By Dr Fadi El Jardali and Racha Fadlallah, Knowledge to Policy (K2P) Center-American University of Beirut
On 4 August, set amidst the global pandemic, Beirut was the center of another crisis of epic proportions. This time, an explosion of 2,750 tonnes of ammonium nitrate in the port shook Lebanon’s capital city to its core, killing 200 people. With thousands wounded and tens of thousands of homes damaged, the lethal cocktail of COVID-19 and the explosion has left the population bereft, and with deep anger at their political leaders.
It has been a hard year for the country as Lebanon has just marked one year since the anti-government protests on its proposed WhatsApp taxations. Even before 2020, the Lebanese government had consistently failed its people in many ways. A sky-high GDP, civil wars and waste-management crisis has contributed to a fledging economy and extreme inequality. The biggest inequality of all, was and still is, health.
As over 2,000 delegates come together for the Sixth Global Symposium on Health Systems Research to explore the theme of ‘Reimagining Health Systems’, if ever there was ever a time to reimagine Lebanon’s health system, it is now. Amidst the many disparities in Lebanon, health is at the top. COVID-19 has revealed many things about our societies, but one thing is that inequities are the defining feature of the pandemic. Those that are the most vulnerable to infection live in densely populated communities (from high-rises to refugee camps), experience unfair working conditions (i.e. garment and meat factories), live in multi-generational households, and are ageing populations with multiple health issues.
In Lebanon, the lack of focus on public health is notable. The pandemic has exposed the consequences of the political decision to not support the public health sector since the end of the civil war (with only 1.8% of MoPH budget invested in public hospitals (pdf)). The health system remains a sick care system, focusing on the cure, not on the cause – with very little investment in preventative measures.
Healthcare is barely affordable for nearly half the population and heavily privatised- meaning those who are the most vulnerable are least likely to access the care they need. The way the private health sector has acted during the pandemic, remaining visibly absent in the initial weeks of the pandemic, with limited engagement later on (even though it had over 85% of hospital beds in the country (pdf)), illustrates that the lack of regulation from the state is highly problematic.
While the global community is consumed with slowing the global pandemic, the reality is that there will be more crises. Failing to prepare now would be another fait accompli. As we face the likes of climate change, populism and much more, we must recognise the impact of political, social and environmental forces on the health of a population.
The health sector in Lebanon operates in a silo and disconnected from other ministries and sectors, with dominance of an unregulated private sector in provision and financing of care. Spiraling costs, inefficient structures, and rapidly changing demographic, epidemiological and economic trends mean that, without radical transformation, the healthcare system will fall short of recovering from the crises of the last year, let alone the ambitious goal of achieving universal health coverage by 2030 and the broader Sustainable Development Goals.
A radical new vision is needed if we are to strive for health systems that are accessible and equitable for all. Lebanon must:
- Develop a comprehensive multi-sectoral emergency preparedness plan: Authorities should learn from COVID-19 and the Beirut explosion and develop and revise their emergency preparedness plans to address stewardship and governance, information management systems, human resources, medical products and supplies, financing (dedicated contingency fund), service delivery and community preparedness.
- Invest in public health sector infrastructure: it is critical to revitalise the public health sector through increased investment in public hospitals and primary healthcare centers; strengthening of the public health sector workforce; construction of public health laboratory capacity; and advancement of data and analytics capabilities.
- Reinforce the role of government as a coordinator and regulator of health systems to harness capacities and resources of multisectoral, state and non-state actors, comprised of private and civil society organisations.
- Redefine the relationship between private sector and government: the pandemic holds lessons on the regulatory frameworks needed to harness the potential of the private sector, and the government’s capacity to enforce regulation in a way where both parties share risks, costs, benefits, resources and responsibilities.
- With an ageing population and growing non-communicable diseases burden including mental illnesses, it is critical to establish a human resource policy and plan that provides strategic direction for education, recruitment, retention, and capacity building of the healthcare workforce.
- Address the root causes of health inequity: the government must no longer regard health only as a biomedical issue; they must acknowledge that political, social and living environments have strong implications for health, and recognise that we simply cannot achieve better health for all without tackling these underlying causes that continue to perpetuate health inequity.