HOSPITALIZATION in LEBANONProgress of PUBLIC HOSPITALS
Antoine ROMANOSUNRWA Workshop
23/6/2011
• Health Indicators (Figures and Facts)• Hospital care (Private/Public)• Health system(Medical Professions/Health facilities)• Health coverage (Public funds)• Hospitalization Rate• Public hospitals (History and progress)• SWOT Analysis• RHUH (FIGURES)• Towards HEALTH CARD
HOSPITALIZATION IN LEBANON ROLE OF THE MOPH
Global Core Objectives of a Health Care System
• Universal access to all citizens• Effective care for better health outcomes• Efficient use of resources• High quality services• Responsiveness to patient concerns
Selected health indicators of LEBANON 2005-2009
Unit 2005 2006 2007 2008 2009
Total GDP
Billions LBP
32.945 33.917 37.926 45.346 52.650
Allocated to MPH from total Gov.
budget
% 3.6 3.12 3.05 3.26 2.7
Annual Budget MPH Billions
LBP360.3 348.8 361.6 373.9 439.7
Annual Budget MPH per
capita
USD 63.3 60.1 61.1 62.1 73.3
National health
Exp./Capita
USD 460
NHE as %GDP
% 8.3
Public Spending on the Social Sectors
Social Ministry of entity
Ministry’s Budget Total Public Spending
LBP Billion % of Government
Budget
LBP Billion
% of Government
Budget
Education 922.86 8.24% 1147.86 10.25%
Health 346.94 3.11% 593 5.30%Social Affairs
96.92 0.87% 96.92 0.87%
Total 1,366.72 12.22% 2,993.63 26.74%
Source: Ministry of Finance 2007
PUBLIC HOSPITAL
• Contracts with financing agencies (MOPH)• Hospitalized uninsured patients pays 5% of the bill in
comparison to 15% paid in private hospital ,the MOPH reimburses 85%
• The public hospital prices are thus 10%lower than those of private hospitals
• Public hospital is strictly not allowed to select patients nor to impose extra fees
• MOPH does not provide any preferential treatment to P.H and respects the patients freedom in choosing the physician and the hospital
PRIVATE HOSPITAL
• Development was relatively less affected by civil disturbances and continued to grow both in number and capacity
• Represent 90%of the total N. beds in the 1990’s• The percentage decreased later with the opening of
new public hospitals to 75%• Hospitals owned by physicians and philanthropic or
religious congregations (association of private hospitals )
• This pre-existing oversupply ,induced a greater demand and use of in-patients health services
Distribution of private hospitals according to bed capacity by MOHAFAZAT2007
MOHAFAZAT Less than 100 BEDS
100-200 BEDS
More than 200 BEDS
TOTAL
BEIRUT 15 4 4 23
MOUNT LEB 43 12 1 56
NORTH LEB 24 3 1 28
SOUTH LEB 21 2 1 24
NABATIEH 9 0 0 9
BEKAA 23 5 0 28
TOTAL 135 26 7 168
Distribution of MOPH contracted hospitals and allocated budget by MOHAFAZAT
Hosp % 2000 2002 2007 CEILING/ year
Million LBP
% Allocation
BEIRUT 23 13.7 22 8 11 28.248 13.4
MOUNT L 56 33.3 50 23 43 61.885 29.4
NORTH L 28 16.7 22 17 25 45.547 21.6
SOUTH L 24 14.3 19 11 15 30.904 14.7
Nabatieh 9 5.4 4 5 9 10.921 5.2
BEKAA 28 16.7 23 12 22 33.151 15.7
TOTAL 168 100 140 76 125 210.657 100
Amount Categories No. of Bills
No. of Bills (%)
Cost Cost (%)
< 500.000 45.093 25.51 % 15.948.713.175 6.99 %
Between 500001 & 1000000 63.139 35.71 % 46.055.179.208 20.2 %
Between 1000001 & 1500000 34.284 19.39 % 42.276.216.653 18.54 %
Between 1500001 & 2000000 11.912 6.74 % 20.557.670.241 9.02 %
Between 2000001 & 3000000 10.417 5.89 % 25.315.425.850 11.1%
Between 3000001 & 4000000 4.059 2.30 % 13.870.003.361 6.08 %
Between 4000001 & 5000000 2.524 1.43 % 11.346.203.658 4.98 %
> 5,000,000 5.360 3.03 % 52.651.075.949 23.09 %
Grand Total 176.788 100 % 228.020.488.094 100 %
Repartition of Hosp. cost by bill (LBP)
Patients Repartition by age /Cost /MOPH
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
0- 0-5 Years
1- > 5- 10Y
ears
2- > 10- 15Y
ears
3- > 15 – 20Y
ears
4- > 20 – 25Y
ears
5- > 25 – 35Y
ears
6- > 35 – 45Y
ears
7- > 45 – 55Y
ears
8- > 55 – 65Y
ears
9- > 65 Years
ND
Cost(%)
Count(%)
Number of Visas issued between private and public hospitals 2008
7726
40294
36044
31503
27530
8638
15976
7543
15339
10486
4465
12965
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
بيروت جبل لبنان الشمال البقاع الجنوب النبطية
المحافظة
خاصحكومي
Medical professions and Health Facilities
Manpower and physical resources Indicators per 10.000 population
2005 2006 2007 2008 2009 2010
Physicians 27.4 28.4 28.5 35.4
Dentists 10.1 9.8 10.9 13.3
Pharmacists 11.5 13.8 12.1 12.2
Nursing and Midwifery
16.1 13.2 17.9 22.2
Hospital beds
36 36 35 34.5
Occupancy rate /HospitalsOccupancy rate /Hospitals
Source: Ministry of Health
52%45%
37%
53%54%56%58%60%64%65%65%68%
72%80% 80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
OECDBah
rain
WBG
KuwaitSau
di Arab
iaSyr
iaTunisi
aJo
rdan
OmanLeb
anon Ira
nAlge
riaUAE
Moro
ccoEgy
pt
New technologiesMohafazat Population CT Scan RMI Open Heart
CentersBEYROUTH 416.000 13 12 6
BEKAA 504.000 23 4 3
MOUNT LEB 1.600.000 36 13 7
NABATIEH 236.000 4 0 0
NORTH LEB 820.000 15 3 3
SOUTH LEB 428.000 13 6 3
TOTAL 4.004.000 104 38 22
New technologies
DIALYSIS 36
Linear Accelerator 8
PET- SCAN 2
Comparison between LEBANON and FRANCE
(Yearly hospitalization cost )IndicatorLEBANON FRANCE
POPULATION4 MILLIONS60 MILLIONS
Yearly hospitalization cost
(USD)600.000.00073.200.000.000
Yearly hospitalization cost /Capita)USD (1501220
Hospital syndicate2005
Comparison (total exp. on health/GDP)2004
Country GDP Spending per person
$Lebanon 10.5% 469
USA 10.9% 4270
Switzerland 10.9% 3857
Germany 10.8% 2697
France 9.4% 2288
UK 7.5% 1675
Hospital coverage
• In 2007 ,the household survey(CAS) provided the number of people who don’t have any type of medical coverage across all age of groups
• These individuals are considered to be eligible population for the MPH services coverage
MOPH Coverage in numbersYear N of
admissionsN of patients
admittedRatio Total
Hospitalization Cost
(Billions LBP)
Average Cost
/Admission(USD)
2008 218.000 158.000 1.37 213 650
2009 226.000 169.000 1.33 220 650
2010 230.000 173.000 1.32 245 710(Increment of 8.5%)
Coverage by Insurers
05
101520253035404550
MPH CNSS Army Private CSC ISF
44
30
7.6 7.5 6.33.8
MOPH coverage in numbers
• Average number of patients treated over the last 5 years :185.000/Year
• Average number of Admissions over the last 5 years :225.000/Year
• Rate of Admissions to Hospital:11%
Government’s Health ServicesThe Major Providers
Financing Body # of People Eligible Government Budget for
Health Coverage
(L.L)
MOH 1,761,758 301,591,500
Army & Security 564,459 187,274,500
NSSF 1,200,000 482,770,000
COOP 252,739 87,050,000
Government’s Health ServicesHospitalization
Financing Body Hospitalization Expenditures (L.L)
MOH 250,000,000
Army & Security 115,147,500
NSSF 279,060,000
COOP 40,600,000
Percent hospital utilization among eligible by Gender ,2009
• The prevalence of medical conditions among those eligible reaches 12.9 %
• The pattern of service utilization for females probably follows delivery services in younger age groups
• The utilization for both genders increases with age as the proportion of working population
• And hence the medical coverage which is largely related to the professional status , decreases
Gender Percentage
Male 11.6
Female 14.2
Hospitalization RATE (%)2005
MOPH NSSF CSC ARMY SF(ISF,GSF,
SSF)
TOTAL
11.3 23 12.5 22.9 30.5 16.6
The evolution of MPH subsidized admissions in public and private hospitals between 2005-2009
Private hospitals % Public hospitals %
2005 85.89 14.11
2006 81.68 18.32
2007 72.73 27.27
2008 69.44 30.56
2009 70.44 29.56
The evolution of MPH subsidized admissions in public and private hospitals between 2005-2009
85.89 81.68
74.73 69.44 70.44
14.11 18.3227.27
30.56 29.56
Governmental hospitals/VS Public Institutions: Definition
► Public institutions :Listing 1
► Governmental hospitals :Listing 2
► Public institutions: Data by region
► Public institutions :Current functioning status
► Public institutions : Mission & discussion
► Public institutions : Infrastructure & its problems
► Privilege of Public institutions over private hospitals
► MOH contributions to Public institutions
►Swot Analysis
► Public institutions :A new era to come or improve : Discussion
Governmental hospitals v/s public institutions : Definition
Governmental hospitals v/s Public institution
Gov. Hospital Public institution
Human resources
MOH ●Directly by the Board of Directors upon demands & in coordination with Council*Civil service board (Law 583/2004)
Financing Directly by MOH ● Financial autonomy (self budgeting )● Collections from third payers
Supervising &
Management
Designated manager
by MOH
● Board of Directors ● General manager ● Supervision by MOH via representative at the Board
Equipments MOH ● MOH● Direct purchasing
Provisions MOH ● Direct purchasing & bid
PUBLIC INSTITUTION HOSPITAL : DEFINITION & MISSIONAutonomous Organizations
• Administrative Autonomy• Financial Autonomy• Moral personality• Under the tutelle (Supervision )of the
Ministry of Public Health
PUBLIC INSTITUTION HOSPITAL : DEFINITION & MISSION
►Governmental Public institution
► Offers health services (treatment & preventive )
●Without discrimination
● At High quality
● At Low cost
► Complementary with private sector
► Cooperation with all Health Partners (Universities, insurance…)
GOVERNEMENTAL PUBLIC HOSPITALS : LISTING 1
Bekaa Nabatieh North Lebanon Beirut Mt Lebanon South lebanon
► Zahleh ► Nabatieh ► Tannourine ► RHUH ► Dahr el Bachek ► Saida
► Rachaya ► Marjayoun ► Halba ► Karanti ► Baabda ► Jezzine
► k.Kanafar ► Mais el Jabal ► Sir Dinnieh ► Sibline ► Saksakieh►Baalbeck
► Bint Jbeil ► Ehden ►Kartaba►Hermel
► Hasbaya ► Tripoli ► Bouar
►Tibnine ► Becharreh ►Chahhar el gharby
► Orange Nassau
LISTING 1
South Lebanon
BeirutMt Lebanon
North Lebanon
NabatiehBekaa
326765
GOVERNMENTAL HOSPITALS NOT YET PUBLIC INSTITUTION : LISTING 2
► Tyr
GOVERNEMENTAL HOSPITALS :LISTING 1 + LISTING 2
GRAND TOTAL
►Number of hospitals= 37
► Number of beds = 2635
GOVERNEMENTAL HOSPITALS :LISTING 1 + LISTING 2
GRAND TOTAL ►Number hospitals= 37
► Number of beds = 2635
Governmental Hospitals
Governmental/public Institutions
NEW HOSPITALS
N= 1TYR
N= 29N=7 Damour,sarafand,
Shebaa, Barty ,Mayfouk,Kana,
Aley
► Public institutions: Data by region
PUBLIC INSTITUTION HOSPITALS:DATA(BY REGION)
BEKAA DATE OF AUTONOMY
NUMBER OF BEDS
NUMBER BOARD OF
DIRECTORS
NUMBER OF EMPLOYEES
Zahleh 1998 150 5 330
Rashaya 2000 45 3 99
Baalbeck 2005 100 5 220
Hermel 2005 100 5 220
Kherbet Kanafar
2005 25 3 55
NABATIEH DATE OF AUTONO
MY
NUMBER OF BEDS
NUMBER BOARD OF
DIRECTORS
NUMBER OF EMPLOYEES
Nabatieh 1997 100 5 220
Marjayoun 2001 50 3 110
Mais el Jabal 2002 100 5 220
Bint Jbeil 2002 100 5 220
Hasbaya 2003 40 3 88
Tibnine 2005 70 3 154
PUBLIC INSTITUTION HOSPITALS:DATA(BY REGION)
North DATE OF AUTONOMY
NUMBER OF BEDS
NUMBER BOARD OF
DIRECTORS
NUMBER OF EMPLOYEES
Tannourine 1999 50 3 110
Halba 1999 45 3 99
Sir dinnieh 2000 45 3 99
Becharreh 2003 20 3 44
Ehden 2002 12 3 26
Tripoli 2002 150 5 330
Orange nassau
2003 30 3 66
PUBLIC INSTITUTION HOSPITALS:DATA(BY REGION)
Mt Lebanon
DATE OF AUTONOMY
NUMBER OF BEDS
NUMBER BOARD OF
DIRECTORS
NUMBER OF EMPLOYEES
Dahr bachek 1999 100 9 220
Baabda 2000 100 9 220
Sibline 2003 100 5 220
Bouar 2005 100 5 220
Chahhal el Gharby
2005 70 3 154
Kartaba 2005 10 3 22
PUBLIC INSTITUTION HOSPITALS:DATA(BY REGION)
South Lebanon
DATE OF AUTONOMY
NUMBER OF BEDS
NUMBER BOARD OF
DIRECTORS
NUMBER OF
EMPLOYEES
Saida 2000 150 5 330
Jezzine 2005 40 3 88
Saksakieh 2005 20 3 44
PUBLIC INSTITUTION HOSPITALS:DATA(BY REGION)
Beirut DATE OF AUTONOMY
NUMBER OF BEDS
NUMBER BOARD OF
DIRECTORS
NUMBER OF EMPLOYEES
University Beirut
1999 540 9 1188
Karantina 2000 150 5 330
PUBLIC INSTITUTION HOSPITALS:DATA(BY REGION)
PUBLIC INSTITUTION HOSPITALS:DATA (BY REGION)
Number of BEDS
REGION
420BEKAA
460NABATIEH
352North LEBANON
480Mount LEBANON
210South LEBANON
690BEYROUTH
► Public institutions :Current functioning status
PUBLIC INSTITUTIONS HOSPITALS : CURRENT STATUS
FULL ACTIVITY PARTIAL ACTIVITY/Health Center
NO ACTIVITY *Under Rehabilitation
N= 22 N=3 N=4
RHUH- Karantina /Chahhar el Gharby-Dahr el Bachek-Baabda-Bouar-Sibline/Rachaya-Zahle-Baalbeck- Hermel/Saida/Sir dinnieh-Tannourine-Halba- Tripoli-Becharreh/-Bint Jbail-Hasbaya –Mais el Jabal-Nabatieh-Marjeyoun
KartabaEhdenJezzine
Saksakieh-Khorbet kanafarOrange Nassau
Tibnine
51
Mohafazat
Visa System/Hosp. in Public hospitals
200520062007Beyrouth4,5291101612,224
Mount Lebanon4,10743035,947
North5,71169359,808
Bekaa2,52528916,268
South4583592,429
Nabatieh8,289820410,971
Total25,619 (14%)33,708 (18%)47,649 (26.5%)*Total
Public+ Private181,605183,997180,158*Number of Public
Hospitals141921DATA/Visa System – Source :Years2005-2006-2007
*Visa system2007till end of OctoberVisa system2007till end of October
► Public institutions : Mission & discussion
GOVERNEMENTAL HOSPITAL : A PUBLIC INSTITUTION ITS MISSION
►Provide health care with the highest quality possible at the lowest cost
Question 1: What care? :
Discussion 1: Preventive v/s primary care v/s tertiary care
DISCUSSION 1: PARAMETERS TO CONSIDER
●Orientation of the Board of directors
● Geographical demands
● Funding resources
● In house capabilities
● Human resources
● Overall directives & orientation of MOH
► Public institutions : Infrastructure & its problems
PUBLIC INSTITUTION HOSPITAL:INFRASTRUCTURE
MOHMOH
BOARD●Administrative independence
●Financial independence
LAW
BYLAWS
HUMAN RESOURCES
MISSION ACCOMPLISHED ?
PUBLIC INSTITUTION HOSPITAL:INFRASTRUCTURE
Question 2: Infrastructure v/s UNDERMINING structure
Discussion 2 : ●Rigid law not allowing flexibility● Historical political dependance of the MOH● Painful & lengthy procedure for recrutement● Employement heritage due to civil war ● Financial independence v/s dependence of MOH ● Disbursement alike private hospitals ?
► Privilege of Public institutions over private hospitals
PUBLIC INSTITUION HOSPITALS:RELATIONSHIP WITH “PARTNERS ”
HOSPITAL
Ministry of Health
Ministery of finance
Social security National office
Other third party payers ●Financial control office(Court of AUDIT) ● Civil Service Board
Universities
Question 3 : Similar relationship as with private hospitals?
Development &Reconstruction Council
DISCUSSION 3: PARAMETERS TO CONSIDER TO PRIVILEGE PUBLIC INSTITUTIONS HOSPITALS
●“Shortcut” system to speed up financial process & budgeting
●Encourage Public insurance towards Governmental hospitals ?BUT within the mission of the hospital
●Liberalize investment of the hospital assets ?
●Concept of complementarities with private hospitals
● Patient’s part is 5 % v/s 15 % in private hospitals *● MOH contributions to governemental hospitals*● More independence by modifying law = Decret 5559/2001*
* Done or in process
► MOH contributions to Public institutions
MOH CONTRIBUTION TO PUBLIC INSTITUTIONS HOSPITALS
REGION YR 2003(Billions)
YR 2004(Billions)
YR 2005(Billions)
TOTAL(Billions)
BEIRUT 13,O85 9.2 22.285
SOUTH 10.2 0.9 11
Mt LEBANON 3.8 0.55 2.5 6.85
BEKAA 3.5 3.5
North 8.3 5.35 13.65
57,285Grand Total =
MOPH Itemized budget for the past three years
2007(‘000LBP) 2008(‘000LBP) 2009(‘000LBP)
Hospitalization in private sector
250.000.000 256.000.000 305.000.000
Public hospitals 15.000.000 15.000.000 12.000.000
Total MOPH budget
361.631.670 373.917.225 439.747.598
MOPH Itemized budget for the past three years
• While the total government budget has increased
• The MOPH budget has decreased to less than 3% of total gov. budget
• 72% goes for hospitalization coverage in public and private sector
• 15% for drug procurement (66 BillionsLBP/2009)
Visas for patients admitted at the expense of MOPH 2009
PRIVATE 159377
PUBLIC 66870
TOTAL 226247Issued to 136993
patients
Visas for patients admitted at the expense of MOPH 2009
PRIVATE 159377 70%
PUBLIC 66870 30 %
TOTAL 226247Issued to 136993
patients
Ratio Coverage in Numbers
MOHAFAZAT PRIVATE % PUBLIC %
BEIRUT and NABATIEH 30 70
NORTH L and BEKAA 70 30
MOUNT L and SOUTH L 80 20
FIGURES and FACTS
• In places where there are active public hospitals ,the number of admissions issued to the public sector exceed that for the private sector
• Examining Visas issued over the months during the year 2009 shows that they range from 20.000 to 24.000 Visa /month
FIGURES and FACTS
• Improving quality services in public hospital to the extent that admissions are being increased
• Considering the active number of beds that is originally lesser than the private sector ,the occupancy of public hospitals seems to have reached saturation
• The ratio of public to private admissions revolves around 30/70 for the 2 consecutive years 2008 and 2009
• Regional services (Health Decentralization)
Rehabilitation of Public Hospitals.Contracts by CDR for Health system from1/1/1992 au 31/12/2004 ,
millions US Dollars
260 Millions US Dollars
Situational analysis (SWOT)
STRENGTHS WEAKNESSES
OPPORTUNITIES THREATS
Situational analysis (SWOT)STRENGTHS
• New model of management (Public hospitals)• Competency with private sector• Infrastructure/Buildings/ Equipments• Specialized Human Resources (Employment
policies)• Hospitalization coverage (Contracts with public and
private Funds)• Mission of the public hospital (None- profit ?)
WEAKNESSES
• Human Resources (Lack of some specialties)
• Relationship with MOPH/Heavy burden of administrative procedure
• Rigidity of laws and regulations
• Salaries and wages policy (in comparison with private hospitals)
• Political Interferences with the board and directors
OPPORTUNITIES
• Economical situation/oblige citizens to run towards public hospitals
• MOPH support (Performance appraisal…Training programs…)
• International Agreements (Loans, new equipments…)
• Information technology• Agreements with Universities( Public/private)• Increase of demands and needs
THREATS
• Private sector notoriety (Hospitals/ physicians…)• Decision making in private hospitals• Advanced technology• Specialized human resources• Employment policies (OFFER/DEMAND)• Same hospitalization coverage type (Public/Private)• Public hospitals geographical distribution
► Public institutions :A new era to come or improve : Discussion
PUBLIC INSTITUTION HOSPITALS :A NEW ERA TO COME ?
Question 4: Is it possible ?
Discussion 4 : YES but /WHY/ HOW
Directives of the MOH:
► Improving quality :Better delivery ? Medical protocols + specialized units = Cooperation with foreign institutions
●Japanese delegation for improvement *● AUH with University Hospital Bir Hassan *● Lebanese University with Baabda,Dahr *
bachek & University Hospital
► Centralize overhead at least regionally Decreasingcost
► Improving MOH Central committee supervising gov .hospitals*(Already present decree 11807 Jan 30st 2004)
A NEW ERA TO COME or BE IMPROVED ? HOW
* Done or in process
*
A NEW ERA TO COME or BE IMPROVED ? HOW
► Partnership with academic institutions on Some issues such as training for MD and RN’s
► Simplify the financial process = Quicker reimbursementLess penalties
► Handling protocols + medical charts + complementarities within the governement hospitals + Mission of every hospital :
Creation of a central council composed of Presidents of the Board and MOH representatives
► More organised inhouse work = Infrastructure of the hospital *External financial audit *
American University with University hospital Bir HassanLebanese University with Baabda & Dahr el Bachek *
* Done or in process
A NEW ERA TO COME or BE IMPROVED ? HOW
►Improving quality of care :
●Accreditation already in place ● Medical Committees as per LOP
● Central committee supervision
►Improving the mechanisms of drug delivery:
● Pilot study for a model for chemotherapy treatment
● Place for generic medication ????
*
* Done or in process
HOSPITALIZATION IN RHUH 2008
TotalAdmissions 19945
100913 daysAve. LOS 5.1d
General 15485 96007 days
Day Chemotherapy 4460 4906 days
Average Census 263 / 305 Occupancy: 86%
MOH : 73% NSSF : 13% Other : 14%
NUMBER OF PATIENTS BY MOHAFAZAT /RHUH 2008
HEALTH CARD
PRIMARY HEALTH PRIMARY HEALTH CARECARE
SERVICESSERVICES
HOSPITALIZATIOHOSPITALIZATION SERVICESN SERVICES PRIMARY
HEALTHCARE CENTER
DISTRICT PUBLIC HOSPITAL
CENTRAL PUBLIC HOSPITALC
PRIVATE HOSPITAL(
CHALLENGES• Health Decentralization• Hospitalization Cost containment• Towards Alternative hospitalization(Community care)• Enhancing home care• Central purchasing• Relation with local authorities and NGO’s
• Primary health care• Geriatric medicine / Mental health• Emergency services • Referral system
THANK YOU