ParPadox of the Lebanese Health care System and the Role of the NSSF

Lebanese University

Faculty of Economics and

Business Administration

First branch

Paradox of the Lebanese Health care System and

the Role of the NSSF

A research submitted for the fulfillment of the requirements for the Degree of

Master Research in Business Administration

(Finance and Banking)

Prepared by

Lama Ali Danash

Debate Committee

Dr. Hussein Badran .......................................................................... Chairman

Dr. Rita Naimeh ............................................................................... Supervisor

Dr. Mohammad Wehbi ............................................................. Co-supervisor

Academic Year 2012-2013

To the souls of those who died deprived from the health care

Acknowledgments

Many people contributed to this project and my entire graduate experience. I

owe a debt of gratitude to my thesis committee. Each member inspired me in a

different and important way. The chair of the committee, Dr. Hussein Badran,

pushed me to improve as a student and as a professional and always took time

to teach me something new. The supervisor, Dr. Rita Naimeh, provided me

with advice and comments to end with this valuable project. The co-supervisor,

Dr. Mohammad Wehbe, provided us with a beneficial lecture ―Financial

Information System‖ which facilities many things in this project.

Thanks for the continuous support and kind communication which had a

great effect regarding to feel interesting about what I was working on. Finally

yet importantly, I wish to extend my gratitude to my family and supportive

friends for their encouragements to complete this academic year.

خالصة

. في اآلونةالتي تمس حياة الماليين من المبنانيين في كل لحظة ةالضروري الخدمات منالرعاية الصحية تعتبر . الصحيةالرعاية امكانية تحسين طريقة تقديمالصيدالنية ، والمعرفة االدوية،اظير تطور التكنولوجيا األخيرة

القضايا من الرعاية الصحية وسيولة الحصول عمىعمى الرغم من ىذه اإلنجازات ، أصبحت التكمفة، والجودة ، قد حممت تكمفة الرعاية الصحية ىذا وان الزيادة الممحوظة في المبناني. التي تشغل بال التشريعية والسياسية الرئيسية

فضال التغطية الصحية. المبنانيين يفتقرون الى العديد منكما ان . عبء كبيرا األسرو التأمين الصحي انظمة الحكومة ، مي الرعاية الصحية والمستيمكين .تكاليف تقديم الرعاية المجانية ىي عبء كبير لمقدعن ان

سوق . انيا تعرض اإلدارية و المالية ةيالناحوتيدف ىذه األطروحة إلى دراسة نظام الرعاية الصحية المبناني من راضا تطمب ىذه الدراسة استعتابل العام. مب ، القطاع الخاص مقزوايا مختمفة: العرض مقابل الط منالخدمات الصحية

دور الصندوق ىذا وانيا تعرضالخاصة والعامة. الييئاتجميع ستطالعات سابقة إضافة لجمع البيانات منااللجميع م مناقشتيا منذ فترة طويمة .تي تفي التصدي ليذه التحديات ، وىي الفكرة الت الوطني لمضمان االجتماعي

التأمين تقديم الصحية المتعددة في مييئاتأساسيين . أوال، ما ىو الدور الحالي ل اشكاليتينطروحة ألىذه ا تتناول ، وكيف يمكن تحسين ىذه الرعاية بشكل يؤمن كفاية المواطن من التغطية المنخفض الجودة والعالي التكمفةالصحي

لمصندوق الوطني لمضمان االجتماعي تضييق فجوة يمكن ثانيا، كيف الصحية ويحافظ عمى ربحية الييئات الصحية؟ ؟ خدمات التي يقدميا وتوسيع دائرة االنتسابفي اطار ال في تقديم الرعاية الصحية الالمساواة

الخاصةالرعاية مع عمى حد سواء قطاع الخاص ىو المزود الرئيسي لالستشفاءاألطروحة أنو بالرغم من أن ال تبين من قبل خارج المستشفيات ل رعاية مرضى يتمو يتم المال العام ، بينما حساب اصة تزدىر عمىالمستشفيات الخفان

األسر .

ضوح أن اإلنفاق عمى الصحة يدد استدامة النظام . كما أنو يظير بو فان الزيادة المستمرة في التكمفة تومع ذلك ، مضمان الوطني ل دور صندوق اظيارإلى مستوى ينذر بالخطر من حصة الناتج المحمي اإلجمالي. ىدفنا ىو قد وصل

تطبيقو لصالح إصالح النظام الصحي .دائرة اإلجتماعي من خالل توسيع

Abstract

Health care is an essential service that daily touches the lives of millions of Lebanese at

major and weak times. Recently, technology, pharmaceuticals, and knowledge have

considerably improved how care is delivered and the prospects for recovery.

Despite these unusual accomplishments, the cost, quality, and accessibility of Lebanese

health care have become main legislative and policy issues. Considerable increases in the

cost of health care have placed significant stress on government, households’ health

insurance system. Many Lebanese lack health coverage. The costs of providing

uncompensated care are a large load for health care providers and consumers.

This thesis aims to examine the Lebanese health care system from the managerial and

financial points of view. It allows for an over viewing of the health services' market by

undertaking it from different angles: supply versus demand, private versus public sectors.

This study requires a review of all previous surveys additional to the collection of related

data with all private and public agencies. It also examines the role of NSSF in addressing

these challenges, an idea that has long been debated.

The thesis addresses two basic questions. First, what is the current role of multi-

insurance health providers in low quality health care versus high cost, and how can it be

enhanced to increase consumer welfare in parallel with the providers return? Second, how

has, and how should, the National Social Security Fund work to narrow the gap of the

Lebanese health inequality regarding services and expansion in application?

The thesis reveals that, although the private sector is the main provider of both hospital

and ambulatory care, private hospitals are booming on public money, whereas outpatients

care is mainly financed by the households.

However, at the price of an ever increased cost, threatening the sustainability of the

system. This is what is achieved in this thesis, as it shows obviously that expenditures on

health have reached an alarming level of the GDP share. Our purpose is clearing the role of

the NSSF by expanding its application in favor of reforming the health system.

Résumé

La santé est un service essentiel qui touche quotidiennement la vie de millions de

Libanais à des moments importants et faibles. Récemment, la technologie, les produits

pharmaceutiques et les connaissances ont considérablement amélioré la prestation des soins

et les perspectives de reprise.

En dépit de ces réalisations exceptionnelles, le coût, la qualité et l'accessibilité des soins

de santé libanais sont devenus des principales questions d'ordre législatif et politique.

L'augmentation considérable du coût des soins de santé a mis un accent important sur le

gouvernement, le système d'assurance- santé des ménages ». Beaucoup de Libanais ont un

manque de couverture sanitaire. Le coût des soins non compensés est une charge importante

pour les fournisseurs de soins de santé et les consommateurs.

Cette thèse vise à examiner le système de soins de santé libanais à partir d’un point de

vue managérial et financier. Il permet une visualisation du marché des services de santé en

procédant à des angles différents : l'offre face à la demande, le secteur privé et le secteur

public. Cette étude nécessite un examen de toutes les enquêtes précédentes supplémentaires

pour la collecte des données relatives à tous les organismes publics et privés. Il examine

également le rôle de la CNSS à relever ces défis, une idée qui a été longuement débattue.

La thèse aborde deux questions fondamentales. Tout d'abord, quel est le rôle actuel des

prestataires de santé multi- assurance dans les soins de santé de qualité inférieure et du coût

élevé, et comment peut-il être amélioré pour augmenter le bien-être des consommateurs et le

gain des fournisseurs ? Deuxièmement, comment, la CNSS devrait elle travailler pour

réduire la lacune des inégalités de prestation de service concernant la protection sanitaire et

l’expansion de son accès.

La thèse montre que, bien que le secteur privé est a la fois le principal fournisseur les

soins hospitaliers, les hôpitaux privés se prospèrent au détriment de l’argent public, alors

que les soins en ambulatoire est essentiellement financé par les ménages.

Cependant, l’augmentation continuelle des coûts, menace la pérennité du système. Ce

qui est réalisé dans cette thèse, montre évidemment que les dépenses de santé ont atteint un

niveau alarmant de la part du PIB. Notre but est de compenser le rôle de la CNSS en

élargissant son application en faveur de la réforme du système de santé.

(Article 22, UDHR)

Table of Contents

Introduction .................................................................................................. 1

Part One: Lebanese Health System Profile ............................................... 6

Chapter I: Background on Lebanon ............................................................... 6

A. Macro picture ..............................................................................................................6

1. Geographic and administrative profile ..........................................................................6

2. Demographic and social profile ....................................................................................7

3. Economic profile ...........................................................................................................8

B. History of Lebanon .....................................................................................................10

1. Ottoman period .............................................................................................................10

2. French intervention .......................................................................................................10

3. Lebanon after independence ........................................................................................ 11

4. Civil war .......................................................................................................................11

5. Lebanon today ..............................................................................................................12

Chapter II: Lebanese Health System ............................................................ 15

A. History of health system .............................................................................................15

1. Pre-independence phase (1864-1943) ......................................................................... 15

2. Independence phase (1943-1960) .................................................................................15

3. Reforms (1960-1975) .................................................................................................. 16

4. Civil war (1975-1992) ................................................................................................ 16

5. Current health system ................................................................................................. 18

6. Millennium Declaration goals for Lebanon .................................................................19

B. Determinants of health ...............................................................................................23

1. Poverty ......................................................................................................................... 23

2. Employment .................................................................................................................26

3. Environment .................................................................................................................27

C. Health status indicators .............................................................................................28

1. Mortality in Lebanon ....................................................................................................28

2. Morbidity in Lebanon ...................................................................................................30

3. Risk factors (Intentional and non-intentional) .............................................................37

4. Special groups .............................................................................................................39

Part Two: Lebanese Health Sub-system Profile ...................................... 44

Chapter I: Health system indicators .............................................................. 44

A. Health system Infrastructure ..................................................................................44

1. Ambulatory care ..........................................................................................................44

2. The hospital sector .......................................................................................................45

3. Technology and heavy equipment in hospitals ............................................................51

4. Pharmacies and laboratories .........................................................................................53

5. Dialysis, physiotherapy and radiology centers ............................................................54

6. Insurance companies ...................................................................................................55

B. Human Resources .......................................................................................................55

1. Orders and Syndicates ..................................................................................................57

C. Health care financing in Lebanon ............................................................................59

1. National Social Security Fund (NSSF) ........................................................................59

2. Security forces coverage ..............................................................................................60

3. Cooperative of the Civil Servants ................................................................................60

4. Ministry of Public Health – insurer of last resort .........................................................61

5. Mutual funds .................................................................................................................61

6. Private insurance ......................................................................................................... 61

7. Other health insurance funding resources ....................................................................62

Chapter II: Lebanese Health care System Financial Analysis ...................... 67

A. Lebanese health expenditure .....................................................................................67

1. External resources for health (% of total expenditure on health) .................................67

2. Health expenditure, private (% of GDP) ..................................................................... 67

3. Health expenditure, public (% of total health expenditure) .........................................68

4. Health expenditure, public (% of government expenditure) ....................................... 69

5. Health expenditure, public (% of GDP) ..................................................................... 69

6. Health expenditure, total (% of GDP) ..........................................................................70

7.Health expenditure per capita (current US$) ................................................................ 71

8. Health expenditure per capita, PPP (constant 2005 international $) .......................... 71

9. Out-of-pocket health expenditure (% of private expenditure on health) .................... 72

B. Data analysis of the Lebanese health quality versus cost .......................................73

1. Population and Sample Selection ................................................................................ 73

2. Instrumentation .............................................................................................................73

3. Questionnaire construction & Conceptual Framework for Data Analysis ...................74

4. Results ..........................................................................................................................74

C. Financial analysis of Lebanese Health expenditures ..............................................77

1. Pharmaceutical sector ...................................................................................................77

2. Hospitals .......................................................................................................................79

3. Ministry of health .........................................................................................................81

4. Expenditure by public financing agents .......................................................................82

5. Private insurance market ..............................................................................................83

6. Analysis of sources and uses of funds ..........................................................................85

7. Choice of providers by type of service ........................................................................ 87

Chapter III: Cross Country Comparison ....................................................... 90

A. International comparison of health expenditure .....................................................90

B. Assessment of the Lebanese Health Care System Performance ............................92

1. Sustainability ................................................................................................................92

2. Cost containment .........................................................................................................92

3. Rationalizing capacity in the hospital sector ................................................................93

4. Reallocating expenditure from curative to primary health care ...................................93

5. Controlling capital investment in medical technology .................................................93

6. Rationalizing expenditure on pharmaceuticals .............................................................93

7. Expanding health insurance coverage, limiting multiple coverage ..............................93

8. Equity ...........................................................................................................................94

Chapter IV: The Singapore Healthcare System ............................................ 95

A. Overview ......................................................................................................................95

1. Political Unity and Constancy of Purpose ....................................................................96

2. Establishing Priorities ...................................................................................................96

3. Promoting a way of Collective Well-Being and Social Harmony ...............................97

4. Respect and Education for Women ..............................................................................98

5. Building the Foundation ...............................................................................................98

6. Ensure Good and Affordable Basic Medical Services for All Singaporeans .............100

7. Engage Competition to Improve Service and Raise Efficiency ..................................100

8. Interfere Directly in the Healthcare Sector ..................................................................100

B. Demographics ............................................................................................................101

C. Health system Indicators ..........................................................................................102

1. Hospital beds ..............................................................................................................102

2. Physicians ...................................................................................................................103

D. Health care Expenditures .........................................................................................103

E. Lessons to learn .........................................................................................................105

1. Price and Outcome Transparency ................................................................................105

2. Higher Co-Pays ..........................................................................................................106

3. Payment by Capitation and Outcome, not Fee for Service .........................................106

4. Differentiated Service .................................................................................................107

5. Catastrophic Health Insurance .....................................................................................107

6. Transition from Hospital to Home and Community Care ...........................................107

Part Three: Lebanese National Social Security Fund ............................ 108

Chapter I: Applied Branches and Categories subject to NSSF ................... 108

A. Establishment of the National Social Security Fund ..............................................108

B. The Gradient in the application of social security in Lebanon ............................108

C. Branches of social security and their submissions .................................................110

1. Branch of sickness and maternity ................................................................................111

2. Branch of emergency work and occupational diseases ...............................................112

3. The branch of family allowances ................................................................................112

4. Branch for end of service ...........................................................................................113

D. People subject to all branches of social security .....................................................114

E. People subject to certain branches ...........................................................................116

Chapter II: Expansion in the application of NSSF ...................................... 119

1. The branches and submissions under study ...........................................................119

1. Dental care ...................................................................................................................121

2. Branch of emergency work and occupational diseases ...............................................122

3. The pension and social protection system ..................................................................125

2. The reasons for increasing the categories covered by Social Security .................128

1. Tobacco farmers ..........................................................................................................129

2. Writers and artists ........................................................................................................130

3. Municipal workers .......................................................................................................131

C. Data analysis about NSSF’s beneficiary health care satisfaction .........................132

1. Population and Sample Selection ................................................................................132

2. Instrumentation ............................................................................................................132

3. Questionnaire construction & Conceptual Framework for Data Analysis ..................133

4. Results .........................................................................................................................134

Chapter III: The financial situation of the NSSF ......................................... 137

A. Funding National Social Security Fund currently in Lebanon ...........................137

1. Finance by professional Subscriptions .......................................................................137

2. Financing by tax ..........................................................................................................138

3. Finance by a dual system .............................................................................................139

4. Funding of the Lebanese social security system .........................................................140

B. Financial situation ....................................................................................................145

1. The current financial situation of the National Social Security Fund .........................146

2. Financial results of the National Social Security Fund 2000 - 2009 ..........................148

3. The reasons for the accumulated deficit for both branches the sickness and maternity and

that of family allowances .................................................................................................152

C. Proposals to restore fiscal balance and cover the costs of expansion ..................156

1. Reduce expenses ..........................................................................................................156

2. Increase revenues ........................................................................................................157

3. Invest Social Security funds reserves .........................................................................159

Conclusion ......................................................................................................................161

Recommendations ..........................................................................................................166

References .......................................................................................................................170

Illustrations

List of Tables

Table (1): Demographic indicators in Lebanon .................................................................... 7

Table (2): Social Indicators in Lebanon ............................................................................... 8

Table (3): Economic indicators in Lebanon ......................................................................... 9

Table (4): Progress in MDG 4 – Reduce under-five mortality in Lebanon .........................20

Table (5): Maternal and reproductive health statistics in Lebanon .....................................21

Table (6): National Statistics for Tuberculosis in Lebanon (2009) .....................................23

Table (7): Average per capita and per governorate consumption (1000 LBP) ....................24

Table (8): Poverty measures per Mohafazat (2004-2005) ..................................................25

Table (9): Mortality in Lebanon (2011) ..............................................................................28

Table (10): Distribution of hospitals per size ......................................................................47

Table (11): Distribution of technology by region (2010) ....................................................52

Table (12): Geographic distribution of pharmacies and labs (2011) ...................................54

Table (13): distribution of dialysis, physiotherapy and radiology centers by region ......... 54

Table (14): percentage of population covered by various financing agencies ....................63

Table (15): Tutelage, entitlement, coverage and sources of financing of funding agencies 64

Table (16): Benefits under Various Public Financing Schemes ..........................................66

Table (17): frequency results of Q‖0‖ of the questionnaire .................................................75

Table (18): Distribution of hospital expenditures (%) .........................................................80

Table (19): Distribution of hospital reimbursement by type of service (%) .......................81

Table (20): Budgetary resources in the public health sector ...............................................82

Table (21): break-down of public expenditure on health services provided by the private

sector .....................................................................................................................................83

Table (22): Distribution of Private Insurance Expenditures ................................................84

Table (23): Private insurance account ($) ............................................................................84

Table (26): Distribution of health care expenditure ............................................................85

Table (27): Percentage of distribution of Out-of-Pocket Expenditures by Sector ...............85

Table (28): sources of funds to health providers (million LL) ...........................................86

Table (29): Choice of providers ...........................................................................................88

Table (30): International Comparison of Health Expenditures ............................................91

Table (31): Most efficient health care systems within the world .......................................95

Table (32): Singaporean demographic indicators .............................................................102

Table (33): number of secured subject to all branches 2012 .............................................116

Table (34): number of secured people subject to some branches 2012 .............................117

Table (35): number of foreigners registered in Fund and non-beneficiaries ....................118

Table (36): frequency results of Q‖0‖ of the questionnaire ..............................................134

Table (37): annual financial result for each branch 2000 (Amounts in billion LBP.) .......148

Table (38): annual financial result for each branch 2001(Amounts in billion LBP.) ........149









Table (47): Debt owed for the National Social Security Fund (Amounts in billions LBP)

.............................................................................................................................................153

Table (48): Interest on treasury bonds 2000-2009 (Amounts in billions of LBP.) ........... 154

List of Figures

Figure (1): Distribution of children by reason given for not-immunizing them ..................20

Figure (2): Distribution of the population by poor and non-poor categories (2004-2005)..23

Figure (3): Employment rate in Lebanon by gender (2009) ...............................................27

Figure (4): Mortality in Lebanon by age (2011) (rate/1000) ..............................................29

Figure (5): Mortality in Lebanon by region (2011) (rate/1000) .........................................29

Figure (6): Evolution of death rate between 2004 and 2011 ...............................................29

Figure (7): Mortality by causes in Lebanon (2011) ............................................................30

Figure (8): Number of patients suffering from infectious diseases by region (2011) ........31

Figure (9): Cases of tuberculosis in Lebanon (2011) ..........................................................32

Figure (10): Distributions of patients suffering from cancer (2011) ...................................32

Figure (11): % of declared cases of HIV/AIDS (2011) .......................................................33

Figure (12): Distribution of the population at the "Hopital de la Croix" (2010) ................34

Figure (13): Data on Burn cases in Lebanon (2010) ..........................................................35

Figure (14): Road accident cases in Lebanon (2011) .........................................................36

Figure (15): Age of initiation of drug consumption (2011) .................................................37

Figure (16): % of risk factors by age and gender in Lebanon (2009) ..................................38

Figure (17): distribution of elderly population by age, gender and region (2011) .............39

Figure (18): Institutions that provide elderly care (2010)....................................................40

Figure (19): Distribution of disability according to gender, age and region (2009) ............41

Figure (20): Distribution of diseases by type in prisons (2011) .........................................43

Figure (21): Distribution of number of beds by region ......................................................47

Figure (22): Number of hospitals having contracts with the MOPH by type and Mohafaza

49

Figure (23): Percentage of hospitals in public and private sectors distribution per

Mohafaza...............................................................................................................................49

Figure (24): Percentage of hospitals distribution per Mohafaza ..........................................50

Figure (25): Number of admission by type of hospital and geographic location (2011) .....50

Figure (26): The evolution of MOPH subsidized admissions in public and private hospitals

between 2005 and 2011 ........................................................................................................51

Figure (27): statistics of professional orders........................................................................58

Figure (28): External resources for health (% of total expenditure on health) ...................67

Figure (29): Health expenditure, private (% of GDP) .........................................................68

Figure (30): Health expenditure, public (% of total health expenditure).............................68

Figure (31): Health expenditure, public (% of government expenditure) ...........................69

Figure (32): Health expenditure, public (% of GDP) ..........................................................70

Figure (33): Health expenditure, total (% of GDP) .............................................................70

Figure (34): Health expenditure per capita (current US$) .................................................71

Figure (35): Health expenditure per capita, PPP ($) ............................................................72

Figure (36): Out-of-pocket health expenditure (% of total expenditure on health) .............72

Figure (37): pie chart frequency result of the questionnaire ................................................75

Figure (38): Health expenditure by source of financing ......................................................86

Figure (39): Treasury sources of health financing ...............................................................87

Figure (40): Sources of private health financing ................................................................87

Figure (41): Total population in Singapore ......................................................................101

Figure (42): number of beds in Singapore ........................................................................102

Figure (43): Number of physicians in Singapore ..............................................................103

Figure (44): Total expenditure on health as % of gross domestic product ........................103

Figure (45): GGE vs. PE as % of total health expenditure ...............................................104

Figure (46): out-of-pocket expenditure vs. private prepaid plans as % of PE ..................104

Figure (47): per capita GHE vs. per capita THE ...............................................................105

Figure (48): pie chart frequency result of the questionnaire ..............................................134

Figure (49): Accumulated debt of the state (2000-2009) ..................................................154

Introduction

Good health is, by definition, an integral part of sustainable human development. Good

health as a right and as a responsibility is covered by the concept of health security and

health accountability. Health security demands equity and health accountability implies the

obligation on the part of state and health professionals as well as a wider societal

responsibility to take account of the impact of development and other policies on health. To

fully achieve the dimension of health in social and economic development, it is essential to

invest in health as economic growth is based on a productive work force. It is also essential

to realize more equitable access to the benefits of development, as inequities have severe

health consequences and cause an unacceptable threat to human well-being and security.

Health indicators are among the major measurements used to assess the socio-economic

standing of the population, as well as to determine the position of a country with respect to

the development and sustainability processes. Among the major criteria adopted in this

context, are the health demographic indicators (mortality, morbidity, diseases,). However,

another factor that is also playing an integral role in evaluating health status is the existence

of the suitable policies, calling for equitable supply of health services at a reasonable and

bearable cost. The role of the government is essential in this regard not only as a provider

and producer, but also as a regulator, promoter and supervisor of these services. Most

societies are currently going into the process of minimizing the role of governments as a

direct actor in different fields, however, social services are still being handled by

governments, either directly through the provision of the primary health care, or indirectly

through setting up the suitable environment, to avoid monopolies and insure fair coverage.

Lebanon’s spending on health, as a percentage of the national income, is currently the

highest in the Middle East and North Africa (US$ 872 per capita, and 7.4% of the national

product in 2011).1

1 WHO Department of Health Statistics and Informatics (May 16, 2012). "World Health Statistics

2012

http://www.who.int/gho/publications/world_health_statistics/2012/en/index.html


In Lebanon, the situation is relatively complicated, mainly as to the wide variety of

players (financing, providers and even regulators) and the lack of communication among

these different players. The long period of civil war has contributed to intensifying and

widening the problems facing the health sector in Lebanon, the fact that was mainly

reflected in the relatively huge size of the "health care bill", measured as a percentage of

gross domestic product, coupled with an apparent inequitable access to health care services

for the different regions and social segments. It is needless to say that the role of the private

sector grew dramatically during the war period, with the persistence of out-dated policies

governing the performance of the sector. This fact was illustrated through the regional

imbalances in the distribution of hospitals, medical and par-medical staffs, in addition to the

ascending trend in the health care prices, mainly relative to the consumer prices.

Six government health funds cover around 38% of the population, while 8% are covered

by private insurance companies. As for the remaining 54% of the population, it is the MOH

that covers their high-cost hospital and pharmaceutical services.2 Scattered funding and the

lack of control over the private market seriously impede MOH and public insurance funds

from purchasing health services at a good price from the public sector. Only 5% of the

public health sector expenditure is allocated to primary health care services. Actually, the

use of the primary health care network is extremely low, and it seems to be motivated by the

availability of free medications.

In Lebanon, there are social expenditures on health, education, and others. But those are

not performed within the framework of a social vision having well determined objectives,

programs and institutions. When some officials justify the social aids, presenting the annual

budgets figures in the fields of education, health and social assistance, they tend to neglect

the social policy and programs. One of the French companies that elaborated the orientation

plan for the Social Security showed the first defect represented by the absence of a clear

vision regarding the social security; the same thing applies to health and education. It is

therefore our right to ask: Is there a health policy? How can we allow the multiplication of

health orientations such as social security, Health Ministry, the cooperative of civil servants,

internal security service and cooperative, mutual, assistance funds?

2 National Health Accounts, 2008

The body in which influential people in government have interest, is the first to be

supported, whereas the bodies in which they have no interests is marginalized, neglected

and deprived form the state’s assistance even if the law clearly stipulates the state’s

obligations towards it.

These obvious imbalances call for an elaboration on the structure of the existing health

system, and tracing the different schemas relating the different components of this system to

come out with a set of policies to enhance the overall performance of the sector.

This inefficiency in the health care system, the neglect of the environment and the

adoption of unhealthy lifestyles by a significant number of citizens, have been the target of

every public health intervention in the country, as well as other donors, and agencies’

interventions. However, till now the health body system in Lebanon is still suffering from a

lot of diseases the most prevalent is the fiscal deficit.

In the passionate debates over healthcare, one fact is often lost—Lebanese people pay

more but get less for their health care than inhabitants of other countries. However, efforts

must be done to change the fact. How can we improve the quality of care and reduce our

expenses, saving a millions by making our health care system more efficient?

The thesis addresses two basic questions. First, what is the current role of multi-

insurance health providers in low quality health care versus high cost, and how can it be

enhanced to increase consumer welfare in parallel with the providers return? Second, how

has, and how should, the National Social Security Fund work to narrow the gap of the

Lebanese health inequality regarding services and expansion in application?

In order to tackle these two problematic questions and analyze them, the thesis followed

an analytical methodology contains a data analysis of a study done about the Lebanese

health quality satisfaction compared with the cost they pay. This thesis depends to a large

extent on previous studies in the same sector done by many organizations mentioning WHO,

World Bank, Lebanese National Health Account and others. Also it studies the role of the

NSSF in health services. This study was built on questionnaire filled by Lebanese people

from the society. Its purpose was to investigate the issue of the health care quality they

receive via the multi-insurance scheme in Lebanon and the cost they bear. Also we focus on

the financial situation of the NSSF and the success of the new suggestions of expanding the

field of application as one of the everyday concern of the Lebanese people since its

application cover the largest number of Lebanese citizens and cover the most

comprehensive of the risks.

I have faced a lot of problems during the thesis beginning with collecting information on

the distribution of expenditures by function, and linking expenditures to utilization. The

information on private sector expenditures was not easily available Even when data was

available its quality, validity, and reliability remained a matter of concern. Reliable data on

the number of beneficiaries and dependents by type of social insurance scheme is difficult.

Additional to that the different agencies classify expenditures differently, and do not have

the same definitions for functions and services.

This thesis is carried out with the aim of highlighting how the current structure of the

health system is affecting the health care bill, and consequently the right of citizens, from

the different regions and income levels, to equitably access health services. This issue is

raised in light of the sensitive situation the country is currently going through, recording

notably slow rate of economic growth and apparent recession, uncontrollable and

continuous levels of budget deficits, and growing public debt exceeding the gross domestic

product. One of the major consequences of the fiscal and monetary policies adopted in the

recent years was widening the gap among the different social classes, creating further

imbalances in income distribution, consequently adding more burdens to the low and middle

income groups that were, severely affected during the civil strife, and limiting thus their

access to the basic social services (health, education,..).

The first part of the study presents a quick review of the main demographic and health

indicators recorded in the country. The second part illustrates the different sources of health

financing and their contributions to the overall health care bill and analyses the flow of

funds between financing agents and health service providers. The third part elaborates on

the role of the national social security fund in the Lebanese social health policy. And finally

ends with a conclusion and some policy recommendations.

Part One: Lebanese Health System Profile

Chapter I: Background on Lebanon

A. Macro picture

1. Geographic and administrative profile

The Republic of Lebanon is a democratic, parliamentary state sited within the Near East.

It is a country of 10452 sq. km. on the Mediterranean Sea. It is composed of six

administrative provinces (or Mohafaza) divided into twenty-six districts (or Qada), counting

the district of Beirut.

The natural resources of the country include limestone, iron ore and salt, but, maybe

the most precious resource of Lebanon is water which is not well managed where huge

quantities of water are lost annually.

Environmental concerns include deforestation (forest covers less than 6% of Lebanon),

soil erosion and desertification. Lebanon also suffers from significant traffic, burning of

industrial wastes and pollution of coastal waters from raw sewage and oil spills. Medical

waste management has been a main issue in the past few years with still no accord reached

concerning the appropriate methodology to the arrangement of hospital waste. 3

2. Demographic and social profile

The Lebanese population is estimated at around 4036000 inhabitants with (85%) living in

urban regions, 38% of whom are found in Mount Lebanon. There is a physically powerful

switch at the demographic level, with 25% of the population below the age of 15 and 10%

older than 65, indicating that nearly half of the population is active with a dependency rate

of 52%. Furthermore the fertility rate of 1.9 is relatively low. Life expectancy is 74 years,

ranging between 71 years for men and 77 years for women; and the national growth rate is

1.8%.

Table (1): Demographic indicators in Lebanon

Indicators N (per 1000 citizens) %

Area (sq. km) 10425

Total population 4036

Mount-Lebanon 1537 38.1

North Lebanon 831 20.6

Bekaa 544 13.5

South Lebanon 456 11.3

Beirut 387 9.6

Nabatiyeh 282 7.0

Urban population 854

Men 1993 49.4

Women 2042 50.6

0-14 years 992 24.6

65+ years 391 9.7

Dependency rate 52

Crude birth rate 980 24.3

Crude mortality rate 234 5.8

Total growth rate 1.8

Total fertility rate (per woman) 1.9

3 Country Cooperation Strategy for WHO and Lebanon 2005–2009, available at:

www.who.int/countryfocus/.../ccs_lbn_final_en.pdf

4 Reference year: 2006 , http://www.emro.who.int/lebanon/

http://www.who.int/countryfocus/.../ccs_lbn_final_en.pdf

http://www.emro.who.int/lebanon/

Source: MOPH, 2011, Statistics Bulletin, available at:

http://www.moph.gov.lb/Publications/Pages/StatB2011.aspx

The illiteracy rate is around 10.3% with a labor force participation rate of 39% for those

above 15 years. Illiteracy rates remain higher for women with a rate of 13.7% for women

above the age of 15 compared to that of 6.6% for men above that age. Similarly, the labor

force participation rate for women over 15 years of age is 18.5%, substantially lower than

that of men, which is 60%.

Table (2): Social Indicators in Lebanon

Indicators5 Total (%) Men (%) Women (%)

Illiteracy rate (>15 years) 10.3 6.6 13.7

Labor force participation

rate 39 60.6 18.5

Current education level of enrolled individuals (>3 years)

Preschool 12.4 12.9 12.0

Elementary 36.0 36.7 35.4

Intermediary 18.8 18.6 19.1

Secondary 15.1 14.6 15.6

University 16.9 16.7 17.2

Source: MSA, 2007 - The National Survey of Household Living Conditions,

http://www.bloggingbeirut.com/docs/chapter2.pdf

3. Economic profile

Since the end of the civil war in 1990, Lebanon’s economy has recorded significant

growth, and much of physical and financial infrastructure has been rebuilt. Nevertheless, the

government faces serious challenges in the economic field. It has funded reconstruction by

borrowing heavily – typically from domestic banks. By mid-2008, the national debt had

reached the level of $45 billion, of which 51.7% was of domestic origin.6 50% of the fiscal

budget serves the debt. Despite the enormous amount of public debt, Lebanon’s rating has

5 Total population: 4036000 (MOPH, 2011, Statistics Bulletin,).

6 Ministry of Finance report, 2011, http://www.finance.gov.lb/en-

US/finance/ReportsPublications/DocumentsAndReportsIssuedByMOF/Documents/Sovereign%20and

%20Invensment%20Reports/Country%20Profile/Lebanon%20Country%20Profile%202011.pdf


http://www.bloggingbeirut.com/docs/chapter2.pdf

http://www.finance.gov.lb/en-US/finance/ReportsPublications/DocumentsAndReportsIssuedByMOF/Documents/Sovereign%20and%20Invensment%20Reports/Country%20Profile/Lebanon%20Country%20Profile%202011.pdf



remained acceptable. The National debt in Lebanon7 by the end of June 2012 rated the

following:

the gross public debt reached LL 67 060 billion (US$ 44.5 billion), a 5.83% increase over

the end of December 2011 level

net public debt stood at LL 60 909 billion (US$ 40.4 billion), registering an increase of LL

2072 billion over the end of December 2011 level

domestic currency debt registered LL 34 672 billion, higher than the end of December 2011

level by 10.52%

Foreign currency debt totaled LL 32 388 billion, 1.24% higher than the end of December

2011 level.

GDP growth has slowed notably in the past few years. Rising oil prices, the economic

hold back, and payments of debts have all weakened public finances. Consequently the

government debt has risen to 175% of GDP. The trade balance showed a deficit of US$

8999 million in 2011.8

Sensible progress has been made on the structural financial reform agenda. Most public

sector reforms have been of an administrative nature, with a number of legislative proposals

awaiting in parliament, together with those on revenue administration and debt

management, laws to order capital markets and bank mergers, as well as competition and

domestic market reform.

Table (3): Economic indicators in Lebanon

Indicators Value

GDP (billions L.P.) 62224

GDP annual growth (%) 3

Annual inflation rate (%) 4

Unemployment rate (%)9 9.2

7 Ibid.

8 Central Bank annual report, 2011, http://www.bdl.gov.lb/webroot/statistics/

9 CAS annual report 2011, http://www.cas.gov.lb/images/Mics3/CAS_MICS3_survey_2011.pdf

http://www.bdl.gov.lb/webroot/statistics/

http://www.cas.gov.lb/images/Mics3/CAS_MICS3_survey_2011.pdf

Source: Lebanese Republic, President of the Council of Ministers, October 2012, Economic

Accounts, http://www.ilo.org/dyn/travail/docs/721/

B. History of Lebanon

1. Ottoman period

The Ottoman (modern-day Turkish) Empire rose between 1512 and 1520.10

In World War

I, the Ottoman Empire joined forces with Germany and Austria-Hungary in battling the

Allied Forces of England, France and later, the United States. When the war ended, the

Ottoman Empire was no more. The Allies put Lebanon under French control. The first

Lebanese constitution went into effect in 1926.11

2. French intervention

At the end of World War I, the Allied forces put Lebanon under French military

occupation. In 1923, the League of Nations (forerunner to the United Nations) formally

gave Lebanon and Syria to France.12

Under French rule, education, public utilities and

communication improved. Beirut prospered as a trade center. As the middle class of Beirut

grew, so did a frail sense of common national interest and a desire for more independence.13

But France was having troubles at home. Its neighbor Germany had slipped into the rule

of the Nazis. When France fell to Germany in 1940 during World War II, British and Free

10

The Massacres of 1840-1860, http://www.geocities.com/CapitolHill/Parliament/2587/1860.html

11 Daily Star, http://www.dailystar.com.lb

12 The Maronites and Lebanon (2003),

http://www.geocities.com/CapitolHill/Parliament/2587/maronite.html

13 Lebanon History (2003), http://workmall.com/wfb2001/lebanon/lebanon_history_index.html

http://www.ilo.org/dyn/travail/docs/721/

http://www.geocities.com/CapitolHill/Parliament/2587/1860.html

http://www.dailystar.com.lb/


http://workmall.com/wfb2001/lebanon/lebanon_history_index.html

French troops occupied Lebanon. These troops proclaimed Lebanon and Syria independent,

but because their own status was so precarious, the Free French continued to occupy

Lebanon.

In 1943, they allowed elections to take place. Under the new president, the legislature

adopted changes in the constitution that did away with French influence. The French

objected. On Nov. 11, 1943, the French arrested almost the entire Lebanese government,

leading to war. The British intervened, and the French restored the government and

transferred power to it.14

In 1945, after more insurrection and as World War II reached its climax, the British and

French began withdrawing from Lebanon. By 1946, the withdrawal was complete, and

Lebanon became officially independent.

3. Lebanon after independence

Lebanon's history from independence can be defined largely in terms of its presidents,

each of whom shaped Lebanon by a personal brand of politics.

In 1958, during the last months of President Chamoun's term, an insurrection broke out,

aggravated by external factors. In July 1958, in response to an appeal by the Lebanese

Government, U.S. forces were sent to Lebanon. They were withdrawn in October 1958,

after the inauguration of President Shihab and a general improvement in the internal and

international aspects of the situation.

President Franjiyah's term saw the outbreak of full-scale civil conflict in 1975. Prior to

1975, difficulties had arisen over the large number of Palestinian refugees in Lebanon and

the presence of Palestinian fedayeen (commandos). Frequent clashes involving Israeli forces

and the fedayeen endangered civilians in south Lebanon and unsettled the country.

Following minor skirmishes in the late 1960s and early 1970s, serious clashes erupted

between the fedayeen and Lebanese Government forces in May 1973.

14

Encyclopedia of the orient (July 27, 2002), http://i-cias.com/e.o/lebanon_5.htm

http://i-cias.com/e.o/lebanon_5.htm

4. Civil war

In 1970, Jordan expelled the PLO from its territories sending many civilian refugees and

armed guerillas into Lebanon. Meanwhile, the communist countries were having economic

problems.

Armies and funding were flowing to Lebanon and many political parties were turned into

armed forces while the Lebanese army was getting weaker and unable to take control. In

April 13, 1975, a brutal fight broke up the war in Lebanon. In 1976, the Syrian army

invaded the Lebanese northern region of Akkar, and advanced into the Bekaa valley east of

Lebanon.

The League of Arab Countries tried to send peace-keeping troops to Lebanon, but they

were forced to leave the country for the Syrian army later. Palestinian militiamen kept

launching attacks from the areas they controlled in South Lebanon against Northern Israel.

The Israeli response was more severe and often impacted Lebanese civilians.

The attacks developed into an Israeli invasion of Southern Lebanon in March 1978. The

United Nation Interim Forces were deployed in South Lebanon to reduce the tension and the

Israeli forces pulled back later.

In the early eighties, Lebanon was being destroyed with contentious fighting, while PLO

militias occupied most of Beirut and kept launching attacks against Northern Israel.

5. Lebanon today

In 1982, Israel invaded the southern half of Lebanon up to and including Beirut. In

October 1989, the Taif Accords were signed and, in November of the same year, Elias

Hrawi was elected President. 15

A new Government, known as the national reconciliation

Government, was formed and began implementation of the Taif Accords.

In October 1990, the fighting came to an end, and, in 1991, most of the militias were

disbanded by the Lebanese Army. On 2 September 2004, the U.N. Security Council adopted

15

―Risk Factors—Risks Relating to the Government—Uncertainties Regarding Formation and Policies

of the New Government‖, available at: http://www.ccfr.org.cn/cicf2012/papers/20120201114734.pdf

http://www.ccfr.org.cn/cicf2012/papers/20120201114734.pdf

Resolution 1559, which was co‐sponsored by the United States and France. 16

Among other

matters, Resolution 1559 declared support for a free and fair electoral process in the

Republic without foreign interference or influence, for the restoration of the territorial

integrity, full sovereignty and political independence of the Republic, the withdrawal of

foreign troops from the territory of the Republic and the disarming of Lebanese and non‐

Lebanese militia.

On 14 February 2005, the former Prime Minister, Mr. Rafik Hariri, together with a

number of his bodyguards and assistants, was assassinated in Beirut.17

Between 1992‐2004,

Mr. Hariri served as Prime Minister for a total of approximately ten years. He was

instrumental in the economic revival and reconstruction of the Republic following the 1975‐

1990 conflict and was the principal architect of the Paris II Conference.18

On 1 December 2006, the opposition commenced a sit‐in in downtown Beirut, as well as

a number of large demonstrations and a general strike, which the opposition sought to

enforce by blocking public roads, which lasted until the conclusion of the Doha

Agreement.19

On 5 May 2008, the Council of Ministers adopted a series of resolutions, including: (i)

increasing the minimum wage from LL 300,000 per month to LL 500,000 per month; (ii)

reassigning the Chief of Security of the Rafic Hariri International Airport to another

position; and (iii) declaring that the telecommunications network operated by Hizbollah on

the territory of the Republic is illegal and unconstitutional.20

In January 2012, Decree № 7426 was adopted (i) increasing the monthly minimum wage

for private sector employees from LL 500,000 to LL 675,000 and (ii) providing for a cost‐

of‐living increase up to a maximum of LL 299,000 per month, both effective 1 February

16

―Conflicts With Israel,The July 2006 War‖, available at: http://smallwarsjournal.com/jrnl/art/the-

2006-lebanon-war-a-short-history 17

The Special Tribunal for Lebanon, available at: http://www.stl-tsl.org/en/ 18

―The Economy—Economic History—Fiscal Reform and the Paris II Conference‖, available at:

http://www.institutdesfinances.gov.lb/english/loadFile.aspx?pageid=838&phname=FileEN 19

―History, Recent Developments, The Doha Agreement‖, available at:

http://www.mof.go.jp/english/customs_tariff/wto/n05.pdf 20

―Recent Developments, Doha Agreement‖, available at:

http://en.wikipedia.org/wiki/Doha_Development_Round

http://smallwarsjournal.com/jrnl/art/the-2006-lebanon-war-a-short-history


http://www.stl-tsl.org/en/

http://www.institutdesfinances.gov.lb/english/loadFile.aspx?pageid=838&phname=FileEN

http://www.mof.go.jp/english/customs_tariff/wto/n05.pdf


2012. Although Decree № 7426 applies to private sector employees, similar increases have

been proposed in favor of public sector employees. Such increases in the minimum wage

and other salaries could have an inflationary impact on prices. In addition, in September

2012 cost of living payments for public sector employees were increased with retroactive

effect from 1 February 2012. The Ministry of Finance disbursed LL 632 billion (U.S.$419

million) in 2012 to cover this increase. The annual expenditure for this cost of living

increase is estimated at approximately LL 851 billion (U.S.$564 million). In addition, the

Council of Ministers approved the transmittal to Parliament of a new salary scale for public

sector employees, which may be retroactive. Ongoing demonstrations and strikes in support

of this measure, including by members of labor unions and public sector employees, have

been occurring in Beirut, and there have been calls for public sector strikes and further

demonstrations if the measure is not referred to Parliament. The Prime Minister and the

Minister of Finance have stated that this measure will not be implemented until new revenue

sources are identified to cover the new expenditures.21

21

―Risk Factors, Risks Relating to the Republic, Fiscal Deficit‖ and ―Risk Factors, Risks Relating to

the Republic, Prices and Inflation‖, available at:

http://www.un.org/en/development/desa/policy/wesp/wesp2013/wesp13update.pdf


Chapter II: Lebanese Health System

A. History of health system22

1. Pre-independence phase (1864-1943)

Around the middle of the 19th century, the medical field became known in Lebanon. It

was a characteristic of huge cities and included a few qualified doctors or surgeons.

Throughout this era, health care was carried out in medical units belonging to charitable

institutions. The government’s main concern was to protect the people from infectious

diseases and environmental risks.

After World War I, under the French mandate, a number of institutions were established

including the first Health Department which was found within the Ministry of the Interior.

All the public administrations that were set up at that time in addition to the few small

22

Extracts Ammar, M. (2011), Inter-professional collaboration, Paediatric unit case in a university

hospital in Lebanon (PhD thesis).

private hospitals that were established were highly influenced by the French especially in

terms of inspection, control and centralization.

2. Independence phase (1943-1960)

Lebanon’s independence was declared in 1943. Health-related problems became the only

responsibility of the Ministry of Health and Social Affairs whose main role was the

oversight, coordination, and legislation of these matters additionally to the protection of the

surrounding and the observation of transmissible diseases. During the 1950s, this Ministry

began developing a public health system thus establishing the interior structures and a

network of hospitals and primary health care centers where the poor may get care. In spite of

these initiatives, a huge part of the country remained deprived of these services thus limiting

the accessibility of the population to healthcare. Private hospitals started to grow and offered

better quality services. Efforts were carried out to strengthen the ties between the private and

public sectors.

3. Reforms (1960-1975)

Starting in 1958, the Lebanese government undertook a series of reforms within the

health field namely:

The 1961 decree that stipulated that additionally to its restrictive role in the health field,

the Ministry of Health was in charge for the public health of the population and the health of

the disadvantaged. Therefore, principles of primary health care, likewise a regional private

and public network were developed to confirm the healthcare of the population.

The creation in 1963 of the National Social Security Fund (NSSF) by decree number

13955 and the Cooperative of Civil Servants (CSC) by virtue of the law issued by decree

number 14273. The NSSF is a semi-public, autonomous, social institution with a legal

personality and financial and administrative autonomy. It was based, once again, on the

European model of social security. The CSC is a public organization under the authority of

the Council of Ministers.

Even though these reforms were essential, they did not have the required positive impact.

On the contrary, they weakened the role of the Ministry of Health in the public sector and

formed duplications in terms of services settled and health coverage. The result was obvious

in terms of:

The appearance of new modes of compensation, such as fee for service which had

considerable consequences including the abuse of medical consultations, laboratory tests, x-

rays and medication prescriptions.

An increase of publicly managed social insurance funds (a total of 6) ending with

competition and political fights, instead of cooperation and coordination.

4. Civil war (1975-1992)

With the start of the Civil War in 1975, the services of the Ministry of Public Health

(MOPH) declined and with time, the Ministry became dysfunctional. The demand for aid

and healthcare increased and in parallel, the public sector collapsed leaving the private

hospitals as the only practical source for healthcare. The Ministry found itself beneath the

requirement of contracting to these hospitals in order to provide care for war victims as well

as the general population.

As a result, the MOPH became the major funder of these hospitals and its role shifted to

that of a contracting agent. Health expenses increased swiftly. They represented 80% of the

Ministry’s budget and covered mainly secondary and tertiary healthcare services. The

MOPH also had to distribute expensive medication free of charge. By the end of the war, the

MOPH was taking care of the health of the population with no social coverage as the NSSF

seemed unable to cover healthcare expenses due to the rapid increase in their cost as well as

the existing economic situation. The only remaining ray of hope lied in private insurances

which unfortunately were only available to a specific socio-economic class and could not,

alone, cover the needs of the entire population.

War had a negative impact and harmful consequences. Its influence was catastrophic on

infrastructure, human resources and the economy of the country, in both the private and

public sectors.

At the end of the war in 1990, the Lebanese health system was at its worst. The war had

damaged the health sector, as well as several other sectors in the country. Although most of

the issues of the healthcare system stemmed immediately from the war, some were inherent

to the conception of the system itself (The World Bank 2000). Regardless the causes, the

main outcomes are summarized below:

• In terms of governance the country found itself with a MOPH that was unable to play its

role as a health system regulator due to weak institutional, financial and managerial

capacities. The whole public hospital network had started to collapse and consequently the

public hospital sector was paralyzed, and became dependent on the private hospital sector

that now existed, a predominant place in the Lebanese health field.

This sector continued to grow but in a very messy way leading to an increasing trend

towards highly technological curative care at the expense of preventive care and primary

healthcare.

• In terms of equity and efficiency the health coverage of the population was inadequate.

There was a considerable gap between the quality and the quantity of services provided, as

well as inequalities in their geographic distribution, therefore reducing their accessibility.

• In terms of human resources qualified personnel were attracted by job opportunities

elsewhere leading to the migration of health professionals.

• In terms of financing regime and healthcare expenses the existing fragmentation and

compartmentalization between numerous public, semi-public and private funds

(approximately 100) (Kronfol, 2006), as well as the absence of efficient controlling

mechanisms led to weakened purchasing power and expensive administrative costs as well

as perverse behaviors aiming at increasing income (Ammar, 2003). In addition, the

continuous upsurge in costs placed the country at a level close to that of industrialized

countries with a very heavy financial burden on household expenses.

5. Current health system

The present health system is described by several authors as being fragmented and

pluralistic. The public sector has been absent for a long time because of the civil war. Since

then, the MOPH realized a number of achievements. The health reform that started more

than 15 years ago has achieved the aims that are recognized by worldwide experts, such as

those described in the WHO 2010 World Report on Health.

―Lebanon’s reforms: improving health system efficiency, increasing coverage and

lowering out-of-pocket spending‖. The key components of these reforms have been: a

restoring of the public-sector primary-care network; improving quality in public hospitals;

and improving the rational use of medical technologies and medicines. The latter has

included increasing the use of quality-assured generic medicines.

The Ministry of Health has also sought to strengthen its leadership and governance

functions through a national regulatory authority for health and biomedical technology, a

certification system for all hospitals, and contracting with private hospitals for specific

inpatient services at specified prices. Improved quality of services in the public sector, at

both the primary and tertiary levels, has resulted in increased utilization, particularly among

the poor.

Utilization of preventive, primitive and curative services, particularly among the poor,

has improved since 1998, as have health outcomes. Reduced spending on medicines

combined with other efficiency gains, means that health spending as a share of GDP has

fallen from 12.4% to 8.4%. Out of- pocket spending as a share of total health spending fell

from 60% to 44%, increasing the levels of financial risk protection.

6. Millennium Declaration goals for Lebanon

The Millennium Declaration adopted in September 2000 by the UN General Assembly

has been ratified by 189 member states. It includes eight goals, twenty-one targets and fifty-

eight indicators.

The eight goals are:

1. Eradicate extreme poverty and hunger

2. Achieve universal primary education

3. Promote gender equality and empowerment of women

4. Reduce under-five child mortality

5. Improve maternal health

6. Combat HIV/AIDS, malaria and other diseases

7. Ensure environmental sustainability

8. Develop a global partnership for development.

These goals are interdependent and influence each other. Three goals (goals 4, 5 and 6)

out of the eight are focused on health. Today, 13 years later, results are encouraging,

especially with respect to child and maternal health. However, additional efforts are still

required for combating AIDS, malaria and tuberculosis.

Target: Reduce the under-five child mortality rate by two-third by the year 2015

Lebanon has made important efforts towards achieving MDG 4, especially in reducing

infant mortality. The gap is observed across the country especially in disadvantaged regions

where mortality and morbidity rates are higher and vaccination rates are lower.

Table (4): Progress in MDG 4 – Reduce under-five mortality in Lebanon

Indicators 1996 2000 2007 2015

Under-five mortality rate (per 1,000) * 32 33 18.3 12

Under-five mortality rate (per 1,000) * 28 26 16.1 10

Proportion of children under-one year immunized

against DPT (%) ** 94.2 93.6 57 95

Proportion of children under-two years immunized 88 79.2 56 90

against MMR (measles, mumps, rubella) (%) **

Source: * CAS and League of Arab countries, 2006, Lebanon Family Health Survey (PAPFAM)

2004, Principal Report

** Based on vaccination carried out by the public sector (excluding the contribution of the private

sector which varies between 10 and 85% according to regions).

The MOPH, in cooperation with the private sector, has revised the national vaccination

calendar in order to gradually introduce new vaccines that will supported common

vaccination.

Figure (1): Distribution of children by reason given for not-immunizing them

Source: MOPH-WHO (joint report), 2009, Study on the measles coverage in Lebanon

However, there seems to be a problem with awareness about availability of some

vaccines and vaccination campaigns especially in regions mostly at need of vaccination

(Bekaa and South).

According to data available from the MOPH, neonatal causes (64.9%), injuries (11.1%),

pneumonia (1.1%) and diarrhea (1%) are the main causes of mortality among children

below five years of age. Twenty-two percent (22%) of deaths result from unknown causes.

MDG 5 – Improve maternal health

05

1015202530354045

Previouslyvaccinated

Doctor'sadvice

Unaware ofthe campaign

Refusal ofschool

Obstacles orlack of

information/motivation

reason for not immunizing the children

Beirut

Mount-Lebanon

Bekaa

North

South

Target: Reduce the maternal mortality rate by three-quarters and achieve universal

access to reproductive health by the year 2015,

Maternal mortality rate was estimated at 86.3 per 100000 live births (PAPFAM 2004) in

2008. Since then however, considerable efforts have been exerted to improve maternal

health in general.

Table (5): Maternal and reproductive health statistics in Lebanon

Indicators 1990

* 1996* 2000* 2004**

2009

*

Maternal mortality rate (per

100000 live births) 140 107 - 86.3 23

Proportion of births carried out

by qualified professionals (%) N/A N/A 96 98

Modern and traditional

contraceptive prevalence rate

(%)

53 61 63 74.2

Antenatal Care coverage (at least

one visit) (%) 87.1 87 93.9 95.6

Source: * CAS and League of Arab countries, 2006, Lebanon Family Health Survey (PAPFAM)

2004, Principal Report.

** WHO-MOPH, 2009, Reproductive Age Mortality Survey, (RAMOS).

The RAMOS study (2009) showed a maternal mortality rate of 23 per 100,000 live births

(with an uncertainty margin of 15.3 to 30.6). The prevalence of maternal death varied from

one region to another with a rate in the Bekaa and the North that are two and 1.5 times

higher respectively than the national average (21.3% and 16.1 against 10.7%),. The South

presented the lowest rate. The main causes for mortality were bleeding and asepsis

(Maternal Morbidity and Case Fatality Rate Study, MOPH, 2009, Unpublished)

MDG 6 – Combat HIV/AIDS, malaria and other diseases

Target: Have halted by 2015 and begun to reverse the spread of HIV/AIDS; Ensure,

by 2010, to all those in need, access to HIV/AIDS treatment

HIV/AIDS

Lebanon is still considered a country with a low prevalence of HIV. The potential risks

associated with the population’s high mobility, migration and relative sexual permissive

behavior require immediate and intensive interventions.

The total cumulative number of cases reported by the national program on combating

HIV/AIDS since 1989 was by the end of 2011, 1455, with an average of 85 new cases per

year.

Target: Have halted, by 2015, and begun to reverse the spread of malaria and other

major diseases.

Malaria

The disease has been eradicated in Lebanon since the 1950’s. Sporadic cases are rarely

reported among Lebanese living in endemic areas.

Tuberculosis

The joint MOPH and WHO National TB control program adopted the DOTS program in

1998, to combat tuberculosis, and has achieved encouraging results with a 100% coverage

rate by the end of 2009, as compared to 92% in 2005.

The Lebanese Government, through the MOPH has been providing treatment and care

for all Lebanese citizens suffering from tuberculosis and HIV/AIDS.

Table (6): National Statistics for Tuberculosis in Lebanon (2009)

Year 2002 2003 2004 2005 2006 2007 2008 2009

National 378 330 330 331 311 357 378 368

Non- 48 50 63 60 64 119 145 133

national

total 426 380 393 391 375 476 523 501

Source: WHO-MOPH, 2009, National Report on Tuberculosis

B. Determinants of health

1. Poverty23

The study carried out on poverty, growth and revenue distribution in Lebanon showed

that 21% of the Lebanese population was classified as poor while 8% (300,000 individuals)

were considered extremely poor. Moreover, the study highlighted the existence of regional

disparities: these are insignificant in Beirut whereas they are significantly higher in Akkar,

North Lebanon. Poverty levels are highest in South Lebanon.

Figure (2): Distribution of the population by poor and non-poor categories (2004-2005)

Source: Laithy, H. ; Abu-Ismail, K., ; Hamdan, K.; 2008, Poverty, growth and income distribution in

Lebanon, Country study, International Poverty centre, number 13. http://www.eldis.org/go/country-

profiles&id=35243&type=Document

Expenditure level and inequality

23

Laithy, H. ; Abu-Ismail, K., ; Hamdan, K.; 2008, Poverty, growth and income distribution in

Lebanon,Country study, International Poverty centre, number 13. http://www.eldis.org/go/country-


0

20

40

60

80

Extremly Poor Poor Non-Poor

Distribution of the population by poor and non-poor categories (2004-2005)

http://www.eldis.org/go/country-profiles&id=35243&type=Document




• Mean per capita consumption was highest in Beirut (6,514,000 LBP) (more than one and

one-half times the national average) and lowest in the North (3,975,000 LBP) (three-

quarters of the national average).

• The distribution of expenditure among the population was relatively uneven. The bottom

20% of the population accounted for only 7% of all consumption in Lebanon while the

wealthiest 20% accounted for 43% (over six times higher).

• Inequality within-Mohafazats accounted for most of the inequality in Lebanon (about 92%

of aggregate inequality in consumption can be attributed to within-Mohafazats inequality).

Table (7): Average per capita and per governorate consumption (1000 LBP) (2004-2005)

Mohafazats Mean nominal per capita consumption

Beirut 6514

Mount-Lebanon 4512

Nabatieh 3924

Bekaa 3385

South 3007

North 2532

All Lebanon 3975




Regional disparities

Poverty measures indicated:

• A low prevalence of extreme poverty (<1%) and overall poverty (<6%) in Beirut.

• A low prevalence of extreme poverty (2-4%) and a below-average prevalence of overall

poverty (close to 20%) in Nabatieh and Mount-Lebanon;

• A higher-than-average prevalence of extreme poverty in Bekaa and the South, an average

prevalence of overall poverty in Bekaa (29%) and a higher-than-average prevalence of

overall poverty in the South (42%).



• A high prevalence of extreme and overall poverty in the North (18% and 53%,

respectively).

Table (8): Poverty measures per Mohafazat (2004-2005)

Mohafazats Extremely poor Poverty in the entire population

Bierut 0.67 5.85

Nabatieh 2.18 19.19

Mount-Lebanon 3.79 19.56

Bekaa 10.81 29.36

South 11.64 42.21

North 17.75 52.57

Total 7.97 28.55




The North consisted of 20.7% of Lebanon’s population as well as 46% of the extremely

poor population and 38% of the entire poor population. The extremely poor households

were also predominant in the South and Bekaa governorates. The moderately poor

households were also over-represented in the South.

There were considerable differences in poverty within the North governorate with Tripoli

and the Akkar/Minieh-Dennieh regions presenting the highest percentages of overall

poverty. In contrast, the Koura Zgharta/Batroun/Bsharre areas had relatively low poverty

rates.

With respect to poverty, it is important to note that:

• Unemployment rates in Lebanon were high among the poor.

• Youth unemployment was aggravated by poverty.

• Households exposed to a combination of adverse factors faced the highest risk of poverty.



• Households headed by individuals with less than elementary education constituted 45% of

all the poor.

• Poverty was closely associated with school participation. There was a lower likelihood of

school enrolment, attendance and retention for poor children

• Widowed heads of households with children were more likely to be poor

• Poverty was affected by place of residence. Households in the North were four times more

likely to be poor compared to households in Beirut.

2. Employment

In general, the private sector absorbed a larger share of the employment. A quarter of

the labor force is relatively unskilled while another quarter was highly qualified. Salaries

differed by gender with the women’s average salary lower than the men’s. Highly qualified

individuals suffered more from unemployment. Foreign labor contributed to the economy as

145,684 (11% of the labor force) work permits were delivered in 2009, 80% of which were

given to domestic workers.

The economic activity rate of the population aged 15 years and above, reached 48% in

2009. In other words approximately half of the population was working or available for

work.

Clearly services had the biggest share of the economy (39%), followed by trade (27%)

and manufacturing (12%). Half (50%) of those in employment were employees paid on a

monthly basis and 31% were self-employed.

Unemployment is defined according to ILO as ―all individuals aged between 15 and 64

years who were not working one week before the study but were actively seeking

employment and were available for work‖. Considering this definition, the national

unemployment rate in 2009 was 6% with a higher for women (10%) compared to men (5%).

Figure (3): Employment rate in Lebanon by gender (2009)

Source: CAS, 2011, the labor market in Lebanon, Statistics in Focus, issue 01.

The highest unemployment rates were recorded among young people, particularly

women below the age of 30 years. Beirut and the North recorded higher levels of

unemployment rates (around 8%). Lower unemployment rates were found in the South

(5%), Baalbek and Hermel (4%). Unemployment rates were high among highly skilled

persons, 9% for those people who had already obtained a university degree and 8% for

individuals with a secondary level of education. The unemployment rate was higher for

women except among the uneducated.

3. Environment

Major environmental degradation in Lebanon has resulted from the years of war

including: air pollution, inadequate solid waste management, water pollution in some

remote places, and uncontrolled use of pesticides for agriculture and public health. There are

various institutions and sectors involved in environmental management Country

Cooperation Strategy for WHO and Lebanon Country Cooperation Strategy for WHO and

Lebanon but with unclear responsibilities and no coordination of activities. Medical waste

management has been a major issue of debate in recent years with no clear consensus on

how this problem should be tackled; hospitals continue to dispose of their waste in an

unorganized way and the relevant law passed by the Ministry of Environment is not

enforced.

Employment rates by gender (%)

Male

Female

The sanitary engineering department of the MOPH is responsible for assessing water

supply and sanitation projects, and quality control of air, water and soil. However, it is

unable to fulfill its mandate and implement legislation due to lack of qualified personnel,

staff and allocated budget. There is no national centre for poison information and control

although the WHO office in Beirut and the Faculty of Pharmacy at the Lebanese University

are working jointly on creating a collaborative anti-poison centre in Lebanon.

C. Health status indicators

1. Mortality in Lebanon

In 2011, the mortality rate was 5.4/1000. This rate has been rather stable since 2006. The

declared and registered deaths reached 21 012 in 2011. The highest death rate is found in

Beirut, followed by Nabatiyeh; whereas Mount Lebanon has the lowest rate. Life

expectancy at birth was 74 years (77 years for women and 71 years for men).

The maternal death rate is 23/100000 live births. Cardiac arrests were the most frequent

causes of death cited by physicians or Ministry of the Interior employees on death

certificates. The main cause of death was linked to circulatory system diseases (22%),

followed by neoplasm (19%) and cardiac arrests (17%). No death due to eye and related

diseases, ear and skin mastoid or subcutaneous tissue, or pregnancy, childbirth were

registered in this hospital based mortality survey. Also, there were no deaths due to mental

or behavioral disorders in the hospital survey.

Table (9): Mortality in Lebanon (2011)

Gender n

Male 10055

Female 7994

Total 21012

Life expectancy at birth (years) 73.6

Source: MOPH, 2011, Statistics Bulletin,



Figure (4): Mortality in Lebanon by age (2011) (rate/1000)



Figure (5): Mortality in Lebanon by region (2011) (rate/1000)



Figure (6): Evolution of death rate between 2004 and 2011

0

5

10

15

20

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1..

5

5..

10

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15

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85

-90

90

+

Mortality in Lebanon by age (2011)

Mortality in Lebanonby age (2010)

02468

10 Mortality in Lebanon by region (2011)

Mortality in Lebanon byregion (2011)





Figure (7): Mortality by causes in Lebanon (2011)

Source: MSP, 2011, Hospital-based causes of death reporting system

2. Morbidity in Lebanon

0

2

4

6

2004 2005 2006 2007 2008 2009 2010 2011

Evolution of death rate between 2004-2011

Evolution of death rate

between 2004-2011

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Mortality by Cause

Mortality by Cause


a. Infectious morbidity

Morbidity due to vaccine preventable diseases was 0.06% with the highest level in

Nabatiyeh (0.07%) and the lowest in the Bekaa (0.03%). The most frequent infection in

2011 was viral Hepatitis B which represents 74% of the total vaccine preventable diseases.

Food and water borne diseases were the most frequently reported in Lebanon with a rate

of 0.4‰. The highest rate was in the Bekaa (0.7‰) and the lowest in the South (0.1‰). The

most common infection is viral Hepatitis A, which represents 31% of the total food and

water borne diseases. No cases of cholera and trichinosis were declared.

Morbidity due to other infectious diseases was 0.07‰ in Lebanon. Nabatiyeh and the

North region presented the highest rates (0.08‰), whereas the South had the lowest

(0.03‰).

Figure (8): Number of patients suffering from infectious diseases by region (2011)

0

10

20

30

40

50

60Vaccine preventable diseases

Mount-lebanon

North

Bierut

Nabatieh

Bekaa

South

Source: MOPH, Data 2011, http://www.moph.gov.lb

b. Tuberculosis

The declared prevalence in Lebanon was estimated at 12/100000 inhabitants in 2009.

Beirut and Tripoli account for the highest number of patients suffering from tuberculosis,

107 and 40 respectively, with the highest incidence rate in Beirut district and Hermel

district.

Figure (9): Cases of tuberculosis in Lebanon (2011)

0

50

100

150

200Food and Water borne disease

Mount-Lebanon

North

Bierut

Nabatieh

Bekaa

South

05

101520253035404550

Other Diseases

Mount-Lebanon

North

Bierut

Nabatieh

Bekaa

South

http://www.moph.gov.lb/

Source: WHO, 2011, Report on Millennium Goals for Lebanon

c. Chronic morbidity

i. Cancer

In 2007, the number of declared patients was 8868 (2.3‰) with 50.1% women. The age

group with the highest percentage of cancer cases was that of 70 years and above (27%) and

the least affected was that below the age of 30 (8%). The most common type of cancer was

for the malignant tumor of the breast cancer with a rate of 20%, whereas the least frequent

one was malignant tumors in the bones and auricular cartilages (1%). T

Figure (10): Distributions of patients suffering from cancer (2011)

Cases of Tuberculosis (%)

Lebanese

Foreigners

% of Patients suffering from cancer by Gender

Women

Male

Undetermined

Source: MOPH, 2011, Cancer Records

ii. HIV/AIDS

Any case of detected HIV must be declared to the MOPH – Prevention Directorate. The

number of cumulated cases until November 2011 was 1455 with 109 new cases detected in

2011 (0.03‰) 8. 93% of cases were men.

Figure (11): % of declared cases of HIV/AIDS (2011)

% of Patients suffering from cancer by Age

<15

15-19

20-29

30-39

40--49

% of Patients suffering from cancer by type

breast

lips

lymphoid tissue

respiratory organ

urinary tract

% of declared cases of HIV/AIDS by Gender

Men

Women

Source: MOPH, 2011, National Program for combating AIDS

iii. Mental health

The Hopital de la Croix is the only specialized psychiatric hospital in the country. In

2008, 110 patients were admitted for mental health problems; three-quarters of which were

men and 35% were under the age of 20 years.

Figure (12): Distribution of the population at the "Hopital de la Croix" (2010)

% of declared cases of HIV/AIDS by Age

<30

31-50

>51

Undetermined

Distribution of the population at the "Hopital de la Croix" by Gender

Men

Women

Source: Psychiatric Hospital of the Cross, 2010

d. Open heart surgeries covered by the MOPH

The number of open heart surgeries covered by the MOPH in 2010 was 4038. More than

half were angioplasties with stent and 30% were coronary bypasses.

e. Burns

The only specialized center providing care to burn patients is found within the Geitawi

Lebanese Hospital which was founded in 1927 and is run by the Maronite Congregation of

Nuns of the Holy Family. The Burn Center was established in 1992 and has a capacity of 10

beds.

Over a period of 1 year (2010) a total of 84 burn cases were admitted between January

and May. The majority of patients were men (70%), more than half of which (65%) were

under the age of 30 with 30% under 10 years of age. The most common cause was from

accidents at home (60%), and 13% resulted in death.

Figure (13): Data on Burn cases in Lebanon (2010)

Distribution of the population at the "Hopital de la Croix" by Age

<20

20-24

25-29

30-34

Source: Getawi Hospital 2010, Traumatology Unit, http://www.hopital-libanais.com

Data on Burn cases by Gender

Male

Female

Data on Burn cases by Age

0-10

11..20

21-30

31-40

41-50

Death data on Burn cases

Yes

No

Data on Burn Cause cases

Accidents at home

Accidents at work

Leisure activities

http://www.hopital-libanais.com/

f. Road accidents

The Lebanese Red Cross and Kunhadi, a local NGO, estimate the number of road

accidents in 2011 at approximately 11161 cases.

Figure (14): Road accident cases in Lebanon (2011)

Source: Yasa, http://www.yasa.org ,data of the Internal Security Forces, 2011.

3. Risk factors (Intentional and non-intentional)

a. Drug Use

The number of individuals admitted to the rehabilitation program of Oum El Nour

between 2003 and 2011 seems stable, with an average of nearly 85 admissions per year. The

age at first consumption is in more than half of the cases between 14 and 19 years (58%)

with slightly less than 25% initiating their consumption between 20 and 24 years.24

24

http://www.skoun.org

0

10

20

30

40

50

Accidents Injured Killed

% of Road accident cases by region

Mount-Lebanon

Beirut

North

Bekaa

South

0

50

100

Male Female

% of Road accident cases by Gender

Injured

Killed

http://www.yasa.org/

http://www.skoun.org/

Figure (15): Age of initiation of drug consumption (2011)

Source: http://www.oum-el-nour.org/factsstat10.php?i=3010.2

7

b. Cigarette Use and other Risk Factors

Thirty-nine percent (39%) of adults were current smokers, whereas 57% claimed to have

never smoked. Half of the individuals between the ages of 45 to 54 were current smokers,

whereas 70% of individuals aged between 25 and 34 never smoked. The current smoking

rate was higher among men (47% vs. 32%).

Twenty-one percent (21%) of adults currently consumed alcohol with 32% for the men

and 11% for the women. It is noteworthy to mention that 43% of those between 25 and-34

years are former drinkers.

Physical activity was measured on a scale varying between high and low activity. Almost

half of the individuals (46%) showed low physical activity, with the highest percentage

(54%) being for those aged between 25 and 34 years; 52% of the men and 40% of the

women report low physical activity.

Age of initiation of drug consumption (2011)

14-19

20-24

25-29

30-34

35-39

http://www.oum-el-nour.org/factsstat10.php?i=3010.2

Seventy-three percent (73%) of the sample (59% for men and 65% for women) are

classified as overweight (BMI ≥25), whereas 27% are obese with an almost equal rate for

men and women (29% vs. 27%).

Figure (16): % of risk factors by age and gender in Lebanon (2009)

Source: Sibai and Hwalla, 2009, WHO STEPS surveillance28

4. Special groups

a. The Elderly Population

In 20011, there were 288,467 of elderly was individuals in Lebanon, with about 65% of

them aged between 65 and 74. The percentage of elderly men was slightly higher than that

of women. The highest rate was found in Mount Lebanon (38.6%), whereas the lowest rate

was in Nabatiyeh (6.9%).

Figure (17): distribution of elderly population by age, gender and region (2011)

Male Female Male Female Male Female Male Female

25-34 35-44 45-54 55-64

% of Risk Factors by Age and Gender

physical activity high

physical activity moderate

physical activity low

Meals taken outside

obese

over-weight

consumption of alcohol

consumption of cigarettes

Source MOPH, 2011, Statistics Bulletin,


Figure (18): Institutions that provide elderly care (2010)

Distribution of elderly of population by Age

65-69

70-74

75-79

80-84

85 +

Distribution of elderly population by Gender

Men

Female

Distribution of elderly population by age

Mount-Lebanon

North

Bekaa

South

Beirut

Nabatieh


Source: MOSA-UNFPA, National report on services offered to elderly in Lebanon, 2010

All organizations that provide services to the elderly face financial, logistic and legal

problems, and have to deal with shortage of staff, the families of their elderly residents, as

well as governmental institutions.

b. Disabled

The Ministry of Social Affairs estimates this number to be around 4% of the Lebanese

population, i.e. in the range of 158473 individuals.

In 2009, the rate of disability was higher for men. Nearly 45% of the disabled are

between 6 and 34 years of age with almost 30% between 35 and 65 years. Mount Lebanon

has the highest rate of disabled individuals, followed by the North. Four kinds of disabilities

are registered with the highest rate for those in the motor disability category.

Figure (19): Distribution of disability according to gender, age and region (2009)

61

29

9

19 10

Institutions that provide elderly care (2010)

Mount-Lebanon

Beirut

Bekaa

North

South

Source: MOSA, 2009, Access and Right Program.

c. Prisoners

Distribution of disability according to Gender

Men

Female

Distribution of disability according to Age

0-5

6..18

19-34

35-65

Distribution of disability according to Region

Mount-Lebanon

North

South

Bekaa

Nabatieh

Lebanon has 21 prisons distributed all over the Lebanese territory. The majority of these

prisons serve adult males. There are three prisons for women only one specialized for

minors. Some minors are also kept in the Roumieh prison in a special department.

Many recommendations were proposed during the first congress on the health in

prisons that took place in Lebanon in 2008. These recommendations included:

1. Elaborating a specific health system for prisoners

2. Developing the current medical structure

3. Increasing the number of hospitalization beds in hospitals; especially beds in the intensive

care unit

4. Reinforcing mental health

5. Developing an individual medical file for every sick prisoner

6. Providing the medication required for treatment

7. Developing a declaration system for emergencies

8. Establishing an efficient transport system for sick prisoners

9. Ensuring the presence in the prisons of a permanent medical team

10. Developing a prevention policy

11. Improving incarceration conditions

12. Guaranteeing the rights of prisoners.

In 2011, the Lebanese prisons had an estimated capacity of up to 3000 prisoners. This

number was largely exceeded, as the capacity of prisons was 1.5 to 2 times higher than its

real capacity.

Figure (20): Distribution of diseases by type in prisons (2011)

Source: ISF -September 2011ble 50

Distribution of diseases by type in prisons

Chronic diseases

Cancer

Infectious diseases

Other diseases

Consumption of medication

Dental care

Part Two: Lebanese Health Sub-system Profile

Chapter I: Health system indicators

The concept of health for all, to which Lebanon has subscribed, places equal access to

quality health care at the center of health development. This goal can best be achieved

through sustained services that provide better care, use resources more efficiently and

facilitate regular access to basic care. The strength of the health care system rests on the

quality and quantity of resources available such as hospital capacity, advanced technology

and medical expertise.

These resources have made possible the observed overall high level of accessibility to

health care services. However, the health sector in Lebanon appears to have an inverted

structure whereby resources are essentially concentrated in tertiary care rather than in

secondary and primary health care levels.

Also, the impact of such resources on improving the health situation remains questionable

in the absence of clear policies for the development of needed human resources, including

those needed in support of sophisticated technology, and the absence of adapted regulatory

mechanisms for control of costs and ensuring the quality of care.

A. Health system Infrastructure

1. Ambulatory care

The country has 950 dispensaries and primary healthcare centers operating with minimal

human and physical capacities and offer limited services. Primary healthcare centers are in

constant evolution and offer a multitude of services including prevention programs,

reproductive health programs, family planning and prenatal care. They also develop training

programs and offer logistic support, via a wide network, in buying and distributing essential

medication. In spite of this, the public primary healthcare system remains weak. The number

of individuals making use of these centers remains limited (estimated at a maximum of 20%

of the population) and the quality of services varies by region and provider.

The MOPH has chosen 130 centers among all the primary healthcare centers operating in

the country to establish a primary healthcare network distributed as follow:

Seventy-one % (71%) of the 130 primary healthcare centers (PHC) of the national PHC

network of the country belong to NGOs. Of the 130 PHCs, 21 are under a trial period, 14

belong to the public sector (10 belong to and are managed by the MOPH, and 4 belong to

and are managed by the MOSA), 29 belong to the MOPH and are managed by NGOs or

local authorities and 106 are managed and belong to NGOs and/or municipalities.25

The private sector is the main source of ambulatory medical care in the country. This

phenomenon is facilitated by the large supply of physicians. NGOs play a critical role in the

success of programs of vaccination, AIDS control, iodine deficiency, diarrheal disease

control and to a lesser extent in health education and school health. The set up of these

health centers is varied. Some have lots of staff, various specializations and extensive

equipment; others are poorly equipped in terms of facilities and staff.

All ambulatory care, including that provided at the level of NGOs centers, is structured

to respond to emergency and acute demands but lacks in comprehensiveness and continuity.

The function of these centers is to provide a balanced and good quality care, including both

curative and preventive care.

Disease prevention is an integral part of any effort to improve the health situation of the

population. Some national health promotion and disease prevention programs have been

25

WHO EMRO, 2011, Health System Profile, Lebanon

successfully introduced with the help of UN organizations. Still, the priority given to kidney

dialysis contrasts with the absence of hypertension and diabetes national prevention

programs; diabetes being the underlying cause in over one-fifth of kidney failures; and the

priority given to open heart surgery contrasts with the lack of a national primary prevention

initiative for the control of smoking.

2. The hospital sector

The hospital sector has witnessed very rapid expansion. This has occurred concurrently

with the development of sophisticated medical technologies in the world. It has been

observed globally that the introduction of advanced technologies usually influences the

hospitalization capacity. In Lebanon there has been a concomitant use of both heavy

technology and bed capacity. This has undoubtedly fueled the escalating costs of health care

in the country.

In the absence of any regulating mechanism, and encouraged by the government policy

to subsidize sophisticated medical interventions, the private sector has been encouraged to

invest in such technologies. These are now spread in all regions in contrast to the persistent

lack of some basic medical disciplines and hospital services, in such areas as medical

emergency care and prenatal services.

Also, the small number of sophisticated medical technology procedures handled by each

of the health facilities do not allow for an adequate accumulation of expertise in the field.

Besides, it is commonly observed that acquisition of sophisticated equipment is not always

coupled with training or opportunities for the development of human resources in the field.

Another important weakness of the health care system is observed in pre-hospital care

such as in emergency care. The existing services are rudimentary and concerned with

transportation and transfer of patients. The services are diffused and their management is

uncoordinated. They are completely dependent on voluntary staff which are often

inadequately trained and equipped.

The public hospitals were until recently under-equipped, offered bad quality services and

lacked qualified professionals. These hospitals provided free general care, were managed

like administrative units of the MOPH and did not benefit from financial autonomy. Their

management was centralized and the budget allocation was based on estimations rather than

studies of actual need.

The hospital sector in Lebanon suffers from the inefficiency at more than one level, first

being the size.

Hospitals in Lebanon are generally small (less than 70 beds); this delayed the appropriate

management of quality of acute care. About 70% of hospitals in public sectors have 70 beds

or less, 30% have between 71 and 200 beds, with 0% having over 200 beds.

Table (10): Distribution of hospitals per size

Beds Public hospitals Private hospitals

Up to 70 beds 14 96

71 to 200 beds 6 43

Over 200 beds 0 4

Source: MOPH, Statistics bulletin, 2011

There is a different classification of hospital size where 67% of private hospitals in

Lebanon have less than 70 beds, i.e. classified as small. Lebanon has only 43 private

hospitals with 71 to 200 beds, and only 4 with 200 beds or more; these are located in Beirut

and its suburbs. Besides, the size of a hospital correlates not only with efficiency, but also

with the cost and quality of medical care provided.

The private hospital sector is the main component and backbone of the Lebanese

healthcare system. Highly developed both in number and capacity, it includes 135 long and

short stay hospitals, with a total of 12648 beds (Private Hospitals Syndicate, 2009) which

account for 82% of the country’s total capacity. They are mainly general multidisciplinary

hospitals with 80 to 400 beds per hospital.

Figure (21): Distribution of number of beds by region

Source: Syndicate of Private Hospitals, 2011; MOPH, 2011; Ministry of Defence, 2010.

The supply of beds in Lebanon has been balanced since 2005; the number of beds

available per 1000 individuals was maintained between 3.43 and 3.60. Currently, the

number of hospital beds available in Lebanon s estimated around 14864 beds, i.e. a ratio of

3.5 beds per 1000 individuals.

Among 181 Countries surveyed by index-mundi website, Japan has the highest hospital

beds density, 13.75 beds/1000 populations while Ethiopia and Cambodia have the lowest

rate at 0.18 and 0.1 beds/1000 population. Lebanon is ranked 59th in total, however, as

compared to the Arab World, Lebanon is ranked the 1st.26

Occupancy is the other efficiency reason. This could be attributed to one (or both) of the

following two reasons:

a. There are some public hospitals that have been equipped and ready to function, but not

operational yet due to administrative reasons. The inefficiency lies in the fact that nothing is

being done to operate these hospitals so as to cover the huge investment costs pertaining to

building, equipping and most importantly financing these hospitals.

b. Many groups find it easier and more profitable to construct and run new tailor-made

hospitals rather than operate existing ones. These groups usually develop private or

religious-institutions hospitals.

26

Index-mundi website http://www.indexmundi.com/facts/lebanon

3350

4686

665 782 1701 2027 1766

365

010002000300040005000

Distribution of number of beds by region

Number of beds

http://www.indexmundi.com/facts/lebanon

There is a total of 163 Hospitals contracting with the MOPH, 84.66% of the Hospitals are

private Hospitals while 15% are public hospitals. The highest concentration of hospitals is

attributed to Mount-Lebanon with 37.40% of the total number of hospitals while the lowest

number of hospitals available is in Nabatiyeh at 675%.

Amongst private hospitals, Mount Lebanon holds the highest number of hospitals

(40.58%) followed by North Lebanon (18.84%) with the lowest number existing in

Nabatiyeh (3.62%). Between public hospitals, the highest number of hospitals available is in

North Lebanon and Nabatiyeh (24%) with the lowest number in Beirut and South Lebanon

(8%).

The Ministry of Public Health contracts with both the public and the private hospitals for

the services it pays for with the aim of ensuring universal accessibility to services in an

equitable distribution. Accordingly, the MOPH issues contracts with 138 private hospitals

where the patient share is 15% of the hospital bill, and 25 public hospitals where the patient

pays only 5% of the bill.

Figure (22): Number of hospitals having contracts with the MOPH by type and Mohafazat


Figure (23): Percentage of hospitals in public and private sectors distribution per Mohafaza

2 5 6 4 2 6 11

56

26 23 17

5

0102030405060

Number of hospitals having contracts with the MOPH

by type and Mohafazat (2011)

Public

Private


Figure (24): Percentage of hospitals distribution per Mohafaza


05

1015202530354045

Beirut MountLebanon

North bekaa South Nabatiyeh

Private

Public

8

37

20

16

12 7

Total distribution of hospitals among Mohafaza

Beirut

Mount Lebanon

North

bekaa

South

Nabatiyeh

There were 236,643 MOPH subsidized admissions to hospitals during 2011. The share of

the private hospital is estimate around 69.41% compared to 30.59% of the total number of

admissions. Mount Lebanon has the highest rate of admissions (23.28%) followed by North

Lebanon (21.28%) while the lowest admission rate is in Beirut (9.82%).

Among private hospitals there were 164,244 admissions, where, Mount Lebanon holds

the highest share of admission (27.48%) followed by Bekaa (23.4%) with the lowest number

existing in Beirut (5.37%).

Figure (25): Number of admission by type of hospital and geographic location (2011)


However the number of admissions in the public hospitals reached 72,399. Amongst

public hospitals, the highest number of admission is in Nabatiyeh (21.64%) followed by

North Lebanon (21.37%) with the lowest number in South Lebanon (8.27%).

As expected, in areas where there are active and contracted public hospitals, the number

of admissions in public hospital exceeds that in contracted private hospitals.

Figure (26): The evolution of MOPH subsidized admissions in public and private hospitals

between 2005 and 2011

14408 9962

15475 10900

5989

15665 8828

45134

34879 38439

27830

9134

0

10000

20000

30000

40000

50000

Public

Private


Year after year, the public hospitals are continuing to offer an improving quality services,

and their admissions have been increasing steadily. But, this increase has reached a plateau

revolving around 30/70 ratio with the private sector. This is due to the fact that originally

the number of public active beds is lower than that of the private beds in addition to

reaching a maximum occupancy rate in the public hospitals.

The main end result of the above-mentioned hospital sector inefficiency factors is

revealed in a high cost of providing health services. High cost of medical care implies a

problem in Lebanon especially when compared to the minimum and the average wages,

since it indicates a significant mismatch between the two.

3. Technology and heavy equipment in hospitals

Advanced medical equipment is possibly more offered in Lebanon than in many

developed countries, but is not utilized to its full capacity. Kidney dialysis facilities could

handle double the current patient load. Computerized tomography (CT) scans in the smaller

hospitals operate only between three and eight examinations per day. Apart from their

impact on the quality of care in terms of over-prescribing and under-utilization, these

technologies influence directly the increasing costs of health care.

Table (11): Distribution of technology by region (2010)

Beirut

Mount-

Lebanon Bekaa North South Nabatieh Total

MRI 7 8 4 5 6 1 31

0

20

40

60

80

100

2005 2006 2007 2008 2009 2010 2011

public

private

Echo-graphy 49 54 23 32 24 7 189

Tomo-densitometry 12 36 15 16 13 4 96

PET scan 2 1 1 1 0 1 6

Radiology 72 75 27 36 35 10 255

Mammography 10 28 7 16 10 3 74

Endoscopy 49 65 31 44 40 8 237

Bone densitometry 10 11 3 4 4 0 32

Lithotripsy 6 13 6 8 4 0 37

Hemo-dialysis 8 19 7 11 6 1 52

Open heart surgery 22

Cardiac

catherization 32

Organ transplant

centers 5

Bone marrow graft

units 3

In vitro fertilization 12

Radiotherapy 8

Total 1091


Also, the small number of complicated medical technology procedures handled by each

of the health facilities do not allow for a sufficient accumulation of proficiency in the field.

Besides, it is commonly observed that achievement of sophisticated equipment is not always

attached with training or opportunities for the development of human resources in the field.

Most private hospitals are highly equipped and developed in a free-market and with

unregulated development which results in a considerable number of high-tech equipment in

all hospitals, putting Lebanon, in terms of technology, at the same level as high income

countries. Consequently, the main characteristic of the health field remains that of a

confused sector with a surplus of beds, an over-investment in equipment and an abundance

(almost 75%) of hospitals with less than 100 beds. The main reason for this situation is

essentially the absence of control of the MOPH that encouraged the opportunistic tendencies

of consumers and suppliers.

4. Pharmacies and laboratories

There are around 7,000 registered pharmaceutical arrangements, in addition to a large

number of non-registered ones. Some drugs are also provided through foreign aid and are

distributed through dispensaries. The local industry supplies 15% of the drug market; the

rest being imported from more than 380 different factories in 21 countries. Licensing is

necessary by law for all drugs in the country and when the product is first introduced into

the market. Some effort has been already made to develop the registration system, but it is

certainly not possible to achieve good control with the very large number of imported drugs.

The network of drug distribution outlets is very large and diversified. Apart from the

dispensaries, around 1,200 independent and hospital-based pharmacies exist, of which 200

are thought to be illegal. The profit made on sales of drugs is very high. In private

pharmacies, drugs are freely sold to patients, some even without prescription. An

examination system is in place but functions with limited efficiency due to lack of clear

procedures and trained staff.

The lack of guidelines on treatment and poor control on distribution outlets are fueling

unreasonable prescription patterns. There is a tendency among health providers to over-

prescribe medications, mainly more expensive ones, even when lower cost alternatives exist.

Antibiotics constitute 24% of the market followed by tranquilizers and other psychoactive

drugs (21.8%). This consumption pattern points not only to the importance of the drug bill

but also to the risk of developing antimicrobial resistance and tolerance to other

medications. Important promotional and educational efforts are needed to promote a more

rational attitude among health providers and the public at large towards prescription and

drug consumption.

In 2011, there were 2536 (91.3% private and 8.7% within hospitals) pharmacies in

Lebanon. The highest percentage of private pharmacies was in Mount Lebanon (44.4%) and

the lowest in Nabatiyeh (6.3%). Hospital pharmacies were mostly located in Beirut (40.3%),

with only 3.6% in Nabatiyeh.

Table (12): Geographic distribution of pharmacies and labs (2011)

pharmacies labs

Hospital Private Hospital Private

Bierut 89 223 20 41

Mount-Lebanon 57 1027 38 67

North 24 349 22 29

South 23 343 23 31

Nabatieh 8 145

Bekaa 20 328 18 13

Source: Order of Pharmacists, 2011; Syndicate of Biologists, May 2011.

5. Dialysis, physiotherapy and radiology centers

In 2011, the largest concentration of dialysis (23) physiotherapy (171) and radiology (78)

centers was found in Mount Lebanon, and the lowest in Nabatiyeh.

Table (13): distribution of dialysis, physiotherapy and radiology centers by region (2011)

Dialysis Physiotherapy Radiology center

Beirut 8 59 22

Bekaa 9 26 24

North 12 79 35

Mount-Lebanon 23 171 78

South 7 34 20

Nabatieh 3 12 6


6. Insurance companies

The number of active insurance companies decreased by 15% from 2001 (61 companies)

to 2011 (52 companies). The total gross premiums on the Lebanese market were estimated

at 1.2 billion dollars in 2010.27

27

Ministry of Economy and Trade, 2010, Annual report

This represented an increase of 12.5% from 2009. Since 2001, the premium yearly

turnover was multiplied by 2.8, the profits by 4.5, assets by 3.9, equities by 3.3 and reserves

by 6.3. The fire, accidents and miscellaneous risks branch has dominated the market with a

market share estimated at 70%. The progression of these branches in 2011 is of 12%. The

life insurance branch represented 30% of the overall turnover, with a progression of 15% in

2011.28

Between 2007 and 2011, the medical insurance branch evolved by 16.1% per year for all

categories, except for the claims paid which increased by 13.7% per year for the same

period. The market is heavily concentrated as the first 10 companies capture 80% of the

market.

B. Human Resources

There is evidently a surplus of physicians. The total number of medical doctors is

currently estimated to be between 7,900 and 9,500 physicians, including those practicing but

not legally registered. The physician - population ratio is presently estimated to be between

one doctor for every 330 persons and 392 persons. This is higher than in most parts of the

world, having 1 to 446 reported for the United States of America.29

The majority of doctors are graduates of medical schools abroad with widely different

training backgrounds and of variable quality. Only 37.8 % of doctors received their basic

medical education in Lebanon. The rest have been trained in 66 different countries, mainly

Arab and Eastern European countries. As a result, many of these doctors are not equipped to

meet the country’s health needs.

The medical work force operates in an environment which is largely unregulated and

dominated by the private sector. National protocols for disease management and treatment,

and continuing medical education and quality assessment schemes, are lacking. Highly

specialized medical categories such as surgery are in surplus; whereas there is scarcity of

28

Ibid. 29

WHO website http://www.who.int/gho/countries/lbn/en/

http://www.who.int/gho/countries/lbn/en/

well-trained primary care and family medicine practitioners. Some regional imbalances also

exist with physicians concentrated mainly in urban areas.

While there is a surplus of medical personnel, except for primary care practitioners,

family doctors and other public health related specializations, there is a critical lack of other

categories of health workers, particularly nurses and midwives. The imbalance in health

manpower resources becomes even more glaring when relating the number of existing

physicians to that of nurses.

Other health care workers and technical paramedical staff categories such as health

inspectors, laboratory and X-ray technicians are also in short supply. This is a cause of

concern, especially with the development and implementation of national strategies for

primary health care and reactivation of national specific- disease control programs.

The launching of the school for training health inspectors as a joint venture of the

Ministry of Public Health and the Ministry of Vocational Training is an attempt to overcome

the shortage in this field. On the other hand, an important gap is noted between the rapid

rate of acquiring advanced medical technology in the country, and the preparation of skilled

technicians for its operation. Training programs for medical equipment engineers and

maintenance technicians are very scarce.

Health professionals today include physicians, pharmacists, dentists, nurses, as well as

other paramedical professionals such as physiotherapists, psychologists, speech therapists,

psychomotor therapists, and others. These professionals are educated and trained in

Lebanon or abroad (France, Europe, Latin America, Eastern Europe, North America).

Health professionals are granted a working permit from the Ministry of Public Health

and must register in their Order or professional Syndicate to obtain the authorization to work

in Lebanon.

1. Orders and Syndicates

a. Physicians

In 2010, around 11782 physicians 70% of which were specialists were registered in the

two Orders of Physicians in the country (Beirut and North Lebanon)30

. Approximately, 10-

15% of registered physicians did not practice in Lebanon. The rate of doctors in Lebanon

was on the average 2 per 1000 inhabitants but was unevenly distributed among regions, with

a large concentration in the capital.

b. Pharmacists

There were 5457 pharmacists.31

c. Dentists

Dentists, like physicians, were in surplus in Lebanon. In 2008, they reached 5116, with

the highest concentration in Beirut and Mount Lebanon. Only 3795 dentists were practicing

at the time32

.

d. Nurses

The number of nurses registered at the Order of Nurses in Lebanon as of April 30, 2011

was 9460. Nearly 72% were active. Among the active nurse population, 81% are women

and 19% men. Approximately 68.51% were between 26 and 40 years old, and 46.41% had a

university degree. Almost 71.92% worked in Lebanon, whereas 10.68% did not work or had

retired. Five thousand nine hundred and sixty-five nurses (87.6%) worked in hospitals,

80.3% in private and 19.70% in public hospitals. The ratio of qualified nurses/population is

3/10000. This ratio is one of the lowest in the world. The nurse/physician ratio is 1/2.5; this

ratio is generally reversed in most countries33

.

e. Physiotherapists

The number of physiotherapists registered at the Order as of April 2010 was of 1431,

among which 780 are women. The majority (731) live in the Mount Lebanon region 34

.

f. Other health professionals

30

Order of Physicians in Beirut and North Lebanon, 2010 31

Order of Pharmacists in Lebanon, 2009 32

Order of Dentists in Beirut and the North, 2008 33

Order of Nurses in Lebanon, 2011 34

Order of Physiotherapists in Lebanon, 2010

In 2009, the number of biologists was 249 with 103 working in hospital labs and 146 in

private laboratories.

Moreover, the country has 291 opticians, 28 orthoprothesists, 48 laboratory and 3

radiology technicians registered at the MOPH.

Figure (27): statistics of professional orders

Source: Order of Physicians 2009; Order of Dentists, 2009; Order of Pharmacists, 2009; Order of

Nurses in Lebanon, April 2011; Order of Physiotherapists, April 2010; Syndicate of Biologists,

2009; Syndicate of drug importers and druggists, 2009; Syndicate of Opticians, 2009; Syndicate of

Ortho-prosthesists, 2009; Syndicate of laboratory technicians, 2009; Syndicate of radiology

technicians, 2009.74

C. Health care financing in Lebanon

In 2011, the total expenditure on health care in Lebanon amounted to 3 988 786 million

LL and the per capita expenditures to 621$. The total expenditure on health is 6.6% of the

GDP and is higher than other countries in the region. The proportion of government budget

allocated to health sector is a little over 2.7%. Public sources account for 18.2%, private

11782

5324 5457

9460

1431 249 40 291 28 48 3

0

2000

4000

6000

8000

10000

12000

14000

Number of Professionals

Number of Professionals

sources for 79.8% of health care financing and international donors for the remaining 2%.

The single largest source of financing comes from households which represents 69.7% of

total expenditures. In terms of expenditures, public sector providers accounted for 1.7%,

private sector providers for 89.2%, and others accounted for the remaining 9.1%. This

pattern of expenditures reflects the fact that Lebanon relies largely on the private sector in

the health services.35

There are six employment based social insurance funds publicly managed in Lebanon,

the largest one is the National Social Security Fund (NSSF) meant to cover all employees in

the formal sector (private sector and government-owned corporations, in addition to

contractual and wage earners of the public administration). The Civil Servants Cooperative

(CSC) covers the regular government staff. The remaining four funds cover the Military and

Security Forces. CSC is under the tutelage of the presidency of the Council of Ministers and

the others are overseen by three separate ministries other than MOH.

1. National Social Security Fund (NSSF)

The NSSF was established in 1964 and is similar to the French model of social security.

As essentially a service for workers, the NSSF comes under the Ministry of Labor. The

MOPH has little input into its operations or decisions. The NSSF is the most important

source of public health insurance in Lebanon. It covers, in principle, Lebanese citizens who

are: workers and employees in the private, non-agricultural sector; permanent employees in

agriculture, employees of public institutions and independent offices who are not subject to

civil service; teachers in public schools; taxi drivers; newspaper sellers; and university

students.

Health coverage includes sickness and maternity allowances amounting to 90% of

hospitalization costs and 80% of medical consultations and medication excluding dental

care.36

Thus to a large extent, the Fund is financed from private sources yet it is a public

institution. The household survey revealed that only 26.1% of the Lebanese population was

covered by the NSSF.

35

WHO website http://www.who.int/gho/countries/lbn/en/ 36

National Social Security Fund- A brief review, August 2005


2. Security forces coverage

Insurance for the security forces is organized through several funds. The Military are

covered by the Ministry of Defense. The Internal Security Forces have their own plan, under

the Ministry of Interior. The staffs of Public Security, Customs employees and those of State

Security are covered through 2 different funds, under the Office of the Prime Minister. All

uniformed staff members are covered with their dependents and their parents. Together,

these funds constitute the second most important source of public health insurance.

Coverage here is the most generous: 100% of hospitalization and medical expenses for

the member, 75% for spouse and children and 50% for dependent parents.

3. Cooperative of the Civil Servants

The Cooperative of the Civil Servants (CCS) is the third most important source of public

health insurance which was instituted in 1964. The CCS insures all employees of the public

sector who are subject to the laws of the Civil Service.

Health insurance covers 90% of hospitalization costs and 75% of consultations,

medication and dental treatment for the employee (up to a ceiling, beyond which the CCS

covers all). The CCS is operated by the Office of the Prime Minister and is financed from a

1% deduction off the payroll of the individual; the balance is covered by the Government.

4. Ministry of Public Health – insurer of last resort

The MOPH funds the hospitalization costs for any citizen who is not covered under a

public insurance plan. This coverage is independent of the income and assets of the

individual. In addition, the MOPH covers the cost of some interventions such as

chemotherapy, open heart surgery, dialysis and renal transplant, and drugs for chronic

diseases. This coverage engulfs some 40%– 45% of the Ministry’s budget for contracted

services. As such, the Ministry has the largest share of the total cost of public expenditure,

including insurance, on health services in the country.

The MOPH covers 85% of hospital care: the incumbent is expected to pay 15% of the

hospital bill. However, even this co-payment is frequently waived altogether, on account of

need. Recently, the Ministry has taken steps to introduce ―flat rate‖ payments in its contracts

with private hospitals.

5. Mutual funds

There are a growing number of mutual funds covering health expenses in the context of

syndicates, associations and other groups. This sector comes under the Ministry of Housing

and Cooperatives. The law governing mutual funds allows any group of 50 persons (or

above) to form a mutual fund.

The linkage could be professional, religious or community-based. Tax laws that provide

tax breaks to not-for-profit groups have led to a proliferation of mutual funds that offer

health insurance coverage to those enrolled in the fund. Mutual funds do not pay taxes on

the premium, unlike the private insurance companies.

6. Private insurance

Private health insurance is well established in Lebanon. According to the Ministry of

Economy, approximately 70 private insurance companies provide both complementary and

comprehensive health insurance policies. The former are to complement and fill gaps in the

benefits provided by NSSF, CCS, and health insurance arrangements for the army and

police. The latter refer to stand alone health insurance policies that can cover a range of

benefits, including inpatient and outpatient care, and coverage for pharmaceutical expenses.

Nearly 85% of the policies are purchased by employers as an employee benefit or to fill

gaps in NSSF coverage. The private insurance market is not well regulated. Consequently,

insurers indulge in ―cream skimming‖, selecting only good risks and either denying

coverage or setting very high premiums for individuals with pre-existing conditions.

Private insurance companies are taking full advantage of the system by selecting younger

and better-off clientele. Expensive interventions are usually excluded and the burden of this

is being shifted onto the MOPH. According to the National Household Expenditure and

Utilization Survey, 8.3% of residents adhered only to private insurance; of that 0.7% held

more than one policy, and 2.5% had private insurance as complementary to the NSSF

coverage.37

7. Other health insurance funding resources

7.1. Local and foreign not-for-profit organizations

There is a relatively small proportion of the total health bill that is covered by local and

foreign not-for-profit organizations and NGOs operating generally at the local level in

poorer urban districts and underprivileged rural areas. Medical care offered through NGOs

increased during the war but this has waned somewhat since 1990. However, the

involvement of the community in the provision of medical care did offer some innovative

models for the financing, governance and management of health services.

7.2. Donor assistance

The sharpest decline in donor assistance has been to immunization and control of

diseases and there has been a significant increase in support for family planning activities.

The MOPH and other government agencies are the primary beneficiaries of donor

assistance.

7.3. Large companies

Major firms such as banks and large manufacturers often offer employees health

insurance. The majority of this health expenditure represents reimbursements for services in

private clinics. Survey results show that 78% of companies have private insurance for their

employees, which is complementary to the NSSF in 75% of the cases: 20% of these

companies provide extra health services that may not be covered by NSSF or the private

health insurance.38

7.4. Out-of-pocket payments

The most important item in the total health bill is the out-of-pocket payments, which is

the health expenditure borne directly by individuals, covering supplementary payments by

those who are covered by insurance or the MOPH as well as full payment by those who are

not covered by any insurance or are not beneficiaries of MOPH assistance. Household

37

National Household Expenditure and Utilization Survey, 2008 38

Households Living Conditions, Central Administration of Statistics, 2011

expenditure accounts for 69.7% of total health expenditure. Of this, 97% is spent in the

private sector, 2% in the NGO sector, and just 1% in the public sector.

On average, households spend a little over 14% of their household expenditure on health

services. However, the burden of out-of-pocket expenditure, measured as a proportion of

household expenditure, is not equitably distributed. Nearly a fifth of expenditure in

households in the lowest income category goes to health. The amount spent on health

decreases with income where households of highest income spend only 8% on health care.

Spending on health by households (14.1%) ranks second after food (31.4%). The average

out-of-pocket health expenditure in 2008 amounted to US$ 343.14 15.2% of household

spending on health goes for purchasing pharmaceuticals. If the proportion of hospital bills

for drugs is included, that share rises to 21.5% of household health expenditure.

Table (14): percentage of population covered by various financing agencies

Financing agency % of population covered

NSSF 26.1

Civil service cooperative 4.4

Army 8.8

Internal security 1.9

GS+ SS 0.4

Private insurance 8.0 (complete coverage)

4.6 (gap coverage)

Mutual funds 1.6

MOPH 42.7

Source: national health accounts, 2011

Table (15): Tutelage, entitlement, coverage and sources of financing of funding agencies

fund tutelage entitlement coverage Financing

NSSF Ministry

of labor

Employees of the

formal sector

Contractual

and wage earners of

the public sector

Employees of

autonomous public

establishments

Teachers in

public schools

taxi drivers

newspaper

sellers

university

students

physicians

starting Feb. 2001

Hospital care

(90% direct payment

to hospitals)

Ambulatory

care (85%

reimbursement to

user)

Dental care

(not implemented

yet)

Employer: 12%

of salary (7% starting

April 2001)

Employee: 3% of

salary (2% starting

April 2001)

Government:

25% of total

expenditures + the

employer share for

government contractual

and wage-earners

Contributions

for taxi drivers, students

and newspaper sellers

CSC

Presiden

cy of the

council

of

Regular staff of the

public sector and

dependents

Ambulatory and

dental care (75%

reimbursement for

employee 50% for

Government budget (of

which 1% deduction of

the payroll)

ministers family members)

Hospital care

(direct payment to

hospitals 90% for the

employee, 75% for

family members)

ARMY

Ministry

of

defense

Uniformed staff

members and their

dependents

Ambulatory and

hospital care (100%

for the member, 75%

for the spouse and

children, 50% for

dependent parents)

Government budget

ISF

Ministry

of

interior

affairs

Uniformed staff

members and their

dependents

Ambulatory and

hospital care (100%

for the member, 75%

for the spouse and

children, 50% for

dependent parents)

Government budget

MOH Ministry

of health

Uncovered Lebanese

(Upon request)

Hospital care

(85% direct payment

to hospitals, 15% co-

payment with some

exemptions)

Dispensing

expensive drugs for

catastrophic illnesses

Providing

vaccines and

essential drugs to

public and NGOs

health centers

Government budget

Private

insuran

ce

Ministry

of

economy

and trade

Voluntary enrollment

Variable

Households (risk-

based premiums)

Employers and

employees for

complementary

insurance

Mutual

fund

Ministry

of

agricultu

re

Voluntary enrollment

Variable

Households

Government

subsidies; ear-marked

taxes for the judges

mutual fund

Source: regional national health account

Table (16): Benefits under Various Public Financing Schemes

Type of

Services

MOH NSSF CSC Armed Forces

Hospitalization 85% 90% 90% 100%

Physician No Up to 13000LL 75% up to

12000 LL

Up to 20000 LL

Specialists No Up 18000 LL 75% up to

12000 LL

Up to 30000 LL

Ambulatory No Yes 90% 100%

Drugs No yes yes Yes

Emergency

clinics

No As physicians

and specialists

As physicians

and specialists

As physicians and

specialists

Emergency

hospitals

Hospital As

hospitalization

As

hospitalization

As hospitalization

Dental

coverage

No No 75 %of tariff 100%

Ophthalmology No No 75% up to

35000 LL

60000/80000/1000

00LLL

Immunization Yes at

health

centers

No No no

Treatment

abroad

No No 90% pre

admission

10000$ pre

admission

Open heart 8000000

LL

90% As MOPH 100%

Kidney

treatment

19000000

LL

90% As MOPH 100%

dialysis 135000

LL/session

100% 100% 100%

Source: regional national health account

Chapter II: Lebanese Health care System Financial Analysis

A. Lebanese health expenditure

1. External resources for health (% of total expenditure on health)

External resources for health care funds or services in kind that are provided by entities

not part of the country in question. The resources may come from international

organizations, other countries through bilateral arrangements, or foreign nongovernmental

organizations. These resources are part of total health expenditure.

External resources for health (% of total expenditure on health) in Lebanon were 0.96 as

of 2011. Its highest value was 5.22 in 2007, while its lowest value was 0.94 in 2010.

Figure (28): External resources for health (% of total expenditure on health)

Source: World Health Organization National Health Account database

http://apps.who.int/nha/database/DataExplorerRegime.aspx

2. Health expenditure, private (% of GDP)

Private health expenditure includes direct household (out-of-pocket) spending, private

insurance, charitable donations, and direct service payments by private corporations.

Health expenditure, private (% of GDP) in Lebanon was 4.68 as of 2011. Its highest

value was 8.30 in 1998, while its lowest value was 4.30 in 2009.

Figure (29): Health expenditure, private (% of GDP)

0

1

2

3

4

5

6

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

External resources for health (% of total expenditure on health)

External resources forhealth (% of totalexpenditure on health)

http://apps.who.int/nha/database/DataExplorerRegime.aspx

Source: World Health Organization National Health Account database supplemented by country data

(www.who.int/nha/en)

3. Health expenditure, public (% of total health expenditure)

Public health expenditure consists of recurrent and capital spending from government

(central and local) budgets, external borrowings and grants (including donations from

international agencies and nongovernmental organizations), and social (or compulsory)

health insurance funds. Total health expenditure is the sum of public and private health

expenditure. It covers the provision of health services (preventive and curative), family

planning activities, nutrition activities, and emergency aid designated for health but does not

include provision of water and sanitation.

Figure (30): Health expenditure, public (% of total health expenditure)

0

2

4

6

8

101995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Health expenditure, private (% of GDP)

Health expenditure, private(% of GDP)

0

10

20

30

40

50

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Health expenditure, public (% of total health expenditure)

Health expenditure, public(% of total healthexpenditure)

http://www.who.int/nha/en



The value for Health expenditure, public (% of total health expenditure) in Lebanon was

25.50 as of 2011. As the figure below shows, this indicator reached a maximum value of

45.63 in 2005 and a minimum value of 25.50 in 2011.

4. Health expenditure, public (% of government expenditure)




health insurance funds.

Health expenditure, public (% of government expenditure) in Lebanon was 5.79 as of

2011. Its highest value was 11.87 in 2005, while its lowest value was 5.79 in 2010.

Figure (31): Health expenditure, public (% of government expenditure)



5. Health expenditure, public (% of GDP)

0

5

10

15

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Health expenditure, public (% of government expenditure)

Health expenditure, public(% of governmentexpenditure)






health insurance funds.

Health expenditure, public (% of GDP) in Lebanon was 1.60 as of 2011. Its highest value

over the past 16 years was 3.75 in 2002, while its lowest value was 1.60 in 2011.

Figure (32): Health expenditure, public (% of GDP)



6. Health expenditure, total (% of GDP)

Total health expenditure is the sum of public and private health expenditure. It covers the

provision of health services (preventive and curative), family planning activities, nutrition

activities, and emergency aid designated for health but does not include provision of water

and sanitation.

Figure (33): Health expenditure, total (% of GDP)

0

1

2

3

4

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Health expenditure, public (% of GDP)

Health expenditure, public(% of GDP)




Health expenditure, total (% of GDP) in Lebanon was 6.28 as of 2011. Its highest value

was 11.45 in 1997, while its lowest value was 6.22 in 2010.

7. Health expenditure per capita (current US$)

Total health expenditure is the sum of public and private health expenditures as a ratio of

total population. It covers the provision of health services (preventive and curative), family



The value for Health expenditure per capita (current US$) in Lebanon was $622.03 as of

2011. As the graph below shows, this indicator reached a maximum value of $622.03 in

2011 and a minimum value of $360.94 in 1995.

Figure (34): Health expenditure per capita (current US$)

0

5

10

151995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Health expenditure, total (% of GDP)

Health expenditure, total (%of GDP)




8. Health expenditure per capita, PPP (constant 2005 international $)


total population. It covers the provision of health services (preventive and curative), family



The latest value for Health expenditure per capita, PPP (constant 2005 international $) in

Lebanon was 923.79 as of 2011. The value for this indicator has fluctuated between 923.79

in 2011 and 704.99 in 2003.

Figure (35): Health expenditure per capita, PPP ($)

$0.00

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Health expenditure per capita (current US$)

Health expenditure percapita (current US$)

0

200

400

600

800

1000

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Health expenditure per capita, PPP ($)

Health expenditure percapita, PPP ($)




9. Out-of-pocket health expenditure (% of private expenditure on health)

Figure (36): Out-of-pocket health expenditure (% of total expenditure on health)

Source: World Health Organization National Health Account database supplemented by country

data (www.who.int/nha/en)

Out of pocket, expenditure is any direct outlay by households, including gratuities and

in-kind payments, to health practitioners and suppliers of pharmaceuticals, therapeutic

appliances, and other goods and services whose primary intent is to contribute to the

restoration or enhancement of the health status of individuals or population groups. It is a

part of private health expenditure.

Out-of-pocket health expenditure (% of total expenditure on health) in Lebanon was

56.47 in 2011. Its highest value was 59.61 in 1998, while its lowest value was 39.40 in

2005.

B. Data analysis of the Lebanese health quality versus cost

1. Population and Sample Selection:

The population of the study was selected randomly from whole Lebanese people in the

society without a previous knowledge about their demographic indicators or social level

they refer. Respondents had to be affective members whom are financially responsible about

the health expenditures.

0

20

40

60

80

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Out-of-pocket health expenditure (% of total expenditure on health)

Out-of-pocket healthexpenditure (% of totalexpenditure on health)



2. Instrumentation:

The instrument of the study is a questionnaire made up of nineteen questions to be filled

on the preference of respondent and a question to give a comment about the social

insurance, it is arranged to collect Data that helped the study to make findings that will be

included in this thesis.

The questionnaire is divided into three sections:

a. Introduction:

In its first part, the questionnaire informed respondents about its purpose which was to

investigate the issue of their satisfaction within the health quality they receive compared to

the high cost they bear.

It also assured that the participation in this questionnaire was voluntary and the collected

information will only be used for educational purposes.

b. Identification Variables:

In this part, the questionnaire asked about the respondents’ general information about

them including gender, age, and status, number of dependents, employment, education and

monthly income.

There is a Q‖0‖ of the study which determined whether the respondents feel that the

health services’ fees they pay is reasonable to the service they are provided with.

c. Dependent Variables:

In this section, there were 11 questions about the health insurance and the share the

respondents pay additional to their satisfaction with the quality of service they provide.

3. Questionnaire construction & Conceptual Framework for Data Analysis:

Based on the review of literature and previous studies and Data stated in the chapters

above, this questionnaire was developed on variables determine the higher cost of the health

service in Lebanon regardless the variety of the insurance providers available.

1. As for Q "0", Frequency was enough to examine if results are valid or not and to show

really the percentage of the Lebanese that believe that they pay for health services more that

they receive.

2. As for dependent variables, frequency tables and pie graphs were used to obtain valid

results built strong base for a clear vision about the population this thesis is studying and

addressed to as well.

4. Results:

Frequency tables proved successfully that more than half of number of questionnaire

were valid, and that most answers showed regarding respondents a well knowledge and

concern of the health and medical situation in Lebanon.

a. Q "0" :

Do you think that the health service’s fees are reasonable for the health service rendered?

Table (17): frequency results of Q‖0‖ of the questionnaire

Frequency Percent

Valid

Percent

Cumulative

Percent

Valid Yes 132 66 66 66

No 24 12 12 78

Not too

much 44 22 22 100

b. Results of dependent variables:

In this thesis, results of five statements out of nineteen will be shown in pie graphs, these

statements were chosen for being more important in serving the purpose of the study.

Knowing that 132 respondents answered yes on Q "; Source: data analysis of 132

questionnaires filled with data from 132 Lebanese 2013.

Figure (37): pie chart frequency result of the questionnaire

yes

29%

no

71%

Do you or any of your dependents suffer from chronic

diseases or disability?

yes

66%

no

12%

not too much

22%

Do you think that the health service’s fees are reasonable for the health service rendered?

c. Our assessment:

37%

48%

8% 7%

On which health service do you spend more expense

hospitalization medication examination service laboratories

64% 20%

16%

Do you face some problems to cover your share of cost of

the medical care

yes no not too much

47%

23%

30%

Do you think that doctors and hospitals are satisfied with

everything they need to provide a sufficient medical care

yes no not too much

In our 200 interviews, the questionnaire examined how the Lebanese people suffer from

the health service cost and the quality they receive. We can also recognize the weak role the

health providers are playing.

The questionnaire results push us to analyze the cost of the health services and the

coverage of the different providers in Lebanon so that to end up by a choice which providers

is the lower in cost with better quality.

C. Financial analysis of Lebanese Health expenditures

1. Pharmaceutical sector39

The pharmaceutical sector in Lebanon forms a significant part of the health services bill;

where it covers about 26 % of total household health care expenditures. 85% of drug

consumed are imported, with only 15% being manufactured locally.

a. High Levels of Profit Margins

The high health expenditure recorded refers to the high proportions of consuming trade

names and imported drugs, where the prices of the imported drugs are significantly higher

than that of the local by a multiple of 1.69 the locally manufactured prices. This obvious

difference in the prices refers to different margins added to the original price at the

following levels:

· Freight (7.5%)

· Clearance (10%)

· Agent’s Margin (10%)

· Pharmacist’s Margin (30%)

However, efforts are being done by MOH to reduce the drugs prices, by moderating the

margins received at the levels listed above. The solutions were applying different lower

margins to different categories of drugs depending on their selling prices. ―A‖ lies in the

39

Lebanon National Health Accounts 2009, December 2009

least expensive category of less than US$ 10, and ―D‖ in the most expensive one of more

than US$ 100. The new multipliers to each of the four categories are as follows:

· A: 1.7

· B: 1.65

· C: 1.5 and

· D: 1.3

This measure aimed to reduce the medications bill by 5% to 6%40

and the total health bill

between 1.34% and 1.61%41

, as medications constitute 26.8% of household health care

expenditures.

However, this measure has resulted in withdrawing some drugs from the market or

halting their import, mainly those of category ―D‖, as it is no longer as profitable to import

them. Thus, the end result was either the unavailability of essential drugs or the activation of

black markets. It thus proves necessary to carry out either a complementary measure to

ensure the availability of substitute drugs at all times or to replace the current measure by

another more comprehensive one.

b. High Dependence on Trade Names

The high proportion of the consumption of trade names which increase the drug

expenditures out of total health expenditure is due to the lack of the encouraging policies for

consuming generic and local drugs as an alternative for trade names and imported products.

40

As per an interview with the Minister of Health, Dr. Mohammed Jawad Khalifeh in Al-E’mar wal

Iktissad journal, September 2005 41

CRI calculations based on: (a) National Household Health Expenditures and Utilisation Survey, (b)

Multi-Purpose Survey (CAS 2004) and (c) the Al-E’mar wal Iktissad interview with the Minister of

Health (September 2005)

Imported drugs market is controlled by a group of importers and distributors who work

interdependently and dominate the market. They follow an aggressive marketing leading to

increased consumption of imported drugs, and disregard of locally produced ones,

especially with the lack of awareness campaigns that encourage people to use local drugs. It

should be also mentioned, that many doctors play a vital role in this marketing, seeking

extra profits through special deals provided by the distributors.

c. Rise in the Number of Pharmacies and Pharmacists

The large number of pharmacies in the Lebanese market is also a reason for the relatively

high prices of drugs. In order to be gain profits, these pharmacies keep their high selling

prices in such a way as to compensate for the low number of customers.

2. Hospitals

a. NSSF and the Increasing Hospitalization Rates

NSSF in-hospital services can be classified into three different types: delivery, surgery

and in hospital medication. In this respect, the cases of the NSSF in-hospital medication out

of the total number of in-hospitals cases is quite significant so as it record an average of

60% overall the Lebanese regions.

This high contribution of the NSSF in the in-hospital medication reflect the curative

nature of health care in Lebanon, however it hint at some irregular practices taking place

reflects the tight economic and social conditions of people (demand side) and low hospital

occupancy rates (supply side).

On the demand side, the patient seeks a medical consultation upon which he pays the

fees to doctor, drugs and medical tests. If these paid fees are equivalent to those set by

NSSF for the required services, the patient will receive 80% of the total amount paid, but

not before five or six months later. However, patients pay for the medical services received

much more than the NSSF set prices, leading to a total compensation received much less

than the set 80%. This procedure involves of high costs, low return rate and long delays

represents an unfair practice especially against the poor.

As for the supply side, some hospitals respond to their low occupancy rates by setting

attracting arrangements with patients, as a result of the availability of beds and consequently

low revenues. Hospitals would admit patients (even if their condition does not require

hospital admission) and provide them with consultations, drugs and medical tests that they

would have otherwise required outside. In these cases, patients will be exempted from

paying their due fees where the bill will be compensated by the NSSF. In this respect, the

patient would have avoided the high costs and the hospital would have benefited from

employing its empty beds, and thus receiving revenues.

b. Public Investment in Hospitals

Table (18) shows that 73% of the amount Ministry of Health’s reimbursements for

hospital care was on surgical care and the remaining 23% were for non-surgical care. The

CSC spent 59% of its hospital reimbursements for surgical care, the ISF 53%, the Army

51%, and the NSSF 60%.

This distribution probably reflects the fact that the Ministry of Health is the insurer of

last resort and hence tends to pay more for inpatient admissions. With regard to the other

agencies hospitalization costs are part of the benefits available to their beneficiaries.

Table (18): Distribution of hospital expenditures (%)

category MOPH Armed

forces

CSC NSSF

Non-surgical

costs

27 49 41 40

Surgical costs 73 53 59 60

Source: Lebanese National Health Accounts

Table (19): Distribution of hospital reimbursement by type of service (%)

category MOPH Army forces NSSF CSC Weighted

average

Surgery 16.7 11.1 13.1 16.1 14.3

Doctor fees 8.6 11.8 11.1 11.4 10.7

Anesthesia 4.8 2.3 4.7 4.9 4.2

Room and board 15.6 16 17 12.8 15.4

Operation room 12.6 9 18.2 10.3 12.5

Lab tests 12.2 13.1 10.5 9.2 11.3

Radiology 7 6 6.9 4.6 6.1

MRI 0.5 0.8 0.8 0.2 0.6

CT Scan 2.4 1.9 0.6 1.1 1.5

Drugs 15.7 16.7 11.9 19.3 15.9

Medical

supplies

2.8 7.5 4.5 3.7

4.7

Others 1.1 3.8 0.7 6.4 3.0

Source: Lebanese National Health Accounts

3. Ministry of health

In Lebanon the Ministry of Health is the insurer of last resort. The Ministry of Health

funds the hospitalization costs for any citizen who is not covered under an insurance plan

(social or private). This coverage is independent of the income and asset status of the

individual. In addition the Ministry of Health also covers the cost of some narrow specialties

such as chemotherapy, open heart surgery, dialysis and renal transplant, and drugs for

chronic diseases.

Table (20): Budgetary resources in the public health sector

2009 2010 2011

MOPH allocated budget (as % of total government budget) 2.7 2.5 2.7

Public expenditure on health (as % of GDP) 439.7 486.7 527.9

Annual MOPH budget (USD per capita 73.3 82 87

Source: MOPH 2011, Statistical bulletin

With a modest allocation of 2.7% of the total government budget, the MOPH has to

cover the hospitalization cost of uninsured patients and provide them with expensive

treatments that cannot be afforded by some households

A proportion of the MOPH’s annual budget is allocated for covering uninsured

patients, with the aim of ensuring universal accessibility to health services. These

allocations have been growing over years with the development of the Ministry’s

financing function, leaving scarce resources to prevention, public health and regulation

functions.

4. Expenditure by public financing agents:

Among the six social providers in Lebanon, NSSF comes in the second rate after

MOPH in the number of beneficiaries with 1293220. With reference to the total cost

spend, NSSF come in the first rate with 575899104 LL. However, the spending per

beneficiary accounts 534386 LL for NSSF being in the third rate having the lowest

amount after the MOPH and army with 221854 LL and 372013 LL respectively. This

break down can end up with a conclusion that NSSF turns first as an efficient health

provider either from number of beneficiaries or with the costs spent.

Table (21): break-down of public expenditure on health services provided by the private

sector (thousand LPB)

NSSF GSF Army SSF ISF CSC MOH

Number of

beneficiaries 1293220 17172 270300 6774 93131 236870 1954818

Number of

adherents 590502 6360 102000 1736 32114 75197 1954818

Number of

hospital

admissions 253840 2160 61996 1463 32062 29714 220038

Cost of

hospital

admission 334 4855 68304 1936 29610 50056 293714

Cost of

ambulatory

care 241185 6359 15491 2842 14755 54969 54308

Total cost 575899 11215 83796 4779 44365 105025 361402

Spending/

beneficiary 534 783 372 846 571 532 221

Source: Walid Ammar, 2009, health beyond politics

5. Private insurance market

The private insurance market is growing rapidly in Lebanon. According to the Ministry

of Economy sources approximately 70 private insurance companies provide health

insurance. They provide both complementary and comprehensive health insurance

policies. The former is to complement and fill gaps in the benefits provided by NSSF,

CSC, and health insurance arrangements for the Army and Police. The latter refer to stand

alone health insurance policies that can cover a range of benefits including inpatient and

outpatient care, and coverage for pharmaceutical expenses. It is estimated that 8% of the

population has comprehensive coverage and 4.6% gap insurance.

Compared to other countries in the region, Lebanon has a fairly well developed private

insurance sector. Private insurance is licensed by the Ministry of Economy. Insurance

companies are required by law to set aside 40% of premiums as reserves.

Nearly 85% of the policies are purchased by employers as an employee benefit or to

fill gaps in NSSF coverage. Insurance policies in Lebanon typically cover in-patient care.

Outpatient services are covered for additional premiums with co-payments of around 20%.

There is anecdotal evidence that private insurance companies transfer the burden of

high cost cases to the Ministry of Health as the latter does not have the ability to verify

whether application have insurance or not.

Table (22): Distribution of Private Insurance Expenditures

Item percentage

Physician Fees 36%

Pharmaceuticals 28 %

Hospitalization Costs 16%

Administrative Expenses 20 %

Total 100 %

Source: Lebanese National Health Accounts matrices

Table (22) shows an estimate of the breakdown of expenditures by private insurance

companies by type of service. Physicians’ fees account for 36% of expenses,

pharmaceuticals for 28%, hospitalization costs for 16%, and administrative expenses for

20%. Many insurance companies still consider health to be a loss leader.

Expenditures on private insurance as a percentage of GDP in Lebanon are higher than

other countries in the region such as Kuwait and Egypt. The table below shows the

premiums paid for the policies where it amounts 380$ and 670$ for a policy with a coverage

between 200$ and 450$. This shows a very high gap in between the cost the insurers bear

and the coverage they receive.

Table (23): Private insurance account ($)

Policies Gross

premiums

Expenditures

Hospital care 207699 79440025 42161278

Hospital and ambulatory

care

252876 168589682 113740296

Total 460575 248029707 155901574

Source: MedNet Liban Health Insurance Portfolio, 2011

6. Analysis of sources and uses of funds:

Households spent 69 % of total health expenditures. Of this 97% was spent in the private

sector, 2% in the NGO sector, and just 1% in the Public Sector. However these expenditures

are distributed with 41% on private providers with 25.4% on drugs and only 24.5% for

hospitalization.

Table (26): Distribution of health care expenditure

Public hospitals 1.7%

Private hospitals 22.8%

Private providers 41.0%

Pharmaceuticals 25.4%

Others 9.1%


Table (27): Percentage of distribution of Out-of-Pocket Expenditures by Sector

Sector %

Public 2

Private 93

donors 5


Public sources account for 19 % and private sources for 79 % of health care financing.

International donors account for the remaining 2 %. The treasury funds the five public

insurance providers with the highest amount for the MOPH with 339663 million LL.

However the households’ payments are all directed towards the private insurance with a

percentage of 98% where the remaining 2% are for the mutual funds and NSSF.

Table (28): sources of funds to health providers (million LL)

Health

provider

treasur

y

Private sector dono

rs

total % of

health

financing

employ

ers

household

s

MOPH 339663 0 0

6453

1 404193 10%

Armed

forces 192345 0 0 0 192345 5%

CSC 58666 0 0 0 58666 2%

NSSF 103134 225464 56365 0 384964 10%

Mutual

funds 21411 0 22594 0 44005 1%

Private

sector 0 176290 2593240 0

276953

0 72%

Total 715220 401755 2672199

6453

1

385370

4 100%

% of health

financing 19% 10% 69% 2% 100% 10%

Source: Regional National Health Accounts

Figure (38): Health expenditure by source of financing


Figure (39): Treasury sources of health financing


18%

80%

2%

Health expenditures by source of financing

public source

private source

donations andloans

47%

3%

15% 10%

25%

Treasury sources of health financing

MOPH Mutual Funds NSSF CSC Armed forces

Figure (40): Sources of private health financing


7. Choice of providers by type of service

Table (29) reflects the fact that the private sector dominates the market in Lebanon. For

outpatient care the private sector is followed by the NGO sector with the Public sector

accounting for only 9% of all visits. With regard to hospitalizations the private sector once

again accounts for nearly 86% of all admissions with the Public sector accounting for 9%.

The Public Sector fares a little better when it comes to one day surgery probably because

it both pays for this as well provides these services at its facilities. Dental care is almost

exclusively the domain of the private sector. This predominance of the private sector in

Lebanon makes it clear that any attempt at containing costs and improving efficiency will

require the participation and buy-in of the private sector. At the same time unless this sector

is better managed meaningful changes to the health system cannot be achieved.

Table (29): Choice of providers

Type of care public private Donors

Outpatient visits 10.8 76.3 12.9

Hospitalization 9.8 83.4 6.8

Surgery 20.3 72.6 7.1

12%

88%

Sources of private health financing

Employers contributions Household

Dental care 2.1 83.9 14.0

Source: These data are based on ―National Household Health Expenditure and Utilization Survey‖,

2011

In summary:

The health system is very costly with a very expensive health bill accounting for 7.4% of

gross domestic product.

Equity is not well protected, despite the fact that the MOPH has provided a coverage safety

net; this inequity is well documented by the high cost incurred by households. The

percentage of income spent on health by households is higher in the poor population.

The heath system is inefficient with an oversupply of medical technologies and regional

disparities in their distribution.

Main Findings

The main findings inferred from the analysis and the survey done is summarized below:

Summary Statistics

Total Population: 4,800,000

Per Capita Expenditure: 622 USD

Health Expenditure as % GDP: 7.4 %

% GOL budget allocated to health: 2.7%

Sources of Funds:

Public: 19 %

Private:

Households 69 %

Employers 10%

Donors: 2%

Distribution of Health Care Expenditures:

Public Hospitals 1.7%

Private Hospitals 22.8%

Private Non-Institutional Providers 41%

Pharmaceuticals 25.4%

Others 9.1%

Chapter III: Cross Country Comparison

A. International comparison of health expenditure

Historically, health care

spending among developed nations has grown considerably each year. However, beginning

in 2010, spending has flattened. As of 2011, health care cost $1017per person in the world.

As for Asia, Pakistan records 28$ as health expenditure per capita totaling 2.2% of GDP.

India being an over populated country as China, they spend 126$ and 373$ per capita

accounting 4.2% and 5.1% of GDP relatively.

The spending per capita reaches 1039$ in turkey, 2592$ in Singapore and 3120$ in

Japan, noting that Singapore and Japan are of the first five countries having better health

quality at lower cost.

As for the European countries, the spending per capita approximates between 881$ for

Romania and 6612$ for Luxemburg. Here it is must be noted that from the first ten countries

having the highest health expenditure in the world, Europe contain eight of them beginning

with France rating tenth with 3997$, then Germany rating ninth for 4342$, Denmark rating

eighth with 4467$, Austria rating sixth with 4398$, Luxemburg rating fifth with 6712$,

Netherlands rating fourth with 5112$, Switzerland rating third with 5297$ and Norway

rating the second with 5391$ totaling as percentage of GDP between 7.9 in Luxemburg and

11.9 in France.

For Africa, the spending per capita on health accounts 17$ in Eritrea being the lowest

amount around the world. As for South Africa the amount is high reaching 915$ per capita

accounting 9.2% of GDP.

By comparing the Arab countries, it is noted that Yemen, Sudan, republic of Syria,

Egypt, Iraq and Jordan spend below 500$ for health expenditure per capita accounting

between 3.5% and 9.6% of GDP. As for Lebanon, it is classified in the category which

involve Saudi Arabia, United Arab Emirates and Qatar spending between 872$ and 1621$

per capita totaling 2.6% and 7.4% of GDP being the latest for Lebanon.

The United States of America rates at the first being the country with the highest health

expenditure in the world with 8233$ per capita totaling 17.6 of GDP. As for Canada, it rates

the seventh in the countries having the highest cost spending 4443$ per capita and

accounting 11.4% of GDP.

Table (30): International Comparison of Health Expenditures

Location Total Health

Expenditure

Per Capita

Total Health

Expenditure Per

Capita, PPP ($)

Total Health

Expenditure % of

GDP

Asian counties

Pakistan $28 57 2.2

Afghanistan $52 46 7.6 Bangladesh $61 53 3.4 India $126 124 4.2 China $373 347 5.1 Malaysia $645 629 4.6 Iran (Islamic Republic of) $797 728 5.7 Turkey $1,039 957 6.7 Singapore $2,592 2111 4.1 Japan $3,120 3045 9.5

European countries

Romania $881 818 5.6 Italy $3,046 3071 9.4 Spain $3,057 3067 9.6 Greece $3,069 3054 10.6 France $3,997 3969 11.9 Germany $4,342 4219 11.7 Austria $4,398 4288 11 Denmark $4,467 4345 11.5 Netherlands $5,112 4881 12 Switzerland $5,297 5105 11.4 Norway $5,391 5353 9.7 Monaco $5,915 5932 4.2 Luxembourg $6,712 6592 7.9

African countries

Eritrea $17 16 2.8 Central African Republic $30 30 4 South Africa $915 930 9.2

Arab countries

Yemen $155 139 5.5 Sudan $162 159 7.3 Syrian Arab Republic $175 182 3.5 Egypt $293 286 4.8 Iraq $346 342 8.4 Jordan $493 493 9.6 Tunisia $544 479 6.4 Libyan Arab Jamahiriya $573 722 3.9 Oman $591 826 3 Lebanon $872 965 7.4 Saudi Arabia $914 964 4.4 Bahrain $937 1083 4.7 Kuwait $1,133 1671 3.8 United Arab Emirates $1,562 1956 4.4 Qatar $1,621 1965 2.6

American countries

Haiti $76 71 6.1 Canada $4,443 4314 11.4

United States of America $8,233 7960 17.6 World $1,017 Source: WHO Department of Health Statistics and Informatics (May 16, 2012). "World Health

Statistics 2012

B. Assessment of the Lebanese Health Care System Performance:

1. Sustainability

Lebanon spends 7.4% of its GDP on health care services. Unless there are significant

gains in the country’s economic performance, the current pattern of health care expenditures

(as a per cent of GDP) will put significant strain on scarce health resources. In the long-

term, this will likely adversely affect the current level and quality of services provided.

2. Cost containment

The Lebanese health care system is an example where the financing and provision

functions are separated but without effective controls to contain costs. The principal

financing intermediaries have a separate supervising Ministry. This makes inter-agency

coordination difficult. At a minimum, consideration should be given to setting up an

institution that can coordinate payments, monitor utilization, and oversee providers across

the different public financing agencies.

3. Rationalizing capacity in the hospital sector

There is a fact that 62% of public expenditures are spent on hospital care. Quality of care

and financial viability of many of these facilities remains a concern.

4. Reallocating expenditure from curative to primary health care

Less than 10% of resources are currently allocated to primary health care. There is a need

to both strengthen the capacity of the system to deliver primary health care services as well

as increase funding for these services.

5. Controlling capital investment in medical technology



The government reimbursements for high cost services have resulted in a rapid growth of

high technology centre. This in turn has contributed to cost escalation. For efforts at cost

containment to be effective, policies need to be developed that will control investments in

medical technology.

6. Rationalizing expenditure on pharmaceuticals

Lebanon has not only a high per capita expenditure on pharmaceuticals (US$ 120) but

almost all of the drugs are imported proprietary products. To effectively contain overall

health care expenditures, the Government should initiate policies for improving the

efficiency by which pharmaceuticals are imported, distributed and sold in the country and

improve its management and overseeing of this sector.

7. Expanding health insurance coverage, limiting multiple coverage

In Lebanon health insurance is tied with employment and those in low income

households are less likely to be employed in the formal sector. Further, the presence of

multi-insurance coverage allows for inefficiencies and cost escalation. The Government

needs to improve its management of the private insurance market and reduce multi-

insurance coverage.

8. Equity

Household out-of-pocket expenditure accounts for 69% of the health expenditure in

Lebanon. The burden of out-of-pocket expenditure appears to be inequitably distributed,

with lower income households spending a much greater proportion of their income on health

than higher income households.

Even though the MOPH as the insurer of last resort pays for hospitalization costs for all

(including those with low incomes) there is no formal financing mechanism for primary and

preventive health services. The government should consider designing a targeted program to

provide good quality basic health services for those with low incomes.

Chapter IV: The Singapore Healthcare System:

A. Overview

Table (31): Most efficient health care systems within the world

Efficiency

score

Life

expectancy

Healthcare cost

(% GDP per

capita)

Healthcare

cost (per

capita)

Sweden 62.6 81.8 9.6% 5331$

Switzerland 63.1 82.7 11.5% 9121$

South

Korea

65.1 80.9 7.2% 1616$

Australia 66 81.8 8.9% 5939$

Italy 66.1 82.1 10.4% 3436$

Spain 68.3 82.3 10.4% 3027$

Japan 74.1 82.6 8.5% 3958$

Singapore 81.9 81.9 4.4% 2286$

Hong Kong 92.6 83.4 3.8% 1409$

Source: http://www.bloomberg.com/visual-data/best-and-worst/most-efficient-health-care-countries

By analyzing the health care systems over the globe, one country that has the most

effective results at the rock bottom cost was Singapore. Singapore has achieved amazing

results within the primary quality of its healthcare system and in dominating the value of

care. In per capita terms and as a proportion of Gross Domestic Product (GDP), its

healthcare expenditures are the lowest of all the high-income countries within the world.

How did this happen? How has Singapore been ready to accomplish these forms of

results? Three compelling qualities enabled it to attain fantastic successes in numerous

areas, healthcare involved. They are long-term political unity, the power to acknowledge

and establish national priorities, and also the consistent need for collective well-being and

social harmony of the country.

1. Political Unity and Constancy of Purpose

From the time the British withdrew from Singapore and left its former colony to support

itself, Singapore has been ready to develop and grow as an integrated whole. There had

been an uncommon degree of unity among the country’s numerous ministries, a spirit of

cooperation among governmental departments that creates attainable formulation of policies

that reaches across ministries.

http://www.bloomberg.com/visual-data/best-and-worst/most-efficient-health-care-countries

The government realized early that improvement in health conditions and care had to be

approached as an inseparable part of the overall development planning for the country.42

As

a heavily urban city-state, caring for the health of the individuals meant quite simply

building hospitals and clinics. Health would be affected by life style: housing, water supply,

food provide, air quality, waste disposal, and more.

Ensuring the health of the Singaporeans had to be designed into each side of urban

planning, requiring a comprehensive approach and also the cooperation of various ministries

over all the varied sectors of presidency. There have been additionally issues that the

government was not doing enough for the elderly whose families were suffering severe

financial strain for older family members’ care.

The government responded with a new program of inflated outlays to handle citizens’

issues. It pronounced enlarged financial supports for lasting care, even for patients being

cared for in the house, giving middle-income families some financial relief.

2. Establishing Priorities

The health of the public was not a prime priority for the government at the start of

independence, where the fundamentals of public health, healthcare planning and

development would need to wait till the state achieved a level of military and economic

stability.

This ordering of priorities was apt for the time, as it was vitally important first to set up

the defense of this small nation, so to draw in investors to set in motion economic progress,

and tackle problems of unemployment, housing, and education. After these essential issues

had been addressed, others, including healthcare, could be taken on.

42 Ministry of Social and Family Development. ―Ministerial Committee to Spearhead Successful Ageing for

Singapore,‖ 4 Mar. 2007. Available at

http://app.msf.gov.sg/PressRoom/MinisterialCommitteeToSpearheadSuccessfulAgei.aspx.

http://app.msf.gov.sg/PressRoom/MinisterialCommitteeToSpearheadSuccessfulAgei.aspx

Wisely, the initial focus in Singapore was on public health: putting right sanitation

procedures in site, dominating infectious diseases, all flourishing efforts.

In time, the priorities set by the government verified to be effective. The security

situation stabilized and also the economy grew to the advantage of all. The GDP grew from

just below $8.5 billion in 1964, to over $50 billion in 1983, to nearly $300 billion in 2011.43

3. Promoting a way of Collective Well-Being and Social Harmony

One among the most vital tenets of Singaporean governance is that a powerful society

requires social harmony. If tensions between social teams and races are to be avoided, all

teams ought to be enclosed in the life of the country and should benefit, to some extent,

from its successes.

To even out the intense results of free-market competition, we tend to redistribute the

national income through subsidies on things that improved the earning power of citizens,

like education. Housing and public health were also clearly desirable. However finding the

proper solutions for private medical aid, pensions, or retirement benefits was not simple.

The solution was a policy where people set five percent of their wages into the fund and

their employers matched it. The accumulated cash may be withdrawn at age 55. The

government had a long-range vision to extend the investment of the fund over time and

broaden it to permit people to save for and pay for education and healthcare similarly as

retirement and home-buying.44

In the long run, however, the government recognized that the health savings program

would not be enough to support care, and alternative systems were placed, including a

medical insurance program and a social safety web.

4. Respect and Education for Women

43 Singapore Department of Statistics. Yearbook of Statistics Singapore, 2011. Singapore: Singapore

Department of Statistics, 2011.

44 Chong, S.A., Mythily et al. ―Performance Measures for Mental Healthcare in Singapore.‖ Ann Acad Med

Singapore 37, 9 (2008): 791–6.

Singapore recognized early on the importance of respect and education for women, as

well as seeing to their health needs. The government accomplished a great deal well before

the women’s movement began in several countries.

Specifically, women’s health education was considered as an important to the long run of

the country. The Education Ministry took the lead in educating young women regarding

vital health topics.

5. Building the Foundation

a. Bringing Care to the People

An early move was to bring medical aid services nearer to the individuals by developing

a network of satellite outpatient dispensaries and maternal and child health clinics. They

presented a one-stop center for immunization, health promotion, health screening, well-

women programs, family planning services, nutritional recommendation, psychiatric

counseling, dental care, pharmaceutical, x-ray, clinical laboratory, and even home-nursing

and rehabilitative services for non-ambulatory patients.45

b. Introduction of User Fees at Public Clinics

Services at the outpatient clinics had been free-of-charge; however the government

quickly modified that. The principles of free medical services run over the fact of human

behavior, definitely in Singapore.

Once doctors given free antibiotics, patients took their pills or capsules for some days,

did not get better, and threw away the balance.46

They then seek advice from private

doctors, bought their antibiotics, completed the course, and recovered. This daring move

45 Central Provident Fund, ―My CPF—Having Children: Providing for Your Precious Ones. Life Events:

Having Children: Immediate Concerns 2011.‖ Available at http://mycpf.cpf.gov.sg/CPF/my-cpf/have-

child/HC2.htm. Ministry of Health, ―Marriage and Parenthood Schemes. Costs and Financing: Schemes and

Subsidies 2011.‖ Available at

http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/Marriage_and_Pa

renthood_Schemes.html

46 ―Grow and Share’ Package Overview,‖ 2011. Available at http://www.growandshare.gov.sg/Overview.htm

http://mycpf.cpf.gov.sg/CPF/my-cpf/have-child/HC2.htm


http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/Marriage_and_Parenthood_Schemes.html


http://www.growandshare.gov.sg/Overview.htm

reminded Singaporeans that healthcare is not free, for which the state would not be building

a welfare system. People would be expected to a large degree to pay their own manner.

c. Early Human Resources/Manpower Designing

Before 1960, there have been fewer than 50 medical specialists in Singapore to serve

Singapore’s two million residents. To boost their numbers, the government sent its brightest

doctors within the public sector to the best medical institutions around the world for

training. This action raises a new generation of extremely experienced specialists and set the

stage for developing Singapore’s current world class capability in highly-specialized,

advanced medicine.

Over the years, Singapore has continued to form strategic partnerships with healthcare

organizations all around the world and continues to send doctors for training at world-class

medical facilities. In 2009, 1,750 doctors practicing in Singapore were foreign-trained.

d. Healthcare Infrastructure enhancements

Early on, the government began advancing the infrastructure at public hospitals. One at a

time, services were improved, investments were made in modern equipment, and difficult

specialties were developed. Motivated hospital construction and enlargement programs have

been undertaken to encourage community participation and initiative in providing

healthcare.

e. Housing

Although not a section of the healthcare system, the country’s early housing initiative has

contributed immeasurably to the health of Singaporeans. Several Singaporeans were living

in ―unhealthy slums and crowded unlawful resident settlements.‖ At the time, the

government started investing in good, clean cheap housing that greatly improved living

conditions and health conditions. The government did not stop at providing housing. Over

the years, alternative investments were created in clean water, proper sanitation services,

clean atmosphere, good nutrition, and health education. All these actions completed a vital

in improving the health status of Singaporeans.

6. Ensure Good and Affordable Basic Medical Services for All Singaporeans

The government declared the necessity to form a good, basic medical package available

to all people, no matter their means. The essential package had to be cheap and be provided

by hospitals receiving government subsidies. The package should be reviewed frequently to

reflect, among other things, the purchasing power of Singaporeans and productivity

increases in medical science.

7. Engage Competition to Improve Service and Raise Efficiency

The resources available for healthcare were restricted and should be placed for

economical use. Market forces should be used to encourage efficiency, improve quality of

services, develop additional elections for patients, and make sure patients are getting good

value for their money. The healthcare providers were in a very distinctive position to

regulate the demand for their services as patients rely on doctors for recommendations since

they were unaware of better or competing alternatives.47

Yet, too much competition and too

several providers would possibly drive up the demand for medical services, since patients

would naturally want to try new treatments or technologies or popular doctors. Oversupply

or overabundance of choices would successively drive healthcare costs up instead of

keeping them under control and defeat the aim of encouraging competition.

8. Interfere Directly in the Healthcare Sector

Singapore’s chosen approach to the healthcare market as a form of highly-calibrated

capitalism. Government intervention is permitted in certain conditions to redirect the

market. This approach is clearly recognized by funding public hospitals and other care

facilities but also encourages the participation of private hospitals and clinics.

Situations which may demand government action included preventing an oversupply of

healthcare services, moderating demand, and making reasons to keep costs down. The

interference has included creating and adjusting medical savings programs, sponsoring

47 M.D. Barr, ―Medical Savings Accounts in Singapore: A Critical Inquiry,‖ J Health Polit Policy Law 26, 4

(2001): 709–26.

insurance programs, providing subsidies to hospitals and polyclinics, determining the

number of beds and their distribution in public hospitals, funding new medical faculties,

controlling the number and type of doctors who can practice in the country, and regulating

and limiting the kind and range of private insurance programs available to Singaporeans.

B. Demographics

The Republic of Singapore consists of the main island of Singapore, off the southern tip

of the Malay Peninsula between the South China Sea and the Indian Ocean, and 58 close

islands.

As of 2012, the population of Singapore is 5.312 million people, of whom 3.285 million

(62%) are citizens while the rest (38%) are permanent residents or foreign workers/students.

The median age of Singaporeans is 37 years old. The life expectancy at birth is 81.9 years

old.

Figure (41): Total population in Singapore

Source: WHO National Health Accounts, 2013

The total fertility rate is estimated to be 0.79 children per woman in 2013, the lowest in

the world and well below the 2.1 needed to replace the population. The literacy rate among

adult of age 15 and above rated 95.86% which indicates the importance of education in the

governmental calendar. The Singaporean unemployment rate has not exceeded 4% in the

0

1000

2000

3000

4000

5000

6000

Population (in thousands) total

Population (in thousands)total

past decade, hitting a high of 3% during the 2009 global financial crisis and falling to 1.9%

in 2011. The gross national income per capita reaches 59380 $.

Table (32): Singaporean demographic indicators

Indicator

mortality rate (per 100 000 population) 326

Annual population growth rate (%) -2.1

Crude birth rate (per 1000 population) 9.91

Crude death rate (per 1000 population) 4.3

Gross national income per capita (PPP int. $) 59380

Literacy rate among adults aged >= 15 years (%) 95.86

Life expectancy at birth 81.9


C. Health system Indicators

1. Hospital beds

Hospital beds include inpatient beds available in public and private hospitals and

rehabilitation centers. Hospital beds (per 1,000 people) in Singapore were 2.71 as of 2011.

Its highest value over the past 51 years was 4.39 in 1960, while its lowest value was 2.71 in

2011.

Figure (42): number of beds in Singapore


2. Physicians

0

1

2

3

4

1994 2001 2003 2005 2006 2007 2008 2011

Number of beds

number of beds

Physicians include generalist and specialist medical practitioners. Physicians (per 1,000

people) in Singapore were 1.92 as of 2010. Its highest value over the past 50 years was 1.92

in 2010, while its lowest value was 0.42 in 1960.

Figure (43): Number of physicians in Singapore


D. Health care Expenditures

Health expenditure, total (% of GDP) in Singapore was 4.56 as of 2011. Its highest value

was 5.12 in 2009 whereas its lowest over the ten years was 2.9 in 2002.

Figure (44): Total expenditure on health as % of gross domestic product


0

1

2

3

1994 1998 1999 2001 2003 2010

Number of physicians

number of physicians

0

1

2

3

4

5

6

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Total expenditure on health as a percentage of gross domestic product

Total expenditure on healthas a percentage of grossdomestic product


budgets, external borrowings and grants, and social health insurance funds. The value for

public Health expenditure (% of total health expenditure) in Singapore was 31.02 as of

2011. As for the private expenditure (% of total health expenditure) was 68.98 which is

more than the double of that of the public. This ensures the importance of the the private

sector involvement in Singaporean health system.

Figure (45): GGE vs. PE as % of total health expenditure


Out-of-pocket health expenditure (% of private expenditure on health) in Singapore was

82.41 as of 2011.

Figure (46): out-of-pocket expenditure vs. private prepaid plans as % of PE


0

20

40

60

80

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

General government expenditure v.s. private expenditure

General governmentexpenditure on health as apercentage of totalexpenditure on health

Private expenditure onhealth as a percentage oftotal expenditure on health

0

20

40

60

80

100

120

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Out-of-pocket expenditure asa percentage of privateexpenditure on health

Private prepaid plans as apercentage of privateexpenditure on health


total population. The value for Health expenditure per capita (current US$) in Singapore

was $2,286.38 as of 2011. This indicator reached a maximum value of $2,286.38 in 2011.

The latest value for Health expenditure per capita, PPP (constant 2005 international $) in

Singapore was 2,786.96 as of 2011.

Figure (47): per capita GHE vs. per capita THE


E. Lessons to learn

Singapore has developed the most efficient, high-quality health care system within the

world, and one that provides us with vital lessons. While Lebanon is not near to adopt

another country’s health system entirely, we can learn from the best. How can we tend to

make this happen? At this point are some lessons from Singapore experience.

1. Price and Outcome Transparency: Singapore obliges that all prices for doctors and

hospitals are publicly available. This permits the patient and payers to shop for the best

price. In contrast, pricing in Lebanon is not clear, with the costs of pharmaceuticals,

0

500

1000

1500

2000

2500

3000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Per capita governmentexpenditure on health (PPPint. $)

Per capita totalexpenditure on health (PPPint. $)

services, and procedures differ from one supplier to another.48

Similarly, information

concerning medical outcomes is not clear. Price and outcomes transparency will eliminate

arbitrary pricing, allow customers to chose the best services at the best price, and

considerably lower health care costs.

2. Higher Co-Pays: They are the fees we pay each time we tend to visit a doctor, have a

treatment, or go to the hospital. Higher co-payments are essential to Singapore’s system.

Knowing that they must pay a sizable portion of their medical bills, people are extremely

wary in using health services. However Singapore also makes it attainable for its citizens to

pay by commanding an individual saving program. Such a program is not advantageous in

Lebanon, instead, co-payments should be indexed to income—the higher the income the

higher the co-payment.

3. Payment by Capitation and Outcome, not Fee for Service: Today most doctors and

hospitals are paid for each diagnostic or medical procedure performed. The result has been

huge numbers of tests and procedures and greater costs. The solution may be by a mixed

payment plan. Singapore's health care system is basically funded by individual

contributions. However, the system is supported by the public sector: individuals are needed

to contribute a percentage of their monthly salary based on age to a personal fund to obtain

treatments and hospital expenditures. Additionally, the government provides a safety net to

cover expenses for which these personal savings are insufficient. Private health care still

plays an important role in Singapore's system, but takes a backseat to public contributions,

which boast the best part of doctors, nurses, and procedures performed. Such a hybrid

system would allow hospitals and doctors some measure of predictable income while

48 National Coalition on Health Care, ―Health Care Spending as Percentage of GDP Reaches All-Time

High,‖ 12 Sept. 2011. Available at http://nchc.org/node/1171

http://nchc.org/node/1171

compensating them for unexpected patient load.49

Patients win as well: the more efficient

the treatment, the better are the outcomes, and the lower is the cost.

4. Differentiated Service: Public hospitals in Singapore offer five different groups of service,

all with admission to the same doctors and procedures. The differences are in the services.

People who chose the lowest level are addressed in multi-patient zone, whereas those who

select the highest levels have totally private rooms.

5. Catastrophic Health Insurance: The most common health insurance in Singapore covers

catastrophic events that need expensive or expanded treatment. Nearly every citizen of

Singapore has such coverage. The deductibles are very high, with the insured paying 20 %

of the cost of care50

. A government safety web helps those most in need and if the extra-

costs exceed the ability to pay.

6. Transition from Hospital to Home and Community Care: Singapore has recognized that

the demands of an aging population on the health care system require a shift from hospital to

home- and community-based care. The costs of treating the quickly growing number of

elderly patients in high-tech, multi-specialty hospitals will ruin their budget. So Singapore

has go aboard on an ambitious plan to deliver quality care at home and in community health

centers through expanded training and improved use of technology.

49 Salma Khalik, ―Medisave Can be Used in 12 M’sian Hospitals,‖ Straits Times, 15 Feb. 2010. Available at

http://www.asiaone.com/Health/News/Story/A1Story20100216-198974.html

50 Sam Ro, ―Revealed: !e Cost of Health Insurance around the World,‖ Business Insider, 26 Apr. 2012.

Available at http://www.businessinsider.com/cost-ofhealth-insurance-around-the-world-2012-

4#ixzz1zZizuLFo


http://www.businessinsider.com/cost-ofhealth-insurance-around-the-world-2012-4#ixzz1zZizuLFo


Part Three: Lebanese National Social Security Fund

Chapter I: Applied Branches and Categories subject to NSSF

A. Establishment of the National Social Security Fund

Since the downfall of the Berlin Wall in 1989, the world is governed by one bloc. At the

economic level, there is hegemony toward globalization, privatization, market economy

technology development, and the formation of large economic coalitions; whereas on the

social level there is hindrance in role of the welfare state. The absence of such role led to

many perils threatening the social protection systems and workers’ rights such as the

maintenance of jobs, health insurance, free education, and social security.51

Lebanon is part of this changing world, as it is affected and influenced by the prevalent

economic orientations: Liberalizing economy, adopting open-space and open-market

policies, and resorting – in theory – to privatizations. All this is occurring in the shadow of

the increase in the mass of public debt and its price volume, economic stagnation, the

closing of many productive institutions and the great dangers affecting the workers and the

persons with limited revenue. This in turn led to the intensification of the social crisis

affecting mostly the social security issue. One cannot tackle the social security outside the

framework of the social situation, and its effect outside the social policy. Indeed security

forms part of a whole and this whole is the adopted social policy.

B. The Gradient in the application of social security in Lebanon

―Everyone, as a member of society, has the right in social security, the right to provide it,

through national effort and international cooperation, and consistent with the structure of

51 Makhzoumi,fouad, The National Dialogue Party Political Program, available at:

www.alhiwar.info/Political_Program_English.p

http://www.alhiwar.info/Political_Program_English.p

each country and its resources, economic and social rights and cultural rights indispensable

for his dignity and development of his personality in freedom.‖52

Note that the Universal Declaration of Human Rights of 1948 (i.e. since 63 years) gave

each person in the community the right in social protection.

"To enact legislation for social security, the employer must pay the employee for the

expense of service for any reason ..." 53

, we conclude from this article cited by the legislator

in the Lebanese labor law in 1946 that he was thinking since that time about the

development of legislation for social security. Indeed, this social security saw the light after

seventeen years of hint to it, and thirteen years of its plan in 195054

, under the Social

Security Law Decree port 13955 Date 26/9/1963.

The legislature put the plan to be applied over the three phases; by its completeness, the

social security includes, as a whole or some of its branches, all the Lebanese. Thus, the

Lebanese legislature has adopted the main lines of policy of the modern social security, in

terms of either totalitarianism or the terms of the mandatory nature of its provisions.55

The actual application of the law of security began after the set of the first section, a

branch of the compensation system of the service end, in place in 1/5/1965. However, we

can ask after more than 46 years on this date, is this law applied as a whole to all the groups

mentioned in it? Are all branches declared in the Code of Social Security applied? Is three-

phase plan that was originally developed for the application of the Social Security Law

carried out? Alternatively, have it been modified? Are all the presentations mentioned in the

sections already set in place applied? Who is subject to the guarantee under the provisions

of the general text? In addition, who are the people held under the special provisions? What

are the applicable sections? Who is subject to all branches of social security? In addition,

who are those subject to part of them? What are the benefits they provide?

52

22انادة – 10/12/1948 –اإلػال انؼان نحقىق االسا 53

54انادة – 23/9/1946قاى انؼم انهبا تارخ 54

Durand Paul – La politique contemporaine de sécurité sociale – Paris – Dalloz – 1953 – P157

55

13ص – 1987 – 2ط – 1ج –انستفذو ي انضا االجتاػ انهبا –د. اج شىفا

The Lebanese legislature followed the legislators in other states that have systems to

ensure a social gradient in the application of this guarantee in the terms of the sections

included either in the social security system or in terms of people whom are applied to them.

The articles 8, 9, 10, 11 and 12 of the Social Security Law set the stages of application.

1 - First stage: This stage begins after the expiration of 18 months from the date of

publication of the Social Security Law in the official gazette (published on 09/30/63). This

phase began with the implementation of the branch system of compensation at the end of

service 1/5/65 and include all categories of employees who work in the non-agricultural

enterprises.

2 - The second phase starts after two years at most from the date of implementation of the

first phase, and include all categories of wage earners working in agricultural institutions.

3 - Third stage: This stage begins after at least two years from the date of implementation of

the second phase, including the categories of persons who are not covered by the first and

second phases like employers and independent workers.

However, this plan for the implementation of social security have been exposed to

significant modification, in particular, under Law No. 16/75 Date 11 April,1975 which

amended Article 9 of the Social Security Act which specifies the persons subject to social

security since the first phase. the government became able to decide whether to subject one

or more of the categories of drivers of public vehicles, craftsmen, and other categories of

Lebanese persons who were in need to be subject since the first phase even if they are

employers and independent workers, through decrees taken in the Council of Ministers upon

the proposal of the Minister of Labor and end of the Board of management of the Fund.56

C. Branches of social security and their submissions

Social Security includes the following sections:

a. sickness and maternity branch

b. work injury and professional disease

56

انقطغ – 1انبذ –انفقزة أوال – 9 انادة – 26/9/1963تارخ 13955قاى انضا االجتاػ انفذ بانزسىو

c. family allowances

d. end of service indemnity

And it is implemented in three phases:57

It was supposed that the application of the branch of sickness and maternity to begin

before the other branches, although the Social Security law did not specify the branch that

should be applied first, but there are reasons to give this branch a priority over the other

branches, in addition of its citation at the head of branches enumerated in Article 7 of the

Social Security Law mentioned above, it is the only branch which was not regulated by the

laws or the private provisions. The Labor Law includes provisions dealing with the old age

and compensations at the retirement. Moreover, Legislative Decree No. 25 issued on May 4,

1943 forms a sort of protection to the employees in relation to work emergencies. Lebanon

was one of the thirtieth countries in the world which recognized in 1947, the importance of

paying compensation of family allowances branch and the first country in the Middle East at

this level, the imposition of legislative decree No. 29 issued on May 12, 1943 had given to

each employer or worker and all working widow and every working woman married from a

disabled husband family allowance compensation.58

As a whole it had not been taken into account the priority of branches and the

implementation of the branches started in the following order:

1. Branch of sickness and maternity:

The date of implementation of this branch was defined as follows: As of 11/01/1970 to

Subscriptions maturity, as of 1/2/1971 for entitlement to benefits under Decree 14035 Date

16/3/1970 amended by Decree No. 456 Date 27/1/1971.59

57

7انادة – 26/9/1963تارخ 13955قاى انضا االجتاػ انفذ بانزسىو

58

20 -19ص – 1987 – 2ط – 1ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا 59

265ص –يذكىر سابقا –غ وانفق واالجتهاد انضا االجتاػ ف انتشز –د. ػايز ػبذ انهك

The submissions of sickness and maternity branch as specified in paragraph 1 of Article

15 of the Social Security Law include the following:

a. Preventive medical care and treatment.

b. In case of maternity testing and prenatal care and care necessary during and after childbirth.

c. In the case of temporary inability of work resulting from illness or maternity, sickness and

maternity compensation. However, this part of the guarantee of the disease and motherhood

has not been implemented so far are applied, in this case in respect of disability from work

because of illness, the provisions of Article 39 of the labor law relating to sick leave; With

regard to disability from work because of maternity provisions of Article 28 of the Labor

Law on maternity leave.

d. In case of death, compensation of burial expenses.

It is noted that the Lebanese legislature leave the choice to the guaranteed to choose his

doctor and the institution which he wants from the hospitals between institutions and

physicians accepted by the Fund.

2. Branch of emergency work and occupational diseases:

Not implemented so far, it applies to emergency work that affects employees provisions of

Legislative Decree No. 136 Date 09/16/1983, and apply the provisions of the Code of

Obligations and Contracts on occupational diseases. As for the benefits of the branch of

emergency work and occupational diseases were announced in Article 32 of the Social

Security Law amended by Decree-Law No. 116 Date 6/30/1977 as follows:

a. Medical care.

b. Compensation for temporary inability of work.

c. Disability pension compensation in case of permanent disability, total or partial.

d. Pension of holders of the right and compensation of burial expenses in the case of the death

of the guaranteed.

Finally, it should be noted that all of these submissions have not been applied so far.

3. The branch of family allowances:

This branch was placed in force on November 1, 1965, and it provides payments of sum of

money for married employees in the form of family allowances for spouse and children up

to 5 children maximum in accordance with the provisions of Articles 46 and 47 of the Social

Security Law. He does not believe any educational benefits contrary to the name.

4. Branch for end of service:

this branch has been developed and place in force in 1/5/1965, under the Decree 1519 Date

24/4/1965; and therefore become mandatory to associate this branch, each employee hired

after that date, where it was left for the employee already hired either to remain subject to

the provisions of labor law or to choose the branch of end of service (retirement) in

accordance with the provisions of Article 49 of the Social Security law.

So the retirement system had partially substitute the layoff compensation system, which

was in force under the labor law; Article 49 of the Social Security Law stipulates in its first

paragraph as follows: ―until the legislation of the aging security60

, a fund is established to

compensate the retirees ... ―; So that it can be said that this section is temporary and is a

transitional stage to reach old age security.

In general the system provides for wage earners secured mandatory or optional end of

service compensation when there is a one of the following conditions: the total years of

work at least 20 years or to be suffering from a disability of at least 50% or that the

guaranteed has reached sixty years old, or in the case of marriage of women from the

employee and she left work during the twelve months following the date of her marriage or

in the case of the death of the employee in accordance with the provisions of Article 50 of

the Social Security Law. The subjection of the guaranteed to this branch ends at the age of

sixty-fourth in accordance to the provisions. Finally it should be noted that the employee is

given reduced compensation if he left his work and the amount of compensation 50% of the

original value if he is engaged 5 years at most, 65% of the original value If more than five

years and ten years most, 75% of the original value If more than ten years and 15 years at

most, 85% of the original value If more than 15 years and less than 20.

60

389ص – 2005 –بزوث –صادر –انضا االجتاػ ف انتشزغ وانفق واالجتهاد –د. ػايز ػبذ انهك

D. People subject to all branches of social security

The people who are subject to all branches of social security are:

a. permanent employees: the permanent employee is the employee associated with the

institution with a working relationship in accordance with the operative part of Article 624

of the Code of Obligations and contracts under the employment contract of indefinite

duration, subject to the Social Security Law, whatever the duration or the type or nature,

shape, or validity of the contract which he links to his employer and whatever the nature of

wages or earns in accordance with the provisions of Article IX, Section 1, first paragraph

section A of the Social Security Law.

b. Temporary employees: those whom their work nature requires their use temporary and

associated with their employers under the written contracts, as defined by paragraph 1 of

Article II of Registration and registration. They are subject to Social Security Law, in

accordance with the provisions of Article IX, paragraph, first item 1 section A.

c. Probationer employees: they are associated with the employer by an employment contract

on a trial basis. They are subject to Social Security Law, in accordance with the provisions

of Article IX, Section 1, first paragraph a section.

d. Seasonal employees: Having decided that the seasonal employee who does seasonal work

for a period not exceeding eight months, they work in the activity associated with certain

seasons. They are subject to the Social Security Law and in accordance with the provisions

of Article IX, paragraph, first item 1 section A.

e. Trainees: it was defined in Article III of the Labor Law as workers under preparation who

have not yet acquired their craft in the authentic experience of the employee. They are

subject to Social Security Law, in accordance with the provisions of Article IX, Section 1,

first paragraph a section.

f. Lebanese employees non-associated with a particular employer: people working for more

than one employer at one time, so difficult to determine their association with any of them

permanently. The Article ninth paragraph, first item 1 section b of the Social Security Law

on the subordination of Lebanese employees non-associated to specific employer, who are

working in the sectors of the sea and harbors, construction, loading and unloading of all

branches of social security.

g. Members of the teaching staff in institutions of higher education and technical institutes:

They are subject to Social Security Law, in accordance with the provisions of Article IX,

Section 1, first paragraph c section.

h. People working in the public sector: The text of the law announced their subjection in

Article IX, paragraph, first item 1 section d: "People Lebanese working for the state or

municipalities, or any department or public institution or independent systems, whatever the

duration, or type, or the nature of, or shape, or their appointment, or contracted with,

including clients of the Ministry of Information .... Where the permanent state employees

are accepted from the subjection to security. "

i. Sellers of newspapers and magazines: Full-time for the sale of newspapers and magazines as

independent workers, who are a class of non-traders, have been subjected by Decree No.

4885 Date 18/2/1982 amended by Decree No. 265 Date 24/2/1983.

j. Drivers of public vehicles: Owners and non-owners of their cars (non-associated with a

work contract with the owner of the car are not any of the action.) Has been subjected by

Decree No. 4886 Date 18/2/1982 amended by Decree No. 265 Date 24/2/1983.

k. Permanent employees working in an agricultural institution: Article X of the Social Security

Law stated the subordination of all Lebanese employees’ workers and users, trainees and

interns, working on Lebanese territory for an employer and one or more of the Lebanese or

foreign, during the second stage of the application of social security.

l. Journalists: They are those who just do not get a legal subordinate relationship with the

employer, because of who possess this relationship have been subjected since the beginning

of the first phase of employees, while the subject of those under the Law No. 16/75 Date

11.04.1975 from the date of 8/5/1975, and journalist is taken from the profession of

journalism and his basic means of livelihood, as defined by Article 10 of the Law

publications.

m. Foreign employees: for the foreigners, they are subject to and benefit from all the branches

when the State to which they belong, recognizes the Lebanese principle of equal treatment

with nationals as regards social security, and who possess a work permission, and these

countries are France, Italy, Belgium, Britain . The rest are subject only to sickness and

maternity and family allowances branches but do not benefit.

And the following table shows the number of secured subject to all the branches in the

year 2012

Table (33): number of secured subject to all branches 2012

Job description secured in 31/12/2012

Employees 439747

Employees in the marine sector 91

Drivers of public vehicles 40679

Sellers of news papers and magazines 46

Total 480563

Source: statistics center in NSSF

E. People subject to certain branches

They are of two types:

1 - Persons subject to the benefits of medical care in cases of sickness and maternity and

emergency work and occupational diseases:

a. Permanent government employees: they are defined in paragraph 2 of Article I of the

Legislative Decree No. 112 Date 06/12/1959, and they were subject under the provisions of

Article 9, first paragraph item 2 a section of the Code of Social Security.

b. Members of the teaching staff in private schools entering into owners and non-entrants in

the owners and it means those carrying out the functions of teaching or educational

administration, and are subject by Law No. 20/72 Date 23/12/1972 as of 1/10/1971.

2 - Persons subject to the benefits of medical care in cases of sickness and maternity:

a. University students: those who do not benefit from the submissions of other health

insurance, starting from the academic year 1973-1974, under the implemented law by

Decree No. 5203 date 03.23.1973.

b. Physicians accepted in the Fund: They are those who provide in medical care for patients

guaranteed, when they are not subject to the guarantee in another capacity, or any system of

mandatory another, they are subject under the provisions of Article 9, paragraph First of

item 4 of the Social Security Law, which stipulated a decree that has been issued on

02.02.2001 under the number 4822 and placed in force in 1/6/2001.

c. Town mayor: They are subject all the duration of their rule to medical care benefits in

addition to compensation and burial expenses under the law No. 225/2000 dated 29/5/2000.

d. Writers and artists: they are subject under Decree No. 8073 Date 12/3/1996 until the

determination of the conditions of submission under a decree issued by the Council of

Ministers.

e. Optional security: under the Decree no. 7352 Date 1/2/2002 stated in Article 11 of the

Social Security law, it was place in force in of 1/3/2003.

And the following table shows the number of guaranteed people subject to some

branches in the year 2012

Table (34): number of secured people subject to some branches 2012

Job description in 31/12/2012 Guaranteed

Members of the teaching staff in private

schools 33477

University students 56792

Town mayors 2094

Retired doctors 7016

Optional guaranteed 12782

Total 112161


As for foreigners who do not belong to one of the countries that recognize the Lebanese

principle of equal treatment with nationals as regards to social security they are subject to

both sickness and maternity branch and family allowances but do not benefit from the

submissions of these two branches.

The following table shows the number of foreigners registered in the Fund and non-

beneficiaries up to 31/12/2012:

Table (35): number of foreigners registered in Fund and non-beneficiaries

Tot

al

docto

rs

studen

ts Oven workers

teache

rs

employee

s Job description

032

02 1 2 62 401 22561 Number


Chapter II: Expansion in the application of NSSF

A. The branches and submissions under study

There is no doubt that the number of branches currently applied in Lebanon and the

amount of benefits provided by NSSF are very few, if compared with its launch in the mid-

sixties. We can obviously notice that the last branch applied was sickness and maternity

branch since 01.11.1970, noting that it haven’t been completely applied yet.

There had been many reasons, most notably the outbreak of the Lebanese civil war 1975

- 1990 , the NSSF who began the implementation of its branches in the 01/05/1965 with the

end of service indemnity branch , had carried out three out of the four branches provided

for in this law until the date of the outbreak of this war . This war led to the dismantling of

the society and the state and the deterioration of the standard of living and the destruction of

infrastructure. People were obliged to adapt to the new situation, which was the declining

role of the public sector and the growth of the role of non-governmental sector in the areas

of health and financial aids, so the familiar and religious institutions played an integral role ,

and political parties established their own institutions to provide aids , declining role of the

government and public institutions in this area , including the NSSF. There are also other

reasons for this decline such as the deteriorating economic and political situations in

Lebanon and its surroundings since the end of the civil war.

But all that has to motivate the management of the NSSF and the government to develop

the social security, and expand its services, since historical indications show that poverty

and lack of insurance and security are the most important factors of the outbreak of many

crises. In periods of crisis, governments must give citizens a sense of protection from risk.

With reference to the national conciliation document in Taif has focused on social justice

and balanced development and financial, economic and social reforms.

However, legally there are many legal provisions that call for increased benefits, where

there are many benefits stipulated by the Lebanese Social Security Law issued on

26.09.1963 have not yet been implemented; These submissions and branches can be

summarized in the following form:

1 - Branch to of work emergency and professional diseases, which are stipulated in articles

28 to 45 of the Nations Social Security law.

2 - Disease compensation provided by the National Social Security Law as part of the

sickness and maternity branch in articles 23 to 25.

3 - Maternity compensation stipulated in the National Social Security Law as part of the

sickness and maternity branch in Article 26.

4 – Aging insurance hinted by the National Social Security Law in paragraph 1 of Article

49.

5 - Retirement System, hinted by the National Social Security Law in paragraph 5 of Article

54.

At the level of international and regional standards, Convention No. 102 Date June 4, 1952

issued by the International Labor Conference concerning minimum standards of social

security stipulates that each government member in the convention shall cover three risk of

at least the following risks: medical care, subsidy disease, unemployment benefit , old age

benefit , employment injury benefits , family allowance , maternity allowance , disability

benefits, noting that Lebanon has not ratified this convention.

The Arab Convention No. 3 about the minimum level of social insurance, date

27/03/1971 in Article VII has recommended that social security shall includes at least two

branches of the following sections: work injury insurance, health insurance ( against the

disease ) , maternity insurance ( pregnancy and childbirth ), disability insurance , old-age

insurance , death insurance , unemployment insurance, family allowances .61

In fact, Lebanon had provided a large part of these minimum standards, but these

standards are no longer sufficient at the present time. The Social Fund is now suffering from

a fiscal deficit, and the government suffers too from a large deficit in its budget, and

employers and employees are unable to pay a high proportion of subscriptions due to the

current economic situation. The management of the Social Fund is currently working on

expanding the field of services, where they were preparing a series of studies and laws for

this purpose.

1. Dental care

Paragraph 2 of Article 17 of the National Social Security Act Decree 13955 Date

26.09.1963 listed the medical care benefits of the sickness and maternity branch ,as stated in

item A section III of this paragraph that the dental care should be applied after the issuance

of the decree by the Council of Ministers on the proposal of the Minister of Labor and

Social Affairs and the end of the Governing Council.

And so after, the sickness and maternity branch had been applied without the dental care

since the decree hadn’t been issued until this date. In 15 March, 2001, the board of directors

in the NSSF adopted Resolution No. 182 aimed at licensing for the National Social Security

Fund to provide dental cares.

After 38 years of the issuance of the law, and after the issuance of the opinion of the

Council of State of approval No. 158 Date 03.22.2001 .On 24 March 2001, Decree 5104

about licensing for the National Social Security Fund to provide dental care was issued

identifying in its first article the benefits covered by the dental care.

61

35ص – 1987 – 2ط – 1ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا

In 1/7/2001 was the default date for the application of the dental care benefits. Since

dental care health implementation requires accuracy in logistics, administrative and financial

procedures, the Board of Directors has asked to postpone the implementation of the project

until November 2001, so the Council of Ministers issued Decree 6516, dated 11/10/2001,

which amended the text of Article III of the former Decree No. 5104 mentioned that the

default date of the implementation became in 1/11/2001. The Fund issued a medical system

special for dental care, in addition to the agenda and pricing of medicines and coding and

tables of drugs and laboratory tests and radiographs.

In August 2001, a contest was made to select dentist’s observers and they accepted 20

dentist. National Social Security Fund Administration began to make tenders for the

preparation of the reception centers.

In the 2002 budget, Board of Directors approved amount 34 billion pounds to cover the

cost of dental treatment, including processing centers and crew observer. Since that date,

and until now, the dental care hadn’t been applied. knowing that the World Health

Organization ( WHO ) ranked Lebanon worst in the region in terms of oral health and its

impact on public health , where the index of number of brackish teeth , lost ,or stuffed rated

5.7 % among children aged between zero and twelve years old, compared with 3.3 % to

neighboring countries.

It is proposed to start the implementation of these submissions, by starting working out

basic treatments gradually, so as not to be a high cost to the Fund, also the percentage of the

Fund’s contribution can be decreased in the beginning to 40 %,62

for example, and the

insured bear the remaining 60 %, knowing that the other official health institutions cover the

dental care.

2. Branch of emergency work and occupational diseases

62

سؤال يىج ي انائب حىري إنى انحكىيت ػ – 10ص – 2005تشز األول 18انثالثاء – 2073انؼذد –صحفت انستقبم

يصز ضا طب األسا

The branch of emergency work and occupational diseases is the only branch texted in the

Lebanese National Social Security Law and haven’t been implemented until now, even

though it has passed so far about 50 years of the issuance of this law.

And thus the provisions of Legislative Decree No. 136 dated 09/16/1983 are applied on

emergency work and the provisions of the Code of Obligations and Contracts is applied on

occupational diseases.

We can summarize the reasons that requires the development of this branch as follows:

The system of employer's responsibility currently in force , despite the developments that

have passed it , it was not optimal system to meet the occupational hazards , it had many

disadvantages, most notably is that the employer bears the compensation for damages

resulting from these risks , and he tries to evade from it in multiple ways , so that the

employee will be obliged to resort to the law in order to get his right.63

So it was normal that

all the society should bear the risk that face the employee, so the employer will not any

more compensate on the damages that face the employee, however he will contribute in the

compensation by paying a subscription of a certain percentage of the wage of each worker ,

through National Social Security.

And the risks covered by the emergency work and occupational diseases branch in

accordance with the provisions of Articles 28 and 29 of the National Social Security Act

are:

a. Emergency which affects the insured during or on the occasion of doing his job.

b. Emergency faced by insured during the period he is going from his home to the workplace

or returning from it , with a condition that the way should be without interruption or

deviation from the natural way for a reason independent of his work

c. Emergency which affects the insured during or on the occasion of the ongoing rescue

operations in the institution where he work.

d. Emergency which affects the insured outside Lebanese territory during or on the occasion of

doing his job.

e. Occupational diseases.

63

756ص –يذكىر سابقا –انضا االجتاػ ف انتشزغ وانفق واالجتهاد –د. ػايز ػبذ انهك

It is important to differentiate between work emergency and occupational disease

because conditions for the worker to take the compensation from the fund vary according to

its source. With regard to work emergencies, the emergency that satisfies the standards

stated in the law, is considered a work emergency, and covered by work emergency branch.

64The occupational disease is not covered by the fund unless it is recorded in the list of

occupational diseases as set by Article 29 of the Social Security Act.

Emergency can be defined as: ―any act affecting human body as long as it is surprising

and caused by an external cause."65

The disease can be defined as any slow and gradual contact by the human body as a result

of an internal factor.

The Submissions of work emergency and occupational diseases branch are the following:

a. medical care Submissions: all the submissions listed in the provisions of Article 33 of the

National Social Security Act.

b. Work emergency compensation: paid in case of temporary disability beginning of the

eleventh day of the date of work stoppage. The compensation range between three-quarters

of daily average earning and half of that gain in case the insured is in the hospital, according

to the provisions of Article 34 of the Social Security Act.

c. Disability pension : stipulated in Articles 35 to 38 of the Social Security Act , which is paid

in case of total or partial permanent disability:

In the case of total and permanent disability: the insured receive a disability pension for

whole life equal to two-thirds of the annual value of his earnings.

In the case of partial permanent disability: in case of disability of at least 30 %, the insured

shall receive a disability pension determined, according to the degree of disability. In case of

disability less than 30%, the insured shall receive a compensation paid at once, and be

equivalent to three annual payments of partial disability pension that is worth to him.

d. Right owners’ pensions after the death of insured: This amount is equal to two-thirds of

annual earnings, or 50 % of this gain according to the provisions of Article 40 of the

64

760-759ص –يذكىر سابقا –اػ ف انتشزغ وانفق واالجتهاد انضا اإلجت –د. ػايز ػبذ انهك 65

635-3 –فزح أبى راشذ – 20/12/1950تارخ –و.ع.ث. جبم نبا

Insurance Law. It is paid to the right owners under Decree 4896 Date 08/02/1974 ,

according to the order of priority, and in accordance with the provisions of Article 39 of the

Law social Security. And right owners are the spouse, children, father and mother (required

for the insured to be the only supporter for his parents in Lebanon and their wage shall be

less than the minimum wage rate);66

in the absence of a husband and children, the pension is

taken by his siblings or grandparents.

e. Burial expenses compensation: is a constant amount determined by the decree issued by the

Council of Ministers, paid for the right owners in case of the death of the insured, according

to the provisions of Article 45 of the Law of National Social Security Fund.

It should be noted that before placing this section in to implementation, some amendments

should be done to the law, particularly in terms of imposing some conditions on the right

owners who receive the disability pension after the death of insured and in terms of

reducing the beneficiaries , so that not to charge on the fund very high amounts .

According to our opinion, provisions must be adopted to the right owners similar to the

beneficiaries of the submissions of the sickness and maternity branch set them in Article 14

of the National Social Security Law. It also important to pay attention to the application of

the provisions of Article 59 of the Social Security Law relating to taking the necessary

measures to provide safety and health conditions in order to prevent work emergency and

diseases, which would reduce the injuries and therefore the costs to the National Social

Security Fund.

3. The pension and social protection system

It was Supposed that this system will replace the end of service indemnity branch since

this branch doesn’t provide an income to the insured for life time after his retirement, while

the insured get a compensation once after his retirement, but this compensation it not

enough especially in these economic situations from inflation and declined purchasing

66

207ص – 1985 –بزوث – 1ط – 2ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا

power.67

the pension and social protection system includes the submissions of security and

maternity for retirees.

The Lebanese legislator has hinted from the beginning to his desire to apply this system,

we conclude that from the text of Article 49, paragraph 1: " until the issuance of the elderly

insurance, the end of service and indemnity branch is established ... " As in the text of

Article 54, paragraph 5: "You can convert indemnity for the benefit of the employee who

has completed sixty years of age to a pension for life ... ―.

The end of service and indemnity system is the only way for the elderly to complete their

lives secured after they spent their lives working and producing.

There are two basic ways to retire:

Capitalization method, a system based on taking savings from the income during the

period of work to invest them and benefit from the profits. So there is a direct relationship

between savings of each person during his productivity period and the pension which he

gets during his retirement. Capitalization has disadvantages that are the risk of volatility in

the market.

Retirement based on a system of distribution. An obligatory monthly subscription should

be paid from the wages. These subscriptions are distributed on the employees after their

retirement. There is a relationship between the duration of contributions, its amount, and the

amount of pension which the insured will have.

Some countries, especially in Western Europe, adopted important systems for Social

Security to give specific submissions based on distribution system funding , while others

adopted specific retirement programs managed either by the state (as in Singapore and

Malaysia) or regulations within the framework of the state (Chile and Argentina ).68

67

345ص – 1985 –بزوث – 1ط – 2ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا

68

480ص –يذكىر سابقا –انضا اإلجتاػ ف انتشزغ وانفق واالجتهاد –د. ػايز ػبذ انهك

In Lebanon, it has developed several draft laws to the pension system. With respect to

retirement pension, legislator tries to merge between capitalization and distribution. It is

based on the capitalization because the pension depends on the elements of age, number of

years of participation and individual account of the insured of which consists of

contributions paid and owed and portion of this account from the investment of funds,

according to the provisions of Articles 50-1 and 50-6 of the bill. It is also based on

distribution through guaranteeing minimum pension of LBP 180,000 from those who

participated in this system for a period of twenty years and the amount increase by 3000

LBP for each additional year of subscription, until it reaches 240,000 LBP, in accordance to

the provisions of paragraph 3 of Article 50-7 of the project.

In relation to pension, it is pension allocated to the insured, who suffer from permanent

disability, physical or mental, as the result of a work emergency or occupational disease,

which reduces his ability to work or to earn income by two-thirds at least, and prevents him

from performing any work, according the provisions of Article 51-1 of the proposed project.

As for the pension of the right owners , it regulates the transmission of the pension upon

the death of the insured who benefits from the pension system , or meets the conditions to

benefit from this pension , or disability pension , to his right owners whom are his legal wife

who doesn’t practice any profession or dependent and independent paid work, and the

husband of the insured and the legitimate or adopted children , and Father and Mother, in

accordance with the provisions of Article 52-1 of the proposed project. Article 52-2 of the

same project Has distributed pension according to the following: 40% for the surviving

partner and this percentage is reduced to 30% of pension in the case of his/her parents or

one of them alive; and 40% for children; and 10% for the parents or one of them surviving

this ratio becomes 30% in the absence of any of the other beneficiaries.

As for the submissions of sickness and maternity for retirees, Article 53 of this project, had

subjected pensioner who completed the age of sixty-fourth or reached the retirement age and

the owner of a disability pension and pension owners from the right owners to the sickness

and maternity branch in the National Social Security Fund, and they benefit from the

medical care submissions as well as the burial cost compensation.

Finally, we can list some notes about this project:

The project must be based on facts and figures relating to the labor market and the number

of employees and the number of public and private institutions and the average age and the

average number of families and the average income ... In order not to be threatened by

failure

Ensure the government’s ability to pay its portion in order to prevent any deficit that

threatens the whole system.

The project requires in Article 49-1 the creation a new public institution with legal

personality and financial and administrative independency for the management of the

pension social security fund.

B. The reasons for increasing the categories covered by Social Security

The number of people subject to National Social Security at the end of the year 2012

reached about 393523, the beneficiaries on their responsibility reached more than

1,200,000 citizens.

The aim of Lebanese legislator target upon the issuance of the National Social Security

Law in 1963 is to cover all the Lebanese at the end of the third and final phase. Article 12 of

the law text as follow: "In the third phase, special law defines the conditions of the

application of the social security system, or some of its branches, to people whom are not

submitted yet to its provisions in the first and second phases.

And so far, many years have passed and the goal hadn’t been reached yet. Perhaps one of

the most important reasons for the delay is the Lebanese war and the economic and social

conditions.

There are many factors that impose the coverage of the social security on various

members:

Achieve equality among the Lebanese of different categories according to the Lebanese

constitution.

Economic factors: In the absence of social security coverage to all categories of citizens,

the only solution for them is the traditional way to handle with the consequences of the risks

that threaten their economic status and their future which is savings. However, this method

has several disadvantages, since it is linked to a large extent with the level of income. The

holders of small incomes cannot save, but they spend all their income on essential needs.

Accordingly, the ability to retain certain amounts saved is limited to those of large incomes.

Also, the money loses its purchasing power because its value diminishes over time.69

social factors : the need to Social Security , arise due to the evolution of modern life and

its requirements , the high cost of living and disintegration and decline in family ties, and

thus difficult to handle with the consequences of the social risks .70

There are many categories that are in need to be covered by Social Security benefits,

however the most essential to be covered are:

tobacco farmers

writers and artists

municipal workers

1. Tobacco farmers

countries Usually tries to encourage the rural population to stay in the villages through the

support of farmers , and there is no doubt that Lebanon is among the countries most in need

to follow this policy due to large- displacement movements that empty countryside led to

overcrowding in cities , especially the capital Beirut and its suburbs .

69

30-29ص – 1987 –بزوث – 1ج – 2ط –انستفذو ي انضا االجتاػ انهبا –د. اج شىفا 70

31ص – 1987 –بزوث – 2ط – 1ج –انستفذو ي انضا االجتاػ انهبا –د. اج شىفا

The best way to encourage the farmers to stay in their villages is to help them in providing

the protection from risks through including them in the Social Security System.

For the agricultural sector, the legislator had included permanent workers in agricultural

institution for all branches of social security under the law No. 8 / 74 date 03/25/1974 and

Decree No. 7757 dated 07.05.1974, while it excluded the farmers and the independent

agricultural workers.

The selection of tobacco farmers group among other farmers refers to several factors:

They can be easily subjected to social security, because their numbers are known and can

be easily identified.

Their ability to pay their subscriptions especially that tobacco is one of the plants that the

Lebanese government to encourages its marketing.

Tobacco cultivation is concentrated in the south and the Bekaa and Akkar, which is the

most deprived areas and must remain under the government’s sponsorship and interest. The

distribution of areas planted with tobacco in Lebanon is as follows: 76 % in the South, 17 %

in the North, 4.6 % in Mount Lebanon, and 2.4 % in the Bekaa.

Its contribution in reducing the prohibited plants, and in the development of the rural

economy, and also contribute in providing jobs for thousands of people, farmers, employees

and workers.

Importance of tobacco farming, where tobacco is one of the main agricultural crops in

Lebanon, comes in fourth place after the production of lemon, banana and olive.

The Tobacco and Cigarettes Company estimates the numbers of tobacco farmers by about

30 thousand families ( about 16,000 families in the south) , which means about 150,000

citizen benefit from Social Security in case of including this category for all branches of this

security.

The National Social Security Fund must work on the necessary studies to determine the

best way to include this category in the social security system, and the preparation of

necessary laws and decrees.

2. Writers and artists

For the category of writers and artists, the situation is different for that of tobacco farmers,

since there is a decree for their including but they are still waiting the issuance of the decree.

Legislator has amended Article 9 of the Social Security Law under the law No. 16 / 75

Date 04/11/1975 , so the first paragraph item 1 H section became as follows: " under decree

issued in the Council of Ministers, and the proposal of the Minister of Labor , and ending of

the Board of directors , and under the conditions specified , categories of public-drives and

artisans , and other categories of non- Lebanese persons mentioned in this article who

should be included since the first phase , for some or all branches of social security , are

specified. "

Under the provisions of this section, the government issued Decree No. 8073 dated 12

March 1996, based on ending the temporary Committee to carry out the management of the

National Social Security Fund r by Resolution No. 212 adopted at the session number 124 /

A / Z Date 11.08.1995 and after consulting the Government Consultative Council based on

the opinion 39 / 96 date of 11/30/1995.

The decree in its first article mandated the subjection of Lebanese writers and artists to

sickness and maternity branch stipulated in the Social Security Law. But the same decree

suspended its implementation till the issuance of a new decree by the Council of Ministers

upon the proposal of the Minister of Labor and ends the Board of Directors of the National

Social Security Fund.

From here, the need to give priority to this category in the subject of their including to the

branches of the Social Security National Fund is for the following reasons:

Issuance of an earlier decree that subject this category to the NSSF, and suspending its

implementation until setting a new decree.

This category represents a civilized picture of Lebanon; however, the state is still absent

from their health insurance, where there are many artists and writers whom are unable to

pay the expenses of their medication.

The addition of this category contribute to achieving the primary objective of the

Lebanese lawmaker and management of the National Fund for Social Security by adding

new segments secured to the base on the road to coverage of all the Lebanese .

3. Municipal workers

The situation of this category is quite similar to the situation of writers and artists, as there

is a law for their subjection, but they are still waiting for determining the date of its

implementation.

The municipal workers are included in the social security system under section d of item 1

of the first paragraph of Article 9 , as amended by Law 16 /75, and under the law 3 / 82 Date

01/28/1982 .

The law No. 10 / 84 Date of 12/18/1984 amended the date of including the municipal

workers However; this decree has not been issued yet, leaving the Lebanese people working

in municipalities outside the circle of submission.

But now the government should as soon as possible issue the decree which requires

subjecting municipal workers to the provisions of the Social Security Law for the following

reasons:

The rate of contributions and earnings, which will be taken as the basis for calculating

these contributions specified in paragraph 4 of Article 68: ―Subscriptions for Lebanese

municipal workers calculated on the basis of earnings texted in the preceding paragraphs

The contributions are easily collected by municipalities or by the Ministry of Internal

Affairs. Paragraph IV of Article 68 provides as follows: " ... and if the contributions of the

municipalities are not paid, they are taken from the Independent Municipal Fund,

C. Data analysis about NSSF’s beneficiary health care satisfaction

i. Population and Sample Selection:

The population of the study was selected at random from Lebanese people in the society

whom they are subjected to the National Social Security Fund without a previous

knowledge about their demographic indicators or social level they refer. Respondents had to

be affective members whom are financially responsible about the health expenditures.

1. Instrumentation:

The instrument of the study is a questionnaire made up of twelve questions to be filled on

the preference of respondent, it is arranged to collect Data that helped the study to make

findings that will be included in this thesis.

The questionnaire is divided into three sections:

9. Introduction:

In its first part, the questionnaire informed respondents about its purpose which was to

investigate the issue of the importance and the impact of the NSSF’s proposal on the

Lebanese health system on both levels of expense and quality

It also assured that the participation in this questionnaire was voluntary and the collected

information will only be used for educational purposes.

10. Identification Variables:

In this part, the questionnaire asked about the respondents’ general information including

gender, age, and status, number of dependents, employment, education and monthly income.

There is a Q‖0‖ of the study which determined whether the respondents feel financially

and qualitatively satisfied with the NSSF’s services.

11. Dependent Variables:

In this section, there were five questions about the NSSF’s services and the impact of the

new proposal on the health sector.

2. Questionnaire construction & Conceptual Framework for Data Analysis:

Based on the review of literature and previous studies and Data stated in the chapters

above, this questionnaire was developed on variables determine the ability of applying the

new NSSF’s proposal and its role in developing the Lebanese health sector even if it will be

a tiny push forward.

1. As for Q "0", Frequency was enough to examine if results are valid or not and to show

really the percentage of the Lebanese that believe that the new proposal can be a step for

better health security in Lebanon.

2. As for dependent variables, frequency tables and pie graphs were used to obtain valid

results built strong base for a clear vision about the population this thesis is studying and

addressed to as well.

3. Results:

Frequency tables proved successfully that less than half of number of questionnaire were

valid, and that answers showed regarding respondents a well knowledge and concern of the

health and medical situation in Lebanon due to the sufferings they face..

a. Q "0" :

Do you feel that you are financially and qualitatively insured within the NSSF’s services?

Table (36): frequency results of Q‖0‖ of the questionnaire

Frequenc

y

Percen

t

Valid

Percent

Cumulative

Percent

Val

id

Yes 236 47.2 47 47

No 178 35.6 36 83

Not too

much 86 17.2 17 100

f. Results of dependent variables:

In this thesis, results of five statements out of twelve will be shown in pie graphs, these

statements were chosen for being more important in serving the purpose of the study.

Knowing that 236 respondents answered yes on Q "; Source: data analysis of 236

questionnaires filled with data from 236 Lebanese 2013.

Figure (48): pie chart frequency result of the questionnaire

yes

63%

no

37%

Do you feel that the coverage of the NSSF is fair within

the economic situation?

yes

56% no

24%

sometimes

20%

Do you face any problem while receiving any

service as a beneficiary of the NSSF?

d. Our assessment:

74%

15%

9% 2%

Do you expect a progress in the services of the NSSF in

the field of expanding the application to cover more

categories?

Yes No Maybe Not interested

59% 16%

18%

7%

Do you think that this expansion will affect the

rate of contributions?

Yes No Maybe Not interested

64%

36%

Do you feel that the NSSF coverage is enough and you

are not obliged to have a complementary insurance?

Yes No

In our 500 interviews, the questionnaire examined how the Lebanese people suffer in

benefiting from the health care that it had to be a right for them. We can also recognize the

role of the NSSF that it plays in the Lebanese health system.

Although the results showed a weak validity where there was less that the half suffering

from the NSSF’s service. However, this questionnaire can be studied neglecting 86

respondents with the answer ―Not too much‖ which reflects the weak knowledge of the

Lebanese people with the services that are from their rights and paying for. So, and starting

with 414 respondents, we can notice that 57% are satisfied with the NSSF’s service.

From the above start, our recognitions continue to find that the beneficiaries are not

complaining about the rate of contributions, however they fear from the rise of this rate as

the new proposal of expansion is applied.

Also there is a high percentage of those who believe that the application of the NSSF’s

proposal can be a positive turn-over for the health system where most of them feel satisfied

with the services provides even though the dental care and pension and social protection are

not involved yet.

The questionnaire results push us to analyze the ability of the National Social Security

Fund to apply this proposal within the financial deficit in its balance.

Chapter III: The financial situation of the NSSF

A. Funding National Social Security Fund currently in Lebanon

Whatever the projects vary, they all need funding to grow and continue since finance is

the backbone of any project. Funding is to provide the cash necessary for the development

of the project, whether it is private or public.

Supplying the Institutions with the necessary funds for their establishment or expansion is

one of the most complex problems that may be encountered, how are the social security

systems funded?

What are the methods of funding the social security adopted in various countries around

the world? Which method is the best and what are the advantages and disadvantages of each

method? Is it possible to combine these methods? What is the method adopted in Lebanon?

There are two methods adopted by countries around the world to finance the social

security systems: funding by professional subscriptions and financing by public taxes.

1. Finance by professional Subscriptions

Subscriptions constitute the main source of financing many systems, including the

systems of the Lebanese and French, where the social security system is funded through the

subscriptions of employers and employees or through subscriptions of the guarantees when

they belong to the categories of non-wage earners; also the government contributes by a

portion of these subscriptions, especially when it comes to the categories of non-wage-

earners, who are unable to pay their subscriptions.

The advantage of funding by professional Subscriptions:

g. Subscriptions entitle the one who pay to participate in the Social Security Administration:

The payment of the employer and employees of the subscriptions gives them the right to

participate in the management of social security and decision-making relating to the conduct

of this system. It also gives them the right to view the methods of investing the funds of the

system.71

The best confirmation that the administrative organization of the National Social

Security Fund in Lebanon, is that the Board of Directors of the National Social Security

Fund consist of 26 delegates, including ten delegates representing employers and ten

delegates representing employees which represent a proportion of three-quarters of the

members of the Council.

h. Subscriptions are a reflection of the principle of solidarity: the payment by employers of

their share of the subscriptions is a reflection of the principle of social solidarity on which it

is the Social Security. Also this principle is shown clearly through family allowances branch

where subscriptions are paid for employees, whether they are married or single men.

71

M.R. Jambu Merlin, cours de sécurité sociale, Paris ,les cours de droit 1968-1969 P 112

i. Subscriptions release the employer from liability: the subscriptions paid by employers

liberate them from liability in respect of certain risks.72

The disadvantages of the method of financing by professional Subscriptions are:

a. The difficulty of determining earnings subject to the subscriptions and the resort of some to

evade the payment of subscriptions owed to them by the avoidance of the announcement of

the numbers of employees or the full wage.

b. Payment based on a percentage of profits does not take into account some of the institutions

because this way this account does not fully take into account the profits of these

institutions. This burden maybe more visible as far as labor is used, which makes some

institutions considering the adoption of the reduction in the number of employees.73

2. Financing by tax

Taxes are the most important source of financing security systems in many countries,

particularly in New Zealand and some Scandinavian countries. Instead of a system based in

its funding on professional subscriptions and dedicated primarily to protect the working

class, it can be adopted the financing of social security by the tax where the State allocate in

its public budget the amounts needed for the social security to provide the benefits to the

beneficiaries, or it imposes a special tax collected for Social Security.74

The advantage of the method of financing by tax is simply the collection, which is at the

same time taxes are collected.75

The funding by taxes leads to a fair distribution of the

burden of Social Security.

The main disadvantages of the method of financing by tax is not the possibility of

evasion of paying these taxes, nor do they provide a link between the stakeholders whom

employers and employees and the social security because they do not pay subscriptions, and

thus do not provide a direct sacrifice of the social security.

3. Finance by a dual system

72

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Durand Paul – la politique contemporaine de sécurité sociale – Dalloz – 1953 – P 331 74

26ص – 1991 –بزوث – 3ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا 75

M.R. Jambu Merlin, cours de sécurité sociale, Paris ,les cours de droit 1968-1969 P 114

According to the traditional model of financing, the distribution of financial

responsibilities relate to the development of branches, where there are equality in the

contribution between workers and employers in the framework of social insurance. With the

modern theory of social security, and expanding the field of protection that started in the

social insurance to reach Social Security, methods of funding has developed, and the

traditional balance of the distribution of burdens had been developed too.76

Has also stated in paragraph 1 of Article 71 of Convention No. 102 Date June 4, 1952

issued by the International Labor Conference, concerning Minimum Standards of Social

Security stated as follows: "financing the costs of benefits provided pursuant to this

Agreement and the costs of management, total funding, from insurance subscriptions or

taxes, or both, in a manner ensuring the absence of heavy burdens on people with small

incomes, and takes into account the economic situation of the Member State and the

categories of protected persons. "

On the Arab level, the Arab document about Social Security issued in 2003 in Article VII

recommended as follows: "The fund of Social Security is through: Subscriptions that are

identified by the system in each country and the amounts allocated by the State in the public

budget for social security as permanent resources and invest the proceeds of social security

fund and reserves and property and other income that accrue to the Social Security Fund.‖77

Currently, we find that many countries that rely in financing social security system

through subscriptions have started to resort to the adoption of double-funding through taxes

and contributions.

Germany, for example, that rely on the system of financing social security through

subscriptions and taxes began to seek to reduce the share of subscriptions from the cost of

public funding, may now have reached to 66% (was 72% in 1990), where Government of

Angela Merkel raised the proportion of value added tax from 16 % to 19% in the January 1,

2007 to finance part of the cost of Social Security.

76

627ص –يذكىر سابقا –انضا اإلجتاػ ف انتشزغ وانفق واالجتهاد –د.ػايز ػبذ انهك 77

5ص –2005 –انتظى انان نهضا اإلجتاػ ف نبا واقؼا وتصىراث –دراست –د. ػايز ػبذ انهك

4. Funding of the Lebanese social security system

Lebanese social security system mainly funded by subscriptions of people subject to this

system, the employers and employees, and the owners themselves, for non-wage earners

category, however the state contributes a portion of this funding.

It is noted that the bulk of subscriptions borne by employers, where employees

contribute only by very low portion (2% vs. 21.5% borne by the employers).

With regard to the majority of employees, the subscriptions are calculated based on a

percentage of the total wages they are paid, not to exceed a certain level of wages (max).

Also the earning subject to the subscriptions should not be below the minimum wage.78

Article 64 of the Social Security Law in its first paragraph stated as follows: "Every

branch of social security announced in Article 7 of this law, enjoy financial independence,

and act with its own resources to cover its performance." So as to determine the rate of

subscriptions for each branch separately, and every branch that provide the balance between

expenditure and revenues.

Article 71 of the Social Security Law stated the following: "the subscription rates are

identified by decree of the Council of Ministers upon the proposal of the Minister of Labor

and Social Affairs and end of the Board of Directors, which are set as a percentage of

earnings subjected to the discounts, so as to enable its revenues to cover benefits and

expenses of administration and composition of the permanent capital of the reserve stated in

Article 66 of this Law. " these subscription rates were adjusted, and are currently distributed

as follows:

a. Branch of retirement compensation: Select the subscription rate of for this section eight and

a half percent (8.5%) of earnings subject to subscription under Article I of Decree No. 2951

Date of 20/10/1965, with no limit to this gain, and it is still in force until now, and this rate

is distributed as follows: eight percent (8%) for the employees guaranteed and half percent

78

31ص – 1991 –بزوث – 3ج –انستفذو ي انضا اإلجتاػ انهبا –شىفا د. اج

(0.5%) to cover administrative costs and burden; and eight percent (8%) of earnings subject

to subscriptions under Article II of the same decree for craft institutions (one of its

conditions that the capital does not exceed twenty thousand LBP.); added to that the

settlement amounts paid by the employer upon the liquidation of the employees

compensation as announced in paragraph 4 of Article 54 of the Social Security law.

b. Branch of family allowances: the subscription rate for this branch has been adjusted and is

currently identified for the non-craft institutions by six percent (6%) of subject earnings

starting in 04.01.2001 under Article II of the 5102 Decree No. 24 / 3 / 2001. As for craft

institutions it have been identified ten percent (10%) of the official minimum wage for the

employee and three percent (3%) of the official minimum wage for trainee starting in

1/3/1992 under Decree No. 2181 Date 29 / 1 / 1992.

c. Branch of sickness and maternity: the subscriptions rate of this branch has been adjusted

and is currently identified for the non-craft institutions by nine percent (9%) of subject

earnings starting in 01.04.2001 under Article II of the 5101 Decree No. 24 / 3 / 2001. As for

craft institutions it has been identified by seven percent (7%) of the official minimum wage

starting in 1/7/1993 under Decree No. 3684 date 22/6/1993

d. Branch of emergency of work and occupational diseases: the rate of subscription of this

branch is not yet identified, because it has not been realized so far.

As for the earning subject to the subscriptions it was defined in paragraph 1 of Article 68

of the Social Security Law, as follows: "The earnings taken for subscription include a total

income from work, including all components and accessories, especially the overtime paid,

and the amounts paid to third parties are usually from people (gratuities), as well as benefits

provided to the worker.79

One can say that all compensation, bonuses and grants given to the employee because of

his membership of the institution or the project is one of the complements of payment unless

officially excluded by a paragraph, whether the professional expenses, or malfunction or

damage. The complementary Elements of the wage are as follows:

79

641ص –يذكىر سابقا –انضا اإلجتاػ ف انتشزغ وانفق واالجتهاد –د. ػايز ػبذ انهك

a. Grants and awards: They are paid extra when they have a relationship with the organization

and conditions of employment and as overtime, granting holidays, end of the year award,

grant budgets, grants production and other. In order to regard the bonus as part of the wage,

it shall meet the elements of the public, and remain permanent and stable.80

b. Overtime Compensation: You must be characterized by the nature of continuity and

stability, and to be paid for periods of special work outside working hours applicable in the

organization.81

c. Compensation of transportation and representation: all the expenses the employee incurred

because of his work are not part of his wages.82

d. Housing allowance: it has been identified in paragraph 2 of Article II as follows: "the

estimated value of the benefit in kind for accommodation per month is 20% of the official

minimum wage if the house is within the scope of the work place.83

If the house is owned by

employer and outside the scope of the work place, the estimated value of benefits in kind is

identified according to the rental value specified by the Ministry of Finance. The amount of

housing allowance cash is one of the appendages of the pay and included in the

subscriptions‖.

e. Food and clothing: paragraph 1 of Article II of the assessment system stated as follows: ―the

subscriptions include the excess of the limit value of the food subsidy specified in the law

No. 137 of 28/10/1999 which is five thousand LBP. per employee and per working day

actually in the form of a meal. Also it includes the excess of the annual value of the clothing

specified in the law No. 137. "

f. Compensation and grant of a personal and social nature: the subscriptions include the excess

of the legal family allowances paid by the Fund. The granting of marriage, birth, death and

school grants are not included in the calculation of earnings subject to subscriptions.84

With regard to the maximum earning subject to subscriptions, it was specified in the

Social Security Law in paragraph 2 of Article 68; by one million five hundred thousand

LBP for both sickness and maternity branch and that of family allowances.

80

245ص – 1ج –انىسظ ف قاى انؼم –انشخب – 8/7/1997تارخ 273و.ع.ث. رقى 81

21ص – 1971 –يجىػت أبى اضز وبشز – 4/2/1971تارخ 165رقى –و.ع.ث. بزوث 82

19ص 1971يجىػت أبى اضز وبشز – 12/2/71تارخ 188-181،ورقى 20/1/1968و.ع.ث. تارخ 83

Encyclopedie Dalloz – Soc. salaire n 95 84

644ص –يذكىر سابقا –انتشزغ وانفق واالجتهاد انضا اإلجتاػ ف –د. ػايز ػبذ انهك

For the amounts approved for the subscriptions of some categories of non-wage earners

are defined as follows: 200% of the official minimum wage as stated in 01/07/93 Decree

No. 3683 date 22.06.1993 and with respect to the sellers of newspapers, magazines, and

drivers non-owners of public vehicles; and by 200% of the official minimum wage for both

sickness and maternity branch and that of family allowances.

As for the distribution of subscriptions in funding branches are defined as follows:

a. Branch of retirement compensation: employer and employees of non-wage earners category

bear Subscriptions belonging to this section.

b. Branch of family allowances: the employer bears the subscriptions of his employees for this

branch. Also the sellers of newspapers, magazines, and drivers non-owners of public

vehicles pay subscriptions to this section. The drivers’ owners of public vehicles pay 5.5%

of the official minimum wage and the state treasury bears the amount remaining.

c. Branch of sickness and maternity: for employees in the non-craft institutions, the

proportions of subscriptions belonging to this section are distributed as follows: 7%

employer and 2% on the employee; and for employees in the craft institutions as follows:

5% employer and 2% on employee guaranteed. Also the sellers of newspapers, magazines,

and drivers non-owners of public vehicles pay subscriptions to this branch. The drivers’

owners of public vehicles pay 5.5% of the official minimum wage and the state treasury

bears the amount remaining.

There are also some groups that are not subject only to the branch of sickness and

maternity; like town mayors where their rate of subscription to fund this branch has been

identified by 9% of twice the minimum wage, distributed as follows: 1/5 borne by mayor

and 4/5 on the responsibility of the State Treasury in accordance to The provisions of

paragraph 2 of Article I of the Law No. 225 dated 29/5/2000. As well as the where their

rate of subscriptions to fund this section have been identified by 9% on the basis of defined

monthly earning sum of one million one hundred thousand LBP., under the provisions of

Article II of the Decree No. 12374 Date of April 30, 2004. As well as for university students

whom their rate of their contributions to the branch have been identified by 30% of the

official minimum wage, per year, for the student and for each beneficiary with him

(husband, children).

With regard to the subscriptions of the State in funding the social security, there are

many reasons that brought the state to contribute to this most notably: the inadequacy of

resources provided by subscriptions, the inability of some economically vulnerable to pay

full subscriptions, achieving greater solidarity among all segments of society.

The most prominent forms of the state's subscription in financing the security is its

contribution by 25% of the value of benefits relating to branch of sickness and maternity as

announced in paragraph 2 of Article 73 of the Social Security law. The state also bears the

proportion of the subscriptions of town mayors and drivers who own public vehicles as

mentioned above.

In addition, the state gave the National Social Security Fund some privileges, even if it is

not sufficient: it relieved the Fund to pay all taxes and fees, including stamp fees and legal

fees, real estate and taxes due on real estate that can be owned by the Fund, in addition to

the mailing exemptions and the possibility of exemption from customs fees when importing

pharmaceuticals and machinery protease according to the text of Article 67 of the Social

Security law. The state can also, in accordance to the provisions of paragraphs 3 and 4 of

Article 66 of the Social Security law to provide money on account to the Fund in the case of

loss of balance in its budget or to grant him exceptional assistance in the case of a national

disaster.

The social security fund include also the value of delays increases, half per thousand for

each day of delay in accordance to the provisions of paragraph 1 of Article 79 of the Social

Security Law, and the value of the fines stated in Articles 75 and 80 and 81 of the same law.

Finally, it can be regarded that the revenues invested of the Fund are important source of

funding, especially with a surplus of funds in the retirement fund, the social security law has

established for this purpose, a financial committee tasked to invest the fund and identify its

powers and functions in paragraph 2 of Article 64. Also the same law gave the social

security fund the right to build and fund the establishment and investment institutions,

clinics and medical or pharmacy and that in paragraphs 1 and 2 of Article 22.

B. Financial situation:

The National Social Security Fund is a safety net for many Lebanese as the only sector

that give social and human services through the implementation of the policy of the

Lebanese state in the context of the social field. For that we must maintain the integrity of

its financial position in light of the current trend to expand the field of application of social

security coverage through the new categories of the Lebanese, and secure additional

benefits. What is the financial situation of the Fund now?

The figures we will focus on in this chapter refer to the Fund's results in fiscal years 2000

through 2009, the numbers that we could get them from the accounting department in the

National Social Security Fund.

1. The current financial situation of the National Social Security Fund:

The financial results until the end of the year 2009 and projected for future years for the

status of the National Fund for Social Security in the three branches and their submissions

(sickness and maternity insurance, family allowances, and compensation for the end of the

service), worth an analysis from the economical, social and Financial points since it is an

indicator for many primary issues and one of the basics of living burdens of interest to more

than 500 thousand guaranteed benefit on their responsibility more than one million and 200

thousand Lebanese citizen.85

In the fiscal subject, the permanent deficits in both the health insurance and family

allowances need a radical and rapid solution on the levels of administrative, political and

living conditions, especially as the size of the accumulated deficit of the branch of health

85

ػذا انحاج –انصفحت اإلقتصادت – 4/10/2010ػذد –صحفت انسفز

insurance exceeded 316 billion pounds until the end of 2009 despite the savings achieved by

the branch at the end of the latter year the by the State's contributions which exceeded the

210 billion pounds of which about 191 billion pounds of the branch above, in addition to

raising the minimum wage 200,000, which contributed in the increase in subscriptions.

But more important is that the money taken to cover the deficit is from the branch of old

age which represent the compensations of the beneficiaries, and this is contrary to law,

because of the independence of the financial and administrative branches. With this in mind

that the revenues of health insurance during the year 2009 amounted to 627.9 billion

pounds, up about 44.42 percent, however, the balance is still missing on the short and

medium term if the issue of contributions and of tax and installment accumulated debt by

the public and private sectors is not solved.

So is the branch of family allowances, which its accumulated deficits reached about 307

billion pounds, making the total deficit in the branch of the service end about 623 billion

pounds. 86

The most serious of all, the Social Security Law imposes composition of reservations and

savings for these two branches, according to the provisions of Article 66 of the Social

Security Law, that the reserve constitute the sixth with regard to sickness and maternity fund

and family allowances; also the same article in the second paragraph announced that if

capital reserve didn’t reach the minimum previously mentioned at the end of fiscal year

certain, the government on the proposal of the Minister of Labor and an end to the

Governing Council may decide to raise the contribution rate starting in July of the year

following the fiscal year that are complaining about the deficit, so that the subscriptions

become sufficient to restore financial balance and achieve the minimum capital reserve

required in the period of three years at most, i.e., that this paragraph has given six months to

increase the contribution rate which is not received after almost 10 years, what constitutes a

contravention of the provisions of the Social Security Law. This requires further treatment at

the legal level, either to amend the law, or to reconsider immediately in the rates of

contribution.

86


The most important point in all of these things is that financial outlooks that show the

results refer to something like a lack of growth in the people associated to insurance, where

it was expected that the employees working in institutions to increase until 2011 by about

1.5 percent, and this means that the association to the Fund is still in its weakest level, an

indicator of more high unemployment on the one hand, the high frequency of workers'

silence on the other hand. This is with reference to the fact that Lebanon needs to create

between 25 to 30 thousand jobs per year, while what the Social Security Fund estimated in

regard with the new members associated does not exceed 5400 guaranteed.87

Searching in the same subject, the end of service branch can be considered as a full

branch since it is based at a rate of 8.5% on the whole wage in its subscriptions, and that its

submissions are limited in cases of resignation or liquidation, making its contributions larger

than its provisions, in particular that the amount of the settlement between the contributions

paid from the employers for employees and the compensation the employee bears. noting

that during the years of inflation and the deterioration of the LBP. and the melting of the

value of compensation of employees after their wages, the percentage of the settlement

amounts reached more than 60 percent of the value of compensation, which made employers

before workers seek to apply the system of old age, retirement and social protection, rather

than the branch end of the service so as to avoid of the value of the settlement amounts

equal to multiple of times the value of compensation and assets of the end of service branch.

88

The most important point is that the assets of the branch of end of the service at the end

of 2009 and the beginning of 2010 was more than 6400 billion LBP., and that the bulk of

this money goes back to the investment of the money of the Branch in Treasury bonds since

the eighties. The end of service branch has achieved a surplus in 2009 reached about 884

billion pounds, with revenue of about 1137.3 billion pounds, an increase of 49.9 per cent,

while the value of submissions reached about 424.9 billion, meaning that the savings

achieved equivalent to twice the benefits and compensation paid by the Fund, this without

87

ػذا انحاج –انصفحت اإلقتصادت – 4/10/2010ػذد –صحفت انسفز 88


any increases or amendment in compensations which had no longer be considered as a

guarantee for the employees who leave their work or those who end their service.

2. Financial results of the National Social Security Fund 2000 - 2009

The Article 64 of the Social Security Law in its first paragraph announced as follows:

"Every branch of the Social Security has its financial autonomy, and act with its own

resources to cover performance."

For this we will present the annual financial results for each branch separately.89

For year 2000:

Table (37): annual financial result for each branch 2000 (Amounts in billion LBP.)

Deficit Surplu

s Expenses Revenues Branch

- 76.3 26565 34168 Sickness and maternity

- 72.7 21268 28565 Family allowances

- 370 18962 55962 Compensation of end of service

For year 2001:

Table (38): annual financial result for each branch 2001(Amounts in billion LBP.)

Deficit Surplu


89

يصهحت انحاسبت –أرقاو انصذوق انىط نهضا اإلجتاػ

107 - 362 255 Sickness and maternity

- 26 201 227 Family allowances

- 300 265 565 Compensation of end of service

For year 2002:


Deficit Surplu


153.7 - 42265 26868 Sickness and maternity

76.7 - 23767 161 Family allowances

- 330.8 31762 648 Compensation of end of service

For year 2003:


Deficit Surplu


118.8 - 442 323,2 Sickness and maternity

87.4 - 247,1 159,7 Family allowances

- 479.4 208,3 687,7 Compensation of end of service

- 4.4 3,5 7,9 Optional security

For year 2004:


Deficit Surplu


110.5 - 455,4 344,9 Sickness and maternity

76.7 - 247,7 171 Family allowances


1.2 - 34 32,8 Optional security

For year 2005:


Deficit Surplu


- 27.9 455,9 483,8 Sickness and maternity



1.9 - 32,4 30,5 Optional security

For year 2006:


Deficit Surplu





- 2.6 38 40,6 Optional security

For year 2007:


Deficit Surplu




- 547.8 200 747,8 Compensation of end of service


For year 2008:


Deficit Surplu


103 - 537,8 434,8 Sickness and maternity



- 2 21 23 Optional security

For year 2009:


Deficit Surplu


- 12.1 615,9 628 Sickness and maternity




Through these numbers we can note the following:

With respect to branch of sickness and maternity: the Fund, this branch had achieved a

surplus by the year 2001, the year when the contribution rate was reduced. We can also note

that at the beginning of this year, the result of this branch had varied; it had a large deficit in

the years 2001, 2002, 2003, 2004, 2006, 2008, and a less deficit in 2007, with a surplus in

2005 and2009.

Regarding to branch of family allowances: it is similar to that of sickness and maternity,

this branch achieved a surplus until 2001, then made a deficit in the following years with a

disparity between high deficits in the years 2002, 2003, 2004, 2006, 2008; moderate deficit

in 2007; and low deficit in 2005 and 2009 the years during which the branch of sickness and

maternity achieved a surplus.

As for the branch of end of service: it achieves a financial surplus each year.

The optional security branch was put in practice by Decree no. 7352 Date 1/2/2002 and

start up force in 2003, the figures do not reflect the existing reality of this branch because its

submissions are almost stopped, and most affiliates’ do not pay subscriptions.

3. The reasons for the accumulated deficit for both branches the sickness and maternity

and that of family allowances:

If we want to analyze the financial results of the National Social Security Fund in the

preceding tables, we find that the reasons for the deficit began to accumulate for many

reasons, perhaps most notably:

a. Reduction of contribution rate: It is the main cause for the turn of the state of the sickness

and maternity fund and family allowances from surplus and the availability of saving

reserves to the state deficit. The subscription rate of these two branches have been reduced

under Decree No. 5102 Date 24/3/2001, which defined in Article II the contribution rate of

the branch of the family and educational benefits by 6% instead of 15%, and Decree No.

5101 Date 24/3/2011, which defined in Article II the contribution rate of the branch of

family allowances by 9% instead of 15%. This means a reduction by 9% for the branch of

family allowances and by 6% for the branch of sickness and maternity. This reduction was

the main reason for the deficit that began in 2001, as shown in the figures above. This

reduction was based on the text of Article 17, paragraph 3 of Security Law: "If the

permanent money reserved increased above the minimum mentioned in article 66, board of

directors, after the approval of the Council of Ministers, could approve the reduction of

contributions or increase of benefits." Indeed, there has been savings in the sickness and

maternity branch reached about 320 billion, but the reduction was significant and not well

studied, leading to the deficit.

b. debt owed to the National Social Security Fund, which is the second cause leading to the

deficit and that is what can be shown clearly in the numbers of the debt owed for the Fund

in general and specifically the state:

Table (47): Debt owed for the National Social Security Fund (Amounts in billions LBP.)90

Government Debt Total Debt Year

16361 31761 2000

24465 47364 2001

33867 613 2002

43762 74465 2003

48365 82668 2004

44069 71569 2005

47865 72462 2006

44565 63568 2007

50364 69762 2008

47769 64365 2009

Source: accounting branch in the NSSF

We can note that the debt of the state constitute more than half of the total debt owed,

and debt to be levied on the state as an employer and shareholder by 25% of the value of

sickness and maternity benefits, and as a shareholder in the contributions of the owner

drivers. If the numbers of the above debt is analyzed, we can explain the reduction in the

deficit in the years 2005, 2007 and 2009. The state's debt in 2005 decreased by 42.6 billion,

which means that the State has paid the amounts due by it for that year and paid a sum of the

accumulated debt and this situation was repeated the same in 2007, when the value of the

accumulated debt dropped by 33 billion, and in the year 2009 dropped by 25.5 billion.

90


Figure (49): Accumulated debt of the state (2000-2009)


c. Directors of the Fund took the opportunity and invested money in Treasury bills, where the

interest rate recorded low values until which it increase between the year 1995 and 1998

when it reach 40%-45%. After that, the interest rate decline again to about 6% in the recent

years:

Table (48): Interest on treasury bonds 2000-2009 (Amounts in billions of LBP.)91

interest Invested amounts Interest rate year

361 1965 14614 %- 16602 % 2000

296 243067 14614 % 2001

91


0

100

200

300

400

500

600

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Government Debt

31263 250862 10688 %- 14614 % 2002

35165 176967 6638 %- 14614 % 2003

20161 135866 5615 %- 6627 % 2004

6363 150766 6627 %- 7619 % 2005

171691 221164 7619 %- 9634 % 2006

20863 343664 7619 %- 9632 % 2007

22162 356861 865 %- 9632 % 2008

43867 4465 6620 %- 9632 % 2009


d. Employers evade the payment of contributions, and authorizing their employees and real

wages.

e. Increase in the international price in medicine

f. Increase of benefits for example, Decree 8641 Date 12/9/2002, and Law No. 220 of 29 / 5 /

2000.

4. expected additional expenditure for the future

In addition to the accumulated deficit in both the sickness and maternity branch and the

family allowances, is expected that these two branches in particular and the other branches

will suffer from additional expenses , that result from the expected expansion in the field of

application and from economic and social factors :

family allowances and education branch : workers ' claims began long ago about raising

the value of family allowances , that are defined under Decree No. 1348 dated 13.06.1991

and the applicable as of 07/01/1991 75% of the official minimum wage for wife and five

children . Has been amended by Decree 5103 dated 24/3/2001 and applied on 1/4/2001,

where the maximum become 225,000 for wife and five children, who means it remained

constitute 75 % of the minimum wage of the time 300000. In the year 2008 the minimum

wage was raise to 500,000 without an increase in the value of family allowances.

Sickness and maternity branch: hospitals and doctors should be asked about a new rate

that will undoubtedly increase the expenses of this branch , in addition to the continuous rise

in the prices of medicines . This is with reference to the completion in applying the

submissions relating to health insurance owed to insured and paying the amounts owed to

hospitals will increase the value of the deficit.

Branches and new submissions that we proposed in this research: For work emergency

branch and occupational diseases branch, it would impose high expenditures on the fund in

the absence of security and the necessary equipment for prevention in the workplace in most

of the Lebanese factories. This will impose variable rates of subscriptions according to the

kinds of professional activities with of extra addition to the contributions of institutions with

equipment not in conformity. For dental care, it will increase the expenses of the sickness

and maternity branch under a large deficit where the studies indicate that the expenses of

dental care could constitute between 10 to 20% of the costs of the branch’s current

expenses. As for the pension and social security system, it is similar to the end - of - service

and indemnity and it is supposed that it is totally funded.

New categories that are proposed to be subjected : for tobacco farmers , their high number

will impose additional expenses on both sickness and maternity branch and family

allowances because their numbers are large (about 30,000 ) in addition of being of rural

place of living, where the percentage of births is high and hence beneficiaries. As well as for

municipal workers, artists and writers who represent a model from all segments of the

Lebanese society and therefore the expenses of branches that they will be subject to and so

the revenue will increase at approximately the same proportions which means increasing the

expected deficit in the two branches. Finally, the attempt to find a solution to the

accumulated deficit and the expected additional expenses has become a matter of urgency.

C. Proposals to restore fiscal balance and cover the costs of expansion

There is no doubt that the social security of Lebanon, has become in need to a modern

comprehensive reconsideration, and for that we should wary about the agreements and

recommendations of the International Labour Organization, and refer to studies and

comprehensive research , organized by international experts , and give necessary

recommendations in the matter . The difficulties facing social security systems in Lebanon

and the world, make it necessary to go to the reform , and in this regard it highlights the

special importance of the reform of financial regulation of these systems , and reconsider the

traditional means of funding.

1. Reduce expenses

National Fund for Social Security, in the context of trying to restore fiscal balance, and

achieve desired reform, Must seeks to reduce expenses , particularly in funds of the

branches that suffer from continues deficit over years, with reference to the need for

attention not to diminish the submissions ; reducing the expenses can be achieved by

reducing administrative and social expenditure :

a. reducing social expenditure:

Adoption of a family doctor as an intermediary between the patient and the specialist doctor

or the hospital ,

Find alternatives to hospitalization (One day Clinic) adopted and developed by many

countries including the United States and most European countries, where it became the

policy of credit that led to a cost reduction by about 30 %.

Activating medical and administrative control devices in hospitals in order to adjust the

hospital bill.

Activating the role of the Directorate of inspection and control, so as to adjust unrealistic

earners who benefit from the submissions with no right for them.

Create , build and invest clinics and medical and pharmaceutical institutions , according to

the provisions of paragraph 1 of Article 22 of the Social Security Law , which relieves the

medical bill ;

Import of medicines and pharmaceuticals and other medical and surgical directly from

abroad, according to the provisions of paragraph 2 of Article 22 of the Social Security Law;

and benefit from the provisions of paragraph 2 of Article 67 of the same Law which

provides exemption from customs tariffs.

Put a (Flat rate) for surgical interventions as happening in many countries.

b. reduction of administrative expenses , by: activating the role of the administrative inspection

of the Fund, as though the administrative costs of the Fund is the lowest percentage among

the all guarantors systems in Lebanon, the current administration is serious about mitigation

(incentives, monitoring productivity, ...).

2. Increase revenues

The funding of the National social Security Fund is based on the contributions of employers

and insured; the success of the process of financial reform of the social Security requires

undoubtedly the increase in the revenue, which requires the government's contribution

through taxes specialized for this funding, even if this is on more than one stage due to the

current economic situation the country passing through.

Here are some suggestions to increase the revenues of the National Social Security Fund,

taking into consideration the financial difficulties facing employers and insured and the

government:

a. Increase the contribution rate: The contribution rate reduction in 2001 was not logically or

based on studies, where the total rate of subscriptions of both the sickness and maternity and

family allowances branch has been reduced from 30% (15% sickness and maternity and

15% family allowances) to 15 % (9 % sickness and maternity and 6% family allowances),

which led to a deficit in both branches since that date. And therefore contribution rates re-

raise of the two branches mentioned, need to take into account not to overburden employers

with very high rates in order to protect national institutions and labor. Raising contribution

rates without any study would have a negative impact more than those resulted from the

reduction, which happened in 2001. the high increase in these rates will increase the

financial burden on institutions which would make it unable to face international

competition also will lead to reduction in the volume of employment to reduce their

burdens. However we can suggest to raise the rate of subscriptions of the family allowances

branch one point so that it becomes 7% instead of 6 %, and raise the rate of subscriptions of

the sickness and maternity branch three points (two points on the responsibility of

employers and point the responsibility of the procedure) so that it becomes 12 % instead of

9 %, which could contribute in funding dental care.

b. Raise the maximum value for Subscriptions: The maximum value of the earnings subject to

subscriptions identified in 2001, by 1,500,000 LP for sickness and maternity branch and

family allowances which was equivalent to five times the minimum wage (the minimum

wage was three hundred thousand pounds). In 2008, the adjustment of the minimum wage ,

which became five hundred thousand LP , without modifying the maximum earning subject

to Subscriptions which became equivalent to three times the minimum wage only. Not so

far, the minimum wages had been modified to become 675,000 LBP .this situation requires

the issuance of a decree to raise the maximum earnings subject to subscriptions to stay at the

same proportion five times the minimum wage, which provides funds to sickness and

maternity and family allowances branches. however the maximum subjected earning policy

should be canceled because its abolishment helps in achieving the redistribution of income

by Social Security, also contributes to the achievement of equality between employees ;

Under the current policy , the employee , who receive a salary of one million LBP. ,pays 2%

of his income as a subscription in sickness and maternity branch ; while the employee , who

receive a salary of three million LBP. contribute by only 1% of his earnings .

c. Activating the role of the Directorate of inspection and control, making it possible to declare

about hidden institutions and employees, and to ensure coordination between the Fund and

the Ministry of Finance monitors, including identifying real wages. also it is working on a

regular and periodic control for all institutions registered with the fund once every five years

as stipulated in item (a) of paragraph 3 of Article 11 of the system of inspection and

monitoring of employers, and to conduct the survey for the hidden institutions once every

ten years at least to declare them and settle their financial positions towards the Fund as

provided in clause (b) of paragraph 3 of Article 11 of the same system; especially since a

large proportion of hidden employees are foreigners , the fact that this category of wage

earners do not benefit from social Security benefits (except for wage earners who belong to

one of the following countries: France, Belgium, Britain , Italy) and therefore those earners

ar not interested to claim their employers about the security , while declaring those earners

provide a high earn for the fund, where subscriptions are paid without the benefit from

submissions.

d. The government and public sector organizations pay the accumulated debt, allowing the

Fund to benefit from these funds through investment.

e. Encourage private sector institutions to repay debts owed them

f. Diversify the sources of funding for social security where the government can impose taxes

and fees specialized for this aim, where to impose such taxes and duties on goods and

sectors that will increase the expenses of medical care, like the taxes levied on alcohol and

alcoholic beverages or smoke.

And as an example is the French experience, where they were supporting social security by

imposing fees on vehicle registration and insurance, and fees on alcohol and pharmaceutical

advertising.

3. Invest Social Security funds reserves

This reserve is a surplus in the money after the benefits and administrative expenses, and

whenever possible, increase the rate of the proceeds of this investment whenever possible

diminish the Subscriptions or increase benefits both quantitatively and qualitatively, in

addition to that, following an investment plan lead to control inflation factors and their

impact on the submissions and on social security funds, so as to maintain the continuity of

the real value of these funds. In Lebanon it was previously limited to investments in banks

and loans to some academic educational and humanity institutions,. Currently investments

are focused on Treasury bonds, which were achieving a high rate of revenues between 1995

and 1998, where the interest rates on Treasury bonds were between 40 and 45%, but now it

is no longer feasible dropping these benefits to between 6 and 9 % in recent years (2004

until now).

Conclusion

The health sector contributes to the development of national wealth, through the terms of

health care services and creation of employment chances. On the other hand, improvements

in income and living conditions have a positive impact on the state of health, as shown in

the case of Lebanon by the reduction in mortality, increases in life expectancy and changes

in epidemiological and demographic profiles. Economic growth also allows for the

development of the health infrastructure and technological innovation.

Unsatisfactory health conditions add to the cost of development through unhealthy

lifestyles, and losses due to morbidity, mortality and disability; and through the burden of

disease and high cost of treatment and hospitalization.

The health-care system displays a number of weaknesses that affect adversely the overall

process of sustainable human development. The public financial resources allocated to

health go mostly to cover increasing spending on reimbursement of hospital care provided

predominantly by the private sector. These have a tendency to over-prescribe expensive

medical technology and high cost drugs in a largely unregulated environment. As a result,

total health expenditures, both in absolute terms and as a percentage of GDP, have risen

sharply (the former doubling in less than three years) to levels comparable to those

prevailing in the industrialized countries, and higher than in most of the rest of the world.

The bulk of health expenditures are paid by households’ out-of pocket; thus affecting

disproportionately the less affluent and the poorer segments of the population.

Little resources are available to primary health care including preventive care. National

health policy is based on health being the right of every citizen. Health policy also

emphasizes increasingly that prevention should take precedence over cure within the context

of primary health and through providing a degree of autonomy to regional and sub-regional

units. The policy also stresses pooling of publicly financed resources to achieve maximum

coordination, effectiveness and efficiency, while at the same time promoting partnership

with the private sector, professional associations and community representatives.

The main problem in the health sector, specifically at the household level, is access to

quality care due to lack of health insurance coverage, low income levels and rigid patterns

of household expenditures, which are devoted to essential items that cannot be reduced or

replaced. Available information indicates that spending by the poor is directed first to food

needs, then to housing, education and transport, in that order. Health care is postponed until

the need for treatment becomes acute and cannot be delayed further. This, in the end, will

raise treatment costs.

This paper addressed basic problem on which the Lebanese suffer from high cost

health insurance for low quality service. The financial analysis shows that the health care

system in Lebanon is suffering from structural problems that are directly affecting the cost

and hence the equal accessibility by all citizens to this service. Among the major

predicaments and constraints contributing to the high cost and inequity features are:

1. The inequity in accessing both protective and healing health care among the different

Lebanese regions which was clearly illustrated through the huge disparities in child and

reproductive health indicators.

2. The relatively huge amount paid as out-of-pocket reflects, to large extent, many constraints

facing the health system in Lebanon. Out-of-pocket spending on drugs is clearly

unmanageable resulting from two major facts: first, the lack of control at the drug market

level. The second fact lying behind the huge drug bill is directly related to the lack of

control on physicians and pharmacists.

3. The pluralistic nature of the health care system and the consequent incoherent and

inconsistent flow of both financial resources and regulations through the chain of players

involved in the health system.

4. The multiplicity of the system results in a redundancy in the administrative staffs

responsible for the health care system. Specifically, the problem arises in the health care

financing agencies, having a notable proportion of expenditures allocated for the

administration and staffing.

5. The health care market ceased, to large extent, to be a social basic service with every citizen

owning the right to have access to. However, it is currently driven by the forces of supply

and demand, mainly in terms of pricing the health services against the quality of services

provided. The problem is further accentuated by the relative weakness of the preventive

health care which is attributing to raising demand for health services, and hence affecting

the trend of pricing of these services.

6. The role of the government in this messy environment is not clearly identified. On the one

hand, the Ministry of Health- being the main government representative in this regard- is

tending to invest in health market by providing additional hospital beds and health centers,

meanwhile the statistics reveal that the market is almost over-saturated, except for some

specific geographic areas. On the other hand, the regulatory role of the government is still

lacking efficiency mainly as to controlling the private sector in terms of pricing of health

services and insuring equitable access to these services.

Also, an international comparison of the health expenditure push us to highlight on the

Singaporean health system which teaches us that patients must understand that health

services cost money and that they should pay a portion of those costs. It teaches us that

hospital and doctor incentives must encourage them to provide the best service at the best

price. Government can create a framework of rules that does that. And it does not have to be

a cold-hearted solution. The framework must also assure that people have the ability to pay,

and it must provide a safety net for those who cannot. Lastly, all health costs and outcomes

should be transparent to the patient and the payer.

The third part was about studying the role of the National Social Security Fund in

developing the health system by applying a proposal that aim for the expansion of its

application by including new categories. Moreover, the proposal also includes the expansion

in the services by covering new services like dental care and pension and social security.

Also it is discussed in this chapter the current financial situation of the National Social

Security Fund and the reasons for the accumulated deficit.

We have come to the following conclusions:

1. The need of social security to cover all risks and should include all the Lebanese people to

achieve equality and the principle of national solidarity and social solidarity.

2. Accelerate the application of the branches and submissions provided for in the Social

Security Law and not applicable till this date (emergency work and occupational diseases

and dental cares).

3. Adoption of the pension system and social protection which embodies the hopes of the

workers and other persons secured in achieving security for them after their retirement, and

after conducting the necessary studies to ensure its continuation.

4. Both branches sickness and maternity and family allowances suffer from accumulated

deficits since 2001, and the reasons for this inability to reduce the subscriptions rates of

branches mentioned, and not to raise the maximum of the gain subject to membership fees

and delay by the State for payment of debts owed to the National Social Security Fund.

5. The need to reduce the expenses of the Fund's administrative and social, without affecting

the submissions.

6. Increase revenues by raising subscriptions rates and raise the minimum and activating the

role of inspection and control and debt collection.

7. The need to increase the state's subscriptions, with the imposition of new taxes and fees

specialized to return the proceeds to fund the National Fund Social Security.

8. Improve the methods of the investment of fund reserve.

I hope that this thesis have successful achieved its objective through giving an overview

of the current situation of social security, methods of funding it, and proposals to restore

fiscal balance. I hoped to find more statistics on the labor market and the number of

employees and the number of public and private institutions and the average age and

average number and average family income, but there were very few statistics.

In the end, some questions that concern the Lebanese public opinions are asked:

When can the National Social Security Fund submissions include all the Lebanese?

When can the Lebanese social security cover all the risks? What is the possibility of

establishing a fund for unemployment which records high rates in Lebanon?

Generally speaking, there is a need to define roles and improve activities on the different

levels of health systems in order to prevent wasting resources, set health standards and

improve the quality of health services. Concerning health reform, the self-evident question

is: will the current health expenditure remain the same?

Recommendations

Health sector reform has been described as a sustained purposeful attempt to improve the

performance of the health sector. It is motivated by the need to address fundamental

deficiencies in health care systems. It is an inherently political process, and it is often

implemented on a sector-wide level.

Countries undertake health reforms when there is evidence of poor performance, when

public expenditure neglects the poor, when resources are scarce and demands are increasing

forcing governments to reconsider the situation, when consumers are unhappy about poor

treatment and when there are concerns about sustainability.

There is an immediate need to introduce fundamental reforms in order to establish a

sound basis for an equitable, efficient and financially sustainable health care system. These

reforms must address the points of weaknesses encountered in the health system in Lebanon

from different perspectives.

1. Recommendations regarding the Lebanese health system

a. Developing National Health Accounts: The introduction of a new national health strategy

cannot take place in the absence of relevant data for appropriate analysis and decision

making. The high complexity of the health care system in Lebanon, coupled with the lack of

reliable data on the structure and functioning of this system, has weakened the performance

of policy-makers as well as the financing agents. The introduction of national health

accounts, which quantify patterns of data on health spending by sources of revenues and

types of services purchased, would significantly contribute to improving the ability of

decision-makers to identify problems and opportunities for change, and to develop and

monitor reform strategies.

b. Regulating the private sector: The uncontrollable growth of the private sector burdens the

ministry of health and hinders the effective operation of the health care market in Lebanon.

In this regard, it is strongly recommended that the ministry of health regain its role as a

regulator of the health care market, rather than as a financing agent. There is a need to

license and monitor the health care market, regulate and control the delivery of health care

services, improve the quality of care, contain health care cost and improve the management

of the heath care sector. In addition, the ministry of health needs to get a better

understanding of the size, composition, and characteristics of the private sector, in order to

be able to contain costs, unify prices, ensure quality of care and build a public-private

partnership (Public hospital autonomy).

c. Unifying Coverage schemes and prices among different Financing agents and

providers: there is a discrepancy in the coverage schemes adopted by the different

financing agents, as well as in the prices charged by the different providers. The major

reason behind these discrepancies is the diversity of the supervisory ministries in the health

care market. It is recommended to have one health financing agent (as the National Social

Security Fund), under the supervision of one regulatory ministry (as the Ministry of Health),

and to establish a high level committee at the Ministry of Health that will coordinate and

supervise this effort.

d. Regulating the pharmaceutical sector: The drug bill has dramatically increased in the last

few years. The proliferation of drug types, coupled with the over-use and the inappropriate

use of these drugs, is significantly contributing to the magnification of the annual health bill

in Lebanon. In this context, it is recommended to undertake some reforms including:

limiting the number of drugs that can be imported by adopting essential drugs lis

Controlling and monitoring the quality, specifications and prices of all imported drugs.

Encouraging domestic drug production within an effective regulatory framework.

e. Ministry of Health efforts on Flat Rate payments and Clinical protocols: The Ministry

of Health is burdened by high health expenditures. The first priority of the MOH is to cover

the bill of private hospitals. The MOH is troubled with this bill and its complexity and the

way of reimbursing private hospitals, setting tariffs and trying to bear cost. One decision

was to change the way MOH reimburses hospitals by using the flat rate payment by

diagnosis or surgical procedures (DRG Diagnosis Related Group) instead of the Fee for

Service (FFS) following the American or the Canadian system. The flat rate system is

attempted to solve the MOH problem with the bill control, the money spent on

administration and using the physician control at the private hospital to control the billing.

But this strategy will create another problem for other financing agents that have no problem

in control. The DRG doesn't fit in Lebanon especially that cheating will affect the quality of

service delivered and so clinical protocol is necessary. What the MOH will face is the

application of the system with the other financing agents. Another problem is highlighted in

this context which is that every decision taken by the MOH should be applicable country-

wide and compatible with the other financing agents.

f. Hospital Classification and pricing: The Private Providers are paid against their

classification. Classification decision results from the committee and is declared and signed

by the Minister. The upgrade of any Hospital classification will automatically affect the

price system of the hospital. The MOH will follow this classification, while other financing

agents will stick to the old classification (e. g., NSSF), resulting in discrepancies among the

different financing agents. One other point to be raised is the specialization of the public and

private hospitals creating redundancy in high-cost technological equipment. The trend in the

advanced countries is toward establishing specialized centers for specific diseases (heart,

cancer, fertility,). Taking into consideration the size of the country and the improving

conditions of the communication means, the establishment of such center seems viable and

will increase the efficiency of the service, and at the same time reduce the cost. The role of

the government should be the formulation of strategies to expand coverage in under-served

areas, develop protocols for specializing the existing hospital and establishing new facilities

and investments by the private sector in new technologies.

2. Recommendations regarding the National Social Security fund

a. Government is called to reconsider the level of spending on social issues, so that the credit

allocated to these expenditures are not used in disseminated projects that are not in relation

to one another. It should adopt a policy according to which expenditures are included within

the framework of a well defined social plan.

b. Contract the squandering and the social expenditures stemming from political, family, and

sectarian considerations, let alone corruption prevalent in public administration. All this

diverts the social spending from its target.

c. The state should have a clear vision about the Social Security Fund in which it defines the

kind of social security it wants, the social categories, which should benefit from such a fund,

and what kind of administrative structure should be adopted in order to ensure all these

contributions, the means of financing, the states part in financing. This vision is important to

adopt following years of lack of trust between state and the Social Security. This is due to

the spoils distribution system, which should be dealt with: such a policy leads to the

designation of according, not to their qualification, but to their political and social positions

as well as their degree of influence.

d. Activate the role of the Social Security by pumping new blood in the administrative body.

The average age of the personnel is 53 years old. A system of incentives should be adopted

to substitute the old sick elements with young ones as these would accompany the evolution

and modernization of the Social Security system and rationalize the health expenditures and

above all nominate new doctors to activate proper supervision and prevent them from being

submerged to sectarian blackmail.

e. Not to submit to political or sectarian pressures. This is what happened when the

administrative board decided to designate new doctors.

f. Strengthening the health system, including improving governance, health financing,

institutional capacity and service delivery, human resources development, medical

technologies and an integrated health information system.

g. Improving partnership for health development, including educating/ informing people,

orienting and involving parliamentarians and national decision makers, enhancing public–

private sector collaboration, collaborating with UN agencies, development banks and

donors, and helping in coordination of external support for health.

References

Books:

English:

1. Central Provident Fund, ―My CPF—Having Children: Providing for Your Precious

Ones. Life Events: Having Children: Immediate Concerns 2011.‖ Available at

http://mycpf.cpf.gov.sg/CPF/my-cpf/have-child/HC2.htm. Ministry of Health, ―Marriage

and Parenthood Schemes. Costs and Financing: Schemes and Subsidies 2011.‖ Available at

http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/M

arriage_and_Parenthood_Schemes.html

2. Chong, S.A., Mythily et al. ―Performance Measures for Mental Healthcare in

Singapore.‖ Ann Acad Med Singapore 37, 9 (2008): 791–6.

3. ―Grow and Share’ Package Overview,‖ 2011. Available at

http://www.growandshare.gov.sg/Overview.htmM.D. Barr, ―Medical Savings Accounts in

Singapore: A Critical Inquiry,‖ J Health Polit Policy Law 26, 4 (2001): 709–26.

4. National Coalition on Health Care, ―Health Care Spending as Percentage of GDP

Reaches All-Time High,‖ 12 Sept. 2011. Available at http://nchc.org/node/1171

5. Salma Khalik, ―Medisave Can be Used in 12 M’sian Hospitals,‖ Straits Times, 15 Feb.

2010. Available at http://www.asiaone.com/Health/News/Story/A1Story20100216-

198974.html




http://www.growandshare.gov.sg/Overview.htm

http://nchc.org/node/1171



6. Sam Ro, ―Revealed: !e Cost of Health Insurance around the World,‖ Business Insider,

26 Apr. 2012. Available at http://www.businessinsider.com/cost-ofhealth-insurance-around-

the-world-2012-4#ixzz1zZizuLFo

7. ―Risk Factors—Risks Relating to the Government—Uncertainties Regarding Formation

and Policies of the New Government‖, available at:


8. ―Conflicts With Israel,The July 2006 War‖, available at:


9. The Special Tribunal for Lebanon, available at: http://www.stl-tsl.org/en/

10. ―The Economy—Economic History—Fiscal Reform and the Paris II Conference‖,

available at:


11. ―History, Recent Developments, The Doha Agreement‖, available at:


12. ―Recent Developments, Doha Agreement‖, available at:


13. ―Risk Factors, Risks Relating to the Republic, Fiscal Deficit‖ and ―Risk Factors, Risks

Relating to the Republic, Prices and Inflation‖, available at:


14. Extracts Ammar, M. (2011), Inter-professional collaboration, Paediatric unit case in a

university hospital in Lebanon (PhD thesis).

15. Laithy, H. ; Abu-Ismail, K., ; Hamdan, K.; 2008, Poverty, growth and income

distribution in Lebanon,Country study, International Poverty centre, number 13.


16. Ministry of Social and Family Development. ―Ministerial Committee to Spearhead

Successful Ageing for Singapore,‖ 4 Mar. 2007. Available at

http://app.msf.gov.sg/PressRoom/MinisterialCommitteeToSpearheadSuccessfulAgei.aspx.

French:

1. Durand Paul – la politique contemporaine de sécurité sociale – Dalloz





http://www.stl-tsl.org/en/






http://app.msf.gov.sg/PressRoom/MinisterialCommitteeToSpearheadSuccessfulAgei.aspx

2. Encyclopedie Dalloz – Soc. salaire n 95

3. M.R. Jambu Merlin – cours de sécurité sociale – Paris – les cours de droit 1968-1969

Arabic:

2005 –بزوث –صادر –انضا اإلجتاػ ف انتشزغ وانفق واالجتهاد –د. ػايز ػبذ انهك .1

1987 – 2ط – 1ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا .2

1985 –بزوث – 1ط – 2ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا .3

1991 –بزوث – 3ج –انستفذو ي انضا اإلجتاػ انهبا –د. اج شىفا .4

Studies:

English:

1. Country Cooperation Strategy for WHO and Lebanon 2005–2009, available at:

www.who.int/countryfocus/.../ccs_lbn_final_en.pdf

2. Makhzoumi,fouad, The National Dialogue Party Political Program, available at:

www.alhiwar.info/Political_Program_English.p

Arabic:

2005 –انتظى انان نهضا اإلجتاػ ف نبا واقؼا وتصىراث –د. ػايز ػبذ انهك .1

Jurisprudence and laws:

10/12/1948 –اإلػال انؼان نحقىق االسا .1

23/9/1946قاى انؼم انهبا تارخ .2

26/9/1963تارخ 13955قاى انضا االجتاػ انفذ بانزسىو .3

–يجىػت أبى اضز وبشز – 4/2/1971تارخ 165رقى –بزوث قزار صادر ػ يجهس انؼم انتحك .4

1971

http://www.who.int/countryfocus/.../ccs_lbn_final_en.pdf

http://www.alhiwar.info/Political_Program_English.p

يجىػت أبى – 12/2/71تارخ 188-181، ورقى 20/1/1968تارخ قزار صادر ػ يجهس انؼم انتحك ، .5

1971اضز وبشز

1ج –انىسظ ف قاى انؼم–ب انشخ – 8/7/1997تارخ 273رقى قزار صادر ػ يجهس انؼم انتحك .6

Patrols:

English:

1. Central Bank annual report, 2011, http://www.bdl.gov.lb/webroot/statistics/

2. CAS annual report 2011,


3. Daily Star, http://www.dailystar.com.lb

4. Encyclopedia of the orient (July 27, 2002), http://i-cias.com/e.o/lebanon_5.htm

5. Households Living Conditions, Central Administration of Statistics, 2011

6. Index-mundi website http://www.indexmundi.com/facts/lebanon

7. Lebanon History (2003),


8. Lebanon National Health Accounts 2009, December 2009

9. MOPH, 2011, Statistics Bulletin,

10. Ministry of Finance report, 2011, http://www.finance.gov.lb/en-

US/finance/ReportsPublications/DocumentsAndReportsIssuedByMOF/Documents/Sovereig

n%20and%20Invensment%20Reports/Country%20Profile/Lebanon%20Country%20Profile

%202011.pdf

11. Ministry of Economy and Trade, 2010, Annual report

12. National Health Accounts, 2008

13. National Social Security Fund- A brief review, August 2005

14. National Household Expenditure and Utilization Survey, 2008

15. Order of Physicians in Beirut and North Lebanon, 2010

16. Order of Pharmacists in Lebanon, 2009

17. Order of Dentists in Beirut and the North, 2008

18. Order of Nurses in Lebanon, 2011

http://www.bdl.gov.lb/webroot/statistics/


http://www.dailystar.com.lb/

http://i-cias.com/e.o/lebanon_5.htm

http://www.indexmundi.com/facts/lebanon






19. Order of Physiotherapists in Lebanon, 2010

20. Singapore Department of Statistics. Yearbook of Statistics Singapore, 2011.

Singapore: Singapore Department of Statistics, 2011.

21. The Massacres of 1840-1860,


22. The Maronites and Lebanon (2003),


23. WHO EMRO, 2011, Health System Profile, Lebanon

24. WHO website http://www.who.int/gho/countries/lbn/en/

25. WHO Department of Health Statistics and Informatics (May 16, 2012). "World Health

Statistics 2012

Arabic:

ػذا انحاج –انصفحت اإلقتصادت – 4/10/2010 –انسفز صحفت .1

سؤال يىج ي انائب حىري إنى – 10ص – 2005تشز األول 18انثالثاء – 2073انؼذد –صحفت انستقبم .2

انحكىيت ػ يصز ضا طب األسا

يصهحت انحاسبت –أرقاو انصذوق انىط نهضا اإلجتاػ .3






ParPadox of the Lebanese Health care System and the Role of the NSSF

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