Better care: Encouraging a larger role for the private sector and introducing a new national authority

Citizens and residents of Bahrain have access to an extensive health care system that provides primary, secondary and tertiary care at both public and private facilities. At present, the state accounts for the majority of health care services, although the private sector continues to expand. The launch of operations by the National Health Regulatory Authority (NHRA) in 2011 is expected to ease entry by private sector players, as well as aid expansion of existing facilities by improving the licensing system for doctors and nurses.

PUBLIC SECTOR: The Ministry of Health (MoH) oversees a large network of public facilities. These include 23 primary health care clinics located throughout the country that offer a variety of basic services, including preventive care, immunisations, and mother and child care. In 2009 (the latest data available), these clinics recorded 3.45m visits, according to the “Health Statistics Report 2010”. The MoH also runs the Salmaniya Medical Complex (SMC), a 1066-bed hospital that provides secondary and tertiary services, in addition to a psychiatric hospital, a geriatric hospital and three maternity hospitals. Health care at these government facilities is free for Bahrainis, with small fees charged to non-nationals. In 2010 the MoH’s total budget – which reflects in large part the cost of maintaining this network of public health care facilities – amounted to BD196.3m ($518.3m), 7% of total government expenditures, and a 1.5% increase over the prior year.

A RANGE OF SERVICES: Services at SMC, which is by far the country’s largest hospital, include cardiology, general medical, nephrology, oncology, general surgical, paediatrics, obstetrics and gynaecology, ophthalmology and dentistry, among others. SMC had 44,048 inpatient discharges in 2010, about 80% of whom were Bahraini nationals. Obstetrics and gynaecology account for the largest category of discharges, followed by general medical, general surgical and paediatrics.

On the outpatient side, SMC had 589,787 visits the same year. Salmaniya also carries out lab work for its own patients as well as for those at other medical facilities, including the government’s primary care centres. In 2010, SMC conducted about 9.5m tests, around 76% of which were sourced from SMC.

The MoH continues to upgrade services at SMC, including the addition of a new intensive care unit (ICU) that opened in early 2012. The BD3m ($7.92m) facility is currently operating with 15 beds, but it will gradually expand to accommodate 22 patients. A new haematology unit is also in the works, a 90-bed centre that will treat patients with blood diseases, with a focus on sickle cell disease. There are also plans to improve access to primary health care facilities, with three new health centres expected to be operational by the end of 2012. Finally, in early 2012, the government approved the budget for building a BD40m ($105.6m) National Cancer Centre, which will bring leading oncology treatment and technology to Bahrain, according to Dr Sadiq Abdul Kareem Al Shehabi, the minister of health.

NEW HOSPITAL: While the MoH provides the majority of public health care, the Bahrain Defence Force (BDF) is also active, running the 350-bed BDF Hospital, primarily treating military personnel. In December 2011 the BDF opened a new secondary-care medical facility, the King Hamad University Hospital (KHUH), which is available for use by the general public and was officially inaugurated on February 6, 2012.

To date, KHUH has 311 beds and is expected to have around 6000 patient admissions and at least 7000 outpatient visits per year. As of January 2012, the hospital had some 500 medical staff (including doctors and nurses), but the administration would like to increase this figure to 1000. KHUH is located in Muharraq, adjacent to the campus of the Royal College of Surgeons in Ireland (RCSI), one of the country’s medical schools. A number of physicians at KHUH, including the chief of staff, hold joint appointments between the hospital and RCSI. It is also expected that KHUH will provide medical training to RCSI’s students, as well as to students who attend the medical colleges located at Arabian Gulf University and AMA International University. The new hospital will be a welcome addition to the health care sector, particularly as it will provide additional training space for medical personnel (see analysis).

Additionally, KHUH is committed to the development of post-graduate training programmes in conjunction with its sister hospitals and RCSI. It is anticipated that these post-graduate programmes will be able to meet most of the training needs of Bahrain's medical graduates and thereby serve the general population.

KHUH offers all of the standard secondary health services, with the exception of cardiology. In addition, the hospital provides lab and radiology services, which it makes available to other government facilities. According to Dr Sheikh Salman bin Ateyatalla Al Khalifa, the CEO of KHUH, there is currently a waiting list for CT/MRI scans at SMC, which KHUH can help to reduce. The new hospital also has a PET scan machine, which was previously not available in Bahrain, with patients having been sent to Saudi Arabia and Turkey for this service. Another new treatment offered by KHUH is hyperbaric oxygen therapy. In the future, the hospital also intends to add oncology to its list of services.

KHUH will be an entirely paperless facility, maintaining only electronic medical records. This system has numerous advantages, including reducing the risk of medical errors. Initially these records will pertain only to KHUH’s patients, but the plan is eventually to extend the system to all government health care facilities, including SMC and the primary health care centres. This could be beneficial for the quality of care, as physicians would have easier access to patient histories.

LONG-TERM PLANS: According to Al Shehabi, the immediate benefits of KHUH to the health care system include easing of pressure on access to SMC, providing the country with a second accident and emergency department, and allowing more convenient access to secondary care for residents in Muharraq. However, in the longer run, KHUH is likely to be the first step in a larger strategic vision, Sheikh Salman told OBG.

According to this plan, SMC would be transformed into a provider of tertiary services, while three new hospitals would each be assigned to serve one of three new health care regions. KHUH is the first of these facilities and has been assigned to the Muharraq region. The remainder of the country would be divided into two regions (northern and southern), with the latter to be served by a new hospital that will be located on the campus of Arabian Gulf University. This facility, which is expected to have 200 beds, is being funded by a SR1bn ($266m) grant from the Saudi Arabian government. Announced in April 2010, the hospital was in the planning stages as of early 2012.

PRIVATE PLAYERS: According to the MoH, there are 13 private hospitals, accounting for 460 beds, including recent entrants such as Royal Bahrain Hospital (RBH), which opened in January 2011. The BD6m ($18.4m) facility was developed by the Kerala Institute of Medical Sciences (KIMS), an Indian health care provider that operates hospitals in Oman, Qatar and Saudi Arabia. RBH, which has 65 beds, is the second facility overseen by KIMS Bahrain – it has operated KIMS Bahrain Medical Centre since July 2004. Overall, private hospitals saw 22,261 inpatient admissions and 831,383 outpatient visits during 2010.

OTHER MAJOR PLAYERS: In terms of 2010 inpatient admission data from the MoH, the three largest private facilities are Bahrain Specialist Hospital (BSH), Ibn Al Nafees Hospital (IAN) and American Mission Hospital (AMH). The 69-bed BSH, which began operations in October 2002, offers a full range of secondary-care departments, including obstetrics and gynaecology, paediatrics, general medical/surgical, oncology, and ear, nose and throat. In 2010 around half of the patients (combined outpatient and inpatient) who visited the hospital were non-Bahrainis, the majority of whom came from Qatar and Saudi Arabia to make use of the services of the hospital. In addition, BSH has a contract with the US Navy to treat personnel from its Fifth Fleet, which is based in Bahrain.

IAN, which was founded as a small clinic in 2002, has experienced significant growth over the past 10 years. In 2010 the facility served 135,224 outpatients and 4597 inpatients, with a staff of 33 physicians and 101 nurses. According to the MoH approximately 22% of IAN’s outpatient visits are from expatriates, and the hospital is working to expand its range of service offerings.

AMH, a non-profit hospital that was founded in 1902 by missionaries of the Reformed Church in America, is one of the oldest hospitals in the Middle East. Inpatient services include general surgery, general medical, paediatrics, and obstetrics and gynaecology. During 2010, the hospital served 3164 inpatients, plus 210,886 outpatients. AMH currently has about 50 beds, but it is planning to establish a new 100-bed facility that will cost around BD20m ($50.8m) to build and is expected to be open by the end of 2014.

MEDICAL TOURISM: In addition to expansion of existing facilities, the private sector is also building new hospitals and other facilities, partially in response to growing demand for medical tourism. In August 2011, Venture Capital Bank (VCB), a Bahrain-based financial services firm, announced it had finalised the design for a new maternity hospital. According to VCB, the new facility, to be called the Royalty Maternity Hospital, has been designed to British medical standards and will be located in the southern governorate. VCB has already financed another project in Bahrain, the German Orthopaedic Hospital, which opened in 2010 and targets the medical tourism sector.

More medical tourism facilities are likely to be established. In January 2012 the Central Municipal Council announced that it had approved plans for a new medical district that will be located near Isa Town. Specialist hospitals and clinics, as well as support facilities such as hotels, are expected to be built as part of this new private health care zone, which will be located in Buhair. According to a statement to the local media by Mohammed Hassan, the director-general of the Central Municipality, there is no government or municipal land in Buhair, so authorities had to come up with different incentives, such as favourable zoning laws, to encourage investment in medical facilities.

HEALTH VILLAGES: One government institution that is actively supporting further growth of the medical tourism sector in Bahrain is NHRA, which since early 2011 has handled licensing of all medical professionals and facilities in the Kingdom (see analysis). According to Dr Bahaa Eldin Fateha, the CEO of NHRA, several of the provisional licences that his organisation issued in 2011 and early 2012 are for “health villages”, which are designed explicitly for medical tourism and typically include a health care facility in addition to a hotel for guests and residences for workers. The investors are based in Bahrain, the GCC and further afield, he told OBG, adding that patients are expected to come mainly from the GCC and the Middle East.

One medical tourism project that has been in the works for some time is the Dilmunia at Bahrain development, known colloquially as “health care island”. The $1.6bn project is being developed by Ithmaar Development Company (IDC), a subsidiary of Ithmaar Bank, a local financial firm. Located on a 125-ha, purpose-built reclaimed island off the north-west coast of the Kingdom, the project will feature a wide variety of health and wellness facilities as part of a mixed-use development. The plans include housing for 12,000 to 15,000 short- and long-term residents, plus commercial and retail facilities. Medical facilities will include a general hospital as well as a wellness centre, a diabetes centre, and a separate hospital for women and children.

The rate of progress at projects such as Dilmunia and other medical tourism facilities could be affected by the social unrest that the Kingdom experienced early in 2011. Even well-established private hospitals in Bahrain could see a drop in their patient numbers should things escalate. For example, Dr Kasim Ardati, the CEO at BSH, told OBG that the number of Saudi and Qatari patients at the hospital declined following the unrest in early 2011.

ACCREDITATION: For hospitals eager to attract foreign patients, accreditation from an internationally recognised organisation such the Australian Council for Healthcare Standards International (ACHSI) or the Joint Commission International (JCI) can be an important and valuable feature. At present, both AMH and the BDF Hospital are accredited by the ACHSI, with the former having held that distinction since 2007. In October 2011, BSH became the first hospital in Bahrain to receive accreditation from the JCI.

As of January 2012, the International Hospital of Bahrain (IHB), a private non-profit hospital with about 100 beds, was in the process of applying for JCI accreditation, CJ Lewis, the hospital’s chief operating officer, told OBG, adding that the JCI is considered the “gold standard” in the accreditation world. Lewis noted that one challenge in receiving JCI accreditation is that all hospital staff must be certified in the areas of basic life support and advanced cardiac life support by the American Heart Association (AHA).

This can be difficult to achieve in Bahrain, where there are only two AHA-certified international training centres, located at the state-run College of Health Sciences (CHS) and SMC. These two organisations do not currently have capacity to meet demand for this kind of training, he told OBG. To overcome this challenge, IHB is becoming certified by the AHA as an international training centre. Once it receives approval from the AHA, it will offer this type of training to all medical professionals in the community.

In some countries, accreditation by an international body is required by the government, as is the case in the UAE. In other countries, such as Saudi Arabia, it is not a legal obligation, but insurance companies will not sign a contract with a hospital unless they have some sort of international accreditation. In Bahrain, as Fateha of NHRA told OBG, the regulator encourages accreditation, but it is not mandatory. This is in part because the NHRA is in the process of establishing its own Bahrain-specific standards. However, hospitals are certainly free to do so, and in many cases this decision is motivated by a concern for improving services and an interest in receiving an external assessment.

INSURANCE: While the private sector is quite active in the provision of medical care in Bahrain, private health insurance is still not widespread. According to Dr George Cheriyan, the CEO of AMH, only a small percentage of the population in Bahrain has private health insurance. In some respects, this is not surprising, as the majority of health care services are provided by public facilities such as SMC. However, even at private hospitals, not all patients carry insurance. Those who have private health insurance typically receive it as part of a benefits package from their employers.

More than 20 domestic and foreign health insurance providers are active in Bahrain, including Aetna, The American Life Insurance Company, Bahrain National Life, MEDNET, MEDGULF, Takaful International, AXA, Arab Insurance Group, GOOD HEALTH, NEXtCARE, Qatar Insurance and Gulf Union Insurance. The market appears to be young and evolving. For example, IHB cancelled most of its insurance contracts in 2009 due to low collection rates and slow payments, Lewis told OBG. However, the hospital has since entered into a contract with a new entrant to the insurance market – t’azur – which has had success in signing up employers in part because their workers would like access to IHB’s services.

Another factor that could affect the market for health insurance would be compulsory medical insurance for expatriates, which has been under discussion for several years but was recently identified as one of the MoH’s six key objectives for the national health reform agenda, Al Shehabi told OBG. A committee at the ministry has been formed to create and implement a mandatory health insurance plan for non-Bahraini residents.

Such a system may not only reduce costs for the government, it would also likely benefit private sector health care providers, according to Ahmed Jawahery, the president of RBH. “If the government made insurance compulsory for expatriates, it would greatly benefit both the health and insurance sectors. This would also allow the private hospitals to reduce the load on the public health care system,” he told OBG.

LABOUR: The market for professional medical staff in Bahrain has two distinct segments: public and private. As of 2010, the MoH employed 1178 doctors, 2880 nurses, 122 dentists, and 196 pharmacists and technicians. Nationals are well-represented at the ministry’s facilities – about half of its nurses and 81% of its physicians are Bahrainis. According to the MoH, the nationalisation rate in the health sector is the highest in the Gulf region. This is in part thanks to the MoH’s long-standing support of training for local medical professionals, including free education for nurses and other health care staff, such as lab technicians (see analysis).

While the hospitals run by the MoH tend to employ a large number of Bahrainis, this is less true of the private sector providers, where labour costs are more of a concern. Employees for private hospitals are often hired from foreign countries, including the Philippines, India and Egypt, according to Cheriyan. However, hospitals are finding it more difficult to recruit and retain foreign physicians as conditions and remuneration are improving in many of their home countries.

On the other hand, licensing expatriate medical staff has become easier. In the past, procuring a licence could take a substantial amount of time and involved a large amount of paperwork. Documentation of education and training could not be submitted electronically – the original documents had to be sent by mail from the source countries, which could take months. Now such materials can be submitted by email or fax, which has reduced the time and risk of losing documents in transit. The length of time required to review applications has also been reduced. In the past it could take six to seven months; now, once a medical institution has submitted a file, the doctor will receive a licence from the NHRA in no more than 30 days (see analysis).

This has been a welcome change for Bahrain’s private sector hospitals. According to Jawahery, the new NHRA system represents a “significant improvement in licensing”. However, he added that he would like to see additional restrictions on doctors and nurses in terms of the amount of time they must work for an employer before moving to another hospital. Indeed, the labour laws have been liberalised in the last several years such that expatriates can shift jobs more easily. As a result, employment terms for nurses have generally improved.

OUTLOOK: The promotion of the health care sector is in line with the priorities set forth in Economic Vision 2030, the government’s long-term development plan. Accordingly, the state has undertaken and made plans for a number of initiatives to expand and upgrade the existing public health care facilities.

However, the government is also working to create favourable conditions for encouraging growth in the private sector and is taking steps to shift the state’s role from provider to regulator. The development of institutions such as the NHRA will certainly help create a level playing field and encourage private investment.