The Path Toward Universal Health Coverage.

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Article

The Path Toward Universal Health Coverage: Stakeholder Acceptability of a Primary Care Health Benefits Package in Lebanon

International Journal of Health Services 0(0) 1–22 ! The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0020731415585990 joh.sagepub.com

Rami Yassoub1, Mohamad Alameddine1, and Shadi Saleh2

Abstract Lebanon is a middle-income country with a market-maximized healthcare system that provides limited social protection for its citizens. Estimates reveal that half of the population lacks sufficient health coverage and resorts to out-of-pocket payments. This study triangulated data from a comprehensive review of health packages of countries similar to Lebanon, the Ministry of Public Health statistics, and services suggested by the World Health Organization for inclusion in a health benefits package (HBP). To determine the acceptability and viability of implementing the HBP, a stakeholder analysis was conducted to identify the knowledge, positions, and available resources for the package. The results revealed that the private health sector, having the most resources, is least in favor of implementing the package, whereas the political and civil society sectors support implementation. The main divergence in opinions among stakeholders was on the abolishment of out-of-pocket payments, mainly attributed to the potential abuse of the HBP’s services by users. The study’s findings encourage health decision makers to 1

Research Department, FIKRA Research and Policy, Doha, Qatar Department of Health Management and Policy, American University of Beirut, Riad El-Solh, Beirut, Lebanon 2

Corresponding Author: Shadi Saleh, MPH, Department of Health Management and Policy, American University of Beirut, Van Dyck - Room 111C, P.O. Box 11-0236, Riad El-Solh, Beirut 1107 2020, Lebanon. Email: [email protected]


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International Journal of Health Services 0(0)

capitalize on the current political readiness by proposing the HBP for implementation in the path toward universal health coverage. This requires a consultative process, involving all stakeholders, in devising the strategy and implementation framework of a HBP. Keywords universal health coverage, Lebanon, primary care

Ever since the International Labor Organization’s declaration of fundamental Convention 102 (also known as the Social Security Minimum Standards Convention) in 1952, governments have endeavored to ensure social security (SS) benefits for their people. These benefits include support for disability, family, unemployment, injury resulting from employment, sickness, old age, survivors of deceased, maternity, social assistance, and medical coverage.1 Unfortunately, after 60 years of its issuance, Lebanon has failed to ratify this fundamental convention.2 Inadequate SS in Lebanon has contributed to a dependency rate – a ratio presented as a percentage that identifies the proportion of individuals either 0–14 years of age or above 65 who rely on persons ages 15–64 (ie, the working sector of the population)3(p138) – of 47.2% based on 2010 estimates. This rate is expected to reach 56.9% by 2050 as a result of the increasing dependency of elders. Employment rates for persons ages 15–64 and above age 65 are at 49.4% and 16.8%, respectively, both falling below global averages.3 Lebanon has no unemployment SS program, and approximately 43% of its population has no formal health coverage, thus being forced to rely on Ministry of Public Health (MoPH) subsidies and out-of-pocket (OOP) payments.3,4 Such deficiencies in ensuring SS and adequate health coverage have undermined Lebanon’s capacity to avert inequality, poverty, and insecurity and to achieve optimal economic performance, rendering it as having “limited statutory provision” for SS. One explanation may be that public spending on SS is a scant 2.77% of the gross domestic product (GDP) and 5.28% with health expenditures included.3 To add breadth to depth, Lebanon is facing an unprecedented rise in noncommunicable diseases (NCDs) affecting the most vulnerable sectors of the population: the poor, women, and youth.4 The World Health Organization identified breast cancer as the most common cancer among Lebanese women,5 and even 2 decades ago, between 1991 and 1998, 48.21% of colorectal cancer cases were among persons ages 19–60.6 With only 46.8% of Lebanese having insurance, whether private or socialbased, NCDs have burdened the healthcare system, costing millions of dollars in direct medical and indirect costs.7 Reductions in productivity resulting from


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lost days are also significant, with illnesses among smokers alone contributing to $102.2 million (all dollar amounts in US dollars) in losses according to 2004 estimates.8 With 44% of health costs being financed by OOP payments, excluding premium and social contributions, the impact of NCDs is intensified.4 This unstable and unsustainable course of social, economic, and health deterioration may be interrupted and reversed by investing in proven strategic options. Investment in Lebanon’s Primary Health Care Network (PHCN), with its existing 197 primary health centers (PHC) distributed across the country, may prove to be 1 viable option.4,9 Statistical estimates indicate that 750 000 individuals accounting for 814 000 visits were accessing the primary healthcare system in Lebanon,10 clearly denoting the willingness of Lebanese to utilize primary healthcare. Such intentions and practices are expected to be augmented with the recent development in the PHCN, due to currently ongoing efforts aimed at accreditation of the network’s centers, rendering the PHCN an optimal setting for the initiation of healthcare reform. Another option with high potential that may support the path toward universal health coverage in the country is development and implementation of a health benefits package (HBP). HBPs are developed with the intention of protecting the most susceptible from the impacts of incapacitating health costs by delivering evidence-based, cost-effective health services to the greatest number of people in a clear, equitable, and sustainable manner, with emphasis on the present burden of disease (BOD).11 Such packages coincide with the principles of primary care that include accessibility, efficiency, affordability, sustainability and appropriateness of services provided, that consider community involvement, the health of the population and continuous care from an intersectoral approach.12–14 Overall, HBPs are optimal for countries with insufficient resources for adequate health coverage. Sierra Leone, with a GDP lower than Lebanon’s, but a larger population to serve, has already established an HBP as a cost-effective means of satisfying health needs.15–17 Moreover, countries such as South Africa and Thailand, both upper-middle-income countries, like Lebanon,17 and Arab states, like Tunisia, have long-established, comprehensive HBPs that are yielding encouraging health outcomes.18–20 Lebanon is in a situation to harvest similar benefits by implementing its own HBP. In light of this, the study’s objectives were to develop a primary healthcare HBP tailored to the NCD-related health needs of Lebanese; to conduct a stakeholder analysis to determine the knowledge, resources/power, position, and conditions of stakeholders regarding implementation of the HBP; and ultimately to develop recommendations designed to satisfy stakeholders’ disagreements and conditions to the HBP and to facilitate its acceptance.


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Methodology Development of Health Benefits Package The development of the HBP and conduction of the stakeholder analysis transpired over three stages. The first stage involved conducting intensive research to identify Lebanon’s main BOD, together with the corresponding health categories and services to be included in the HBP. This was achieved by reviewing MoPH statistics on NCD-related services that were in greatest demand over a period of 1 year.21 Accordingly, health issues requiring the most hospitalizations were concluded to be the main contributors to Lebanon’s BOD, and their related primary care health services were included in the HBP. Furthermore, health services were identified based on their inclusion in existing HBPs of other countries with various economic statuses, populations, and inadequate resources, such as Sierra Leone, Afghanistan, Ghana, Japan, South Africa, Thailand, and Tunisia. Services were also evaluated for their established, evidence-based, and cost-effective primary care nature and their recognition by World Health Organization as primary care services that require limited resources, yet yield substantial outcomes in lessening the burden of NCDs.15–17,22 The HBP’s target population is people not currently belonging to any public or military health-financing plan. These plans include the Civil Servants Cooperative and military plans comprised of the Army Medical Brigade, Internal Security Forces, General Security Forces, and State Security Forces. Lebanon’s public and military health financing plans cover 50100% of costs for an array of dental, ambulatory, and hospital services for beneficiaries and their immediate family members and parents, depending on the plan.4 In total, these plans cover 566 447 of the Lebanese population of 4 259 000. Consequently, 3 692 553 Lebanese remain without a sustainable SS plan, especially those residing in rural areas and constituting 17% of the population, according to 2010 estimates.4,17,23 It is worthy of note that these benefits continue to be provided after beneficiaries’ retirement has been realized, unlike benefits provided by Lebanon’s National SS Fund (NSSF), which cease upon retirement of the beneficiary,4 thus depriving the retiree and her/his dependents of health coverage and leaving them vulnerable to illness and the associated costs of needed health services. This supports the reasoning behind the selected target population, which lacks sustainable, long-term SS. The second stage involved presenting the HBP to an expert panel of 2 medical doctors and a health systems regional expert. The medical doctors individually assessed and approved the various services for their effect on NCDs and their capacity to be provided in primary care settings. In this process, certain services and medicines were omitted, and others were added as deemed appropriate by the physicians. Based on their experience and academic opinions, specific services within the above-proposed HBP were identified as needing specialized


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and critical care, along with advanced medical equipment that may not be within a primary healthcare center’s capacity to provide. Accordingly, such services were identified as being both primary and secondary, ie, they would be assessed in the primary health center and referred to a secondary healthcare setting. Other essential aspects of the HBP also were recommended, including the reasoning behind its selected target population, the method and sustainability of its financing, the healthcare setting of its operation, and the success of its services in countries with similar economic and health infrastructures. This information was included at this stage to reduce ambiguity and doubt about the practicality of the HBP’s implementation and thereby reduce stakeholder resistance.

Study Tool Upon completion of the above, a stakeholder analysis was conducted with stakeholders from the private insurance and health, civil society, and governmental sectors, via closed-ended and open-ended (subjective) questions, in order to identify the willingness of influential players to support the HBP’s implementation. The questionnaire was tailored to correspond with the current HBP, allowing for conducting semi-structured interviews with study participants.

Study Participants Stakeholders participating in the analysis were selected based on their relationship to various aspects of the HBP, together with their knowledge of, experience in, and authoritative role in the healthcare sector. They consisted of individuals and administrators representing organizations, who provided positions and information representative of their organizational affiliation. Overall, 10 stakeholders participated in the study: . Interview 1: A private insurance firm (PIF) represented the private health insurance sector that influences health at the nationwide level, due to the considerable amount of resources at its disposal to either foster or oppose the package and to the number of persons it employs. . Interviews 2 and 3: Senior administrators from a private hospital (PHA) and a private academic medical center (PAMC), representing PHAs. Most hospitalizations and secondary care occur within private healthcare settings, and therefore they contribute to a large portion of the health bill. Moreover, the public seems to have greater confidence in and inclination to visit private rather than public hospitals. Finally, such institutions would be involved in a needed referral system between primary and secondary healthcare settings to ensure continuity of care. . Interviews 4 and 5: Two officials from the MoPH and Ministry of Social Affairs (MoSA) represented the governmental sector or executive power of


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the country. The MoPH oversees the delivery of primary healthcare and the PHC part of the PHCN. In addition, the ministry will be responsible for the administration and financing of the package. As for the MoSA, it runs a number of PHC within the PHCN and is well-experienced with the country’s primary health care sector. . Interviews 6, 7, and 8: Senior administrators from an international nongovernmental organization (INGO) and 2 local NGOs (LNGOs). NGOs in Lebanon have influential roles, especially in advocacy, and if they are established supporters of the HBP, they will be vital players in implementation. . Interview 9: A member of Parliament (MP) with knowledge and influence in the health sector represented the country’s legislative power; the selected MP is a member of the parliamentary health committee overseeing the proposition, formulation, and passing of health policies and laws. . Interview 10: An actuary was included in the study to provide advice on the practicality and financial viability of the HBP. Stakeholders were classified into 3 categories: the private sector, consisting of the PAMC, PHA, PIF, and the actuary; the civil society sector, consisting of the INGO and the 2 LNGOs (LNGOI and LNGOII); and the political sector, consisting of the MoSA, MoPH, and MP.

Sampling Method and Data Collection Convenience sampling was employed to assimilate stakeholders with the greatest relevance to, and involvement in, implementing the HBP and primary care as a whole. Through consultation with health academicians at the American University of Beirut, alongside a thorough online review of existing medical academic institutions, active NGOs, and major health insurance companies, a list of principle players in the country’s health sector was developed. Additionally, the comprehensive list of major primary healthcare centers comprising Lebanon’s PHCN was reviewed, and the associated organizations administering the centers were identified for inclusion in the study. This yielded a list of key public and private primary healthcare organizations. To further increase the representability of the study participants, selected organizations were contacted and/or researched to identify the main persons in charge of the public health/primary health care departments (for NGOs), decision making and strategy setting (for the private sector), and steering national health and health-related policies (for the ministries and MP). To further clarify the rationale behind the selection of study participants, at the level of the political sector, chosen participants were either department heads or high-ranking ministerial officials in direct relation to the minister and/or director general of the corresponding ministries, as was the case for the MoSA and the MoPH; hence, they provided information based on genuine


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experience in the arena of Lebanese health policy formulation and decision making, relying on their knowledge of and influence in the existing healthcare system. Similarly, the chosen MP sits on the Lebanese parliamentary health committee and is a key member in proposing health policies and laws for implementation. Finally, private-sector participants were selected because the chosen PAMC plays a crucial role in the country’s health and health economics as a result of its vast size and affiliation with a top-ranking university within the country; additionally, the PHA boasts considerable experience in health economics, finance, management, and delivery of services. This yielded a finely focused list of well-informed, highly influential primary healthcare stakeholders to approach as study participants. This also served as a good measure to maximize the representativeness and validity of the results generated by the analysis, given the time constrictions to complete the analysis and with the intention of optimizing its efficiency by including the most influential stakeholders. Stakeholders were initially contacted via e-mails and provided with invitation letters to participate in the stakeholder analysis. The invitation letter briefed invited participants on the study’s duration and purpose, interviewer/researcher’s background, and the reason behind their selection. Invitations with no reply were followed up with a phone call. Stakeholders agreeing to participate were provided with a package consisting of the HBP itself and the semi-structured questionnaire, along with a brief description of the HBP outlining its aims, target population, area of care, methodology of development, mode of financing, and advantages to the Lebanese public. Subsequently, interviews were conducted with participating stakeholders at a location of their preference that ensured the confidentiality and privacy of the interview. Certain stakeholders were difficult to reach and required intermediaries to establish contact. Following completion of the interviews and associated questionnaires, answers were entered into a matrix summarizing the numeric response/multiple choice answers and themes generated from the qualitative questions. Ten out of 13 invited stakeholders agreed to an interview. Despite various attempts and modes of contact, 3 stakeholders provided no response, including an NGO, a resident family medicine physician, and an influential private insurance company. The duration of interviews ranged between 30 and 60 min, with some exceeding 1 hour. The interview followed the structure of the questionnaire and stakeholders’ responses were recorded accordingly. Confidentiality and privacy of the interviews, along with full anonymity of study participants, were maintained during and after the study.

Data Analysis The questionnaire consisted of a series of alternating closed-ended multiple choice questions and open-ended questions to determine stakeholders’ overall stance. Stakeholders’ knowledge of primary care and HBPs, position/support


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for the package, and resources available to bolster their position had multiplechoice answers, each with a corresponding numerical value. Knowledge was identified as no knowledge (scored as 0), general acquaintance with the topic (scored as 1), or knowledgeable and/or experienced with HBPs (scored as 2). This classification was based on whether the stakeholder provided no definition of primary healthcare and description of HBPs (score of 0); expressed a preliminary understanding of HBPs, the means of their incorporation into primary health care, and their anticipated benefits (score of 1); or demonstrated vast knowledge of HBPs, their objectives, health, and financial outcomes and in some cases had experience with their implementation (score of 2). Position/support of HBP implementation was identified as strongly opposes (scored as 0), somewhat opposes (scored as 1), neither opposes nor supports (scored as 2), somewhat supports (scored as 3), or strongly supports (scored as 4). Finally, resources available was also recorded numerically and stakeholders were indicated as having no resources (scored as 0), an average amount of resources (scored as 1), or sufficient resources (scored as 2) to support their position. Participants’ promptness, or the time it takes to initiate or provide their support, was also assessed, in which “immediately” indicated being at the forefront and not waiting for others, and “delayed” indicated the intention to wait for others to express their support prior to expressing their own support. Hence, knowledge of, position toward, and resources available for supporting the HBP were determined through stakeholders’ direct assertion and selection of answers corresponding to the aforementioned numerical scores. Stakeholders’ agreement with the HBP’s characteristics of having no associated OOP payments, covering the aforementioned target population, and having its scope of services at the primary care level was determined via direct yes/no questions to each of the characteristics. Thematic analysis was conducted on manuscripts and used to examine the open-ended questions, specifically pertaining to the advantages and disadvantages of the HBP identified by stakeholders, their willingness to make their support public, the conditions they had to expressing their support, and other stakeholders they believed would either oppose or support the HBP together with the justification for each. Ensuring the reliability, generalizability, and overall accuracy of the study’s findings was of utmost importance and at the forefront of the study’s concerns. The open-ended questions were supported with extensive probing to uncover the reasoning behind stakeholders’ viewpoints. Additionally, most interviews were not subject to time constrictions and were at least 1 hour in duration (in some cases longer), thus allowing participants to fully demonstrate their inclination to support or oppose the HBP and their means of doing so. Careful consideration of and research into stakeholders’ size within and understanding of the Lebanese primary healthcare system were conducted, such that selected participants wield exceptional influence over the formulation


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and implementation of health policies in the country. In some cases, participants were identified and referred by ministers in the Lebanese cabinet as being the most knowledgeable about the ministry’s involvement in primary health care policy settings and delivery of services within the associated ministry. Moreover, study participants were given a package containing the HBP and questionnaire, along with a succinct description of all aspects of implementation of the HBP, before the day of the interview, thereby allowing participants to understand the item being proposed for implementation and gather their thoughts and interests regarding the HBP. Furthermore, stakeholders were reassured in writing and verbally of their rights to participate and were ensured complete confidentiality, privacy, and anonymity. These measures allowed the study to generate full, accurate, and reliable answers that truly reflect stakeholders’ perspectives and anticipated action when proposing the HBP for nationwide implementation.

Results Based on the triangulation of information sources, the proposed HBP encompasses multifaceted categories of health and primary care services, including screenings; the provision of medicines and information, education, and communication products; counseling; and laboratory exams (targeting, among others, cancer, diabetes, and respiratory and cardiovascular diseases; see Figure 1). The package is to be financed by the MoPH/government through general taxation, in which various options exist to increase the government’s financial resources for health coverage; therefore, it does not involve OOP payments by beneficiaries.24 Government/MoPH financing is deemed equitable and sustainable as it distributes health risks and resources over an entire population, including the most financially disadvantaged persons. Moreover, it has greater immunity to fluctuations in the economy than financing through social insurance. Aside from the target population and method of financing, the third principle characteristic of the package is its scope of care, being at the primary care level and targeting NCDs. Along with the primary care HBP, the study offered an analysis of nationwide significance that lays out the context and readiness of Lebanon to set upon much-needed health reforms, including (but not limited to) primary health care augmentation, as an initial step to attaining SS and universal health coverage for its population. This was achieved by a stakeholder analysis that, in addition to determining stakeholders’ knowledge of the HBP and willingness and resources to support it, identified other aspects of their involvement. These aspects were classified under the themes of “advantages and disadvantages” of HBP characteristics, “mode of support,” “alliances formation,” “conditions to offering support,” and “other existing supporters and opponents” of the package.


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Figure 1. Essential health benefits.

Mode of Support According to the analysis, the majority of stakeholders across the private health, civil society, and political sectors are knowledgeable about and/or experienced with HBPs and are willing to support the HBP immediately and publicly if


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Table 1. Stakeholders’ Support of Public Support, Formation of Alliances, and Promptness of Response.

Yesa Nob

Public support (No. stakeholders)

Formation of alliances (No. stakeholders)

Response (No. stakeholders)

9 1

8 2

7 3

a

Yes ¼ for public support/formation of alliances/immediately (for promptness of response). No ¼ for public support/formation of alliances/delayed (for promptness of response).

b

certain conditions are satisfied. Nonetheless, certain stakeholders expressed delayed support, preferring to plan and see a pilot run of the HBP first, as asserted by the PAMC: “. . .pilot test first with a segment of the population.” Others preferred to wait and see the political attachments and general politics surrounding the issue, as expressed by one stakeholder: “Lots of politics in issue . . . depends on Minister.”

Alliances Formation Similarly, all stakeholders are willing to form alliances with other organizations and/or individuals to bolster their position; however, specific limitations exist for stakeholders that require the approval of their donors prior to establishing alliances, while others must maintain a neutral standing and avoid political affiliations (See Table 1).

Advantages and Disadvantages of HBP Characteristics Virtual uniformity existed in answers regarding characteristics of the HBP. The private health sector unanimously opposed the absence of OOP payments and was mostly opposed to the target population, yet in favor of the scope of care. Declared reasons for not welcoming the abolishment of OOP payments are grounded in the perceived abuse of the HBP by users. As one stakeholder put it, abuse will result: “. . .especially due to drugs provision. . .waiting time. . .hidden politics.” In contrast, the civil society sector collectively supported the package’s scope of care and target population, and most stakeholders in this sector agreed on the package not having OOP payments. Similarly, the political sector expressed complete approval of the package’s scope of care and target population; however, the majority of this sector’s stakeholders disapproved of not including OOP payments. Largely, the main disagreement of stakeholders was on the abolishment of OOP payments, mainly attributed to the assertion that they prevent abuse of the HBP’s services by users (See Table 2).


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International Journal of Health Services 0(0) Table 2. Stakeholders’ Support of Health Benefits Package Characteristics. OOP (No. stakeholders)

Target population (No. stakeholders)

Scope of care (No. stakeholders)

3 7

7 3

9 1

Agree Disagree

Table 3. Availability of Resources for Support of HBP. Resource type Knowledge sharing Advocacy Capacity building Current support of PHC Advertising Vouchers for HBP users Provision of human resources Transforming HBP into law Professional opinion/studies

No. stakeholders 4 4 3 2 2 1 1 1 1

Abbreviations: HBP, health benefits package; PHC, primary health center.

Conditions to Support HBP Unfortunately, stakeholders in strong support of the package lack sufficient resources, whereas those with adequate resources expressed only moderate support (Refer to Table 3 for availability of resources for support). Both the international and local NGOs, along with the MoSA, “strongly support” the HBP’s implementation; however, inclination to support contracted to “somewhat support” for all of the MP, MoPH, and actuary. Last, with a common position of “neither support nor oppose” the HBP’s implementation, the private sector is least in favor of offering support; if support is provided, it would be on strict conditions. In general, positions ranged from neither supporting nor opposing the package, mainly in the private health sector, to strongly supporting the package, expressed by the civil society sector, with the political sector falling in between. Interesting conditions identified by stakeholders were the PIF asserting that it will strongly oppose the package if it expands to the level of secondary/hospital care: “. . .will oppose if package covers (in the future) secondary/hospital care.” The PIF also emphasized that various conditions need to be fully adhered to before implementation, stressing that: “Certain processes need refinement. . .for


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example, recycling of expired medication. . .MoPH to have actuarial and health ratings that would be publicized.” Moreover, the actuary identified the need to have a pre-established process or system for referring patients that require further care: “Further advanced care needs to be established if further health needs are identified at the level of the patient.”

Other Supporters and Opponents The stakeholder analysis also elucidated other opponents and supporters of the package. NGOs were the most commonly identified supporters, whereas views were divided regarding the MoPH (some believe it would oppose as it lacks the necessary capacity) and private insurance, hospitals, and physicians (specifically since the HBP’s stress on preventive care lessens the private health sector’s longterm profits). The country’s NSSF was another stakeholder where views were divided. One LNGO perceived that the HBP would assist the fund through its difficulties by covering certain services already under NSSF’s scope of coverage, whereas the INGO, MoPH, and MoSA believed that the NSSF would oppose because it would lose services it already covers, which would eventually attenuate its influence at the national level. However, the most surprising opponents identified were NGOs affiliated with religious and/or political entities, as the package would undermine the control they practice over Lebanese by offering them subsidized and complimentary health services.

Discussion Discussion of Results Rising healthcare costs, increasing burdens of chronic diseases, and an unstable and unpredictable economy call for Lebanon to see smart, cost-effective, and nationwide health solutions to treat the country’s growing burdens. Lebanon’s healthcare system is a highly privatized sector with private health institutions dominating the delivery and financial aspects of care. The country has one public health financing plan, Civil Servants Cooperative, which covers only 4.3% of the population, in addition to the various military health financing plans that together account for only 9% of the Lebanese population’s health coverage.4 According to MoPH statistics, the ministry has assisted in covering a large number of costly hospitalizations related to various diseases. In 2010 alone, there was a significant 37 476 hospitalizations related to health problems within the circulatory system and another burdening 23 803 hospitalizations due to various neoplasms. The MoPH was also required to assist in 27 834 cases requiring hospital care and related to diseases and complications of the


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respiratory system. In addition, the MoPH assisted 21 093 cases in financial coverage due to problems in the genitourinary system.21 To add breadth to depth, the risk factors that contribute to NCDs are high in prevalence among the Lebanese population. Smoking persists at 36.8% among Lebanese, with physical activity at 47% and high blood pressure at 39%; in addition, high blood glucose levels persist at 11.5%, and overweight and obesity in persons 20 years and older is at a striking 62.8%.5 This is a major, nationwide problem, especially when smoking, obesity, and physical inactivity are among the main factors contributing to NCDs.25 The country’s health situation has pushed the MoPH to spend more than $425 million to cover uninsured citizens, according to the most recent health accounts,26 a considerable amount for a low- to middle-income country with a GDP just above $44 billion.27 Primary care stands as a strong option to address growing health burdens. The services and medicines part of the HBP will be provided at PHC as part of the PHCN. These centers are distributed across Lebanon and thus accessible to Lebanese in both urban and rural areas. The network began in 1996 with 29 centers administered by NGOs, the MoPH, and the MOSA and has developed into a significant 197 PHC with an approximate catchment area for each center ranging between 15,000 and 30,000 persons. Ever since its establishment, the network’s centers have been involved in delivering primary health care services under the categories of cardiology, pediatrics, and oral and reproductive health, among other primary care services. Hence, the services to be provided by the HBP already fall within the scope of care of the established network, and it has already been supported by top MoPH officials that primary care and preventive initiatives are the “most cost-effective control measure.”4

Acceptance of and Conditions to HBP Considering the above, none of the stakeholders essentially opposed the HBP, but this can be attributed to the MP’s assertion that no party will publicly oppose such a project or initiative (see Table 4). Worthy of concern is the private sector, which, although having the most resources, is least in favor of the HBP (this may be linked to the conditions this sector has raised). The PIF proposes the inclusion of all Lebanese for equality reasons, but this may also be due to PIFs working to decrease the financial burdens they bear for NCD-related hospitalizations, as the package may ameliorate the prevalence of NCDs in the population. Hence, although not directly asserted, PIFs may very well recognize the long-term health and financial benefits the HBP has to offer. Alternatively, the PHA proposed including coverage for secondary/hospital care and would provide support on the condition that users of the package requiring secondary/hospital care are referred to their hospital. Thus, resistance is not for the type of package, but for its breadth of


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Table 4. Stakeholder Support Vs Resources. Stakeholder International NGO Ministry of Social Affairs Local NGO II Local NGO I Member of Parliament Actuary Ministry of Public Health Private hospital Private insurance firm Private academic medical center

Supporta

Resourcesb

4 4 4 4 3 3 3 2 2 2

2 1 1 0 2 1 0 2 2 1

Abbreviation: NGO, nongovernmental organization. a Support: strongly opposes (0); somewhat opposes (1); neither opposes nor supports (2); somewhat supports (3); strongly supports (4). b Resources: no resources (0); average amount of resources (1); sufficient resources (2).

coverage, as a result of additional income generated by full hospital coverage of Lebanese. The PAMC expressed concern about the effectiveness of the package and proposed a pilot test and development of a plan for reimbursing physicians, specifically specialists, before it would provide support. The pilot test may also be to identify the impact of the HBP on PAMCs, perhaps on both a financial and a nonfinancial basis. The above clarify that the private sector’s inclination to support the package is grounded on subsequent financial impacts on its organizations. Even so, this sector may still benefit from implementation of the package if it is approached dexterously. For example, the PIF proposed providing coverage for primary care services if beneficiaries retain membership with the PIF for 10–15 years and the PHA is willing to provide vouchers for referred users of the package. The private sector is balanced out by the civil society sector, which is a strong supporter of the HBP. This support would be more substantial if not for the modest resources of NGOs and their dependency on donors. The INGO and one of the LNGOs that cannot affiliate with or accept benefits from politically affiliated groups reflect this, since such donors may have pre-existing conditions. Nevertheless, these organizations may compensate for their lack of material resources by emphasizing advocacy. In reality, organizing public action is an optimal way of realizing achievements on the political level,28 where NGOs, via advocacy, are well-established specialists in initiating public action. The political/governmental sector complements civil society in overall resources and support. Support by this sector may be attributed to the reasoning


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presented by the MoSA, which is that politicians would favor such a project to compensate for deficiencies at the political level and for setbacks in realizing promised reforms. According to the MoSA, festivals and celebrations are proceeding despite political deadlock, and politicians may welcome the package. This is supported by ongoing initiatives at the health level, such as the planned health card for the impoverished, denoting plans to see through or at the very least begin operational and long-term strategic planning for health reform. Furthermore, the MP’s enthusiastic support for the package and affirmation of sufficient resources available for its implementation may be linked to the recent success, even if only at the legislative level, of passing the national smoking ban law. However, the MoPH’s stand of “somewhat supports” and its anticipated delayed support for the package are discouraging. This reflects the MoPH’s continued failure to realize needed health reforms and its incapacity to free itself of harmful political affiliations and deadlock. Nonetheless, the political sector has an indispensable role to play; in one country, different policies yielded a discrepancy in life expectancy ranging between 35 and 75 years within the same group. Also, with globalization and a population aging at a rate that exceeds economic growth,28 there is a serious need for politicians and lawmakers to make right and timely decisions and reforms.

Knowledge Translation Worldwide, health is a well-established determinant of nations’ economic and social standing. Ill health negatively influences the workforce, requires family members to care for their ill, and imposes academic and social setbacks on children, reducing their capacity to contribute to society in an economically productive manner. Collectively, these factors generate low socioeconomic status and poverty.29 In turn, poverty increases vulnerability to NCDs’ risk factors and causes regression in academic achievement, deviant behavior, and poor health itself.5,30 Lack of medical coverage and OOP payments contribute to both ill health and poverty, fueling the vicious trend. The HBP provides NCD-related services devoid of OOP payments that afford Lebanese social protection based on the principles of social justice, unity, and equity. In fact, the basis and ultimate goal of this research was to strengthen and encourage efforts that support social justice and equity initiatives in the country. Current users of the PHCN incur the same costs whether insured or not4; however, the package abolishes OOP payments, considering the principle that health is a basic human right to be provided regardless of ability to pay. Overall, developing the HBP with preventive services focusing on the BOD and targeting disadvantaged Lebanese who lack sufficient health coverage reinforces the principles of ethical public health practice.31


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Stakeholder Analysis Recommendations Realizing the HBP and its benefits is contingent on satisfying the results generated by the stakeholder analysis. Public health officials and activists, health academicians, political advisors, and concerned international organizations can trigger this realization by harnessing political readiness and immediately forwarding the HBP to government for implementation. Because political instability in developing countries is high, and political environments may change rapidly for the worse,32 immediate action is needed. Additionally, in response to stakeholders’ need to ensure the HBP’s quality of services, a team of biomedical and actuarial professionals should be organized to further validate the cost-effectiveness and sustainability of the HBP and to establish an affordable copayment based on beneficiaries’ socioeconomic status. These actions would help the MoPH gather sufficient resources to abolish OOP payments and avert the anticipated abuse of services until a rigorous regulatory system has been established. This goes hand in hand with the MoPH developing a health monitoring system to detect changes in BOD and in the health and financial impacts of the package, ensuring its transparency and accountability. Collaboration among other stakeholders, such as the Ministry of Labor, NSSF, and MoPH, would allow other SS contingencies to be pursued. Patterns in other countries reveal that social health protection yields sufficient fiscal capacity to allow for the realization of broader SS and health coverage.29 Similarly, it is recommended that the MoPH develop relations with NGOs and the private sector and assist in improving the availability and competency of primary healthcare professionals operating within the PHCN. Equally necessary is an agreeable plan of reimbursement for specialists that will assist in the PHCN, to ensure provision of advanced specialist care/consultations when required (needs that must be considered). Currently, it is well-recognized that health is determined by factors beyond the health sector.28 Accordingly, implementation of the HBP requires institutional changes at public and private organizations, within and beyond the health sector. Foremost, more primary care professionals are needed. In 2001, only 100 general practitioners and three family medicine physicians existed for every 100 000 Lebanese.33 The situation presumably persists, with over 70% of Lebanese physicians being specialists.4 This implies an evident shortage in primary care health personnel. A joint initiative among the MoPH, Ministry of Education and Higher Education, universities, and even embassies of countries graduating Lebanese physicians needs to be formed to regulate the number and distribution of physicians produced. Recent reforms in the PHCN by the MoPH have been credited with enhancing efficiency by decreasing health spending, as a proportion of GDP, from 12.4% to 8.4%.24 This would accompany the MoPH increasing its personnel to administer the package, a critical issue because, for


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more than a decade, 25% of MoPH personnel lost to attrition have not been replaced.4 The MoPH also needs to assume a more politically immune position and demand an increased allocation of the government’s budget (3.09% in 2002 and 3.05% in 2007).4 One manner of achieving a funding increase is by lobbying for the adoption of alternative financing options to increase the government’s fiscal capacity for health coverage, given that public spending on health that is less than 4–5% of GDP hinders the attainment of universal health coverage.34 On a more political basis, the MoPH/government should regulate the overabundance of private health institutions and divert resources to the public health sector, which for the past decade has witnessed an increase in patients that has decreased costs in the ministry.4 Additionally, the NSSF should yield administrative facilitation to the HBP and avoid hindering its implementation, because its cooperation may quicken the package’s realization and assist the NSSF in its financial deficits (exceeding $14 billion in 2005).4 Ultimately, more political accountability is needed to ensure that optimal health reforms are adopted.

Conclusion Lebanon faces increasing health and financial burdens posed by NCDs. Local health authorities and international recommendations identify prevention and primary care as cost-effective solutions to resolve this predicament in a manner deemed optimal for averting health inequity.4,30 Based on the study’s stakeholder analysis, public health entities led by the MoPH are encouraged to form alliances with NGOs, PIFs, and the private health sector for optimal implementation of the HBP. Likewise, improved collaboration between the MoPH and involved stakeholders is necessary to regulate the availability and distribution of health human resources. The study also advises that the MoPH increase its regulatory and administrative capacities, improve the PHCN’s infrastructure, and adopt additional health financing options to ensure the sustainability of the HBP’s delivery in PHC.

Discussion of Limitations and Strengths The limited time available for the semi-structured interviews posed several limitations for the study. These constrictions prompted the recruitment of a convenience sample, which may have reduced the representativeness of the findings to the full Lebanese context regarding the potential of adopting HBPs and investing in primary healthcare. Snowball sampling should have complemented convenience sampling to increase the number of stakeholders interviewed in each sector. This also would have permitted the inclusion of more parties with influence in health, such as syndicates of pharmacists and physicians, which


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would compensate for these limitations and enhance the representativeness of the study’s findings. However, these limitations were offset in some ways. The study ensured the inclusion of the most influential sectors, on both economic and administrative levels. Lebanon has a highly privatized healthcare market in which decision making on health matters is greatly politicized, leaving NGOs the task of addressing deficiencies through advocacy and the provision of health services via their network of centers. The study recognized these national aspects and selected stakeholders from each of the 3 sectors that are prominent players in health decision making. The INGO and one of the LNGOs identified not only advocate, but also run their own PHC within the Lebanese PHCN. Department heads affiliated with the minister and/or director general of the respective ministries were interviewed for the MoSA and MoPH; hence, they provided information based on genuine experience in Lebanese health policy formulation and decision making, relying on their knowledge of and influence in the healthcare system. Likewise, the MP is part of one of the largest political blocs in the Lebanese parliament and plays a pivotal role in health policies and laws. The PAMC chosen is one of the largest, most influential centers in the country, and the PHA has vast experience in health on both academic and economic levels, while being involved in the private market for provision of health services. The rationale behind the selection of study participants emphasizes that, despite the modest number of recruits, the information generated by the study is unique, informative, to a good extent representative of the current health situation, and prognostic of the outcomes of future health reform. Interviews were not recorded and the questionnaire was not translated into Arabic, which may have contributed to information bias. However, most interviews lasted for more than the initially planned 30 min, with some exceeding 1 hour. This allowed for in-depth interviews with extensive probing that permitted the disclosure of unique and comprehensive opinions, conditions, and overall insight regarding the implementation of the HBP and all aspects of associated health reforms. Overall, the study incorporated the major players, in terms of authority, availability of resources, knowledge of and experience in the Lebanese healthcare system, and influence in implementing new initiatives within the health sector. This study provides public health practitioners and health reformists with a unique understanding of the conditions for implementing a HBP and related primary care initiatives, the advantages and disadvantages that stakeholders perceive, and the actions and resources that players in various sectors are willing to put forth to bolster or impede related health reforms. Hence, it sheds light on areas such as the private sector’s concern with maintaining financial profits, and it encourages the development of strategies to overcome these concerns and optimize the potential for implementing the HBP as an initial yet continuous effort to ensure the right to health for Lebanese.


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On the whole, the study lays the first stone for additional research, planning of factors related to the identified conditions, and how such restrictions can be mitigated to ensure the maximum buy-in of all stakeholders for expanding health coverage to the entire population. Acknowledgments The authors acknowledge the timely and supportive efforts of Dr Kassem Kassak in facilitating access to a study participant.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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13. College & Association of Registered Nurses of Alberta. Primary Health Care. Edmonton: College & Association of Registered Nurses of Alberta; 2005. 14. UN. Declaration of Alma-Ata, in International Conference on Primary Health Care, Alma-Ata, 1978. 15. Ministry of Health. A Basic Package of Health Services for Afghanistan. Kabul, Afghanistan: Transitional Islamic Government of Afghanistan-Ministry of Health; 2003. 16. Ministry of Health and Sanitation. Basic Package of Essential Health Services for Sierra Leone. Freetown, Sierra Leone: Government of Sierra Leone-Ministry of Health and Sanitation; 2010. 17. World Bank. Data-Countries and Economies. 2012. [Online]. http://data.worldbank.org/country. Accessed December 20, 2012. 18. Donaldson D and Collins D. The Equity Project: Modelling the Cost of Primary Health Care Services in the Eastern Cape. Pretoria, South Africa: South African Department of Health; 2000. 19. NHIS. National Health Insurance Scheme. October 2012. [Online]. http://www.nhis.gov.gh/ Accessed October 24, 2012. 20. World Health Organization (WHO). Health Systems Delivery, in Health System Profile-Tunisia. Geneva: World Health Organization, 2006, pp.55–73. 21. MOPH. Statistical Bulletin 2010. Beirut: Ministry of Public Health; 2010. 22. World Health Organization (WHO). Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-Resource Settings. Geneva: World Health Organization; 2010. 23. CIA. The World Factbook. December 2012. [Online]. https://www.cia.gov/library/ publications/the-world-factbook/geos/le.html. Accessed December 20, 2012. 24. World Health Organization (WHO). The World Health Report: Health Systems Financing: the Path to Universal Coverage. Geneva: World Health Organization; 2010. 25. Khatib O. Non-communicable diseases: risk factors and regional strategies for prevention of care. Eastern Mediterranean Health J. 2004;10(6):778–788. 26. MOPH. Statistics. 2014. [Online]. www.moph.gov.lb/Statistics/Documents/ NHA2012.pdf. Accessed August 21, 2014. 27. The World Bank. Data. 2014. [Online]. data.worldbank.org/indicator/ NY.GDP.MICTP.CD. Accessed August 21, 2014. 28. World Health Organization (WHO). The World Health Report 2008 Primary Health Care Now More Than Ever. Geneva: World Health Organization; 2008. 29. ILO. Social Health Protection-An ILO Strategy Towards Universal Access to Health Care. Geneva: International Labor Office; 2008. 30. Pagani L, Boulerice B, Vitaro F and Tremblay RE. Effects of poverty on academic failure and delinquency in boys: a change and process model approach. J Child Psychol Psychiatry. 1999;40(8):1209–1219. 31. Public Health Leadership Society. Principles of the Ethical Practice of Public Health, Version 2.2. Washington DC: Public Health Leadership Society; 2002. 32. Varvasovszky Z and Brugha R. How to do (or not to do) . . . A stakeholder analysis. Health Policy Plann. 2000;15(3):338–345.


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Author Biographies The Health Information and Data Collection Supervisor at Qatar’s Supreme Council of Health, Rami Yassoub has been engaged in health systems needs assessment for the past three years. Previously, as a Research Associate and Project Manager at a Qatar based research institute and during his academic track at the American University of Beirut (AUB), Mr. Yassoub was involved in investigating the primary health care sector’s needs to address the increase in noncommunicable diseases. He holds an MPH with a concentration in Health Management and Policy and a bachelor’s degree in science from AUB. Mr. Yassoub’s ongoing research interests and efforts focus on examining public health initiatives that promote population health and coverage through advances in knowledge transfer capacities. This involves studying the formulation and multisectoral implementation of evidence-based health policies and programs that strengthen a healthcare system’s capacity to face the rapidly changing burden of disease and resources availability. Mohamad Alameddine is an associate professor at the Department of Health Management and Policy at the Faculty of Health Sciences, American University of Beirut (AUB). He joined AUB in 2008 from the University of Toronto, where he worked as a senior research associate and, previously, as the Director of International Development on the Faculty of Medicine. He holds a PhD in health management and policy from the University of Toronto and an MPH. from AUB. His research interests focus on health and human resources (labor force dynamics, recruitment and retention practices, and the quality of work environments). He has multiple publications in the field and is regarded as a regional expert in his area of study. Shadi Saleh is an associate professor and chairman of health management and policy at the American University of Beirut. Prior to joining American University of Beirut, he served as a professor of health management and policy at the State University of New York at Albany, where he also was the Director of Certificate Programs and the MD/MPH program. His areas of expertise include health care quality and financing. He serves on the National Committee on Compulsory Health Insurance and Emergency Social Protection Implementation Support Project Committee. He holds a PhD in health management and policy from the University of Iowa and an MPH. and a BS from AUB.

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