Abstract
Lebanon is a small country, part of the Levant region of the Middle East (ME), bordered by Syria in the north and east and Israel in the south. It is strategically located on the eastern shores of the Mediterranean en route to the rest of the ME and the Arabian Peninsula.
Lebanese healthcare system (1990–2019)
After the end of the devastating civil war (1975–1990) in Lebanon, the Ministry of Public Health (MOPH) took significant steps to improve and further develop the healthcare system in the country, delivering high-quality care to the people. Their efforts have led to a significant drop in infant, neonatal and child (under 5 years) mortality rates. 1 Life expectancy increased to 76.28 years, the third in the ME after Qatar and the UAE. By 2018, Lebanon ranked 33rd among the 195 countries in the Healthcare Access and Quality index and first among the countries of the ME. 2
The MOPH runs an extensive network of primary healthcare centres and pharmacies providing ambulatory services to mostly people with low income. This work is supported by several charitable organisations. The MOPH also runs state hospitals, mainly for inpatient services. The state hospitals account for only 18% of the total inpatient beds of the country. Therefore, the private sector delivers the majority of primary and secondary care services. The prices for medical services, medicines and medical supplies are set by the MOPH. The MOPH subsidises medicine. 1
Healthcare since 2019
In July 2022, the World Bank reclassified Lebanon as a lower-middle income country after being in the higher-middle income category for 25 years. This is based on the data collected from 2021.
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This status occurred as a consequence of major events that have affected the country over the last 10 years (Box 1). The Syrian civil war that started in 2012 led to a large influx of refugees – around 1,500,000 by 2014 – according to the United Nations High Commissioner for Refugees (UNHCR), putting pressure on the country’s economy.Lebanon has the most refugees per capita, 156 per 1000 inhabitants in 2018.
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This was followed by the imposition of taxes by the government on fuel, tobacco and phone calls, resulting in mass civil demonstrations in Beirut and other cities. In March 2020, the country was struck by the COVID-19 pandemic. On 4 August 2020, Beirut was rocked by a most powerful non-nuclear explosion in the port, causing the deaths of 204 people, injuries to more than 6500 people and the destruction of homes of more than 300,000 people. Hospitals, already stretched by the pandemic, found it impossible to cope with the injured and those infected with the virus. The economy collapsed, and in October 2021, two main power stations ran out of fuel and the country was without electricity for 24 h. By January 2022, the value of the Lebanese currency collapsed. Thousands of people lost their jobs, and in September 2022, the banks closed for days to avoid angry protests against them. The population is poverty stricken. Important events in Lebanon over the last 10 years.
These tragic events have caused a rapid disintegration of the healthcare system in Lebanon, especially over the past 3 years. Every item of the six basic components of a healthcare system, as defined by the World Health Organization (WHO), has been affected (Figure 1). 5 An explosion in the port of Beirut occurred, affecting more than half of the capital, destroying three hospitals and compounding the pressure on healthcare delivery. Many hospitals suffered significant damage to their buildings, wards, outpatients, laboratories and other sections (Figures 2 to 4).
Building blocks of a health system.
The damage in a ward in the American University of Beirut Medical Centre, minutes after the Beirut port explosion on 4 August 2020.
The damage in a laboratory in the American University of Beirut Medical Centre, minutes after the Beirut port explosion on 4 August 2020.
The damage in the outpatient area in the American University of Beirut Medical Centre, minutes after the Beirut port explosion on 4 August 2020.
The shortage of electricity and the lack of fuel to charge the electricity generators have resulted in the inability to store refrigerated medication as well as blood and its products, thereby severely limiting the delivery of medical supplies to hospitals and pharmacies and putting hospitals in a critical position of not being able to provide proper medical care to their patients. Hospitals are cutting down on elective surgical operations to reserve anaesthetics and other medical supplies for emergency procedures. 6
Another crisis that has arisen is that the government lacks a comprehensive solid waste management strategy. This has led to burning waste in the open, causing pollution of the environment and increasing health problems.
There has also been a significant shortage of medications for hypertension, diabetes and ischemic heart disease, thereby endangering the lives of hundreds and thousands of people. Imported drugs, such as oncology drugs and biologics, are almost impossible to obtain due to inadequacies in payments and lack of credit.7–9 In addition, the MOPH has stopped subsidies to medicines.
Patients with immune-mediated diseases are suffering relapses and poor disease control, and patients with cancer are dying unnecessarily. In November 2021, a comment published electronically highlighted the massive impact of the crises in Lebanon on the workforce and its impact on patients and impending collapse of the health system. 10 According to the chief of the Lebanese Order of Physicians, 25% of the total registered medical and nursing workforce – 3000 doctors and 5000 nurses – have left the country to work abroad. Other non-medical staff have been made redundant. Governance and health information systems in hospitals have suffered significantly.
Conclusion
Our patients are suffering and dying because of inadequate or even lack of treatment as a result of severe shortages of essential medication. In addition, patients face hardship due to socioeconomic factors. As a result, anxiety and depression are complicating their physical disability.
It does not seem like an effective government will be formed in the near future because of a lack of any agreement between the various political parties. The very high price of fuel, shortage of electricity and the possible recession in many parts of the world will not help either.
We are writing this perspective to strongly urge international medical and humanitarian bodies, such as the WHO and other agencies, to provide more help to Lebanon. The country is on the verge of an abyss.