Country profiles

Lebanon

Overview

Lebanon has a surface area of 10 452 km², with a Mediterranean coastline of 211 km; Beirut, the capital, stands in the centre of this coastal strip. The Lebanese terrain is a mixture of coast, mountain and inland plain. The population immediately after the beginning of the civil war in 1976 was 3.2 million, but the exodus of a large number of people due to war conditions resulted in an estimated population of 2.7 million in 1990, and it was 3.7 in 1997. Most of the population occupies the narrow coastal strip. Beirut has nearly one million people (1.5 million in 1976): Tripoli, to the north, is the second largest city with over 180 000 inhabitants. In 1997, the percentage populations of those below 15 years and above 65 years of age were 28% and 4%, respectively. Also in 1997, 84% of females above the age of 15 years were literate and the total adult literacy rate was 88%. No accurate data on health status are available. In 1996, however, the crude death rate was estimated at 7.4 per 1000 population and the crude birth rate was estimated at 27 per 1000 population. In the same year, the infant mortality rate was 27.9 per 1000 live births, the maternal mortality rate was estimated as 10.4 per 10 000 live births, total life expectancy at birth was estimated at 71.3 years and the under-5 mortality rate was calculated to be 32.2 per 1000 live births.The per capita gross national product in 1992 was US$ 960-down from US$ 2350 in 1987.

Fifteen years of civil war caused massive destruction to the country’s infrastructure, estimated at US$ 500 million. Electricity, water and telecommunication systems, as well as the road network, were severely damaged. Coupled with this destruction, there has been a rapid deterioration in the quality of life of the people, in the areas affected in particular and in the whole of Lebanon in general.

The national health policy is based on health’s being the constitutional right of every citizen and an integral component of human rights. The health policy also emphasizes prevention as taking precedence over cure within the context of primary health care and through providing a degree of autonomy to the regional and subregional units, within the concept of "centralized control and decentralized implementation".

Accurate data on dispensaries and/or health centres, including the actual numbers that are functioning, the levels of services offered, their coverage and impact and the types and numbers of staff, are unavailable. Although there are 19 government hospitals in different districts, most of them re completely inactive. On the other hand, 80% of the Ministry of Public Health and Social Affairs budget is used to subsidize private hospitals for treatment of patients who cannot afford to pay. In some cases, public hospital services have deteriorated to such an extent that they lack all basic supplies and equipment as well as the necessary staff. Furthermore, hospitals are not linked to the peripheral health units and therefore, do not serve as referral points for these units for cases that require more advanced care.

Primary health care implementation is now completed in seven of the 25 districts and activities are being extended into another 10. The seven districts in which it has been implemented are equipped with health centres providing services for maternal and child health, family planning, health education, school health, laboratory and radiological investigations, provision of necessary drugs, promotion of good nutrition, vaccination, and provision of supervision for community health workers, as well as collection of data and compilation of statistics. Each health centre refers patients requiring further treatment to an appropriate district hospital.

In the recent rehabilitation/reconstruction plan for Lebanon’s health services, a prioritization of needs for external aid has been carried out. Priorities have been established as follows: essential drugs; expanded programme on immunization; diarrhoeal diseases control; support to public hospitals; primary health care; control of drug abuse; strengthening of epidemiological services; tuberculosis control; and control of water quality.

Although large numbers of professionals left the country, adequate staff with necessary skills, particularly physicians, are available, but salary levels are low, thus forcing them to seek employment in the private sector. The ratio of private doctors per capita in Lebanon is among the highest in the Region. Although this phenomenon partially offsets the erosion in the public health sector, it has not contributed to a meaningful improvement in health care in general.

The district health system, which has been implemented in seven districts, is made up of three components: the community health workers, the health centres and the district hospital. The community health worker is chosen by the village committee and performs home visits and a variety of duties encompassing many aspects of primary health care; he or she also refers patients to the health centre when necessary. The health centre has at least one physician and one nurse and performs the duties mentioned above; it also refers cases to the district hospital which is staffed with a surgeon, an internal medicine specialist, a paediatrician and a gynaecologist, and is the final point in the referral chain of the district health system. When the system becomes fully operational, the hospital can refer the more complicated cases to a regional or central hospital. A district health committee supervises the district.

As the public sector was progressively marginalized as a result of the war, numerous nongovernmental, private, voluntary and sectoral organizations emerged to fill the gap. Unlike other countries of the Region, where nongovernmental organizations such as the Red Crescent and the Red Cross play only a supplementary role, in Lebanon they play a major part in health care delivery. They are charged with certain services such as immunization and blood bank services. However, many of the services provided by private and nongovernmental organizations are not affordable for those who need them most; they are in fact, beyond the financial reach of over 80% of the population.

Although the Ministry of Public Health registered 6638 physicians at the end of 1989, only 2400 were believed to be actually working in the country, giving a rate of 8.9 physicians per 10 000 population. In 1990, there were 3012 nurses (including 500 midwives), giving a rate of 10 nurses per 10 000 population. The distribution of health human resources is far from equitable: Beirut and Beka’a governorates have a higher concentration than the south and north of Lebanon, both of which appear to be underserved.

In 1987, 24 district health committees were established, one in each district. These committees consist of representatives of all health outlets and facilities in the district as well as local representatives from the Ministry of Education and the municipalities. The Governor of the district chairs the committee.

MENTAL HEALTH

Both Christians and Muslims have always put emphasis on the care for the mentally ill. In the outskirts of Beirut, the Lebanese Hospital of Mental and Nervous Disorders was established in 1898. It provided good care, first by English psychiatrists and later carried on by Lebanese specialists trained in England. This hospital was to be rebuilt elsewhere, but the war stopped the construction. There is only one psychiatric hospital. The 1500-bed Psychiatric Hospital of the Cross was founded at the beginning of the 1950s and is run by a Maronite order of nuns. The psychiatrists are chiefly of French background and specialization, but the hospital is open to all professionals. Their number of psychiatrists is relatively low but increasing. Although the hospital belongs to a completely Christian charity, it has a noticeable proportion of non-Christian population. Nursing is performed by nuns and nurses trained "in the field" and is quite satisfactory. The hospital, as any other mental hospital, is constantly at full capacity. This is, as in other countries, due to the lack of follow-up for discharged persons, the tendency of mental illness to recur and to become chronic, and the increasing number of mental disorders. The situation has remained unchanged since 1950.

Psychoses account for 60% of the admissions, but unfortunately most of them are readmissions. Males schizophrenics outnumber females in a proportion of 2 to 1. The Ministry of Public Health supports a large majority of hospitalized patients while only about 100 patients are paying patients.

Another institution, the Mental Hospital of the Muslim Old People’s Asylum, is located in Western Beirut.

It is estimated that there are 45 psychiatrists in Lebanon, some of them are attached to the mental hospital, where they work part-time while having private practice. The others are working in private clinics and refer their patients to one or other general hospital. This gives a ratio of psychiatrists to population of 1.2 to 100 000 approximately.

All of the psychiatrists, after graduating in medicine from Saint Joseph University or the American University of Lebanon faculties, finish their specialized training in hospitals and institutions in France or the USA. In 1987, the Psychiatric Hospital of the Cross signed an agreement with Paris University to enable Lebanese physicians to get trained in psychiatry in Beirut and take the final examination for the Special Studies Certificate in Paris. There are very few clinical psychologists and they work mainly in schools.

There are an estimated 24 000 young drug addicts in the country. Narcotics production tripled during the years of conflict; however, this figure dropped significantly after the war to an estimate of about 8000-10 000 for all drug categories... Heroin is sniffed, inhaled or injected.

The current emphasis on training includes sensitizing medical students to mental health problems by a two-month training course in the fourth year. Postgraduate training includes four years of intensive theoretical and clinical training at the Psychiatric Hospital of the Cross. General practitioners and general nurses receive two to three months’ training. Community involvement includes the activities of the Church in response to the major national problem of drug dependency.

The national mental health programme was prepared in December 1987 with the following objectives: to make mental health care available for everybody, anywhere in Lebanon, without resorting to specialized institutions and centres in the main cities (that means well-planned decentralization of mental health services); to adapt care models to the social and cultural patterns of the rural communities which, up to now, have not, or have received little attention to mental health matters; to expand mental health knowledge and enhance it in the community in order to remove prejudices still existing about mental disorders; to developed suitable programmes to assist the large numbers of displaced persons, the disabled, the bereaved, and so on affected by the war; to provide every mental health clinic created and integrated with primary health care with all the drugs necessary for treatment of mental troubles.

The progress of the national mental health programme has not been satisfactory due to the war and its disruption.

Currently, the Ministry of Public Health of Lebanon, in an effort to improve health services in the country, is addressing itself to improving mental health services in areas of urgent need. Instead of implementing a comprehensive programme, it has decided to limit it to two areas of importance.

Ambulatory mental health services within primary health care centres. This is conceived with the hope of improving referrals and decreasing stigma. Furthermore, the availability of these centres all over the country facilitates implementation and reduces costs. Each mental health team will comprise a psychiatrist, a social worker, a psychologist and a psychiatric nurse who will work in close collaboration with the other physicians of the centre. This interaction aims at promoting preventive and interventional measures in mental health to the health centre’s medical and paramedical staff.

Already two centres for outpatient primary health care and three centres for geriatric custodial care have been identified for this work.

A prevalence and service fact-finding survey for psychiatric morbidity is now being conducted to try and quantify the problems that the war has created in the psychosocial domains.. At primary health care centres , a complete human resources reorganization is under way with the introduction of quality assurance, on-site training of paramedical staff and the formation of psychiatric teams. In the psychogeriatric domain, the medical, paramedical and nursing teams have been formed and on-site training of existing staff is being conducted. In addition, the senior physician visited the United Kingdom on a WHO fellowship in geriatric medicine during 1996. In the area of quality assurance, an extensive database patient chart had been developed with a computer link-up. It is anticipated that once the pilot centres are in full service, the organogram model would be transferred to other centres in Lebanon for implementation.