Seeking to stay ahead of local and regional health trends

Under Article 8 of Bahrain’s constitution, all nationals are guaranteed access to health care. A number of public hospitals and care facilities are available, and the kingdom is also home to several private medical establishments. Indeed, the authorities are looking to encourage the private sector to play a larger role in providing medical treatment and, as a result, significant opportunities exist for investors. The health care sector currently contributes 2.5% to GDP, a figure set to grow to 7% by the end of the decade, according to Bahrain’s Economic Development Board (EDB). Between 2006 and 2011, EDB data show the health care sector expanding at a compound annual growth rate of 11.4%, reaching a total value of $728m.

Demographics

The rise in health care spending has been driven in part by population growth. Between 2001 and 2010, the number of inhabitants in Bahrain nearly doubled from 650,604 to 1,234,571, according to the 2010 census. The population is also young, with some 21% of inhabitants in that year being under 15 and another 29% between the ages of 15 and 29. Bahrain thus has the potential to reap a demographic dividend from its youth bulge if it can ensure that its young people receive competitive education and health services. The rise in population has also been fuelled by a net increase in the number of expatriates: the same census revealed that foreigners outnumbered nationals for the first time, having grown from 38% of the population in 2001 to 54% in 2010.

Demographic shifts also appear to be improving opinions on health issues. A 2007 national survey conducted by the Ministry of Health (MoH) found that 57.1% of the population did not perform physical exercise for leisure and 19.9% smoked, yet more recent polls show health trends are improving. Since 2010 US-based Zarca Interactive has been conducting health surveys of Bahrain, launching the first electronic health survey in the GCC in 2012 and subsequently conducting annual market research in Bahrain. Its 2013 survey found that 34% of residents visited a family doctor or a general doctor for routine medical check-ups annually, while 100% of expatriates did so. The study further noted that 66% of Bahrainis prefer eating low-fat dairy food products, suggesting a growing interest in healthy eating. It also showed changes in perceptions of tobacco use, finding that, as a means of relieving stress, a larger portion of the population preferred exercising (16%) to smoking tobacco (11%). Similar trends were found in Zarca’s most recent study, conducted between January and April 2014, in which it asked 501 Bahrain residents aged 16-55 about their health-related behaviours, finding that 44% of respondents exercised one to three times a week and 87% abstained from smoking tobacco. A comparison of the studies conducted suggests that the proportion of active smokers has fallen in recent years from 19.9% of the population in the 2007 national health poll to just 13% in the 2014 period used by Zarca.

The 2014 Zarca study also found that 54% of respondents had been involved in a diabetic health campaign and 51% in an anti-obesity campaign during the first three months of the year. According to the study, television remains the primary source of information about the health sector for Bahrainis, followed by internet searches. “Attitudes towards healthy lifestyles in the kingdom are beginning to shift, especially increases in awareness that such a lifestyle can reduce one’s vulnerability to diabetes and cardiovascular problems,” Tim Gardner, hospital administrator at the International Hospital of Bahrain, told OBG. “From a business perspective, this means there is a great opportunity for health products to be sold in the market.”

Part of the change in attitudes may also be due to public information campaigns. Promoting a healthy lifestyle remains a core tenet of the national health strategy, as it has been over the past decade. In 2012 Bahrain opened its first “Clinic for Healthy People” in Al Hidd – centres that are designed to help people maintain a healthy lifestyle, consider the risks of genetic diseases and give related advice. The ministry plans eventually to open four more clinics, so that there is one in each governorate of the country.

Government Role

The government is the primary provider of health services in Bahrain. The health care budget allocation rose from BD534m ($1.4bn) in fiscal year 2011/12 to BD676m ($1.8bn) for 2013/14. Total health expenditure in the country – including public services, the Bahrain Defence Force Hospital and the private sector – was valued at $1.18bn in 2013, according to the MoH. Figures given to OBG by the MoH showed that secondary health care accounted for 59% of the ministry’s 2013 budget, followed by primary health care and public health care (27.4%), and administration support services and training (12.9%).

In 2012, there were 3.8m visits to general and specialised health care facilities in the country – roughly three visits per capita per annum. In 2013 the MoH handled an average of 8000 health cases a day (2500 a day at the Salmaniya Medical Complex alone), the equivalent of 25% of the population visiting an MoH centre per month. Expatriates not covered by a health insurance scheme pay BD3 ($7.95) per emergency room visit, while employers pay a health tax of BD60 ($159) for each non-Bahraini employee to fund the provision of health care to expatriates.

Pharmaceuticals

One area where costs have risen sharply is in pharmaceutical sales. The cost of providing drugs and medicines to the MoH – whose pharmaceuticals list contained 969 items in 2012 – rose from BD6m ($15.9m) in 2001 to BD34m ($90.1m) in 2012, an increase of 467%. Recent moves to develop pharmaceutical production in Bahrain could in time reduce these costs significantly (see Industry chapter).

Regulators

In the past five years, Bahrain has set up two state entities to regulate the sector and shape its strategic goals. The National Healthcare Regulatory Authority (NHRA) was established in 2009 to regulate both private and public medical institutions in Bahrain; prior to this, inspection and regulation fell under the MoH. NHRA officials conduct random inspections of hospitals – about once every two years – to ensure high health standards. During the second quarter of 2014, the NHRA moved to standardise prices for pharmaceuticals throughout Bahrain – part of a wider push to standardise medicine and health service prices throughout the Gulf in keeping with GCC mandates. It is also developing a new committee management structure that will allow it more flexibility in its role as primary health care regulator.

The second entity, the Supreme Council for Health, was established by royal decree on January 28, 2012. This institution is focused on developing the strategic plan and goals for both private and public aspects of the health care sector. The minister of health, Abdulkarim Sadiq Al Shehabi, serves as vice-chairman of the council, while other members of the 11-person panel include representatives from the NHRA, Bahrain Defence Force Royal Medical Services, King Hamad University Hospital and private health institutions. One of the council’s goals at present is to make all of Bahrain’s hospitals separate autonomous entities under the umbrella of the MoH. It also plans to launch reforms in health insurance and medical education standards, as well as enhance coordination between Bahrain and international entities over the next decade.

The council also increasingly promotes IT solutions as a crucial aspect of Bahrain’s health strategy, with initiatives in mobile health, telehealth systems and cloud computing. To this end, Bahrain hosted the SehaTech 2014 exposition in September, a three-day event held in collaboration with the Supreme Council for Health and Bahrain Technology Companies Society, attracting many hospitals and medical firms.

A number of e-health solutions are already provided by the MoH. Services ranging from medical inquiries to birth certificate requests are now readily available through its e-health portal, which was developed as part of an e-government partnership with the National Health Information System (I-SEHA). The I-SEHA project is a national electronic medical records programme that began in February 2011, seeking to digitise the country’s medical records. It is being implemented by Indra, a Spanish IT firm that signed an 11-year contract in 2011 to develop the system.

From a regulatory perspective, the creation of NHRA and the Supreme Council for Health have improved efficiency in the health care sector. A 2013 report from the World Health Organisation (WHO) regarding its International Health Regulations programme, which aims to implement global health standards, showed that Bahrain’s reorganisation of its health care sector has been largely effective. The WHO’s review of health care systems around the world gave Bahrain the highest possible score in several categories, including those for legislation, coordination and monitoring of its health sector. Its grades were above the MENA average in every aspect except human resources, a situation the government is seeking to rectify by encouraging more Bahrainis to pursue careers in medicine.

Facilities

The kingdom is home to more than 300 health care facilities, including seven state hospitals and 27 other government-run health centres, as well as 15 private hospitals and 27 privately run health centres. Private sector facilities, which are allowed to charge their clients at their own discretion, saw 19% of all outpatient visits in Bahrain in 2012. The kingdom’s medical sector also maintains 185 private clinics, hospitals and dentists, of which 93 are located in the capital.

The Salmaniya Medical Complex is Bahrain’s principal health care facility. Though the original hospital was founded in 1957, the current medical complex dates to 1978. Since then, it has undergone extensive renovations and upgrades and is now the largest centre in the country for acute care, with a total of 900 beds in its wards. In 2012, the facility saw 25,000 outpatients and 307,000 accident and emergency visits.

The second-largest hospital in the kingdom is the Bahrain Defence Force Hospital, which has 353 beds and offers a host of services ranging from emergency care to paediatric care. Despite its name, this hospital offers health care services to all Bahrain residents and non-residents free of charge.

The newest hospital in Bahrain is the King Hamad University Hospital, which officially opened on February 6, 2012 and covers an area of 64,000 sq metres. The 312-bed facility serves as the primary teaching hospital for the Irish Royal College of Physicians.

The MoH is also responsible for the operation of a number of secondary care facilities. Psychiatric care has been available locally since the 1930s and has grown steadily. Today, one of the largest such hospitals in the kingdom is the Psychiatric Hospital, which has 226 beds. The government also oversees a geriatrics hospital (70 beds), the Ebrahim Khalil Kanoo Community Medical Centre (44 beds), the Abdul Rahman Kanoo Dialysis Centre (70 beds) and two maternity hospitals (with a combined total of 94 beds).

The newest MoH facility is a new Genetic Blood Disease Centre, which was built as an expansion to the Salmaniya Medical Complex. The four-floor centre, which focuses on haematology, includes 90 beds and was built as part of a BD2.65m ($7m) investment in new facilities in Salmaniya, and will be able to treat 14,000 sickle-cell anaemia patients per year as well as those suffering from other genetic ailments.

Additionally, several state-owned companies in Bahrain offer their employees health services with official approval from the government: Bahrain Petroleum Company (BAPCO), Aluminium Bahrain (also known as Alba), Gulf Air and Gulf Petrochemical Industries Company. Of these, BAPCO has the longest tradition of health care provision, having begun offering health care services to its employees as early as the 1930s. Staff at BAPCO’s company hospital in Awali offer employees both general practice consultation and access to staff trained in eight medical specialties, including radiology and internal medicine.

Accreditation

The goal of seeking international accreditation is a major driver of spending by both public and private hospitals within Bahrain. Over the last decade, accreditation by the Australian Council on Healthcare Standards International (ACHSI), which grants this status after a multi-day inspection, has become especially popular within the kingdom. As of 2014, Bahrain has more ACHSI hospitals than any other GCC country. The first hospital in Bahrain to receive this credential was the American Missionary Hospital in 2007. It was followed by the Bahrain Defence Force Hospital that same year; the KIMS Bahrain Medical Centre, which specialises in outpatient services, in 2008; Royal Bahrain Hospital and the International Hospital of Bahrain in 2013; and the Mohammed bin Khalifa bin Sulman Al Khalifa Cardiac Centre in January 2014.

However, there are also other options for hospitals in Bahrain to gain accreditation. One of these, Accreditation Canada, has certified government health care providers such as the Salmaniya Medical Complex and King Hamad University Hospital in Bahrain, and has also assessed medical facilities elsewhere in the region.

Joint Commission International (JCI), established in the US in 1994, is another leading international health care standard. Bahrain Specialist Hospital is the only hospital in the kingdom to be accredited by JCI, with this occurring in 2010 and again in 2014.

Education

The first hospital in Bahrain was the American Missionary Hospital, which had only US staff until it began hiring local nurses in 1934. The first medical training programme, a four-year school for nurses, opened in 1959. The College of Health Science at the University of Bahrain, the kingdom’s oldest institute for medical education, has played a key role in training Bahraini nurses since its founding in 1976, and now trains some 300 students a year. The Arabian Gulf University, established in 1981, admits 150 students a year from the GCC and other Arab countries.

Today, competition for Arabic-speaking medical talent is at a premium within the GCC, where 80% of health firms created jobs in 2013, according to a 2014 report by online recruitment portal GulfTalent. With such demand, Bahraini doctors and nurses are increasingly tempted to work abroad. As a result, Bahrain will continue to need health care professionals in specialties such as palliative care for cancer patients, specialty intervention, radiology, obstetrics and gynaecology. The high level of Bahrainisation among MoH staff – some 82% of doctors, 94% of dentists and 48% of nurses – is partly due to the MoH’s emphasis on specialised training to boost staff retention. The overall MoH figure of 80% reflects a rise of 26 points between 2002 and 2013, while over the past five years, the MoH has allocated an average of $10m a year to staff training.

To meet the growing needs of the sector, two private medical programmes have been established. AMA International University, founded in 2002, is the local affiliate of the AMA Education System in the Philippines, while Ireland’s Royal College of Surgeons opened a unit in Bahrain in 2004. The Bahrain Medical Society, a key health care organisation, first registered with the government in 1972 and now publishes a research journal and offers professional development programmes.

Outlook

Traditionally, Bahrain’s health care spending has been above the GCC average as a portion of GDP, but slightly below it by per capita expenditure. While more government spending is needed, there is also a role for the private sector to play, especially in specialised health facilities and pharmaceuticals. Bahrain is already a regional leader in some areas – i example, it ranked second in the Arab world and 50th out of 178 countries in the 2014 “State of the World’s Mothers” report put out by Save the Children. Yet the country is keen to become a leader in other areas as well, and to start attracting medical tourists. Currently, many Bahraini citizens go to Europe and North America for advanced procedures, but plans to develop new facilities are likely to change this. Medical tourism, in particular, can help achieve the economies of scale that are necessary for many specialised services.

Bahrain is also likely to see a growing demand for services and products that cater to diabetics. For genetic reasons, island countries and Arab states have high incidence of diabetes, and Bahrain is both. The prevalence of Type 2 diabetes in the country is expected to rise from 15.4% in 2010 to 17.3% by 2030. Everything from healthy food to dialysis is therefore likely to become increasingly important to Bahrain’s health care sector. more government spending is needed, there is also a role for the private sector to play, especially in specialised health facilities and pharmaceuticals. Bahrain is already a regional leader in some areas – i n maternity care, for example, it ranked second in the Arab world and 50th out of 178 countries in the 2014 “State of the World’s Mothers” report put out by Save the Children. Yet the country is keen to become a leader in other areas as well, and to start attracting medical tourists. Currently, many Bahraini citizens go to Europe and North America for advanced procedures, but plans to develop new facilities are likely to change this. Medical tourism, in particular, can help achieve the economies of scale that are necessary for many specialised services.

Bahrain is also likely to see a growing demand for services and products that cater to diabetics. For genetic reasons, island countries and Arab states have high incidence of diabetes, and Bahrain is both. The prevalence of Type 2 diabetes in the country is expected to rise from 15.4% in 2010 to 17.3% by 2030. Everything from healthy food to dialysis is therefore likely to become increasingly important to Bahrain’s health care sector.