The role of contractual arrangements in improving health sector ...

Lebanon
and local municipalities. Enrollees and beneficiaries of these financing schemes are discussed
later.
Due to past unregulated growth of the private sector, which dominates the provision of
health services, and various malfunctions of the public sector, the health sector suffers from
chronic inefficiency, poor mix of providers and waste. This is true for both ambulatory care as
well as hospitalization. Over 160 hospitals are licensed, of which more than 85% are private.
There is gross oversupply of small (less than 100 beds) hospitals (73%). Only 5 hospitals have
more than 200 beds. Hospital beds are in oversupply, with 12 000, beds or around 26 per 1000
population. The low occupancy rates (45%–50%) further contribute to poor economies of scale.
There is oversupply of high technology in Lebanon (please see section on CABG under Case
studies) which humbles the limited availability of similar technologies in many industrialized
countries. Correspondingly, there is oversupply of specialized physicians. Indeed, over 70% of
physicians in Lebanon are specialists, the inverse of the ratio in the United Kingdom, where the
specialist/generalist mix is 30/70. Over 11 000 physicians are currently registered in the two
Orders of Physicians in Lebanon. The exact number of practising physicians is not known, but
probably 15%–20% are practicing abroad. Medical practices are not commonly organized
according to groups of either single or multiple specialties, thus increasing overhead and cost of
care and reducing efficiency. Medical care is mostly fee-for-service or flat-rate based. There are
no managed care or capitation plans in Lebanon. Non-physician clinicians are undersupplied in
Lebanon. For example, the nursing rate per capita in Lebanon is among the lowest in the world.
Health care utilization is relatively high in Lebanon. Because Lebanon is a small country,
access to medical services is not a major problem, although some areas remain plagued with low
health care access rates. Around 12% of the population is hospitalized per year. Because of
multiple factors, including undersupply of public hospitals, perceived low quality and social
stigma in a culture that is image-conscious, most hospitalization is in the private sector. Around
28% of Lebanese uses ambulatory care services per month; the average number of ambulatory
care visits per year is 4. There is an abundance of public and nongovernmental organization
ambulatory health centres, over 110 primary care centres and over 400 dispensaries. However,
most ambulatory care takes place in the private sector where it is problem-oriented and
specialist-provided. Emphasis on prevention and health promotion is severely lacking.
There have been multiple attempts at health sector reform in Lebanon since the end of the
civil war. This has included a large World Bank-funded project. Large ambitious reform
packages have not received political support, despite their perceived urgency. In this climate,
public agencies, especially the Ministry of Public Health, are trying to regain regulatory powers
and improve their stewardship of the health sector. This has proved to be challenging considering
the large and powerful private sector, the limited political support, lack of citizen engagement
and limited capacities of the public sector.
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