The Process of Decentralization in Lebanon: South Beirut Municipalities are Improving Primary Healthcare Services and Integrated Local Welfare

The Lebanese Health care system is very fragmented due to the lack of a public health policy, strategic planning of services and their organizational structures. Now, through a new process of decentralization, South Beirut Municipalities are improving primary healthcare services and integrated local welfare

The Process of Decentralization in Lebanon: South Beirut Municipalities are Improving Primary Healthcare Services and Integrated Local Welfare


by Cinzia Chighine*

 Tuscany Region, International Activities


The conflict between Israel and Lebanon in July 2006 and the internal repercussions in Lebanon have outlined a new political and economic scenario. Moreover, the internal contradictions and the external interference have negatively influenced the Lebanese economic growth.

According to the Social Action Plan of the Ministry of Social Affairs, the Lebanese Government Budget, historically oriented to multi-year strategies in the Social and Educational field,  has been totally re-planned in order to meet the new Emergency.

Sustained political and security instability have further widened the fiscal deficit and capped Lebanon’€™s GDP growth near 1 percent in 2014, as the International Institute of Finance declared in a revised assessment of the country’€™s economic situation.

The current scenario shows  four main challenges that will weigh on the Lebanese economic performance:  the Presidential election during the year, the formation of a new Government in Lebanon and an escalation of the civil war in Syria, while the frequency of violent incidents in Lebanon has increased.

A Presidential Election was held in Lebanon on 23rd April 2014. Since no candidate reached a two-thirds majority vote, a second round had been scheduled for April 30, a third round for May 15, and a fourth round for May 22. Due to lack of quorum the elections had been aborted.

The Syrians fled to Lebanon  since the outbreak of the civil war are more than one million and they are causing a strong impact on the economy of the Country, for which the United Nations are now asking for urgent international aid. By now the number of refugees, half of whom are children, is equivalent to a quarter of the Lebanese population and according to the United Nations High Commissioner for Refugees, Antònio Guterres, the flow is accelerating.

Today Lebanon ranks 38 out of 135 countries concerning the Poverty Index and it is in 78th place out of 179 as concerning the Human Development Index. Twenty-two percent  of the Lebanese Population is under 15 years and 12% over 60. Life Expectancy is around 73 years. Child Mortality Rate is around 18/1000, while the Maternal Mortality Rate is around 25 per 100,000 live births (2013).

Even in the Health sector there are some critical aspects that represent significant challenges for the public insurance system. The per capita public expenditure in Health services is out of a total of $ 235.8 while the total per capita Health spending is  $ 923 (2013). Public expenditure on total Health expenditure is 5.8% (data from WHO 2013).

In terms of chronic diseases, there is a prevalence of diabetes (12%), hypertension (32%) and obesity (29% over 20 years).

The Sustainable Health system is normally guaranteed by the repayment for each performance initially covered by the public insurance. The costs are aggravated by the repetition of single performances, by some inappropriateness of care pathways and by inappropriate admissions. Considering these anomalies, the overall costs of the Health system -taking into account the overall volume of the performance- are particularly high: the total health expenditure is around 13% of Lebanese GDP with the unfavorable balance between cost/efficiency and cost/benefit.

The poor offer of Basic Health Services and the not always appropriate prevention, such as the lack of continuity of care and inequity of access to them, are important critical points of the system.

The setting of the private Health and Education system does not favor the widespread access to basic rights for a broad segment of the population.

The Lebanese Health Service consists of 90% by individuals and private facilities structures that deliver performances in hospitals, clinics or in local specialized districts in which they operate.

The specialist medical visits, hospitalizations, laboratory examinations, rehabilitation services are reimbursed by 80 % by the public or private insurance companies. However, about 50% of the general population is excluded by the insurance system. Only those who have a job in the private or public sector enjoy the right to the mandatory health insurance.

Lebanese population loses the insurance coverage with the attainment of the retirement age, except for a few and privileged categories of people. The State reimburses only the costs of first aid hospitalization to them, according to no more adequate rates, because they have been agreed in the past.

The Lebanese Health care system is very fragmented due to the lack of a public health policy, strategic planning of services and their organizational structures. Accordingly, an excessive commercialization of health services increases the gap between rich and poor people.

According to Ministry of Public Health (MoPH) database, the insurance coverage in Lebanon is the following:

Social Security – “€œDaman”€ 26.1%

Cooperative of Government employees 5.5%

Army 9.1%

Security facilities 2.2%

Private insurance 8.8%

Ministry of Public Health 48.3%

About 50% of the Lebanese  population (unemployed people and almost all of the elderly population) is excluded from the public or private insurance system. According to the National Health Program of Lebanese MoPH, the State reimburses only the costs of hospitalization and the first aid service to these citizens. A partial role in filling gaps is covered by various religious congregations and some local NGOs to whom a part of the poor population is referring to.

According to MoPH Database, in addition to the public Health structures managed by the MoPH (nr. 15 units), by MoPH/NGOs and Municipality (nr.14 units), by Ministry of Social Affairs (nr. 3 unit), by NGOs (nr. 53 units) and by the Municipality itself (nr. 1 unit), there are about 800 dispensaries, managed by Lebanese NGOs, to whom only 15% of the population, in large part not covered by insurance, is addressed.

The network of the dispensaries – created as a quick  response to post-war emergencies – is suffering from the lack of minimum quality standards and professional skills in the offered services, and it would require a rethinking in a perspective of public reorganization of basic services.

In 2007 the rethinking of the concept and the prerogatives of dispensaries started in several municipalities in the southern suburbs of Beirut, among the areas most affected by the conflict. The South Beirut dispensaries have been transformed into Primary Care Centers (PHCC) and one of these centers is being accredited by the MoPH.

The Southern Suburbs of Beirut -called Dahiye – include eight municipalities, some of which have been particularly hardly hit by Israeli bombing in 2006. During the conflict many people from southern Lebanon have settled in these suburbs often occupying the skeletons of buildings destroyed by the civil war and never rebuilt.

The Social and Health care services offered to the local population in these areas are extremely limited and not incorporated into the regular activities of the municipalities.

The Lebanese administrative decentralization process -despite an ongoing reform deeply desired by the Lebanese Chairman, in order to incorporate the  recommendations of the Ta’if Agreement (1989) – is  essentially quite new.

The local government is represented by the Municipalities, as the Districts (Mohafazat in Arabic) don’€™t’ have political power in terms of delivery of services to citizens and are not beneficiaries of the financial resources by the central government.

The Lebanese Municipalities -as revealed by a study conducted by the “€œCenter for Administrative Innovation in the Euro-Mediterranean region” €(CAIMED)- don’t have developed relationships with the citizens they are dealing with. The Municipalities provide basic services i.e. Tax collection, without actually establishing links with the people.

Recently, some Municipalities have joined together in  “€œUnion of Municipalities”€.

The “€œOffice of the Minister of State for Administrative Reform”€ (OMSAR) highlights – among the main difficulties it has to deal with in his role as a facilitator for the effective application of the administrative law reform – the lack of support by local governments as they are not ready to change. Actually, the forms of cooperation between different Lebanese actors are limited by the legacy of the civil war.

Lebanon has been the scene of many conflicts, mainly due to its complex social, religious and political composition.

The repercussions of these events fall on the Lebanese people who are still  living situations characterized by poverty, unemployment, lack of opportunities, conflicts and widespread violence at the local level.

The national political instability has not activated the processes of decentralization. The municipalities are representative bodies with small margin of direct intervention on the needs of the population.

The Issue of Health is a strategic factor to strengthen, through the implementation of operational tools, the governance of the territories, exchanges and more dialectical confrontation among the Government Institutions. At the same time , Health Policies are influenced by environmental, economic, social and political issues, that directly affect the community. The Health integrated approach is therefore a “€œroadway”€ for local authorities to strengthen  their role thus gaining its political-administrative function.

In the framework of the UNDP ART Gold program, the Region of Tuscany supports the network among Social Offices of the Municipalities, offices for local development (LEDA) and the Centers for Primary Care (PHCCs), particularly in the suburbs of South Beirut, in order to reinforce, in accordance with the MoPH, the local health systems in areas affected by the now highly migratory flow of Syrian refugees.

The initiative aims to support the general goal of the administrative decentralization process. The PHCCs will reinforce the role of local authorities as public providers in the Municipalities of Al Mreyjeh, Al Chiah and Furn Al Chebbak,  Haret Hreik, Ghobeiry, Tyre, North Akkar Region, in accordance with the recommendations of the Ministry of Health in order to adopt a new approach to Primary Care through the Social Offices.

The experience has allowed to break the fragmentary in the Lebanese Health Sector, improving the population’s access to basic services through the implementation of a modern integrated system of Primary Care.

The network of PHCCs is able to generate operational synergies with the Education system through permanent programs of Education and Health promotion, Health education , prevention and care.

Particularly, the Region of Zgharta, deeply affected by the emergence of the Syrian refugee population is involving PHCCs in a new integrated approach to the Local Welfare.


 *Cinzia Chighine, born in Viareggio (Italy) in 1974, has been professionally active as aid-worker in Africa and Middle East area for a decade. She works now in Florence as a staff member of Tuscany Region’€™s International Activities Department