Bahraini health sector implements new strategies and develops national health insurance system

Although major health indicators have improved in recent decades, a growing and ageing population, an elevated incidence of non-communicable diseases (NCDs), and rising care costs have weighed on Bahrain’s health sector in recent years.

The government is currently making major strides in addressing these challenges, however, most notably through the planned rollout of a national health insurance system, as well as a flagship inspection and accreditation programme aimed at improving patient outcomes and quality of care. Bolstered by rising outof-pocket expenditure and the development of largescale, integrated medical infrastructure, investment in the sector is set to rise in the coming years, supporting steady and sustainable expansion.

Structure & Oversight

The Ministry of Health (MoH) holds primary responsibility for formulating health policy in Bahrain, with a mandate to ensure the kingdom’s population has lifetime access to quality health care. Operating under four guiding principles – sustainability, accessibility, equity and quality – the MoH collaborates with stakeholders including the National Health Regulatory Authority (NHRA) and the Supreme Council of Health (SCH) to achieve its objectives of maintaining high public health care standards through promotion and prevention activities, integrating services across the health system, maintaining high-quality services, policy-making and governance, and improving health service sustainability.

Law No. 38 of 2009 established the NHRA, responsible for developing health care policies in collaboration with the MoH, as well as supervising and licensing all health facilities across both the public and private sectors. The law also established a framework for the registration and pricing of medicines, licensing of pharmaceutical factories, patient complaint processes, and a validation system for medical errors, as well as an approval process for medical research activities. Royal Decree No. 5 of 2013 established the SCH, responsible for setting Bahrain’s national health care strategy, formulating policies aimed at improving health service availability and distribution, coordinating plans, programming across the health care sector in collaboration with multiple stakeholders, and creating a comprehensive health insurance system, among others. Although the MoH has been responsible for public service delivery across the kingdom, in July 2018 the authorities announced that its role would shift towards that of a regulatory authority, following the rollout of a national health insurance system, planned to be implemented in 2019. The ministry’s role will shift to the management of public health services, as well as promoting health and social care, according to a statement issued by the state-run Bahrain News Agency.

Facilities

At present the MoH operates a network of hospitals, specialty care centres and clinics that offer free health care to Bahraini nationals, as well as expatriate services at nominal prices.

At the beginning of 2019 there were 716 licensed health facilities operating in Bahrain – an increase of 7% from 2017 – including over 190 medical centres, 21 hospitals and 132 clinics, with more than half located in the Capital Governorate. In 2018 the total number of health and medical paramedic professionals increased by 9% to 30,621, compared to 28,000 in 2017. The NHRA also reported that the number of pharmacies operating in Bahrain increased by 23% from 2017 to reach 263.

In 2018 BD27.6m ($73.1m) worth of equipment was authorised, including 346 items of medical and diagnostic machinery, and almost 6600 medical products were granted permanent or temporary registration.

Health Policy

Health care development is guided by several mid- and long-term strategies and policy documents, including the National Health Plan (NHP) 2016-25, adopted by the SCH; the NHRA 2016-20 Strategy, emphasising inspection and accreditation activities; and the Bahrain Economic Vision 2030, a long-term economic development and diversification agenda that seeks to modernise Bahrain’s health care sector. The NHP is focused on providing sustainable, high-quality health care services under the auspices of this economic development plan.

One of its primary objectives is the adoption of Bahrain’s Social Health Insurance Programme, known as Sehati, which is expected to improve the utilisation of available resources and alleviate challenges created by population growth and rising incidence of NCDs.

Health Spending 

Current health expenditure as a percentage of GDP has been rising steadily in recent years, with the World Bank reporting that it increased from 2.97% in 2005 to hit 3.45% in 2009, moderating to 3.06% in 2011 before jumping to 4.16% in 2012 and 4.62% in 2014, reaching a 10-year high of 5.16% in 2015, the most recent year for which statistics are available. Domestic government health expenditure has also trended upwards in recent years, with expenditure per capita in current US dollars rising from $386 in 2005 to $501 in 2008, $635 in 2012 and $788 in 2015, according to World Bank data.

Private health care expenditure has risen more sharply in recent years, with out-of-pocket expenditure as a percentage of current health expenditure rising from 19.04% in 2008 to 20.07% in 2011, surging to 26.78% and 26.95% in 2012 and 2013, respectively, before moderating to 25.1% in 2015.

Investment

The Bahrain Economic Development Board reports that foreign direct investment has been flat in recent years, standing at BD5.85m ($15.5m) in both 2016 and 2017. Investment is set to increase significantly over the medium term, however, after the government announced in February 2018 that it plans to develop an integrated medical city north of Bahrain’s Muharraq Governorate, as part of the broader Saada project to develop the Muharraq Waterfront Development. The planned medical complex will offer speciality care facilities including a maternity hospital, sclerosis therapy centre and elderly care facility. Work is also ongoing at the $1bn King Abdullah Bin Abdulaziz Medical City. The project’s first phase will include a 288-bed hospital, outpatient clinic and support services, and is expected to be complete at the end of 2019. Its second phase is expected to include medical clinics and specialised research centres focusing on NCD prevention and treatment. In May 2018 the Ministry of Works, Municipalities Affairs and Urban Planning announced it was inviting tenders for new infrastructure in the city, something that is being partially funded through a $267m grant from Saudi Arabia.

Growth Projections

In May 2018 research firm Alpen Capital reported that Bahrain’s health expenditure accounted for 2.4% of total GCC health spending in 2017, forecasting expenditure would remain at 2.4% of the total in 2018, before moderating to 2.3% in both 2020 and 2022. This is the lowest share among GCC members, largely attributable to Bahrain’s small population, with the firm projecting that current health expenditure would record a compound annual growth rate (CAGR) of 5.1% to reach $2.4bn in 2022, from an estimated $1.8bn in 2017. Spending on inpatient and outpatient care is forecast to hit a CAGR of 5.3% up to 2022, while spending on medical goods and ancillary services will rise at a CAGR of 3.2% over the same period. Alpen Capital reports that Bahrain’s growing population, plans for mandatory national health insurance, rising incidence of NCDs, and the increasing cost of care will drive future growth. For example, hospital bed requirements are forecast to rise by 2% annually between 2017 and 2022 to reach 2979.

Health investment will also be supported by ongoing liberalisation efforts, with the government moving to allow 100% foreign ownership of private companies, including health care facilities, in July 2016.

Major Health Indicators

Although some major health indicators have shown dramatic improvements in recent decades, Bahrain’s health care system faces significant challenges, most notably an ageing population, rising care costs, and an elevated incidence of NCDs. The MoH reports that life expectancy has improved over the previous two decades, rising from 75 years between 2000 and 2005, to hit 76.5 between 2010 and 2015. It is forecast to rise to 77.2 between 2015 and 2020, and 77.9 between 2020 and 2025. Maternal mortality rates have also dropped off significantly since 1990, falling from 26 per 100,000 live births in 1990 to 20 in 2005, and 15 in 2015.

However, as in other GCC countries, Bahrain faces a high incidence of the four main NCDs: cardiovascular disease, cancer, diabetes and chronic respiratory disease. NCDs account for 63% of all deaths in Bahrain, according to the MoH, which reports that the total number of patients treated for cardiovascular disease stood at 133,005 between 2013 and 2016, cancer patients at 574 in the same period, patients with diabetes at 77,850, and chronic respiratory disease patients at 75,840. Bahrainis accounted for the majority of NCDs, with 92,946 cardiovascular disease patients, 487 cancer patients, 52,806 diabetes patients and 54,029 patients with chronic respiratory diseases. Bahrain’s population is expected to record a CAGR of 2% between 2017 and 2022, while its ageing population – more than 13% of residents are over 50 years old – is also increasing demand for health care services.

National Health Insurance

One of the most significant health reforms currently being undertaken in Bahrain is the establishment of the Sehati national health insurance system. Since 2016 the SCH has been working to implement Sehati under the auspices of the NHP and Bahrain Economic Vision 2030. According to Kasim Ardati, CEO of Bahrain Specialist Hospital, the plans are still in an early stage but have the potential to transform the sector. “The SCH plans for private health insurance should bring new opportunities to the private sector, but we are still waiting for clarity on processes, pricing and implementation”, he told OBG.

In June 2018 King Hamad bin Isa Al Khalifa issued a royal decree ratifying the kingdom’s National Social Health Insurance Law, following its endorsement by the National Assembly, with the SCH reporting that its main objectives are freedom of choice, improved quality, transparency and affordability. “The universal health insurance scheme that Bahrain is rolling out, for both Bahrainis and expats, will have a positive outcome for patients and providers. For private providers, those revenue streams that come with every intervention are important, and for the patients, they have the peace of mind that if they have a life-threatening condition, they can access care in the public or private sector,” Dr George Cheriyan, CEO and chief medical officer of American Mission Hospital, told OBG.

The SCH reports that it is currently working on multiple projects to implement the Sehati programme, including the formation of a Social Health Fund Authority, the establishment of a Health Information and Knowledge Management Agency, and working to improve public health providers’ autonomy. The SCH has created a clear roadmap for the implementation of Sehati, with plans to launch the first phase, an expatriate health insurance programme, in the third quarter of 2019, followed by a Bahraini insurance programme in the second quarter of 2020. “We have to stress that the aim of implementing Sehati is not cost saving, but financial sustainability and better control of resources. However, an actuarial study did conclude that an estimated saving of BD200m ($530m) per year could be achieved by 2038 through Sehati’s implementation. Such savings would be directed towards enhancing health services in the kingdom,” Zahra Bader, consultant for health strategic planning at SCH, told OBG.

Inspections & Accreditation

In October 2016 the NHRA began formulating the National Accreditation for Healthcare Systems (NAHS) programme, an inspection and accreditation system that launched in February 2017, just eight months after the planning process began. Described by the NHRA as a “real success story”, the NAHS is an inspection and accreditation process, under which NHRA survey teams visit private hospitals to examine evidence to show that the facility meets and is able to maintain acceptable standards and compliance with its legal obligations. Survey teams are certified by Saudi Arabia’s Central Board for Accreditation of Healthcare Institutions, which operates a similar programme. “They haven’t reinvented the wheel. They’ve taken standards that are internationally practised and contextualised them to the needs of Bahrain. Although the accreditation process is new, it will quickly mature,” Cheriyan told OBG. Hospitals are assessed using 11 core criteria, three supporting elements, and 13 facility-specific elements, producing a final report which awards either diamond, platinum, gold or silver rating. Diamond status is granted to facilities that meet at least 95% of NHRA standards, followed by Platinum (90%), Gold (80%) and Silver (70%).

Promising Results

The NHRA reports that after its first round of inspections, which covered private hospitals, four facilities achieved diamond status, three platinum and one gold, while three private medical centres achieved diamond status, and three platinum. Plans are under way to expand the programme to public hospitals, although a timeline for this has not yet been announced. As well as supporting broad national quality-of-care targets, the NAHS is expected to help Bahrain market itself as a medical tourism destination.“For any health sector, it is important to maintain the trust of patients by ensuring facilities are well regulated and monitored, and if they have a complaint, they know where to go. By raising quality, you improve trust. Also, medical tourism is very much linked to quality and accreditation,” CEO of the NHRA, Dr Mariam Al Jalahma, told OBG.

According to Ardati, Bahrain should look to the rest of the world to boost its international standing. “Improving relations with regional centres of excellence in health care, such as India, will bring new expertise to the country and build our domestic capacities”, he told OBG.

Outlook

Bahrain has advanced its health care development agenda in recent years, with progress towards a national health insurance system gathering pace, while NHRA inspection and accreditation activities set to improve patient outcomes and service quality. Although high rates of NCDs and rising care costs will remain a challenge in 2019, the kingdom has built a solid foundation for steady mid- and long-term expansion.