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

Lebanon
However, the effectiveness of contractual arrangements as a tool for improving health
sector performance can be improved. These arrangements:
Are not yet part of a clear national strategy for health sector reform, therefore their use as a tool can
only be limited in effectiveness and scope. The main limitation today is the fragmentation of
health care financing. Without a uniform financing scheme, which should be the outcome of
a political process, contracts can only have limited success in giving the government the
needed leverage to manage care. Furthermore, considering that 65%–70% of all health care
expenditures in Lebanon are borne by the citizens (with the poor spending disproportionately
high percentages of their income), even with optimization of contracting mechanisms, there
is a limit to what can be done and the main focus should be on improving public financing of
the health care delivery.
Remain fragmented with different agencies contracting with the same providers using different
terms and tariffs.
Are not based on evaluation of measurable indicators for both processes and outcomes. Therefore,
there are very limited capacities at present for evaluation of performance of contracted
parties.
Favour an ever stronger private sector over the public sector, which has been undermined.
Do not provide the government with adequate leverage to shift emphasis from acute care to
preventive and outpatient care. In this sense, contracts serve more to “manage” the current
health sector crisis in Lebanon rather than contribute to effective long term solutions.
Place little emphasis on broad determinants of health. Related to this point, there is little
coordination with other governmental agencies that work on these determinants, such as the
Ministry of Social Affairs.
Rarely solicit the consumer perspective and do not meaningfully involve citizens in choice or
monitoring of contracts. This relates to issue of need for democratization of health care
policy processes.
Do not adequately emphasize models of integration (e.g. prevention–treatment, in-hospital–
community).
CONCLUSIONS AND RECOMMENDATIONS
Contractual arrangements in the health sector are abundant in Lebanon. They are used
mostly for hospitalization and ambulatory care services, with over 80% of the Lebanese
population covered through these contracts. However, contracts also cover a variety of public
health functions. The breadth of these contracts reflects the dominant role of the
nongovernmental sector as compared with the public health sector. Contracting allows the
different public agencies to obtain services needed for beneficiaries in all of Lebanon. The
Report has reviewed the different contractual arrangements of different public organizations and
identified strengths and weaknesses. These are summarized in Table 5. The review also identified
the main obstacles to improving contractual arrangements, which include lack of political