Human resources in the health care services field continue to play a crucial role in shaping the delivery of health care across the globe. Policies to discipline their practice, shape their jurisdictions and decide their reimbursement schemes have never been simple and have always been faced with various political and economic barriers.
Lebanon is a small country situated on the south-eastern side of the Mediterranean Sea with close to 4 million residents. The country has recently emerged from 17 years of civil disturbance (1975–1992) that has left any surveillance statistics in the country struggling with a large margin of error. One such example is the reported physician-to-population ratio. In 1998, one source claimed that there was one physician for every 770 inhabitants (130 per 100, 000 population) [1
], while another indicated that there was one for every 420 residents (238 per 100, 000 population) [2
]. Both these sources used the same database, but with obviously different assumptions about how many were actually practising and the actual size of the population.
In addition to an imprecise assessment of physician numbers, one economic observation and another geopolitical fact complicate our understanding of the dynamics of physicians practice. From an economic perspective, the supply of physicians has increased significantly after the end of the civil disturbance for three main reasons: physicians returning to practise in their home country; new medical schools opening in the country; and Lebanese students targeting eastern European universities to attain their medical degree (many eastern European medical schools were opened to foreign students only after the breakdown of the Soviet Union). Reports show an annual increase of 500 to 700 physicians [2
]. On the other hand, the demand for medical services, especially tertiary care, has grown substantially, resulting in an unsustainable level of expenses, most of which are paid by the Ministry of Public Health (40%) and other public insurers.
From a geopolitical angle, Lebanon is divided into five regions (muhafazat) with observed differences in their urban/rural mix of areas. The small geographical area of the country (some 10 425 km2) and the closeness of regions to each other and to Beirut, the capital, allow much cross-practice between regions. But physicians are unequally distributed between two orders (professional associations) that oversee their practice, although all physicians must pass the same government licensure test. The two orders have slightly different rules for membership and benefits. The two orders advise physicians to seek continuing medical education, but do not require them to do so to maintain the licence to practise medicine. One caters for the physicians of North Lebanon, while the other four regions are under the jurisdiction of the second order (Lebanon order of physicians).
Lebanon is sometimes referred to as "the hospital of the Middle East" because of its good health care delivery. To continue to provide good care, Lebanon must put in place sound health workforce policies that take into account all of the above complex picture. A health sector rehabilitation project estimated to cost USD 50 million was initiated in 1995. The project's main focus was to unify the many non-private financing agencies and to restructure the payment system for health care providers (mainly private hospitals). To our knowledge, no special policies were developed to target physicians' licensure, practice and reimbursement.
The cost attributable to human resources is complicated by the product of two components: expenditures attributable to the providers, and the number of such providers. Therefore, any reform related to supply would definitely have its impact on the magnitude of health care expenditures [3
]. From that perspective, it was crucial to examine the supply of physicians in Lebanon in order to establish a baseline on the profile of providers of care and their practice, and respond to the need as well as their ways and means of improving their knowledge and skills, and hence, their practice. Therefore, this study aimed at examining the supply of physicians residing in Lebanon and assessing their practice patterns and tendency for capacity development.