New multi-national research shows how a long series of politically-driven crises have created a failed state and a public health disaster in Lebanon.
A new Global Challenges Research Fund (GCRF) – the Research for Health in Conflict (R4HC) study led by King's College London and partners at the University of Cambridge, and the American University of Beirut, Lebanon shows how political decisions and clientelism have had a detrimental impact on the health and wellbeing of a population. The report recommends that health and health services be given far greater priority in the economic recovery and development policies of donor governments.
The media image of Lebanon and that portrayed by academics and international diplomats is often contradictory. On one hand, it's seen as a modern and progressive country in a turbulent 'jungle' of a neighbourhood, where the food is world class, and the citizens are 'resilient' to episodes of political trauma. When they are not talking about the food, nightlife and resilience the dominant policy, media and academic stereotypes fall into security, sectarianism and terrorism.
However, as Principal Investigator for the R4HC project Professor Richard Sullivan states 'What many academics, journalists, and international donors completely overlook is how public services, especially health – and contestation over them – greatly affect people's day-to-day lives. These are the routine and street level issues which people care about'.
As the report shows the past two years have been turbulent even by Lebanese standards. The massive explosion in Beirut, Lebanon in August 2020 arrived on top of a Covid-19 induced public health crisis, a 10-year war and protracted humanitarian disaster in neighbouring Syria, years of environmental degradation, currency devaluation, and an economic meltdown. This multi-pronged crisis has wrecked the daily lives of people in Lebanon; the population has been thrown into a state of flux; thousands have fled the country with little hope of stability if they remain.
Millions of Lebanese as well as the estimated 1.5 million Syrian refugees who sought sanctuary in the country now live below the World Bank poverty line, half the country has no health insurance, and one third have lost their jobs due to decades of economic mismanagement and corruption within government and public services. Over 80 percent of health services are controlled by the private sector: it costs money to be healthy and recover from illness in Lebanon.
Dr Adam Coutts (University of Cambridge and Weatherhead Scholar, Harvard University), one of the project leads, comments 'Health and health services in Lebanon have long been politicised issues used for private gain. Desperation and dependency are good for patronage politics…It seems very few of those currently in power really want the state to fulfil its mandate.'
The health sector – a key public good and a potential stabilising force - is on its last legs: a severe lack of medications across frontline health services; the departure of thousands of staff from the health workforce; and the dwindling finances and basic operational resources needed to keep the system going. Thousands have abandoned the health system due to costs. This threatens to create a public health disaster.
Multiple attempts have been made by the World Bank, United Nations and European Union to strengthen and reform the Lebanese public health care system. However, this has been met by a sclerotic political management keen instead to bolster the private healthcare and pharmaceutical industry from which many Lebanese politicians have benefited financially. The Lebanese population no longer trust the political system or government to run any public services.
Dr Fouad M. Fouad project lead in Beirut grimly explains 'When you look at how Lebanon became a 'sick nation' it's even more depressing considering that they were spending between 8 to 10 percent of GDP on health care. This is what many European countries spend'.
Lebanon is not unique in terms of its political ruling class giving low priority to the health and the wellbeing of its citizens. 'It's on the extreme end of the political neglect and market failure spectrum' Dr Coutts commented.
Typically health and social welfare policies across the region are concerned with profit and cure rather than access and prevention. Little thought is given to the basics of preventive healthcare. Regional governments have given lip service to recent donor calls to implement universal health care policies or the social determinants of health equity. Covid-19 pandemic exposed how hollowed out these states have become in terms of their ability to handle and respond to a public health crisis.
Options for Lebanon
Social and economic recovery is going to be challenging. The future for millions of Lebanese and refugees stuck in the country looks bleak. International donors and multilateral agencies have urged all interested parties to 'find opportunity in the present crisis'.
However, as Dr Fouad M. Fouad states, 'The first thing that needs to happen is that clear political commitments are given to securing the health and wellbeing of the Lebanese and refugees. A new social contract needs to be created. Just signing a WHO declaration on Universal Health Care is not enough'.
A series of policy options are proposed to stabilise the situation such as creating a more balanced health and welfare system by reducing the reliance on the private sector. Donors and multilaterals need to focus future investment on state based public healthcare and welfare sectors rather than propping up a wholly privatised system where the proceeds go into the pockets of politicians. It provides a much-needed buffer against future crises for the millions who lack insurance or sufficient incomes. Other recommendations include legally recognising displaced medical workers from Syria for example. A vital human capital investment that can help toward UHC and fill the capacity gaps left by Lebanese health workers who have emigrated over recent months. Above it will address the urgent health needs of refugees and deprived Lebanese communities who cannot afford the large 'out-of-pocket' healthcare expenditures.
Full report available here
This work was funded through the UK Research and Innovation GCRF RESEARCH FOR HEALTH IN CONFLICT (R4HC-MENA); developing capability, partnerships and research in the Middle and Near East (MENA) ES/P010962/1.
For further information and media comments please contact
Professor Richard Sullivan (King's College, London) firstname.lastname@example.org / @SullivanProf +447720398401
English and Arabic: Dr Fouad M. Fouad (American University of Beirut) email@example.com / @mfouad61
Dr Adam P. Coutts (University of Cambridge and Weatherhead Scholar, Harvard University) firstname.lastname@example.org / @AdamCoutts