic conditions were unable to get access to care. The main reasons were inability to afford fees (78.9%), long wait at the clinic (13.3%), and not knowing where to go (11.6%).

The HAUS 2013 found broad improvement in level of knowledge about available healthcare services, such as vaccination, prescription procedures and costs of medications for acute and chronic conditions. However, overall the level of knowledge about available health services was low.

Healthcare costs

According to the HAUS survey, refugees who needed care spent an average of USD 90 in the month preceding the survey. That is equivalent to an estimated expenditure of USD 12.1 million over 1 month by all refugees in the country. The main areas of expenditure were services and treatment at outpatient and inpatient centres (52.5%), outside facilities for medicine and supplies used for treatment (29.0%), transport (8.2%) and self-treatment (3.5%). To cope with the healthcare expenditure, refugees borrowed money (53.9%), used household income (39.4%), and/or relied on relatives or friends for payment (27.8%).

Referral for secondary and tertiary medical care is expensive. According to UNHCR analysis¹⁶, the estimated total hospital bill for January to June 2014 was USD17.5 million. The estimated share of the cost for UNHCR was 13.1 million (75%). The estimated annualised per capita hospital cost was USD37 per registered refugee. Approximately 48% of referrals were for obstetric care, followed respiratory infections (8%), gastrointestinal conditions (7%) and trauma and other injuries (7%). Deliveries (births) account for 92% obstetric admissions (92%); the caesarean section rate among refugees reduced from 35% to 32%¹⁷.  

The future 

The longer term goal of the health sector’s response is to deliver cost effective initiatives that reduce mortality and morbidity of preventable and treatable illnesses and priority NCDs and, to control outbreaks of infectious diseases of epidemic potential. The healthcare sector is exploring innovative healthcare delivery and financing models to ensure access to quality essential healthcare for the targeted population. As part of two year regional planning, a resilience component is bringing together a more aligned focus with development actors and funders. For example, the MoPH is being funded by the World Bank in the Lebanon Road Map Plan. New initiatives, such as the Instrument for Stability – Strengthening Health Care in Lebanon¹⁸  are being established by the GoL in collaboration with UN agencies and the European Union to address tensions around access to healthcare between Syrian refugees and host communities in some areas.  Additional priority health sector considerations centre on:

a) Primary healthcare

Healthcare is prioritised at the PHC level with emphasis on the quality of care, with a shift in focus from parallel healthcare services to providing intensified support through the expanding MOPH PHC network. The PHC network of centres of excellence will be supported to provide more comprehensive services for expanded numbers of patients with improvements in quality of care, availability of resources, number and quality of staff, minimum packages of services, community healthcare at the nursing educator level, community-based awareness for better health seeking behaviour, investing in performance standards and longer opening hours. This will benefit both refugees and the host population. The approach involves engagement with local civil society groups and facilities of the MoSA that work within the network and with private health care providers.

b) Hospital care

Referral healthcare to secondary and tertiary services continues to need improved support to cope with limited government finance and additional utilisation of Syrian refugees. The national referral system presents a number of challenges in terms of its approach to refugees entering into the system. Delivery care and its complications (obstetrics) account for nearly 48% of referral healthcare utilisation of Syrian refugees¹⁹. The health sector will continue to support the MoPH in assessing and improving alternative modalities for deliveries with a community based focus, with a view to decreasing the utilisation of high cost referral care and the medicalisation of normal deliveries for the target population. The health sector also supports the MoPH to reduce unnecessary referrals from PHC centres to reduce costs and improve efficiencies. Alternative solutions, such as strong advocacy for task shifting to allow a broader range of services that can be offered at the PHC level through PHC centres of excellence, the necessity of direct international procurement of medical supplies, and allowance for foreign healthcare staff to work within Lebanon will continue to be explored within the MoPHs health plan. A major barrier to overcome is accessing the data on utilisation rates, which is deemed financially sensitive in Lebanon.

c) Disease control and outbreak prevention

Strong focus is being placed on ensuring disease control measures and that outbreak prevention is not only integrated within all outcomes of the health sector strategy, but is also a stand-alone outcome. Disease does not recognise borders or differing groups within the population. Infectious diseases in Lebanon of epidemic potential will be a threat to both Lebanese and refugees. Resources are devoted to institutional strengthening of the MoPH at the national and local levels. The MOPH health surveillance system and Disease Early Warning System (EWARS) continue to be supported for expansion and improvement. In addition, response plans and capacities are being further developed, particularly at the local level and in areas designated as having higher levels of risk of outbreaks. 

Greater effort is being provided to ensure full coverage of routine vaccinations and appropriate vaccination campaigns are conducted where vaccine preventable disease risk is particularly high. Efforts to ensure cold chain logistics and management are maintained will be reinforced to obtain greater immunisation coverage which is of benefit to the entire population.

Conclusions

The complex and highly privatised healthcare system in Lebanon in itself provides a major barrier to ensuring accessible, affordable and quality healthcare services, not only to the refugees but also host communities supporting them. If the health response budget is not achieved, this will greatly affect which groups can be covered by the response²⁰. It would mean focusing entirely on ensuring access to the most vulnerable and emergency care only. The ability of the health actors to provide financial support to refugees to access health care services would have to be revised, exposing refugees to increased healthcare costs and rates of disease and illness. The health actors will need to maintain strong advocacy positions supporting the Government of Lebanon with respect to advantageous legal and political solutions that will allow for improved healthcare services and reduced financial demands on the response.

For more information, contact: UNHCR Lebanon, email:lebbe@unhcr.org

¹MSNA Health Chapter. Available at: http://reliefweb.int/report/lebanon/msna-sector-chapters-health 

²Health access and utilisation survey among non-camp Syrian refugees. Lebanon, July 2014. http://data.unhcr.org/syrianrefugees/download.php?id=7111 

³Dedicated coordinators lead working groups on protection, education, shelter, WASH (water, sanitation and hygiene), health, food security, core relief items and social cohesion and livelihoods. All sectors are co-led with other UN agencies: education and WASH with UNICEF, health with WHO, social cohesion and livelihoods with UNDP, and food security is led by WFP. OCHA, UNDP, UNRWA and IOM are also active in the country and participate in the coordination structure.  Correct as of September 2014.

⁴ Syrian refugees in Lebanon. Secondary and tertiary health care at a glance. January ?June 2014

⁵ See footnote 4.

⁶Republic of Lebanon Ministry of Public Health Notifiable Communicable Diseases http://www.moph.gov.lb/Prevention/Surveillance/documents/lebanon.htm

⁷ See footnote 2.

⁸ See footnote 1.

⁹ HIS 2013

¹⁰ Chahada N, Sayah H, Strong J Varady C (2013), Forgotten Voices: An insight into older persons among refugees from Syria in Lebanon, Caritas Lebanon Migrant Center.

¹¹Maziak W, Rastamb S, Mzayekc F, Warda K, Eissenbergd T, Keile U (2007) ?Cardiovascular health among adults in Syria: a model from developing countries‘. Annals of Epidemiology. 17(9): 713–720

¹²MEDCHAMP (2011) Project Title: Mediterranean studies of Cardiovascular disease and Hyperglycaemia: analytical Modelling of Population Socio-economic transitions. European Union, 7th Framework programme.

¹³ Forgotten voices. An insight into older persons among refugees from Syria in Lebanon. Caritas Lebanon. This report is summarised in this edition of Field Exchange.

¹⁴ See footnote 2.

¹⁵ See footnote 2.

¹⁶ See footnote 4.

¹⁷See footnote 4.

¹⁸ http://www.emro.who.int/lbn/lebanon-news/improving-health-care-services-in-lebanon-in-the-context-of-the-syrian-crisis.html??

¹⁹See footnote 4.

²⁰See footnote 1.