Table 1.

Summarized results of SWOT analysis of service deliver by level of care

Primary care
Strength	Weakness	Opportunities	Threats
1. Service Readiness at PHC: • Highest readiness for non-communicable disease management. • Followed by general medical, pediatric, dental, and finally reproductive and maternal services. 2. Government Support: • National network of PHC centers provides reduced-cost consultations and free chronic medications and vaccines to beneficiaries across Lebanon. 3. Accreditation and Quality: • Accreditation in PHC associated with improved delivery of healthcare and quality. • Increased customer satisfaction and patient visits reflect quality improvements. 4. Sustained Service Provision: • Healthcare delivery sustained at all levels during the crisis. • Primary health care centers and hospitals (public and private) remained operational. 5. Integration and Resilience: • Integration of non-communicable disease management within primary health care progressed despite the crisis. • Lebanon’s HS maintained service delivery for refugees and citizens, preventing diseases and improving morbidity and mortality levels despite limited system inputs. 6. High Patient Satisfaction: • Remarkably high patient satisfaction with primary healthcare services in Lebanon	1. Refugee Burden on PHC: • Unprecedented challenge due to the burden of refugees on the PHC network. 2. Budget Allocation: • MOPH allocates only 5% of its budget to preventive PHC services. 3. Health Human Resources: • Shortage of FM physicians at PHC centers. • 20% of surveyed PHCs lack registered nurses as required by national standards. • Urban-rural disparities in health human resource availability. 4. Accreditation and Quality: • PHC centers are early in preparation for accreditation. • Lack of quality improvement plans and irregular review of guidelines [16]. • An incident reporting system and care provision summaries are lacking, which hinders the monitoring and improvement of care quality [17]. 5. Service Accessibility and Costs: • Not all PHCs offer medical imaging and blood exams; patients often pay out of pocket. 6. Unfair Treatment and Exclusion: • Witnessed unfairness in service delivery (access to medications, appointments, financial aid). • Exclusion and empty promises reported by respondents with diabetes and lower limb amputation. 7. Health Promotion and Prevention: • Lifestyle counseling and prevention services not accessible. • Agreement on need for health promotion and primary prevention activities across participant groups. 8. Mental Health: • Lack of training for PCPs to identify and treat mental disorders	1. Diverse Funding Sources: • The Lebanese HS benefits from a variety of funding sources, including public funds, private sector investments, and international aid. This diversity allows for multiple conduits for service delivery and the potential to leverage various financial resources to improve primary care services [18]. 2. Patient Experience: • Despite limited diagnostics and poor risk communication options, patients find the PHC more accessible and affordable than other services. 3. Therapeutic Drug Policy: • Lebanon has a therapeutic drug policy that ensures the importation of all essential medications as specified by the WHO. This policy provides a framework for maintaining the availability of critical drugs and could be leveraged to improve medication access and management within the primary care system [19]. 4. Sustained Financing: • Throughout the crisis, the Lebanese HS maintained financing for services at primary, secondary, and tertiary care levels. • MOPH contracts with primary health care centers were preserved. 5. Efficient Resource Utilization: • The HS efficiently utilizes financial resources. • Further investment in this area can significantly impact health outcomes. 6. PHC Prioritization: • Healthcare prioritized at the PHC level, emphasizing quality of care. • A shift from parallel services to intensified support through the expanding MOPH PHC network. 7. People-Centered Approach: • Efforts to optimize PHC service provision and move towards a people-centered HS.	1. PHC Accreditation Challenges: • High staff turnover, heavy workloads, and the absence of a structured referral system pose significant obstacles to implementing and maintaining PHC accreditation standards. These challenges can hinder efforts to meet quality benchmarks and improve service delivery [19]. • Limited financial resources hinder recruitment of specialized staff and equipment purchase for accreditation. 2. Refugee Burden: • The unprecedented burden of refugees on the PHC network is a significant challenge. 3. Inadequate Mental Health Services: • A 2009 study reveals that mental health services in Lebanon are inadequate and lack necessary attention.
Secondary Care
Strength	Weakness	Opportunities	Threats
1. Sustained Health Care Provision: • Healthcare delivery has been sustained at all levels throughout the crisis. • Hospitals (public and private) have remained operational. 2. Maternal Health Improvements: • Significant decrease in maternal deaths in Lebanon, with a 13% reduction in 2015. 3. Essential Equipment Availability: • Infusion pumps and fetal monitoring equipment are readily available across both public and private sectors in Beirut and other regions for safe maternal and newborn health care. 4. Skilled Attendant for Childbirth: • Childbirth with a skilled attendant is almost universal in Lebanon. 5. Response Plans and Capacities: • Local-level response plans and capacities are being further developed, especially in areas at higher risk of outbreaks.	1. Psychiatrist Input: • Lack of expert input by psychiatrists in organizing mental health care at the public health level. 2. Complex and Privatized HS: • For more than 3 decades – the structure of the financing system is a major flaw whose impacts have helped to create a perpetual crisis to date [20, 21]. • Highly privatized HS in Lebanon poses barriers to ensuring accessible, affordable, and quality healthcare services. • 70% of the healthcare facilities in Lebanon are privately owned, as of 2023, less than 30% of the population is properly covered by health insurance [12, 20]. • Affects both refugees and host communities. Most of the population—nearly 1.5 million Syrian refugees and over 200,000 Palestinian refugees—to have minimal access to main healthcare services [12]. • 60% of all health expenditure being out-of-pocket and hence not affordable to many. • 45% of Lebanese citizens delayed or did not seek required medical treatment because it was too expensive [22]. 3. Bed Availability and Surgery Cancellations: • Non-availability of government-contracted beds leads to majority of surgery cancellations. • In the year 2022, approximately 40% of the surgeries scheduled for public hospitals were canceled because beds were not available [22, 23]. • At Rafik Hariri University Hospital, out of the 3,000 surgeries planned, nearly 1,200 were postponed or canceled due to the no availability of beds. • The situation is very grave, especially during peak winters when bed occupancy rates often exceed 90%, leaving very little room for fresh admissions and urgent surgery cases [22]. 4. Patient Discharge Instructions: • Limited patient understanding of discharge instructions. • Low compliance with recommendations. • 70% of patients discharged from public hospitals did not fully understand the instructions given to them, contributing to poor health outcomes and increased readmission rates [12]. • 100% of participants did not receive complete discharge instructions [12]. • Only 30% of these patients adhered to their prescribed treatment plans, highlighting the urgent need for improved communication and patient education in the discharge process [12]. 5. Vulnerable Lebanese Individuals: • Those not covered by existing health insurance funds struggle to afford outpatient care at private clinics. • Access pharmacies or civil society-run health centers instead.	1. Charities and NGOs for Older Adults: • Many charities, associations, and NGOs are oriented to providing vital services for elderly people, on the list are the Lebanese Red Cross and Caritas Lebanon. In these, the elderly has been aided in a plethora of settings: health and social support and rehabilitation settings [23]. • Caritas Lebanon provided over 10,000 free consultations and distributed more than 15,000 packs of medicine to the elderly within 2022 alone [24, 25]. • The Lebanese Red Cross operates various projects that aim at enhancing health and well-being for older people. This has been benefiting over 8500 people during the past year [25]. • 2. KPIs for Hospital Performance: • Key Performance Indicators have recently been more diffuse in hospitals of Lebanon to evaluate and improve health quality. Those would estimate a broad range of performances: patient-centered care, clinical effectiveness, safety, staff orientation, efficiency, client satisfaction, client flow and load, responsive governance, clinical practices, and provider satisfaction. • For instance, implementing KPIs at AUBMC decreased patient waiting time by 20% and augmented overall patient satisfaction by 15% within a year. Another nationwide study in 2021 showed that hospitals operating according to KPI frameworks reported 25% improvements in clinical outcomes against a 30% drop in medical errors in institutions that didn’t apply such frameworks [12]. • In addition, continuous monitoring of KPIs at Rafik Hariri University Hospital increased staff satisfaction by 10% and operational efficiency by 35% over the past three years. The continuity of follow-up founded on KPIs additionally empowered better governance practices, resulting in greater responsiveness and efficiency of management for the hospitals.	1. Financial Challenges: • Payments shortfalls for purchases. • In 2023, public hospitals reported a payment shortfall of approximately 30% for essential medical supplies and equipment, leading to delays in procurement and compromised patient care [26]. • Rising costs due to various factors. Healthcare costs in Lebanon have surged by over 50% since 2019, driven by factors such as the devaluation of the Lebanese pound, inflation, and increased operational expenses. For example, the cost of medical supplies has tripled, making it difficult for hospitals to maintain adequate stock levels [27]. • Regulatory burden, including accreditation requirements. Increased operational costs by an estimated 20%. Many hospitals struggle to meet these requirements due to limited financial and human resources, which in turn affects their ability to provide quality care. • Worker shortages, particularly nurses. As of 2023, the nurse-to-patient ratio in public hospitals has dropped to 1:20, far below the recommended standard of 1:6[22, 27]. 2. Institutional Policies: • Lack of explicit healthcare institutional policies mandating training or continuing medical education for providers in quality improvement and patient safety. • In 2022, only 15% had formal policies requiring ongoing training in these areas. • Less than 25% of healthcare providers participated in CME programs focused on patient safety and quality improvement. • 10% of all hospitalizations in 2023 involved some form of preventable adverse event. 3. Quality Monitoring: • Absence of national standardized quality indicators to effectively monitor progress and ensure quality healthcare delivery. • As of 2023, Lebanon does not have a unified national framework for quality indicators, which hampers the ability to consistently measure and compare healthcare performance across institutions [12]. • A recent assessment revealed that 85% of hospitals lack standardized metrics for evaluating clinical outcomes and patient satisfaction. • 40% of hospitals do not track key performance indicators related to infection rates and readmission rates, crucial for identifying areas of improvement and ensuring high-quality patient care.
Tertiary Care
Strength	Weakness	Opportunities	Threats
1. Children’s Cancer Center (CCCL): • Located in Beirut, Lebanon. • Provides full treatment for 72 Lebanese children with newly diagnosed cancer annually, regardless of their ability to pay. 2. Accessibility for People with Disabilities: • Hospitals and health institutions are sufficiently accessible for individuals with physical disabilities. • Equipped with ramps and elevators. • Health care providers assist people with wheelchairs when needed.	1. Healthcare Institutions in Lebanon: • Semi-autonomous public secondary and tertiary healthcare institutions. • Expensive referral care. 2. Drug Shortage: • National tragedy and a threat to national security. • Projected to last for years, impacting medical management and patient care. 3. Barriers to Dental Care: • Economic factors pose barriers to dental care for children. 4. Health Insurance and Hospital Expenses: • Lack of private health insurance for people with diabetes and lower limb amputation. • Hospital expenses covered by patients themselves. 5. NGOs for Older Adults: • Fragmented and non-sustainable services provided by NGOs for older adults. • Services include medical care, home-based nursing, psychosocial assistance, entertainment, and more. 6. Challenges in Private Insurance: • Costly private insurance in Lebanon. • Coverage refusal for those above 70 years at initial enrollment. 7. Lack of Uniform Pension Plan: • No uniform old age/retirement pension plan in Lebanon. • Unemployed individuals, mostly women, lack pension plans or health coverage.	1. Hospital Services Planning: • Hospitals are planning to provide services such as cardio, open heart, and dialysis. 2. Specialist Engagement: • Specialists consistently follow up on medical news through conferences abroad.	1. Pediatric Heart Surgeon Exodus: • Majority of pediatric heart surgeons left Lebanon for more stable careers in the USA and Europe. • Resulted in only eight pediatric cardiologists and five pediatric cardiac surgeons remaining. • Four pediatric patients passed away within a two-week period in February 2022. 2. Shortages in Cardiovascular Drugs: • Essential outpatient cardiovascular drugs (e.g., antihypertensive, antiplatelet, antiarrhythmic) are scarce. • Increased incidence of decompensated heart failure, myocardial infarction, and unstable arrhythmias. 3.Imported Drugs and Economic Crisis: • Lebanon heavily relies on imported drugs or raw materials for local pharmaceutical production. • Economic crisis, shortage of foreign currency, local currency devaluation, and lifting subsidies impact importation and fabrication processes. 4. Drug Availability Challenges: • High cost of medication leads to lack of drug availability. • Regular supply shortages at the MoPH and the National Social Security Fund (NSSF). • Customs officials and transport delays contribute to patients being unmediated for months, especially for newer unpatented drugs.