Healthy indicators: The sector is diversifying, with an eye towards private investment

Promoting development by nurturing a healthy population is enshrined in Qatar’s constitution and is a cornerstone of the government’s long-term development strategy. Under Qatar National Vision 2030 (QNV 2030), the state commits to “developing an integrated system for health care, managed according to world-class standards. This system will meet the needs of existing and future generations and provide for an increasingly healthy and lengthy life for all citizens. All health services will be accessible to the entire population.” To this end, there have been heavy investments in the sector, as well as new reforms and initiatives. The Qatar University and Qatar Foundation work support the government in this endeavour, helping train future medical staff and conducting research and analysis. With an eye on longer-term sustainability, the government is also encouraging private sector participation. Prosperity has also brought new challenges to Qatar. The prevalence of diseases linked to lifestyle and behaviour, such as diabetes, has increased dramatically, exposing imbalances in the system, as well as the population’s shifting health needs. In response, Qatar has identified the benefits of shifting from a hospital-focused health care system to emphasising preventive care, supported by a strong primary care system.

DEMOGRAPHICS: Qatar’s population has increased rapidly over the last decade, from just over 600,000 in 2000 to 1.8m in 2011, according to the IMF World Economic Outlook. Like most GCC countries, expatriate workers account for much of the rise, and many are male labourers aged 25 to 45. This unconventional population structure means traditional health indicators must be adjusted and evaluated differently. Due to lower incomes, for example, this population segment has less health care utilisation and expenditure. About 40% of the population consists of Qatari and non-Qatari households with a more conventional structure and gender balance. This population has historically had access to high-quality health care services, which have steadily improved over the last several decades. Life expectancy has risen, reaching 78 in 2007, according to the 2009 “Annual Health Report”, compared with 53 in 1960. Infant mortality has also declined, from 17 per 1000 live births in 1981 to 7.1 in 2009.

CAUSES FOR CONCERN: However, a historical lack of focus on preventive care, compounded by rapidly changing lifestyles, has created a different set of health problems. The prevalence of non-communicable diseases (NCDs) has become a major issue, with cardiovascular diseases, hypertension, diabetes and cancer accounting for a significant proportion of mortality and morbidity. According to the Hamad Medical Corporation (HMC), the state’s main non-profit health care provider, diabetes affects 17% of Qatar’s population and accounts for 10% of national health care expenditure. Obesity and other health issues related to a sedentary lifestyle are increasingly a concern, as is tobacco usage, especially among children 13-15 years of age.

Finally, road accidents are a major concern. A handbook on road safety released by the Qatar International Safety Centre reports a person is taken to hospital suffering serious trauma every two hours, with more than 100,000 accidents reported each year. Medical estimates suggest that over 25% of these are drivers involved in road accidents. The government has several initiatives to reduce these numbers. The Supreme Council of Health (SCH), for example, is working with researchers at Weill Cornell Medical College in Qatar (WCMC-Q) to test the effect of speed cameras in Doha.

FINANCING: Health care spending has accelerated over the past decade. According to Qatar National Health Accounts (QNHA), the country spent QR12.1bn ($3.3bn) on health care in 2011, an increase of 27% from 2010 when sector investment totalled QR9.5bn ($2.6bn). Per capita expenditures have fluctuated in recent years, falling slightly from QR5746 ($1578) in 2009 to QR5682 ($1560) in 2010, but rising to QR7028 ($1920) in 2011. This reflects demographic shifts and population growth, and represents a significant increase on the QR1452 ($399) per capita spend seen in 2000.

Of the total QR9.5bn ($2.6bn) spent on health care in 2010, QR7.4bn ($2.03bn), or 77.5%, was funded by the public sector, and QR2.15bn ($590.4m), or 22.5%, by the private sector. The SCH managed about 77% of public funding, followed by Qatar Foundation at 14%. About 71% of private investment came from household out-of-pocket payments, and 28% from private health insurance firms. The breakdown was similar in 2011, with QR9.3bn ($2.6bn), 77%, of the total spent on health care funded by the public sector, and QR2.8bn ($768.9m), or 23%, by the private sector.

EXPENDITURES: The market’s structure is still skewed towards hospitals, the main recipients of the health care budget services. Hospitals accounted for 57%, or QR5.7bn ($1.6bn), of total health care expenditures in 2011, according to the QNHA. Ambulatory health care providers delivering outpatient services and private retail and medical supply companies accounted for 14% and 5%, respectively. However, government policy seeks to shift spending from hospitals, which provide quality health care but are expensive, towards more affordable ambulatory health care providers.

Services being purchased also show opportunity for private sector participation in ancillary services. While health care providers, including hospitals and day-care centres, account for the bulk of total spending, the market for ancillary services, such as clinical laboratories and diagnostic imaging centres, is substantial. The QNHA estimated QR1.8bn ($494.3m), or 19% of the total, was spent on these ancillary services in 2011.

PUBLIC FACILITIES: Qatar currently has 10 hospitals with over 2210 beds and 4500 physicians, according to the SCH. Almost 80% of hospital beds and physicians are employed by the public sector. HMC is the biggest health care provider with 79% of total hospital beds. HMC currently manages eight major hospitals. In 2007 the five HMC hospitals that were operational at the time – Rumaillah, Hamad General, Women’s, Al Amal and Al Khor – received accreditation from the Joint Commission International, a US-based organisation that oversees the accreditation of hospitals outside the US. All hospitals were reaccredited in 2009, and the Ambulance Service and Home Healthcare Services, accredited for the first time that year. HMC continues to schedule accreditation reviews for all new hospitals and facilities as they become operational.

Qatar’s oldest health care facility, HMC’s Rumaillah Hospital, was opened in 1957 in Doha. The facility has nearly 600 beds and specialises in rehabilitation for disabled adults, the elderly and special-needs children. More recently, additional units for plastic surgery, ear, nose and throat surgery, ophthalmology, day care surgery, strokes, dentistry, dermatology, communicable diseases and psychiatric services were added, enabling the hospital to meet a wider range of health care needs.

HMC’s largest centre is Hamad General Hospital (HGH), opened in 1982. It has 590 beds and provides a full range of inpatient and outpatient secondary and tertiary services in surgery, emergency medicine, internal medicine, paediatrics, anaesthesiology, radiology and laboratory medicine and pathology. The hospital also provides the country’s only emergency health care services 24-hours a day, seven days a week, which were boosted with an improved ambulance programme in 1999 and expansions of outpatient and laboratory services. Additionally, HGH provides emergency care from nine walk-in clinics located throughout the country, as well as a discrete paediatric emergency service in Doha and four other smaller centres across the country. Ambulatory dialysis services are provided from the Fahad bin Jassim Kidney Centre, which opened in 2010 adjacent to HGH, as well as from four satellite dialysis units within the country.

The hospital is undergoing a major renovation and expansion programme. Changes include a complete refurbishment of the emergency department and a new 20-theatre operating suite to be built in 2013.

Targeting gaps in services for women, HMC opened the 300-bed Women’s Hospital in 1988. Through this hospital, HMC provides gynaecology, obstetrics, neonatal care, newborn screening and emergency care. The hospital includes an assisted conception unit and an infertility treatment programme that pioneered techniques in the treatment of uterine diseases.

SPECIALIST SERVICES: The National Centre for Cancer Care Research (NCCCR), previously known as Al Amal hospital, is relatively smaller with 75 beds. The centre provides services such as radiation oncology, PET CT, palliative care and nuclear medicine. It also offers early detection, treatment, consultation, rehabilitation, education and awareness services for patients and their families. NCCCR has the capacity to treat over 4000 patients each year. The new Heart Hospital began receiving patients in 2011 with a total capacity of 115 beds. The hospital is in the process of increasing activity and developing new services.

REGIONAL CARE: In line with the National Health Strategy objective to deliver care closer to communities, HMC has established three regional hospitals: Al Wakra, Al Khor and the Cuban Hospital in Dukhan. Al Wakra serves the southern area of Qatar from the Doha airport down to the Saudi Arabian border and has a bed capacity of 230. Al Wakra first received outpatients in May 2011, and in October of that year paediatric emergency cases and any resulting inpatient services were added. Services now include a neonatal intensive care unit and medical inpatients. The hospital will expand in the last quarter of 2012 to encompass a range of secondary care services. These will include medical, surgical, paediatrics and women’s services, as well as critical care beds. The hospital has leading technologies such as an automated laboratory and MRI scanners. Investment in the hospital is in excess of QR1.5bn ($411.9m), including building and equipment costs.

The QR85m ($23.34m), 115-bed Al Khor hospital was inaugurated in March 2005, providing health and diagnostic services for the north of Qatar. The hospital has dedicated intensive care units, including a paediatric emergency unit, and state-of-the-art wards for surgical, obstetrics and gynaecology, medical, orthopaedics and paediatric patients.

The Cuban Hospital in Dukhan has a capacity of 85 beds and is a community general hospital with a wide range of specialist clinics, including a rehabilitation and specialist dental centre. The hospital services the communities and oil fields of western Qatar. The facility opened for outpatients in March 2011 and began treating inpatients in January 2012. The facility is a partnership between the state of Qatar and the Republic of Cuba. A modern hospital built by the state of Qatar, Cuba’s Servicios Medicos Cubanos provides the health professional staff, and HMC provides the administration and support services. The hospital is also a major local employer in the less populated western region.

PRIVATE FACILITIES: The government is actively encouraging private sector participation in the health sector. Like most sectors in the country, hospitals must be owned by Qatari citizens and can benefit from state support in the form of subsidised land and utilities in the first two years of operation.

The private sector system of clinics has a total of 394 beds and employs approximately 1000 physicians and 1000 nurses. This number has grown steadily since 1999, when the entire sector was still publicly managed. The American Hospital Doha, which was opened in 1999, was one of the first private hospitals in Qatar and continues to provide health care services. The Doha Clinic Hospital is another private institution, which was opened in 1994 as a polyclinic, but has since become the first fully integrated private hospital in Qatar. The 80-bed, multi-specialty medical centre offers a wide range of services through a variety of units that include dentistry, dermatology, radiology and intensive care.

Among the bigger private facilities is Al Ahli Hospital, a general hospital. The 250-bed facility opened with limited services in 2004 and is now fully operational. Finally, Al Emadi Hospital provides a holistic service by including health care education for its patients to promote knowledge among the wider community. Its range of specialty care includes treatment of obesity, general surgery, plastic and reconstructive surgeries, dermatology, dental services and emergency services.

PHARMACEUTICALS & MEDICAL SUPPLIES: The private sector is also playing an important role in supporting industries, such as by supplying equipment and importing drugs. As limited demand did not allow for multiple suppliers, the traditional business model in Qatar has created informal monopolies in each sector. In the health sector, this has led to high prices for drugs and medical equipment. Addressing this, the government amended import laws in 2011 to allow greater competition. Private hospitals in particular have benefitted from this move, with some choosing to import certain supplies directly from manufacturers abroad.

EXPANDING FACILITIES: Commissioning of the Hamad Medical City campus is under way and scheduled for completion in 2014. It consists of a women’s hospital with 190 private rooms, a centre for minimally invasive surgery, a rehabilitation hospital and a translational research institute. These facilities will introduce new services and significantly increase the capacity of HMC to meet Qatar’s growing health care demand.

The private sector is also actively expanding its footprint. Anticipating growth, Al Ahli Hospital is planning to grow significantly by adding 100-150 beds to its existing 250-bed capacity. The hospital is considering an innovative collaboration model with community doctors, clinics and polyclinics whereby these entities will be able to lease space within Al Ahli’s facilities.

In a move the further expands Qatar’s cancer treatment capacity, China-based Fuda Cancer Hospital is planning to establish a Qatar branch to bring treatment closer to its Middle Eastern clientele. The hospital has treated almost 200 patients from the region and is looking to possibly collaborate with HMC’s NCCCR, currently the only cancer hospital in Doha.

As well as expanding the range of services on offer, the development in frontline care centres is also expected to benefit support services such as suppliers. “We are very optimistic about growth prospects for medical equipment as the health sector goes through this reform process, and with new facilities opening, we will see continued growth in demand,” Zuhdi Al Jaouni, the general manager of Ali Bin Ali Medical Devices, part of the Ali Bin Ali Group, which imports and distributes medical equipment, told OBG.

SECTOR REFORM: The government has embarked on an ambitious health care reform programme over the last decade. In 2005 the SCH was established to drive the vision, design effective policies, regulate the sector and implement the reform process. The SCH also provides oversight of primary care clinics, hospitals, pharmacies, laboratories and any other public or private sector health service providers, including HMC.

In 2011 Sheikha Moza bint Nasser, vice-president of the SCH, launched the National Health Strategy 2011-16 that feeds into the Qatar National Development Strategy 2011-16, which in turn is guided by the QNV 2030. The strategy identifies seven key goals to be achieved by implementing 35 programmes. The headline objectives are a comprehensive health care system with services are accessible to the entire Qatari population; an integrated medical system offering high-quality services; preventive health care, taking into account the differing needs of men, women and children; a skilled national workforce that is capable of providing high-quality health care services; a national health policy that establishes and monitors standards; effective and affordable services in accordance with the principle of partnership in bearing the costs of health care; and high-calibre research to improve the effectiveness and overall quality of care.

REFORMING FINANCE: The National Health Strategy stipulates that, “the nation must shift from lump sum budgets to performance- or activity-based budgeting, with mandatory requirements put in place for reporting cost data.” The 2009-10 QNHA report proved to be a major step towards this goal, providing an unprecedented level of data on the sector’s funding sources and avenues of expenditure.

Another major reform that may transform the sector is the introduction of health insurance. Currently, visitors purchase an annual Qatar Medical Card for QR100 ($27.46), which gives access to basic medical treatment at the Hamad General Hospital.

In March 2012 the SCH approved a draft law on a Social Health Insurance (SHI) scheme, which at time of print was under review by the Council of Ministers. The scheme, which includes public and private insurance options, will be rolled out in phases. Under phase one, SHI will cover about 75,000 Qatari women, providing free obstetrics and gynaecological care. Next, primary medical services will be covered for all nationals by July 2013, and will include all services from public providers in the country by October 2013, before eventually being extended to most private providers as well. By the end of 2014, all Qatari residents will be included in the SHI, with the majority enjoying a basic benefits package.

The government is expected to cover insurance premiums for Qatari citizens and other eligible expatriates. However, businesses sponsoring foreign workers will be required to provide coverage for their staff going forward. To ensure compliance, residence permits and visas will only be issued with a proof of SHI subscription. Upon implementation, SHI is expected to help drive greater efficiency within Qatar’s health care systems and expand the variety of options available to citizens and expatriates alike (see Insurance chapter).

PRIVATE HEALTH INSURANCE: If signed into law, the SHI scheme is expected to boost the country’s already expanding private health insurance market. The segment has grown rapidly as demand for private sector health services increases. It is estimated that there are 200,000 people currently covered by private health insurance – a 100% increase since 2009. The total volume of premiums is currently estimated to be QR400m ($109.8m), according to official statistics. Many businesses are already offering health insurance as part of employee’s benefits package in preparation for new legislation. However, the government does expect some resistance from local companies, many of which employ a significant portion of expatriate workers.

MONITORING & EVALUATION: Underlying the National Health Strategy is a core focus on monitoring and evaluation to provide an evidence base for ongoing health programmes and future reforms. The QNHA, for example, measures the system’s financial dimensions, providing data and breakdowns on how much money goes into the system, who is financing it, who is managing it and where it is spent. This data will enable policymakers to better target resources and will also provide much needed data for private sector participation. The initial report was released in 2011 and is the first of its kind in the GCC countries.

The SCH is also focused on using an integrated health care data system to monitor services provision by public and private participants with two programmes targeting this goal. The first is the establishment of a health care data programme that sets out specific requirements for data collection and mandates data reporting. This initiative will include establishing registries for priority diseases. The second is a national integrated e-health system that would connect and share information across all levels of the health care system. It would, for example, ensure images taken at hospitals are digitally stored and accessible by physicians.

LICENSING: While the SCH is actively pursuing policies and programmes to support increased private sector participation, it is also developing systems and processes to ensure the quality and equity of services provided. Under this mandate, the SCH has established the Qatar Council for Health Practitioners (QCHP), replacing the existing Medical Licensing Department. The QCHP brings all medical licensing under one department, helping to standardise monitoring and evaluation functions across public and private providers. Though at present HMC will continue to use its existing licensing system for its own doctors and other practitioners, QCHP will eventually take on that role as well.

In parallel, the SCH is investing in technology to streamline the licensing process. It currently takes over 45 days to obtain an operating licence. These processes will be reviewed to make them more flexible for private health care providers. Proposals are being reviewed, including extending licence validity to two years.

DEVELOPING HUMAN CAPACITY: One challenge stemming from the rapid expansion of hospitals and health care providers is a shortage of skilled professionals. The state is working to address these gaps through several initiatives, including attracting foreign expertise in the short term and developing local talent in the longer term. The University of Calgary – Qatar (UCQ), for example, is central to the government’s strategy, and works closely with HMC to develop a national education programme to build up local capacity. “While the shortage of nurses is a global problem, Qatar currently faces a significant hurdle,” Carolyn Byrne, the dean and CEO of UCQ, told OBG. “It is in need of at least 5000 nurses.”

Public hospitals, led by HMC, bridge the gap between education and practical training via several educational programmes. The Hamad International Training Centre (HITC) provides physicians and nurses with training opportunities to improve and develop skills so as to maintain a highly trained workforce. HMC also collaborates with medical schools in the region to provide residencies and other education opportunities for medical students. Additionally, HMC sponsors its doctors to enrol in training programmes abroad.

LINKS WITH EDUCATION: Qatar Foundation’s Education City has invested in bringing global centres of excellence in the medical field directly to Qatar. The WCMC-Q and the Carnegie Mellon University (CMU) are helping shift the longer-term development trajectory of the country’s medical sector by training doctors and scientists locally. WCMC-Q and CMU recently collaborated to initiate joint-programmes in computational biology and biological sciences, expanding the options for medical research and education.

Qatar Foundation’s $7.9bn Sidra Medical and Research Centre is scheduled for completion by December 2012, and will be both a teaching hospital affiliated with WCMC-Q and a medical research centre. Sidra will also host a state-of-the-art clinical simulation centre expected to be one of the most advanced in the region. The Qatar Science and Technology Park (QSTP) also serves to bring industry and academics together in an innovative environment at Education City, with the eventual goal of commercialising research. The initiative is already producing results, such as platform that enables remote monitoring of bodily functions. “The current focus in the research field is about ensuring that a common plan is identified and implemented,” Hatem El Shanti, the managing director of Shafallah Medical Genetics Centre, a comprehensive service and research centre, told OBG. “To become a research hub, Qatar needs to develop a research culture that fosters collaboration and sound coordination between all the entities involved, as well as full transparency.”

NICHE SEGMENTS: Qatar is also home to a sports medical centre, Aspetar Sports Medicine and Orthopaedic Hospital, which offers both athlete care and research on sports medicine. Part of the Aspire Zone Foundation, a global sports venue that operates a sport high school and a sport logistics business unit, the organisation has helped build Qatar’s reputation for sports excellence. Aspetar was accredited by F-MARC as a FIFA Medical Centre of Excellence, and the facility has treated a number of international athletes.

OUTLOOK: The health sector plays a critical role in Qatar’s longer-term development strategy. In addition to providing essential services to residents, investments in health care are expected to help diversify the economy away from oil and gas. The government is actively supporting private sector participation in the sector, opening several avenues for investment and growth. While the public sector has played, and will continue to play, a leading role in the foreseeable future, private enterprise is also starting to show an interest in investing. Recent reforms, particularly in developing a national medical insurance programme, should help boost the role of the private sector further. Building and maintaining a cadre of well-qualified medical professionals will take time, but the country’s long-term investments in the education sector should help bridge these gaps.