Health care system in overdrive to catch up with demography

The development of Qatar’s health care system should be seen in the context of the country’s rapid population growth. According to the Ministry of Development Planning and Statistics (MDPS), the country’s population has more than tripled since 2004, reaching over 2.22m as of January 2015, with Qatar National Bank projecting 7.4% annual growth through 2016. Qatar’s health policy is driven by the need to provide quality health care to this growing population, while at the same time modernising and universalising its health system to meet the demands of shifting disease profiles.

Although it is a complex matrix, Qatar has the resources to address it. The country’s three main government-run health care organisations provided nearly 32m free services to residents in 2013 alone. Through its National Health Strategy (NHS) 2011-16, Qatar is transforming the system from a unitary, hospital-based model to a modern, primary care-led system, bolstered by world-class workers, facilities and service models.

FORECASTS: With government investment and private spending on health care on the rise, Qatar’s health care market is forecast to be worth some $9bn by 2018 – nearly double the $4.6bn seen in 2013 – according a recent report by Alpen Capital, a regional investment bank. The inpatient market should reach $2.5bn by 2018, up from $1.2bn in 2013, while the outpatient market will increase from $3.4bn to $6.6bn.

Qatar is expected to be the GCC’s fastest-growing health care market in the years ahead, with a compound annual growth rate (CAGR) of 14.4% forecast for 2013-18, according to Alpen, driven by a surge of investment from both the government and the private sector. Despite accounting for just 4% of the bloc’s population, Qatar’s share of GCC health care spending is projected to hit 13% by 2018, up from 11.7% in 2013.

Positive market growth forecasts also stem from rising health care costs, with new medical technologies coming to market and increasingly being integrated by health care providers. This comes in conjunction with the opening of new health care facilities, growing demand for services and longer hospital stays, due to greater longevity and the prevalence of chronic disease.

Qatar’s health care market has posted strong growth in the last decade, with a CAGR of 23% in 2006-11. This is largely due to the influx of expat workers, which saw the country’s population double over the period. Despite higher spending, there is a persistent and growing need for health care infrastructure, ranging from pharmacies to specialised care units. Population pressure saw the number of hospital beds per 10,000 residents fall from 25 in 2006 to 12 in 2011 – the lowest in the GCC. The government has been investing heavily to address this issue, with the number of hospital beds in the public health care sector set to increase from 2100 in 2014 to 5581 in 2022, according to the Supreme Council of Health (SCH), which oversees the sector.

As of 2013, there were some 65 new health care facilities under development by the country’s three main government health organisations, which will add 3481 additional beds to more than double current capacity (see analysis). In addition, the organisations were working on a further 42 facility renovation projects.

MARKET GROWTH: Qatar’s health care spending per capita has risen in past decades, to exceed the regional average by around 50% by 2011; however, spending remains low compared to its more developed counterparts. In 2011 it averaged $1776, against $1640 for the UAE; $1166 across the GCC; $3609 for the UK; $4875 in Germany; and $8608 in the US. Given that the state is the world’s richest country in terms of GDP per capita on a purchasing power parity basis, this shows a great deal of potential for further growth in the sector, building on the momentum of past investment.

Alpen identifies five main growth drivers for health care across the GCC, all of which apply to Qatar: population growth, higher per-capita incomes and a rising incidence of lifestyle-related ailments, increasing life expectancy and an ageing population, greater health insurance penetration, and investments in health care projects – from new hospitals to clinic expansions.

PACE OF DEVELOPMENT: The right to health care is guaranteed by Qatar’s constitution, which also charges the state with disease prevention and fostering public health more broadly. Since gaining independence in 1971, Qatar has developed a highly sophisticated health system, as seen in the improvement in the state’s morbidity indicators. The vast financial resources that Qatar has channelled into health care over the past decade and a half in particular have been paying development dividends. Infant mortality fell from 107 per 10,000 live births in 2000 to 63 in 2000 – placing it among the lowest in the region, according to figures from the World Bank. Today, nearly 100% of births in Qatar are attended by skilled medical personnel.

Life expectancy at birth is 79 for men and 80 for women, according to the latest figures from the UN’s World Health Organisation (WHO), exceeding the regional average of 76 and the global average of 70. Another positive indicator is the country’s maternal mortality rate. At 6 per 100,000 live births, according to the WHO, Qatar outperforms the GCC and global averages of 13 and 210, respectively. The adult mortality rate, that is, the number of deaths between the ages of 15 and 60 per 1000 people, was 73 for men and 51 for women in 2012, down from 86 and 79, respectively, in 2000. This compares to global rates of 187 and 124.

By the end of 2013, Qatar’s public health sector had 2182 physicians, up from 1989 in 2012, according to the SCH’s 2013 annual report, with the 10% year-onyear (y-o-y) jump indicating the strength of the country’s recruitment drive. There were also 8234 nurses, up 8% y-o-y from 7648, and 853 pharmacists and assistant pharmacists, up 23% over 693 in 2012.

STRUCTURE: In line with Qatar National Vision 2030, the government established the SCH in 2009, giving it both the resources and remit to make and implement decisions regarding the health care system. It acts as a regulator, in addition to providing services in several areas, including communicable disease testing for all migrants and environmental health tests.

The Ministry of Finance funds the public health care providers and the SCH oversees the two main public health care networks, Primary Health Care Corporation (PHCC), which provides 39% outpatient care and 91% of primary care visits, and Hamad Medical Corporation (HMC), which accounts for 27% and 75% of out- and inpatient care, respectively, according to the SCH. The SCH also funds the Qatar Council for Healthcare Practitioners (QCHP), a professional licensing organisation set up in 2013 to foster efficacy and accountability.

Private health care spending, through means such as insurance and out-of-pocket spending, is an important, if underdeveloped, contributor to the market. As of 2011, 78.5% of Qatar’s health care spending came from the government, down from 84% five years before. However, in the years since, this has increased again in line with renewed investment in the sector, according to Alpen. Out-of-pocket health care spending remains low when compared to developed countries, at 8.5% of the overall health spend – a fraction of the OECD average of 20.3% – according to the SCH.

NHS: Some of the lead priorities of the NHS are to develop primary, preventive health care; make services more affordable and effective; and create a skilled workforce that includes talented nurses. “The perception of nursing is starting to change among the Qatari populace, and Qatari students are now choosing the University of Calgary in Qatar (UCQ) because it is a better programme. Of the 2013 intake, 32% were Qatari and 18% were male. This is a huge feat, as only 4% of the total nursing population in the country are Qatari,” Dr Kim Critchley, dean and CEO of UCQ, told OBG.

In the spirit of achieving these goals, PHCC was created in 2012 to manage primary care centres separately from Qatar’s hospital system. As the state’s core provider of primary care, it is responsible for the country’s expanding portfolio of facilities, with another 19 primary health centres to open over the next five years, more than doubling their footprint. “These new health centres will support PHCC in delivering the physical infrastructure needed to increase access, while broadening geographical coverage to the whole of the country,” Dr Mariam Ali Abdulmalik, managing director of PHCC, told OBG. “PHCC’s plans will meet the huge population growth we have already experienced, as well as cope with further growth in the future.”

The focus on primary care and occupational health is prompting the government to construct primary care centres and small hospitals in areas where expats live and work to facilitate access and encourage use. The primary care model operates like a pyramid, with most interactions taking place at the primary level and only serious cases referred to hospital or other specialist care. In this sense, primary care acts as the foundation of the system and the first point of access to services.

Encouraging residents to visit primary care centres first, to avoid putting undue pressure on hospitals with non-urgent cases, is an on-going process, as hospitals have been the norm. The SCH expects expats to transition smoothly, as many grew up with a similar model, whereas educating Qataris about the new system may take more time and involve an active programme of communication and promotion.

In addition to infrastructure build out, the development, maintenance and monitoring of clinical quality and safety is another sector priority, with a focus on patient services. Creating a consistent level of quality involves workforce training, human resource and IT development, and a strong health education foundation. An example of this is PHCC’s HAYYAK programme, which places a team in each health centre to act as a dedicated support system for patients.

The human resources side has added greater complexity, as many clinical and medical staff are recruited from abroad. There is a global shortage of skilled medical personnel, and the state must compete with the likes of the US and the UK. Furthermore, the challenge of integrating foreign staff into the Qatari system is not insignificant. However, the introduction of a single licencing regime under the QCHP – which recently completed the re-licensing of existing clinicians – was a significant step towards universal standards.

CHRONIC AILMENTS: One of the biggest challenges that Qatar faces is the rise of chronic disease – or noncommunicable illnesses often linked to lifestyle, such as cancers, hypertension and diabetes. Qatar’s population has high risk factors for these illnesses, such as obesity, smoking, sedentary lifestyles, and consumption of processed sugars and fats. Given this trend, the evolving health care system must take those already affected into account and boost prevention efforts.

Statistics demonstrate the challenges that Qatar, like its neighbours, faces in tackling these illnesses. Some 33.1% of Qatari adults are obese, according to the UN Food and Agriculture Organisation, on par with the GCC average of 33.2%. According to the 2012 Qatar Stepwise Survey, some 32.9% of respondents had elevated blood pressure and 16.7% had raised blood glucose, with incidence higher for men in both categories.

In 2013 the SCH implemented a national cancer wait time policy, with all patients with suspected cancer to be seen by specialists within 48 hours – a world first. Definitive diagnosis should be reached within 14 days, with treatment to start in 14 days or less thereafter.

GETTING OLDER: The combination of higher life expectancy and population growth will have a substantial impact on the health system, particularly as the number of residents in late-middle and old age rises. Although Qatar currently has one of the world’s smallest proportions of residents over 65 – just 1.9%, according to the SCH – this will increase in the coming decades, presenting a new challenges for the state. In the meantime, the preponderance of young people, particularly men, will affect the distribution of services needed.

With around 80% of an individual’s health care needs arising after the age of 50, according to the Alpen report, an ageing society does not just represent a cost to policymakers, but also an opportunity for health care providers, equipment manufacturers and pharmaceutical companies. These opportunities are accentuated by the share of Qatar’s residents that have developed lifestyle-related complications. Indeed, according to the SCH, Qatar’s non-communicable disease rate already mirrors that of countries with ageing populations.

INSURANCE REVOLUTION: Among the most significant changes now taking place in Qatar’s health care system – and arguably in the state’s social development as a whole – is the rollout of the National Health Insurance Scheme. The programme, called Seha, marks its second year of operation in 2015. Passed in July 2013, Law No 7 of 2013, known as the Health Insurance Law, established the National Health Insurance Company (NHIC) to implement the programme, with the initial phase beginning in earnest the following month.

Seha is being implemented incrementally, with the intention that the programme will eventually cover all residents. Staggered implementation is needed given the complexity and cost of creating such a wide-scale new system. The first phase was very limited, covering Qatari females aged 12 and over for obstetrics, gynaecology, maternity and related health issues, but by April 2014, the second stage extended comprehensive insurance to all Qatari nationals to cover basic health care needs. The range of services funded by Seha is ever-expanding and now includes both dental and optical coverage. Meanwhile, the NHIC is also broadening the range of accredited health care providers.

Seha should also provide a significant boost to the private health care sector. The system currently covers around 150 providers – most of which are in the private sector – effectively giving Qataris the option to seek treatment at either public or private sector facilities. This large-scale opening of access has already shifted some patient footfall to primary health care clinics – a telling sign, given that Qataris, like elsewhere in the region, tend to gravitate to state-owned hospitals. This should act as a stimulus for private investment in clinics, helping boost capacity in a crucial area.

LOOKING AHEAD: Once fully rolled out, Seha will cover all non-Qatari residents. This is likely to be a more complex task, as expatriates far outnumber Qataris – accounting for 88% of the population, according to MDPS – and are much more demographically varied, ranging from poorly-educated manual labourers to older, highly-skilled professionals. As such, the health authorities want to ensure that Seha is operating smoothly for Qataris before taking on the challenge of extending it. The extension, which was scheduled for 2015 but delayed until late 2016, could begin with higher-risk groups, such as those with low incomes.

Coverage for expatriates will also be more basic, allowing the government to focus resources on nationals. This too will provide opportunities for the private sector to extend policy lines for areas not included in the expat Seha package. The hope is this will offset losses from Qataris opting out of private insurance due to the wide range of treatments covered by Seha.

The insurance market has been growing rapidly. Nonlife premiums grew at a CAGR of 10.1% in 2008-12, the second-highest rate in the GCC, according to Alpen. With non-life insurance penetration at 0.6% in 2012 – against a global average of 2.8% and the UAE’s 1.6% – Qatar’s health insurance market shows a lot of room for growth.

SIDE EFFECTS: Seha’s rollout should substantially increase both access to and demand for health care in Qatar, to the benefit of providers and suppliers. “We hope that as Seha is rolled out, it will not only help our business flourish, but also encourage others to invest in the local production of medical devices, equipment, drugs and so on,” Ahmed Mohammed Al Sulaiti, chairman of Qatar Pharma, a Doha-based pharmaceuticals manufacturer, told OBG. “Qatar Pharma has already seen a noticeable increase in orders coming from HMC, so this should be an indication that the amount of goods being consumed in the industry is on the rise.”

This is slated to help Qatar-based medical equipment companies. Most are export-oriented, given the moderate size of the domestic market, but strong growth at home should help ease some of the pressure they are experiencing in export markets due to competitors from elsewhere in the world.

OUTLOOK: Between 2000 and 2010, Qatar’s health system worked to keep pace with the world’s fastest-growing population. Naturally, this proved to be a significant challenge, especially as the government was committed to ensuring that the care provided was of a high standard – made more important by the demographic and medical complexities of the population.

The NHS, which is nearing its final year of operation in 2016, was developed not only to keep pace with these trends, but to overhaul the health care sector, transforming it into a world-class system with a focus on responsive, primary care and universal service, to operate in tandem with the private sector. By 2016 several of the systems, programmes and institutions that have already been instituted will be fully operational.

For its part, Seha, which already is up and running, will extend access to first-rate health care, boost primary care provision and foster a high level of general public health. Adapting the programme to fit the needs of the country’s disparate expatriate population is the next challenge – and is likely to be a formidable one.

Going forward, other priorities include an intensification of the public health campaign to lower the risk factors and incidence of chronic diseases and ailments, in addition to the expansion of capacity and recruitment efforts, while maintaining quality of service.