Rebuilding Health Post- Conflict A Dialogue for the Future

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Session 5: Social Entrepreneurship: Responsiveness to Evolving Needs
American University of Beirut
Friday December 9th 2016
Dr. Kamel Mohanna
President, Amel Association International General Coordinator, Lebanese and Arab NGOs Network Professor of Pediatrics, Lebanese University

Context
Lebanon might be a small country, a complex one, but certainly, it is number one in the world when it comes to civil society and volunteering, with more than 8,000 registered civil society organizations (CSOs) with the Ministry of Interior.
The role of this sector emerged during the fierce war years, where such associations secured citizens’ needs. They could do so thanks to their role and attachment to the people. Their great concern for society structures in the country prevented the disintegration of society.
In fact, during the Lebanese “civil war” (1975 -1990) and the Israeli occupation, the civil society movement prevented disintegration, and fought the dissolution of the Lebanese community. People held onto their steadfastness despite the cruelty of war and the fact that it lasted for so many years. Despite obstacles, their humanitarian activities and advocacy continue to have an impact on politics in the state, for example, by preventing phenomenon such as malnutrition from occurring.
While governmental agencies were totally paralyzed, civil society became more active in order to compensate for the absence of a strong central government. It did so in the presence of strong militias, as civil society and volunteering body developed into the reverse image to ugly war. At that time, they represented the flame of hope and the strength of the humanitarian values as well as the national idea of united a Lebanon.
One of the important examples of CSOs achievements goes as follows: Before the war, we had 20 associations tending to disabled people, but now nearly 80. There were 250 dispensaries and this figure has risen to 860. In terms of primary health care centers, 760 dispensaries are managed by voluntary bodies.
At that period, we also witnessed the emergence of more coordination among CSOs. As military actions settled down, CSOs began to perceive their role as complementary to that of the government and experienced changes, increasing awareness, self-consciousness. Moreover, globalization introduced a set of principles, such as participatory democracy, sustainable development, good governance, transparency and accountability into the Lebanese civil society.
Amel Association International: a model of change
Amel Association International (Amel) was founded during the mentioned context of bloody war, Israeli invasion in 1978 and sectarian clashes between militias, as a non-sectarian Lebanese organization (NGO), in 1979. Its singularity lies in its non-confessional approach in a country where all institutions, political systems and social relations depend on confessions.
Through its 24 Primary Health Care Centers and 6 Mobile Medical Units and 800 workers, volunteers, Amel has been involved for more than 37 years in Lebanon’s most vulnerable areas, such as in Beirut’s southern suburbs, Mount Lebanon and the Bekaa valley (Lebanon East), all the way to South Lebanon. It has always offered quality services in the sectors of health, psychosocial support, vocational training, rural and gender development, child protection and human rights promotion.
Committed to the “3 P’s” theory (Principles defining a Position that we put into Practice), Amel aims to build a democratic and prosper Lebanon, where the entire population, regardless of its confession, political ideology, social economic level or nationality, will live in harmony; a country where citizenship will become a shared concept, and where fundamental rights (health, education, housing…) will be provided by the state. This would allow citizens to live in dignity, free to think, to believe, to circulate and to speak up.
The action revolves around 3 essential points that are related to a secular economy: – The struggle for an equal distribution of wealth,

– The establishment of a righteous and equal society, since we are all living in the same world and are sharing the same future,
– Resisting neocolonialism in all its forms.
With its experience of over 37 years in Lebanon, Amel became an International association on December 15, 2010 and was registered at the directory of international NGOs in Geneva. The purpose was to share experiences around the world and to strengthen its collaborations with other international NGOs.
Thus Amel Association acquired the status of International association registered in Geneva. The internationalization objective is to reconnect, via friendly civil societies, the north and the south hemispheres with humanitarian principles.
The role of civil society in health sector
According to the latest statistics, 47% of the Lebanese people have no health insurance and can’t access health care easily. Indeed, the health service sector in Lebanon is controlled by a free economic system, where health services are limited to a curative / therapeutic framework and not preventive.
The role of civil society, especially within health sector, was essential during the long years of war. The public sector became ineffective between 1975 and 1989 and during the Israeli attack on Lebanon. Civil society organizations were those who scrambled to fulfill the needs of the people and bring support in all areas.
A transitional approach was then implemented by these CSOs in the early 1990s, after the end of the war, in order to move from emergency intervention to development. This civil society and its 760 healthcare centers became the backbone of the health sector in Lebanon becoming the main provider of health services.
How can the civil society provide first health care?
Millions of citizens, and recently refugees as well, are benefiting annually from thousands of services provided by the civil society and volunteering bodies in primary health care centers (760 of them around Lebanon).
These services include: diagnosis, consultations, and treatment, medications, and awareness sessions, in addition to the easy access to health benefits through free primary health care, under the supervision of Ministry of Public Health.
The most important indicator of this mission’s success is the improvement of human development indicators, the alleviation of poverty and contribution to achieving the millennium goals, including the below points.
Mass Immunization – Global program
This program aims to combat what we call the five diseases (polio, measles, mumps, rubella and tetanus). It has been in place since 1987 under the supervision of the ministry of health, with the collaboration of UNICEF and other NGOs. As such, several goals were achieved before the end of war in 1996: treating these 5 diseases through vaccination.
Moreover, national days for the protection of children took place at the first week from April, May and June and to ensure children’s vaccinations in NGOs. Awareness campaigns were organized, insisting on the importance of vaccination and preventing any misconception regarding vaccination.
Lebanon has achieved good results in fighting the most common children’s diseases such as those that can be treated by vaccination. These achievements are possible with raising awareness, activating the health care in the centers of ministry of public health, social affairs, the NGOs and the civil society clinics, and finally through a national program sponsored by the UNICEF and the WHO.
School health
The formation of the National Committee of the “school health”, which includes representatives from the Ministry of Public Health, Ministry of Education, Ministry of Social Affairs, as well as UNICEF and civil society health centers, made the school health a “major” key focus in the activity of health clinics and centers.
In the eighties, an important decision was taken by the Ministry of Education. It was decided to add “health education” material to formal education programs. A decision was also taken to form the National Committee of Permanent School Health on February 8th, 1993. On 1997, the Committee prepared a training manual for the team in charge of conducting school health examinations.
Furthermore, family planning services were developed over the years by an organization of family planning in cities and rural areas by civil society clinics. Since 5 years, the ministry of public health is supervising the family planning services in centers with collaboration with some NGOs.
The national committee is also distributing medication through a program supervised by the Ministry of Public Health, in collaboration with YMCA. The program covers mother and child care, care for elderly and people with disabilities in order to improve their life.
A strategy for the primary health care through medical centers: Primary Health Care Centers Network
Within the framework of the strengthening of the Ministry of Public Health and in an effort to improve its collaboration with the civil society, the Ministry approved in 1996 and in coordination with the World Bank, to implement the national primary health care strategy. 30 contracts have been signed with health centers, including 20 contracts with the civil sector and civic organizations centers, while 10 contracts were adopted by the Ministry of Public Health. A national committee for the joint implementation of this strategy was later formed.
The mentioned PHCs (Primary health centers) services focused on the following matters: Medical Consultation from various disciplines; oral and dental health, Physical Medicine, X-ray, lab tests, vaccinations, reproductive health and health education. This health care network later expanded to include 42 “active” centers, which reached later “about 150 centers,” across Lebanese regions, taking into consideration the coverage of underprivileged and disadvantaged areas and rural areas. Recently, this network expanded its activities, notably within the framework of the latest national strategy of the Ministry of Public Health.
The civil bodies and CSOs count a lot on this success experiment and consider it to be the actual key to the implementation of the primary health care strategy in the centers, while enhancing the active participation and conduct evaluation process in order to correct the path of this national strategy.
Civil body response and role during the Israeli attack 2006
Lebanon has recorded the strongest resistance against Israeli attacks and invasions, which caused massive destruction to the country on many levels.
The war in 2006 caused the death of some 1400 individuals, while 4500 were wounded. 30,000 housing units were destroyed, 154 bridges and a huge number of facilities, factories and institutions. A major economic setback followed the conflict. It was a real crime that history will never hide.
On 14/8/2006, just a few hours after the end of the war, thousands of displaced people came back to their houses, towns, and the numerous destructions, facing all the challenges of returning to their homes.
What happened to Lebanese at that time was an important indicator to show the power of unity, with the Lebanese acting as one national team, facing this unexpected disaster that affected Lebanon on a long term.
The humanitarian sector, during the first days of the war, suffered from bad coordination and mediocre performance especially in health, social and emergencies sectors. Scandals were revealed after such a weak response from International organizations, such as United Nations and the International Committee of Red Cross during the first two weeks of the attack. These organisations had not filled their duty in the circumstances, despite protests from local NGOs and CSOs.
This was due to the expectation for the military situation to end in the three coming days. Food and medications shortages for displaced citizens coming from “Dahyeh” and “South” toward the mountain, North and “Bekaa” led to sectarian discriminations and clashes, like a plan was set to destroy Lebanon from the inside.
In the midst of all these troubles, something unexpected took place; the creation of a very powerful solidarity between Lebanese citizens in the areas of displacement. What happened between people indicates the strength of Lebanese patriotism. However, this solidarity was not enough to build a new country with fair policies and social conditions.
On the second day of the attack, members of the civic and voluntary bodies network in Lebanon (Caritas Lebanon, council of churches in the Middle East, “Makassed” organization, Beirut association for social development, Rescue people association, Amel, family planning association, “Farah” association, the national center for development and rehabilitation, social movement, “Maarouf Saad” association), in addition to the Islamic health organization and the Lebanese association for health and social support, humanitarian agencies, all collaborated with civil committees. As a result, a committee was established to follow the NGOs. It met with the Minister of Public Health, the Minister of Social Affair and the Prime Minister, in addition to some representatives from the International committee of Red Cross and the United Nations.
After the Israeli attack on Lebanon, the notions of “National Unity” and “Human Solidarity” emerged. The needs in health and emergency domains were organised through a strategic map. Public and civic sectors and international NGOs ensured that the work was humanitarian and national, not factional or political.
The question was: how can emergency and healthcare actions be organized to face the disaster affecting Lebanon? The response included the following elements:
HRC- higher rescue committee
This official body was initiated by the Prime Minister, in coordination with Ministers of Public Health, Social Affairs, Environment, Finance, Interior and representatives of the military, Council of South, Council of Development and Reconstruction and the Lebanese Red Cross. It was related to the emergency and relief action, covering cities and rural areas hand in hand with municipalities, civil and medical bodies and the private sector, under the supervision of the Mayor and the district officer in the judiciary.
Follow-up Committee for civil society organizations
It consisted of representatives from civil bodies and NGOs in Lebanon. Committees involved in the health sector also took part, under the supervision of the Minister of Health. The relief actions were supervised by the Minister of Social Affairs, working on the following:
• Creating an organized structure on the national level, including a map covering the location of the displaced citizens (sheltered inside schools or outside them).
• Distributing missions between partners, under the supervision of specific ministries in order to organize the action and prevent double standards.
• Implementing strategies to overcome the chaotic situation, through solidarity between the Lebanese and the increasing of national unity values.
• Developing an action plan to be implemented during two steps. The first step was to respond to the needs of displaced citizens. The second took place after the end of the attack, when people return to their homes, making sure that the relief plan covered South and “Dahye” and “Bekaa”.
• Collaborating with the international committees and NGOs, such as United Nation organizations and the International Committees of Red Cross, to perform at best the missions assigned. This was necessary as donations in the first two weeks were not enough to cover the consequences of the war and its financial effects on the level of health, relief, and environment.
• Setting the plan to move from destructive war and emergency to rebuilding, reconstructing the country and linking people through development programs.
The social and environmental consequences caused were no less devastating. For example, the big petrol spot spread into the sea after the shooting on “Jiyeh” warehouses, becoming one of the major environmental aggressions caused by the Israeli attack. Furthermore, thousands of bombs left unexploded continue to threaten both human lives and agriculture in Lebanon.
The main issue discovered after the war was the absence of a national strategy to overcome these environmental disasters. For example, tons and millions of liters of petrol were thrown into the sea as a waste. Scientific studies have clarified the consequences of war on the environment. This is why the government in collaboration with NGOs drew plans and strategies for environmental crisis responses in war and even in peace times, to prevent future disasters as the one we are living today in Lebanon:
Recommendations
It has become clear over time that the civil society in Lebanon has always been coping with the sectarianism and the weakness of the state. Many civil society organizations are still sectarian in nature thus reflecting Lebanon‘s division into recognized religious communities. The six or seven major Christian, Druze, Muslim communities offered many of the material resources for organizing Lebanon’s rich associational life. Each sect in a sense created its own civil society. Nevertheless, many professional associations and environmental, advocacy, women’s group that cross-confessional lines and favor the integration of a national Lebanese civil society also exist such as Amel Association International.
A real challenge remains in the responsibility of both the Ministry of Health and the private sector and voluntary bodies. It is to turn theoretical plans into action, in order to see a transition from treatment to prevention policies along with health for all (not just protection from the disease).
Replacing the current health system which is in danger of collapsing, with a fairer, more effective and integrated health system, which means to emphasis on primary health care as a key strategy to adopt and to ensure health for all. This is inextricably “linked” to the economic and social situation of the population. There is a need for an approach beyond sectoral specializations, so as to enhance many fields, including health, education, social affairs, security, agriculture, finance, NGOs private sector, international organizations and industry, in order to achieve the health policy objectives.
Allocating additional resources to the administrative system of the Ministry of Public Health.
Implementing the strategic health map for Lebanon based on the instructions of the World Health
Organization WHO, to dispense aid accordingly to needs.
Strengthening the cooperation between official institutions and private and civil sectors, which are complementary.
Involving public and private sectors and NGOs, with the Ministry of Health filling the role of organizer and supervisor of the health sector.
Reducing hospitalization (health) fees in order to improve the health status as one of the elements of sustainable development, through:
Commit to the “flat rate”
Find alternatives to hospitalization (one day clinic)
Adopt the principle of home health care (Home Care)
The Family doctor as mediator between the patient and the specialist doctor and the hospital
To ensure a better regulation of this vital field of all the Lebanese people, we must develop a
national system for the hospitalization of the basic pillars: the unification of health funds, supporting and activating the public sector of the hospital, and activate the system the establishment of public institutions for the management of government hospitals in the provinces. And put programmed plan for the dissemination of health insurance for all Lebanese citizens, the adoption of the principle of participation in the cost of health services by the citizens.
Implementing a national medication policy to respond to the needs of health care, and to develop appropriate legislation to implement this policy and adopt lists of essential medicines, and to accelerate the development of action into effect of the medication National plan.
Following a modern model to organize the action of the institutions and voluntary bodies, and to enhance their role in the field of primary health care through the reorganization of community centers and public health clinics; mobilize all energies towards the implementation of a comprehensive national health plan.
Re-distributing tasks between the public and private institutions; ensuring the organization of the role of the private sector and civil society in the framework of this national policy; fixing legal conditions and regulations of the centers and dispensaries; pursuing work with the Ministry of Health to find an appropriate legislation to fit the nature of each activity.