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

Lebanon
population. The CSC was set up in 1970 and covers all civil servants and their dependents,
numbering around 190 000.
The NSSF and CSC share several characteristics. Administratively, both maintain relative
administrative autonomy and financial independence and have independent advisory boards.
Health spending at NSSF and CSC is different in scale (US$ 251.5 million versus 48.3 million)
but similar in kind (48.2% ambulatory care and 51.8% hospitalization). Health care costs borne
by these organizations continue to rise. For example, between 2000 and 2002, health spending at
NSSF increased by a whopping 65% but the relative contribution of outpatient versus inpatient
spending to the total bill remained the same. It must be noted that prior to the civil war, there
were ambitious plans to expand the coverage of NSSF to the whole Lebanese population but the
outbreak of the civil war put an end to these plans. With this, Lebanon missed a historic
opportunity to provider national health coverage.
CASE STUDIES
Contracting for ambulatory and primary care services
Contracting primary care services for uninsured Lebanese
Primary care services are provided by four main parties in Lebanon: health centres
belonging to the Ministry of Public Health (these are either operated by the Ministry or managed
by other parties but contracted out by the Ministry); centres belonging to other public institutions
(such as the Ministry of Social Affairs (MOSA) and local municipalities); health centres
belonging to local or international nongovernmental organizations operating in Lebanon; and
private practitioners (whether hospital or community-based). Health care utilization surveys
indicate that private practitioners provide the largest bulk (over 75%) of ambulatory care services
for the uninsured population in Lebanon. However, in this section, we will examine services that
are partly or fully publicly funded, through either the Ministry of Public Health or the Ministry
of Social Affairs, and where contracting is implemented with a wide scope of nongovernmental
organizations.
a) Ministry of Public Health
In response to fragmentation of primary care delivery for the uninsured, inadequacy of
geographical coverage, and absence of control measures and regulatory mechanisms, the
Ministry of Public Health has developed a national strategy for primary health care and has
attempted to implement it through engaging and contracting with public and nongovernmental
organizations health centres. While the strategy document is not yet publicly available, the stated
aim is to ensure the availability of primary care services to the population in all of Lebanon using
a network of primary care centres. The network was launched in 1996 with around 30 centres.
Expansion has been slow, and at present about 45 primary care centres are in the network. Three
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