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

Lebanon
Perhaps the more obvious difference relates to the model of care emphasized by the
Ministry of Social Affairs, which comes closer to the original primary health care through
emphasis on social health rather than on provision of a limited set of primary care services or
essential drugs. Such a model presents a challenge for Ministry of Public Health network centres,
many of which are not equipped to deal with what is needed to implement this model.
Nongovernmental organization health centres also rarely implement this model, although the
Islamic Health Council presents a bright exception.
Contracting ambulatory care services for publicly insured Lebanese
As previously noted, the majority (with the exception of the Ministry of Public Health) of
public financing agencies cover their beneficiaries for a variety of ambulatory care services.
These include, for example, those provided by physicians, both generalists and specialists,
physical therapists, midwives, radiology and laboratory centres, physical therapy centres, and
hearing aid centres. The contracted parties must apply to the financing agency with documents
certifying training, qualifications and other aspects. Almost all licensed providers are accepted if
they apply and meet eligibility criteria. In some cases, e.g. contracts with radiology and
laboratory centres, field visits are carried out to ensure the accuracy of data presented in the
application. Contracted parties sign a standard brief contract. These contracts do not involve
direct cash transfers. Rather, the beneficiary, having received and paid for the service out-ofpocket,
presents documentation of the service and is reimbursed by the contracting agency
according to a pre-set fee schedule minus the deductible.
There is dissatisfaction by all parties with this arrangement. Providers complain of low
fees. Beneficiaries complain of having to pay over fee schedules to obtain the services. The
financing agencies complain of corruption involving both consumers and providers and of
inability to manage the tremendous responsibilities of oversight with a limited staff and large
workload. Other limitations of current arrangements will be discussed later.
4.2 Contracting for hospitalization and related services
Around 12%–12.5% of the Lebanese population gets hospitalized per year. Contracting for
hospitalization is described below according to insurance coverage of citizens.
The uninsured population
Prior to the start of the civil war in 1972, the Ministry of Public Health had begun covering
costs of hospitalization for the indigent, which consumed no more than of 10% of its budget.
Eligibility was extended to include the uninsured as a result of consumer and political pressure
(but not legislature) starting in 1982. After the civil war ended in 1991, this coverage was
conceived to be a temporary measure while plans for national health insurance coverage, which
were in draft stage before the war erupted, were developed. Unfortunately, the latter goal proved
difficult to accomplish. With the escalating cost of hospitalization, this issue has been at the
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