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

Lebanon
Overall, the contracts allow the concerned national programmes to receive WHO expertise
on the basis of cooperation. In addition to the actual activities of programmes, several examples
illustrate that the outcomes of cooperation with WHO may go beyond the programmes
themselves. This is shown, for example, in the contribution of WHO to immunization campaign
following the detection of the polio case in Akkar in 2003 and training of the Ministry of Public
Health personnel and pharmacists in different aspects related to rational dispensing. While the
contracting arrangements with WHO have given important benefits, it is difficult to ascribe all
of these fruits to the use of the contract as a tool. Rather, many of the activities are based on the
voluntary participation of WHO as a concerned agency in Lebanon.
There are certain limitations to the collaborative arrangements between the Ministry of
Public Health and WHO. The different national programmes commonly contract with other
parties, e.g. consultants or other agencies, to carry out specific tasks on WHO consultancy pay
scales. Additional overhead is paid to these third parties, increasing the overall overhead of the
programmes. Furthermore, it is not clear that the different programmes have had the desired
effects. This is seen with regard to the interlinked programmes of tobacco control as well as
noncommunicable disease control, which have not been closely coordinated and have not been
able to effect the desired policy change. The AIDS control programme is the only collaborative
programme that has a written and declared national strategy. None of the other programmes
have clear strategy with indicators, annual reports, performance assessment. Similarly, none of
the programmes have sub-strategies for the different components of the programme. For
example, a primary health care strategy cannot be implemented without a sub-strategy on
reproductive health, which does not currently exist.
Other publicly-financed agencies
Several public organizations (Table 1) cover a range of social services, e.g. health and
education, which may or may not be maintained beyond the age of retirement. These
organizations have health funds which use contracts to secure health care services for their
beneficiaries. Covered health services typically include hospitalization, ambulatory care
(physician- and non-physician provided), drugs, and various health enabling aids. The exact
types of services, class of services, and amount of co-payment by beneficiaries do vary among
the different funds. However, all funds have similar mechanisms for contracting for
hospitalization and ambulatory care; these will be discussed under “case studies”.
It may be worthwhile here to make a brief introduction to the largest two of these
organizations, the National Social Security Fund (NSSF) and the Civil Servant Cooperative
(CSC). The NSSF was set up in 1961 and covers employees of the formal sector, contractual and
wage earners of the public sector, employees of autonomous public institutions and others (e.g.
physicians, public school teachers) and family dependents. The number currently enrolled at
NSSF is around 430 000 Lebanese, and the total number of beneficiaries (including dependent
family members) is estimated to be around 1.3 million, or around a third of the Lebanese
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