The Lebanese citizen belonging to the lower and middle classes used to manage with health insurance for their family before the financial, monetary, and banking crises erupted... to the extent that they were envied for the swift treatments available, unlike in countries like Britain, where a patient awaits three months before entering a hospital. However, today we find ourselves in an enviable situation; medicine is scarce, health coverage is unavailable from guarantor entities and even from insurance companies, which now demand cash dollars only to provide 100% healthcare coverage. For those without foreign currency, accessing treatment has become a rare and difficult issue.
#### Types of Health Coverage in Lebanon
The types of health coverage in Lebanon are various and differ in percentages. The Ministry of Health, responsible for providing health coverage and regulating the healthcare system, used to spend 87% of its general budget on hospitalization and medicines, receiving less than 5% of the budget for preventive programs and primary healthcare. In government hospitals, coverage before the crisis was set at 95%, while in private hospitals, it was 85% of the total bill. Since 2016, the Ministry of Health began covering treatment and hospitalization for those over 64 years old at 100%.
Regarding the guarantor entities, coverage rates and payments vary as follows:
- **Social Security** under the Ministry of Labor usually provides hospital coverage at 90%, with citizens bearing the 10% difference (this equation has flipped today).
- **The Army**, which is under the Ministry of Defense, once enjoyed comprehensive coverage (it now has to cover differences).
- **Internal Security and General Security**, which fall under the Ministry of Interior, also used to have 100% coverage (they now pay differences).
- **The State Employees Cooperative** covers all public employees in general administrations, including the Lebanese University, excluding military personnel, while it provides 90% coverage for hospitalization and 75% for medicine and external examinations. Before the collapse, the Cooperative raised its coverage for cancer treatment to 100%.
**Mutual Funds** - These funds are divided into two types: either compulsory membership, as is the case for notaries and judges, which covers their medical expenses, or optional membership, like that of professors and employees at the Lebanese University who can join their own mutual fund despite benefiting from the State Employees Cooperative or the National Social Security Fund to take advantage of the hospitalization expense differences.
**Private Insurance Companies** for individuals not insured by any of the previously mentioned guarantor funds, which fall under the Ministry of Economy, used to cover those insured at 100%, filling in the gaps with other guarantors. Today, however, they differentiate their coverage based on those who pay premiums in cash dollars versus those who previously deposited in Lebanese pounds and those who paid their dues via transfers and checks. The set healthcare fees for hospitals vary between different guarantors, which Health Minister Dr. Firas Al-Abyad described in an interview with "Nidaa Al-Watan" as “wrong, given that each entity has its own rates and funding due to administrative issues, leading to a lack of a unified payment system.”
#### What Has Changed Today?
Today, with the worsening crisis and the exchange rate of the dollar in the black market rising from 1,515 Lebanese pounds to 27,000 pounds—approximately 17.5 times—the equation in private hospitals has shifted. Hospital costs have increased due to the ongoing electricity outages and reliance on generators powered by diesel. Thus, a chaotic situation arose, resulting in a "tug of war" between hospitals, insurance companies, and guarantor entities, with the citizen being the victim, stripped of the coverage that once protected them.
Consequently, it has become difficult for the insured to enter a hospital without incurring enormous bills, making medical treatment, hospitalization, and access to medicine occasionally exceedingly hard or even impossible. Some guarantor entities still charge hospitals based on the official dollar exchange rate, which has turned the coverage ratio from 90% to 10%, placing the burden of the 90% costs on the patient’s own pocket.
#### What About Other Guarantors?
Al-Abyad states that “the private hospitals association finds that fees need to increase by 9 to 10 times to cover the exacerbated costs.” Consequently, they refuse to admit patients under coverage for surgeries, for example, unless they receive the difference in advance from patients. The same applies to other guarantors.
As for the army, it has raised its rates four-fold, based on an exchange rate of 6,000 pounds, while the Ministry of Health, which received funding from the World Bank, increased its fees by 3.5 times, easing the financial burden on citizens. Bills for patients under state insurance, the State Employees Cooperative, and security forces are still calculated at the official dollar rate.
Amidst the decline in the level and value of insurance coverage and the shift of medical and hospital sectors towards cash dollar payments, “only 10% of citizens can purchase insurance policies in cash dollars,” Al-Abyad confirmed. Hence, these are the only ones who will enjoy 100% coverage. What about the remaining 90%, and is the Ministry of Health able to cover the medical costs in hospitals? Al-Abyad asserts that “those uninsured in the private sector face issues with hospitalization due to the inability of guarantor entities to cover them,” clarifying that “the Ministry of Health is taking steps to secure the highest possible health coverage and lighten the costs for the poor. In addition to increasing the fee rates for private hospitals, it aims to support and strengthen government hospitals by providing diesel for government hospitals worth $5 million from Qatar for their needs over six months. Additionally, we receive assistance from international entities in medical equipment and supplies to slightly lessen the burden of hospitalization costs on the patient.”
He added: “Despite this, we still face challenges in being able to cover all costs incurred by citizens depending on the health condition under which the patient is admitted, as some treatment methods do not require medical supplies, resulting in higher coverage levels. However, if a medical supply is needed and is not supported 100%—like orthopedic supplies, for instance—then the patient must cover the difference.” He pointed out that “there is variation in the cost of a single procedure between hospitals, which is part of the chaos we are facing in the healthcare sector that we are working to mitigate with hospitals.”
Under these circumstances, until long-term solutions are established, “government hospitals remain the primary refuge for citizens who cannot receive treatment in private hospitals,” Al-Abyad concluded.
#### Financing the Health System
One-third of the Lebanese health system has been funded for the past two and a half years through tax revenues, another third from contributions by employers, and the last third paid by patients through insurance policies or by covering the differences upon admission to hospitals.
#### Study of Health Coverage Post-Crisis
The Ministry of Health is preparing a program with the World Health Organization regarding the future of health in Lebanon, expected to be completed and presented in July, as confirmed by Health Minister Firas Al-Abyad. This program consists of workshops aimed at preparing a health future program for Lebanon, identifying funding sources for health coverage, whether from citizens or employers’ contributions to social security... thus outlining a picture regarding the health coverage issue for the post-crisis phase and the path we will take.
Regarding the possibility of obtaining support for this health program, the Minister of Health stated that it depends on the country’s financial situation and the course of negotiations with the International Monetary Fund, the World Bank, and the economic situation. Just as an individual purchasing health coverage depends on their financial status!
