Ageing population and lifestyle-related diseases call for private sector care in Qatar

Since taking its first steps towards establishing a primary health care system and standardised health care services in 1954, Qatar has invested heavily in cultivating a highly developed standard of care for the 2.4m nationals and expatriates who call it home. Like every country in the region, the state faces economic challenges connected to the drop in international oil and gas prices; however, the Qatari government remains committed to health care development as a fundamental objective of Qatar National Vision 2030 (QNV 2030). To meet the country’s rising demand for health care in a period of constrained government spending, the private sector is increasingly being engaged to share the financial burden and offset government expenditure.

Growth Drivers

A number of factors are driving growth in Qatar’s private and public health care sectors. Increasingly sedentary lifestyles – a consequence of rising household incomes – and risk factors stemming from a modern diet have led to a spike in the incidence of diabetes, hypertension, obesity, cancer, heart conditions and other lifestyle-related diseases over the past 10 years, a phenomenon common across the region. According to a 2016 report on the GCC health care industry by Alpen Capital, roughly 42.3% of adults in Qatar – and a growing number of children – were identified as obese in 2014. This was the highest rate in the Middle East and the fourth-highest rate in the world that year; the global average was 12.9%, while roughly 23.5% was recorded for high-income countries.

The chronic, long-term nature of these conditions is supporting increasing demand for health care services and specialised treatment, and driving up costs in the country. According to PwC, non-communicable diseases comprised 22% of total health care spending in Qatar in 2016, and Alpen Capital reported that the incidence of diabetes in the country is set to rise by more than three percentage points before 2035.

The health care sector will also be contending with a larger and older population in the coming years, partly as a result of improvements in health care services. Life expectancy in the country reached 78.8 years in 2015, the highest in the GCC, and around the same as the US average of 78.7 years, according to the latest available data from the World Bank. At the same time, infant mortality is declining. In 1993 there were 14.7 infant deaths per 1000 live births, which dropped to just 7 per 1000 in 2016.

Lastly, Qatar faces issues unique to a country with a very high population of guest workers, many of whom arrive from states that lack equally robust health systems. In this context, the containment of outbreaks has been a significant test of the country’s public health resilience. The combination of a rapidly growing population with high disposable incomes, rising life expectancy, lower infant mortality and a growing prevalence of lifestyle-related diseases is expected to continue driving significant growth of health care services, public hospitals and primary health centres in the years leading up to 2030.

Sector Structure

The nation’s population is broadly segmented between single male labourers reliant on occupational health centres, and nationals and long-term residents requiring access to family medicine. For more specialised care in areas such as oncology and cardiology, Qatar sponsors treatment abroad as an adjunct to the health care system through contractual arrangements with 15 hospitals in the US, UK and Germany, as well as a number of highly specialised centres for rare and complicated cases. Underscoring the country’s increased focus on sector development and the rising demand for medical treatment, local media reported that Qatar’s public expenditure made up about 84% of overall health spending in the country in 2016, with QR20.9bn ($5.7bn) allocated for the sector in the annual budget. Across the rest of the GCC, government health care expenditure averaged 70.3% of total health care costs. Qatar’s 2017 budget included an increase in planned sector spending over 2016, earmarking QR24.5bn ($6.7bn) for the health care sector, or 12.3% of the total budget.

Across the region, only Qatar spends more than $2000 per head annually on health care, specifically $2106 per person in 2014, according to the World Bank. However, the country is also among the countries with the highest GDP per capita in the world.

Although health care spending in Qatar has recently been the highest in the region, government sector expenditure remains among the lowest in the GCC as a percentage of GDP, at 2.1%. A market report published in 2016 by BMI Research suggests that the public health care spend will grow at a compound annual growth rate of 5.8% until 2026, outpacing GDP growth over the same period.

National Health Policy

The achievements of the health sector over the last 10 years have been a result of strong initiatives. The government has made significant investments in public health infrastructure, and has dramatically improved governance in the sector via QNV 2030 and the National Health Strategy (NHS), currently in transition to the 2017-22 framework. The framework for the first NHS (2011-16) was grounded in seven goals that were to be achieved through a development programme of 35 projects and more than 100 outcomes. These goals were aligned to support the health objectives contained in QNV 2030, namely providing access to care, offering high-quality services and preventive care, developing a national health policy, planning public-private partnership projects, focusing on research and building a skilled national workforce.

The lasting impact of the first strategy is the development of a number of essential frameworks for sustainable care, dental and mental health, cancer and diabetes, in addition to the success of the country’s ambulance services attaining excellent response time. Public health projects represented approximately one-third of the NHS, which included preparing a diagnosis programme to detect early-stage cancers, pre-marriage check-ups and improving psychiatric health care.

In 2015 the Supreme Council of Health (SCH) started framing the next five-year NHS for 2017–22 with a somewhat different focus. Whereas the first NHS emphasised an acute, curative, hospital-based approach and included important foundational work (assessing the type of health care system appropriate for the country; basic policies, planning and procedures; and institutional collaboration), the NHS 2017-22 framework introduces a more preventive and community-based model aimed at moving the cycle of “better health, better care, better value” towards a health system of the highest international standards. The new model, developed in close collaboration with the US-based Institute for Healthcare Improvement, is expected to be instrumental in prioritising public health promotion and ensuring patient access to community-based primary care, as well as advanced, high-quality clinical care in tertiary medical facilities.

Sector Regulation

The Ministry of Public Health (MoPH) provides oversight and policy direction for the public and private health care sectors in Qatar. Between 2005 and 2016 those responsibilities were tasked first to the National Health Authority and then the SCH, and ultimately disbanded by Emiri Decree in January 2016. The MoPH does not provide clinical services in the country, but instead entrusts the responsibility for care to the hands of public institutions, such as Hamad Medical Corporation (HMC), as well as the private sector.

In order to achieve the NHS objectives, which emphasise the foundational role of primary health care in the country, Emiri Decree No. 15 was issued in February 2012 to establish the Primary Health Care Corporation (PHCC) as an independent entity with its own budget. According to its website, the PHCC manages 23 primary health care centres. Of the centres, 13 are located in Doha and the rest are located in other populated areas across the country. HMC and the PHCC both operate as principal public health care providers under the MoPH.

Regulation of practitioners falls to the Qatar Council for Healthcare Practitioners (QCHP), established in 2013 by Emiri Decree No.7 to function as an independent council rather than a department within the MoPH. The QCHP retains sole authority for regulating all health care practitioners and facilities in both the governmental and private health care sectors in Qatar through the QCHP Accreditation Department.

In addition to completing its first draft law related to national guiding principles of clinical practices in March 2017, the country has also developed a new system for licensing health care facilities and established the National Continuous Professional Development accreditation system, which came into force on March 7, 2016.

Insurance

Health care provision in Qatar is built on a national risk pool, with more or less free universal health care having been offered since the 1960s. In 2013 the government introduced a short-lived public national health insurance scheme known as Seha. For two years, Seha was run by the National Health Insurance Company, a joint-stock company wholly owned by the government. The programme was funded by the government in a single national payer system and was ultimately only rolled out in its initial phases to Qatari nationals. This was expected to be extended to all residents in the country in 2015, with employers tackling most of the cost for expatriates and the government paying for Qataris’ health care.

The insurance scheme was dismantled in December 2015 because the country found it lacked the experience of managing a complex health system and wished instead to rely more heavily on the private sector’s expertise. As expenses began to rise and criticism mounted over resource management, implementation was paused to take time to reconsider the strategy. The government has yet to publish its replacement scheme for Seha, but it is anticipated that the new programme will be led by the private sector. The Qatar Cabinet of Ministers has confirmed that they intend to support the private sector in a far more comprehensive manner by allowing private health insurance companies to provide insurance coverage for everyone. Once the health insurance law for the new scheme has been approved, the Cabinet will order a new committee to be established, led by the Ministry of Finance, to organise a tender process for private health insurance companies.

In the interim stage between the suspension of Seha and the introduction of its replacement scheme, the government is providing a basic level of service and nationals can get free health care at facilities run by the state-funded HMC and the PHCC. Non-nationals who have a Hamad medical card can also use HMC and some PHCC services. Private treatment is covered through insurance or self-funded.

Implementation of the first stage of the new programme was expected to begin in 2017, according to a timeline provided by the MoPH. In the first phase, up to nine service providers are expected to implement the scheme for up to one year before new service providers are invited to participate. After the scheme is rolled out to 300,000 Qataris, mandatory health insurance is expected to be extended to all expatriates, including blue-collar workers. Over time, this should reduce the burden of health care expenses on the public sector and help ease the pressure on HMC by increasing the private sector’s share in national health infrastructure. Increased coverage is additionally likely to drive the health care market, as out-of-pocket expenditures decrease and private investment is welcomed into the sector.

Issues to address before mandatory insurance is expanded to the entire population include capacity limitations, particularly on the provision of advanced care for complex medical conditions, and the appointment of a clear regulator in the health insurance sector to encourage market entry by international reinsurers. Ali bin Hassan Al Hammadi, secretary-general of Qatar Red Crescent Society, told OBG, “Expanding health care services across the board, whether it be for nationals or the large number of expatriates coming to Qatar, shows the world how serious we are to elevate the sector.”

Infrastructure Projects

As part of the NHS, the now disbanded SCH developed a 20-year blueprint (2013-33) for improving health care across the country. The Qatar Health Facilities Master Plan makes up a key component of this roadmap, identifying supply gaps and planning and delivering new health infrastructure projects.

In 2016 Qatar had 14 hospitals and 23 health care centres, including four private hospitals. In 2013, the latest year for which data was available at the time of publication, there were 487 private sector clinics, and the country’s hospitals offered 2400 beds, or about 11 beds per every 10,000 persons.

Community hospitals are key to the provision of health care in the country, and principal public health care provider HMC currently operates three general hospitals: Al Wakra Hospital, Al Khor Hospital and the Cuban Hospital in Dukhan. These facilities play an important role in relieving pressure on Doha’s hospitals and providing a full range of secondary health care services closer to many patients’ homes.

The country is investing in infrastructure to support expatriate workers, typically based in areas in which community hospitals are not as well positioned. In November 2017 the MoPH announced that two occupation-focused hospitals, specialising in issues facing the labour force, will be opened in 2018 and another one in 2019. These facilities will be designed to provide the appropriate level of care to patients close to where they live, with pathways to specialist services as required. In addition to the MoPH’s specialist services, which are concentrated in Doha, there are three community hospitals, the planned occupational hospitals, a network of PHCC centres and home services, and the private sector filling out the ministry’s network of care across the country.

“We expect patient visits to almost double by 2022, driven by the government’s direction to shift more non-urgent care and related health services into the community and closer to patients,” Mariam Ali Abdul Malik, managing director of the PHCC, told OBG. “Primary care will become the first and continuing point of contact, serving patients’ needs over time in a fashion that is holistic, continuous and coordinated.”

More Options

To further reduce pressure on its existing facilities, the MoPH is rolling out a significant expansion of Qatar’s hospitals and health centres. Six new health centres were inaugurated in 2016, including three health and recovery centres, while the number of public hospitals increased to nine with the addition of the Communicable Disease Centre. New facilities completed at Doha’s Hamad Bin Khalifa Medical City in 2016 included the Women’s Wellness and Research Centre, Qatar Rehabilitation Institute and the Ambulatory Care Centre. The rehabilitation centre had started seeing patients in early 2017 and will be progressively commissioned, followed by ambulatory care and the new women’s hospital.

Local media reported in October 2017 that four new health centres – Al Jamiaa Health Centre, Al Waab Health Centre, Al Wajba Centre for Health and Wellness and Muaither Centre for Health and Wellness – were set to be completed by the end of 2017.

The Sidra Medical and Research Centre also opened in 2016, funded by Qatar Foundation. The outpatient facility, which has been opening in phases, offers services in paediatrics, obstetrics and gynaecology, surgery, radiology, psychiatry, anaesthesiology and pathology. Valued at $2.4bn, the Sidra mega-project, which was originally scheduled to launch in 2011, will include a high-tech 400-bed tertiary care hospital and medical research centre primarily focused on the treatment of women and children. The facility is expected to open for inpatients in January 2018, with all services set to be operational by May that year.

Primary health care centres are one area where the government has slowed down on a number of planned projects. The Public Works Authority ( Ashghal) was to award contracts to build seven new primary health care centres in 2016 as part of a master plan to construct 60-70 new centres over the next decade, according to Ahmad Al Ansari, lead advisor for contracts and project management at Ashghal. The projected number was ultimately cut to three facilities, located in Umm Salal, Rawdath Al Khail and Al Thumama, saving QR4.5bn ($1.2bn) in planned expenditure for 2016. The MoPH granted final approval for 198 establishments in 2016. Major hospital projects expected to go to tender next include a new Ministry of Interior hospital in Doha and a mental health and psychiatry hospital in Al Wakra.

Workforce

According to Alpen Capital, Qatar has the highest nurse-to-patient ratio in the region – 62 nurses per 10,000 people – but has just 28 physicians, including dentists, per 10,000 people. The country continues to face a shortage of skilled medical professionals. Expatriates account for the vast majority of physicians, and while efforts are y under way to improve recruitment and retention of locally trained doctors and nurses by expanding existing medical programmes at universities, the strategies will take some years to have a visible effect. The hospitals and health care facilities that make up Hamad Bin Khalifa Medical City employ 26,000 staff from 111 countries, with 7-10% compound growth in staff every year. In 2016 HMC launched a major recruitment drive to fill 2690 vacancies by the end of the year in preparation for the 2016/17 opening of a string of new hospitals and health care facilities in the medical city. According to the MoPH, one of the biggest challenges is recruitment and trying to build a consistent clinical culture that is safe, effective and quality-oriented in an environment of many new people from diverse clinical and cultural backgrounds.

R&D

In recent years personalised medicine – an emerging branch of biomedical science focused on individual treatment strategies – has begun to gain traction as a means of optimising treatment for increasingly prevalent diseases, such as diabetes, cancer and neurological disorders. The launch of Qatar Biobank in 2012 was a significant step in advancing personalised medicine collecting genome samples, and information about the health and lifestyles of local populations. Having more or less mapped the genome of the Qatari population, the country has an opportunity to develop a meaningful approach to personalised medicine, matching population-level genomics with population-level medical records to understand how genetics and epigenetics interact and manifest themselves in clinical outcomes. The Qatar Genome Programme, a pilot programme under Qatar Biobank, is leading the development of personalised medicine by sequencing genomic data from the local population to identify genotype and phenotype associations that impact health. Since its inception, Qatar Biobank has collected genome samples from 6000 volunteers as part of its recently completed pilot phase, including over 5000 Qataris, whose donations provide a comprehensive resource for geneticists, biomedical experts and other specialists.

Other research programmes are also focused on preventing and supporting early and targeted intervention of certain conditions. The core research facilities at Sidra Medical and Research Centre have the largest next-generation sequencing facility in the Middle East. In collaboration with local partners, they are advancing the understanding of pathophysiological mechanisms of diseases, and develop preventive, diagnostic and therapeutic mechanisms.

Outlook

The value of Qatar’s health care market has grown steadily in the past decade, and several factors are converging to drive long-term growth. As the country grows and ages, the incidence of lifestyle-related ailments is rising. However, lower oil prices, an expanding population and higher levels of chronic disease make it expensive to develop resources and health care access. To meet rising demand, the Qatari government is increasingly engaging the private sector to share the financial burden (see analysis). A near-term focus on improving access and meeting growing demand for medical treatment is expected to provide greater revenue-earning opportunities for global drug manufacturers, medical device manufacturers and infrastructure businesses focused on the construction of health care-associated projects. The introduction of a replacement insurance scheme for Seha and the eventual shift to mandatory health insurance are also likely to boost overall spending.