Deciding to cut budgets is a difficult choice to make and may raise ethical issues. When faced with such a fact of life one needs to prioritise allocation of resources in a just way.
WHY TO CUT?
Cuts in budgets are inevitable in a world where the population increases and productivity does not match demands, and/or we mismanage available resources. In Lebanon these three factors have a bearing on the health of the majority of the Lebanese people. In a meeting between the Lebanese Ministers of Health and Finance on 31 December 2009, the former did not get the budget he asked for (do not misunderstand me; he did not get more). Mismanagement of resources is a universal issue. The unavailability of generics in developing countries is a big problem.1 Physicians inflate the medical bill by not adhering to evidence-based medicine and ethical guidelines.2,3 Ordering unnecessary tests is not unusual; even in emergency departments in academic institutions ordering a CRP test appears to be universal in patients presenting with fever at a time when the evidence for this practice is poor. Drug representatives in Lebanon have open access to physicians. The drug industry effect results in the prescribing of expensive medications.4 Lack of planning inflates health expenditure in Lebanon. The country is oversaturated with physicians; one doctor per 300 inhabitants; sub-specialists constitute 70% of registered medical doctors; there are 22 open heart centres, 38 magnetic resonant imaging centres and eight linear accelerator centers for a population of 4 million.
WHAT TO CUT?
The Lebanese state finances six independent governmental health funds. Each fund has its own administration. Unifying administrative procedures under one organisation allows substantial cuts on expenses.
There are 3.8 hospital beds per 1000 inhabitants in Lebanon with an occupancy rate of 56%. There are around 27 CT and 10 MRI scanners per million inhabitants in Lebanon — compared to 12 and six in Canada respectively.5 High availability of scanners may result in unindicated use of these machines. There is a need to limit spending on hospital beds and high-tech diagnostic machines.
The Ministry of Health allocates 53% of its budget on drugs to provide medicines for chemotherapy. Cutting this figure is justifiable; there is no benefit of chemotherapy in several malignant conditions, mainly those with metastasis.6 The Lebanese population consumes medicines that cost £250 million a year. Generics constitute only 2% of the pharmaceutical market. Policy makers in Lebanon can offset the reduction in the budget by enforcing the use of generic drugs.
The presence of 22 open heart centres implies there are medically unnecessary operations. There is a large debate on the choice of revascularisation procedures with more evidence-favouring angioplasty versus coronary artery bypass graft (CABG).7 Moreover, Morrison et al reported that aggressive treatment of risk factors and medical therapy result in better outcomes than CABG at a lower cost.8
Stitching a torn system due to an inattentive manager (those running the monetary system) does not justify the actions of the administrator (government). It is so disappointing to see governments penalise ordinary taxpayers and reward monetary institutions that mismanage the nations' wealth.
Acknowledgments
We like to thank Doctor Rasha Hamra from the Ministry of Health for providing us with valuable data.
- © British Journal of General Practice, 2010.