Gradual overhaul: As Qatar's population ages, a state-led transformation is under way

Qatar’s health care sector is undergoing vigorous change, for both good and bad reasons. The good news is that Qataris are living longer. The bad is that more are living with lifestyle-related chronic diseases such as diabetes, heart disease and cancer. To meet this challenge, the government has been making sizeable investments in health care: Qatar now spends more per capita on health than any other GCC country, according to the World Health Organisation (WHO). Even more spending is on the way. In the summer of 2013, the minister of health, Abdulla bin Khalid Al Qahtani, announced that Qatar would funnel QR38bn ($10.4bn) into health care over the next five years – a lurch upwards from the recent annual average of QR1.3bn ($367m). The health care budget for fiscal year 2012/13 was QR9.2bn ($2.5bn), up 47% from 2011/12.

Rights & Duties

Health care in Qatar is seen not as a privilege but a right. The state constitution says that “the State shall foster public health, and provide means of prevention from diseases and epidemics and their cure in accordance with the law.” The populace enjoying that right is growing fast and living long. It grew 10.9% in the decade to 2011 – the world’s fastest according to the Supreme Council of Health (SCH) – and 5.9% year-on-year as of end-January 2014, to 2.2m. QNB Group forecasts 10.1% growth for 2014. Median age is 32, and life expectancy has stretched from 75 years in 1990 to 82 now, far above the region's (68) and the world's (70). Qatar has been mobilising to cater to these growing numbers since 2011. Major health programmes under way include the National Health Strategy (NHS); the National Cancer and National Cancer Research Strategies; new hospitals and primary care facilities; the Academic Health System; and electronic systems for clinics. The focus of all these is two-fold: meeting the challenges of Qatar's public health profile, and laying the foundation for future efforts in line with the broader, long-term development goals of Qatar National Vision 2030 (QNV 2030), the health care priorities outlined in the National Development Strategy (NDS) 2011-16, the sector-specific targets of NHS 2011-16, and other related strategies formulated by state agencies.

The duty of supervising health care strategies lies with the Supreme Council of Health. Established in 2005 by emiri decree, the SCH has a remit that includes regulating the health care market and steering its reforms toward producing a high-quality health system in Qatar. Though the SCH does not itself administer services, it regulates and oversees the health insurance industry (both public and private); assessment of credentials and licensing; continuing education in the medical profession; and health care information technology (IT). The SCH is also charged with overseeing public health programmes such as infectious disease control and coordinating with other state agencies to ensure public safety. To balance high standards of care with the need for accessibility and affordability, the SCH has put in place a system calling for evidence-based policies to effect quantifiable changes in the status quo. It is in charge of setting goals for health research, designing policies to achieve QNV 2030 and evaluating progress.

Supporting Arms

As one of its four pillars – human resources – QNV 2030 calls for improvement in the health of Qatar’s population by developing an integrated health care system, managed at high standards to meet the needs of current and future generations, while adjusting for life spans that are increasingly lengthy. The vision calls for health services to be made accessible to the entire population (with provisions for the varying needs of men, women and children), and sets requirements for a health care policy that will produce and monitor high standards; provide affordable services; recruit a skilled workforce; and implement research programmes. NDS 2011-16, a supporting plan to QNV 2030, details, among other priorities, how to provide high-quality health care to Qatar's people.

Strategy For Health

The NHS 2011-16 programme, a major component of the overhaul, outlines the development goals for Qatar’s health care system and defines the SCH's role in fulfilling QNV 2030. The programme marks a shift from the old model where health care is focused on hospitals. Primary care facilities traditionally took on the tasks of secondary care as well, in disease prevention, screening and treatment.

Under the NHS, primary care will take centre stage. The strategy commits to making foundational, systemic changes to health care provision in the country, ranging from yearly health checks for residents to professional development for health care providers. In the long term, the strategy calls for a sharp pivot away from a reactive, hospital-based model to a more preventive, community-based one. The new system aims to improve coordination and quality and to ensure services meet evidence-based standards. Inclusiveness is paramount.

The final blueprint drew on many sources. Key stakeholders, focus groups, hospital physicians, general practitioners, patient satisfaction polls, state-conducted public surveys – all were channelled into the final strategy. The result is a bold undertaking. Since its launch in 2011, about 11% of the new programme’s goals have been achieved, according to official statistics. Working alongside the SCH in this are two government-created bodies, Primary Health Care Corporation (PHCC) and Hamad Medical Corporation (HMC).

Primary Care

Qatar’s population has grown faster than expected, putting strain on hospitals’ capacity. To remedy this, as well as raise health care standards generally, PHCC was founded by emiri decree in February 2012. Its broad mandate is to carry out the National Primary Health Care Strategy 2013-18, a national roadmap launched in June 2013 to guide health care away from hospitals and toward preventive models. To that end, PHCC now operates 23 primary health care centres, 13 of them in Doha city, and the rest in urban areas throughout the central, northern and western regions. The services it covers include not only primary care but also dental, radiology, vaccinations, antenatal and ultrasound, pharmaceuticals, in-home care and educational programs for both staff and patients.

One problem is patient education. About 75% of visits to PHCC-run centres are for uncertain causes, Dr Mariam Ali Abdul Malik, the company's managing director, told OBG. Many visitors go straight to the emergency room for ailments that could have been easily monitored and treated from home. To remedy this, the company has launched a number of initiatives and programmes to promote a healthy lifestyle as well as teach people how to seek the right services.

To raise the quality of health care in Qatar, the PHCC has made 10 specific pledges. These include to request feedback from patients; increase consultation times; adopt a yearly health check policy; publish annual reports of patient assessments; set up a patient helpline; and invite community input to assess needs. The company will also create rubrics for measuring the competency of doctors and nurses, to help link remuneration to service quality, education and training.

To extend the reach of the strategy’s objectives, the PHCC renovated 11 older health centres in 2013. It plans to open six new centres by 2015, seven others in 2016 and to have a total of 33 by 2018. It is also seeking to build its international credentials by applying for accreditation from an independent non-profit, Accreditation Canada International, which is still pending.

Information Sharing

Data-swapping is a key objective. The secure exchange of clinical information could not only improve the delivery of health care, but even save lives by ensuring that critical findings are available to clinicians and emergency health care personnel. This goal calls for a system whereby providers can send files to each other, and house databases for storing and accessing incident reports, disease registers, regulations and records of treatment abroad. The system will provide access to education and research, and give patients a portal for health information.

System integration, a natural counterpart to this, is to be achieved by twin digital health care initiatives, the Health Information Exchange (HIE) and the Clinical Information System (CIS). The HIE system will allow public and private health care professionals to gather, collate and disseminate research information, ultimately aiming to increase health care quality, empower patients and control costs. It will require a supporting IT infrastructure, whose first phase should be operational by April 2016. The CIS, which complements the HIE, is an integrated health care information system that creates an electronic health record for every patient and houses them on a shared database. The system will make patients' health records available to authorised clinicians, enabling them to make informed decisions on first patient contact and all subsequent visits. Doctors will also be able to order procedures, scans, prescriptions and other information over the internet. Less paperwork should free up time to spend with patients. System vendor Cerner and implementation firm Dell Services are helping set up the system being rolled out by HMC and PHCC. Data generated by the CIS should help the two agencies make more effective evidence-based decisions and enhance resource planning.

Hospitals

Public hospitals in Qatar include Hamad General Hospital, the state's main accident and emergency unit; Al Amal Hospital, specialising in oncology; Al Khor Hospital in northern Qatar; Rumailah Hospital, which specialises in acute and long-term rehabilitation; Women's Hospital, the main state maternity unit; Heart Hospital, which integrates cardiothoracic care and surgery; Al Wakra Hospital in the south; and the Cuban Hospital in the west. Many primary health care centres complement public hospitals. The main private hospitals in Qatar are Al Ahli Hospital, Al Emadi Hospital, the American Hospital and the Doha Clinic Hospital. Sidra Medical and Research Centre is due to open doors in 2015. Many private polyclinics also provide services.

Tertiary care, and developments at this level, has meanwhile been entrusted to HMC and PHCC jointly with Sidra. The fiscal year 2012/13 public health care budget included more than QR7bn ($1.9bn) for HMC and more than QR1bn ($273.9m) for PHCC. Established by emiri decree in 1979 and reporting to the SCH, HMC is Qatar's foremost non-profit provider of health care. In its early days HMC was obliged to send some patients overseas for treatment. Now, after years of development, its own in-country facilities are able to diagnose and treat most diseases. Even so, health tourism overseas is still a popular (if costly) option for many Qataris.

Joint Commission International (JCI) has awarded HMC hospitals simultaneous accreditation and reaccreditation – the first hospital company outside the US to achieve this. The operations HMC runs are Hamad General Hospital, Women’s Hospital, the National Centre for Cancer Care & Research, Al Khor Hospital, Rumailah Hospital, Heart Hospital, Al Wakra Hospital and Cuban Hospital. It also runs Qatar's home health care, ambulance service, and the new field of residential care.

To expand the country's stock of health care facilities, 31 new ones are to be built between 2013 and 2021. These include the New Women’s Hospital and others specialising in cancer treatment, mass casualty trauma, ambulatory and minimally-invasive surgery, physical medicine and rehabilitation, and communicable diseases. Institutes for translational research and for neuroscience are also planned. Three new hospitals and four primary care centres to be built aim at meeting the needs of Qatar's predominantly male immigrant labourers. These facilities, to be privately run and located in Mesaieed and in the Doha and Ras Laffan industrial areas, are to be completed in 2015.

Insurance For All

The biggest ongoing development in Qatar's health sector is the roll-out of mandatory health insurance. If all goes to plan, every resident will be covered by the end of 2015.

This change has three aims. The first is to relieve the state of the burden of skyrocketing health care costs; the second is to expand health care services outside of Doha; and the third is to take pressure off of emergency services and promote preventive care as a way to tackle the country's non-communicable diseases. One of these, Type II Diabetes, currently affects about 17% of the adult population. Cost is not the primary concern. “Our target is to provide all the inhabitants of Qatar, even visitors, with the best basic health services – and it is not about profit or loss,” Dr Faleh Mohamed Hussain Ali, assistant secretary-general for policy affairs at the SCH told sector professionals in October 2013.

Although a form of national insurance did previously cover all Qataris for a nominal cost, the new scheme, National Health Insurance (NHI), will expand this coverage net and effect many changes in how Qataris access health care. “People in Qatar are overusing and abusing the current health care system,” Dr Abdul Malik told OBG. “75% of visits are for uncertain causes, so the focus is on enhancing cultural know-how, educating people on where they should go for medical treatment.”

Under NHI, patients will be able to choose from both public and private providers. The previous scheme covered only public ones. Coverage for Qataris will be more comprehensive than for expatriates. Premiums for Qataris will be paid by the government, and those for expatriates by their employer or sponsor. Visitors, meanwhile, will pay a fee along with their visa which enrols them in the scheme automatically. Where no employer exists, expats must buy their own coverage. No monetary cap on coverage has so far been set.

Implementation Plan

In the early stages, the new state-owned National Health Insurance Company (NHIC) will be the sole provider of basic coverage in the country. NHIC will enter into annual contracts with providers, which will adhere to a uniform fee schedule. Private-sector insurers will be allowed to supply supplementary coverage only for procedures such as cosmetic surgery and for specialist care not covered by the public scheme. The NHIC reports to a board of directors composed of members of the SCH, the Central Municipal Council, the private business sector and the labour, finance and interior ministries. The board supervises the NHIC's management and sets its strategy.

This reform effectively locks other health insurers out of the domestic market for a term of about 10 years. The scheme will, however, allow other insurers to offer certain treatments outside the country, and those wishing to supplement their coverage with more services will be allowed to purchase additional coverage from private providers operating in Qatar. This means there will be opportunities for partnerships. It is expected that all providers, public and private, will have integrated into the NHI programme within a decade. Providers will need to build a client base by delivering high-quality service at competitive prices. This, many anticipate, will raise the bar for the quality of health care locally. The NHIC will run NHI, and Al Khaleej Takaful, a state insurer, will act as third-party administrator.

The NHI roll-out has five stages. During stages one to three, the government will cover all insurance costs for Qatari nationals and, between stages one to four, will work in concert with privately-held insurance, giving employers time to merge their existing plans with the NHI. The first stage, introduced in July 2013, covered Qatari women for gynaecological and maternity services at HMC and some private hospitals. The seven hospitals participating in this stage (for both inpatient and outpatient services) were Al Wakra Hospital, Cuban Hospital, Al Khor Hospital, HMC Women’s Hospital, Al Emadi Hospital, Al-Ahli Hospital and Doha Clinic Hospital. This number will increase as the new system advances. The second stage, starting in early 2014, will cover Qatari nationals with basic health services at HMC and other private providers. The third, to begin in the third quarter of 2014 will expand nationals’ coverage to 23 primary health care centres. The fourth, as of first quarter 2015, will cover white-collar expatriates and visitors; and the fifth, as of end-2015, will cover blue-collar expats at three earmarked hospitals.

The provisions for this last group are no mere detail. Expatriate workers make up about 85% of the working population, a figure that includes professionals but mostly consists of low-paid manual and domestic workers. After a spate of deaths among immigrant construction workers in the summer of 2013, provision of health care for such employees came to the forefront.

The main signposts in Qatar's new health care landscape are already in place. These steer the industry sharply away from the 2012 status quo, when emergency rooms were first stop for most ailments. “People should not be able to go to HMC unless they have first been to PHCC and received a reference,” Dr Abdul Malik told OBG. “The emergency rooms are being abused in the country. Our biggest challenge now is to become the cornerstone of health care in Qatar.”

Home Care

Another key pledge, announced in July 2013, was to make home health care services available in 2014 to all in Qatar who are eligible. Home health care encompasses outpatient care, ongoing services and checks such as monitoring blood pressure and blood-sugar – tests essential to combat the high rates of diabetes and hypertension. This pledge will require an especially skilled staff, of which there is currently a shortage. Indeed, the national strategy notes that to properly recruit for home care, the PHCC will need a separate specialist division with its own budget and staff.

The need to source this staff domestically could well require a shift in the national perception of nursing as a career. Many nurses in Qatar are immigrants from low-income countries, hence nursing has been traditionally viewed as a service-industry occupation rather than a genuine profession. To address this perception, the University of Calgary in Qatar (UCQ), in partnership with HMC and Sidra, is trying to recruit more Qataris to train as nursing professionals. Sidra has openings for 4500 nurses and has increased scholarships and grants for nursing students. “The university is very focused on changing the image of the nurse in Qatar. We are therefore trying to recruit more Qataris to raise the profile of the profession and the university,” UCQ dean Dr Kim Critchley told OBG in late 2013. In that year, the first in which she deemed the UCQ admissions truly competitive, the university received more than 300 applications.

Research

Besides overhauling its health care system, Qatar is also altering how it conducts clinical and community research. The focus is on moving from disease-based studies to a more integrative, evidence-based, multidisciplinary approach, a shift meant to harmonise with the new preventive emphasis in the health care overhaul. Taking the lead in this are the non-profit Qatar Foundation (QF); the SCH and HMC; Qatar Science & Technology Park (QSTP); and two medical centres, Sidra and Weill Cornell Medical College Qatar (WCMC-Q).

The big perk of research is its ability to improve the quality of life. For Qatar, this means decreasing premature deaths caused by widespread chronic diseases such as obesity, diabetes and cancer. At a QF research conference in November 2013, chairperson Sheikha Moza bint Nasser affirmed Qatar’s pledge to provide needed resources to reputable research centres.

One notable effort, spearheaded by HMC, was the establishment of an Academic Health System (AHS) to integrate research, clinical practice and education. The system is designed to improve patient care, develop solutions, and provide a sustainable modern workforce by helping train the next wave of professionals in Qatar. Launched in August 2011, the AHS is a partnership between HMC and several other local institutions, including Sidra, Qatar University, WCMC-Q, PHCC, UCQ, and College of the North Atlantic Qatar. Its chief goal is to develop institutes targeting the health care issues most relevant to Qataris: metabolic and cardiovascular disease, and cancer. Neuroscience and translational research will also be top priority.

Another notable initiative is the Qatar Biobank, set up to enable medical research on health issues that prevail in Qatar. Spearheaded by QF in conjunction with HMC, SCH and scientists from Imperial College London, the Biobank recruits Qataris to donate biological samples and share health and lifestyle information, thus assisting custom-tailored research into the health issues faced by Qataris. This is new: most medical treatments have historically been developed by studying Western populations. Qatar Biobank aims instead to study the local, national population, with their own health risk factors. The bank so far has 872 participants from whom it collects 68 samples each. The target is 6000 participants within five years.

Public-private partnerships can also help. The nonprofit WCMC-Q, for one, is incubating research programmes by partnering with local bodies such as the Qatar National Research Fund via its National Priority Research Programme (NPRP). By recruiting, training and retaining the best candidates, WCMC-Q aims to plant a self-sustaining crop of biomedical scientists who will go on to form research projects to tackle public health issues. Those with “ proposals of high merit” can join NPRP's Exceptional Proposals unit, which offers up to $5m per project for up to a five-year period.

Topic Of Cancer

Cancer caused 20% of all deaths in Qatar in 2010, according to the WHO. By 2030, the incidence of cancer in the country is set to more than double. To combat this, the state has launched a national anti-cancer strategy to the tune of more than QR2.2bn ($602.6m). Under this plan, Al Amal Hospital was transformed into a National Centre for Cancer Care and Research. A well-known cancer surgeon, Lord Darzi of Denham, will oversee the strategy, which will promote screenings, quick access to specialists, treatment by multidisciplinary teams of clinicians, public awareness campaigns, palliative care and survival and bereavement services. Later on, a new cancer hospital will be built at the HMC site. To carry all this out, HMC will need to recruit droves of specialists – about 70 cancer doctors and more than 100 cancer nurses. In January 2013, at HMC's request, UCQ’s first classes began for its new masters in nursing programme, which aims to train advanced-practice nurses with a focus on oncology.

Outlook

With so many transformations ongoing, the health care sector in Qatar will be a vibrant place for many years to come. There are now private-sector opportunities in research, furnishing staff for clinics, supplying pharmaceuticals (see analysis), building new facilities and running IT services. As for the national health strategy, while room for private insurers to participate is small in the short term, this is likely to expand over time. Private companies with investments and a long-term strategy in the country could see themselves well placed in the future by forging strategic partnerships, both public and private, today. Once Qatar’s health care sector is reorganised, those in the private sector who have laid foundations well are likely to thrive.