Maintaining high-quality universal care while expanding the role of the private sector

Long a priority of Brunei Darussalam’s government, the domestic health care system continues to rank among the best in the region even as it shifts its priorities in response to a change in the health issues facing the local population. Having already tackled the problem of communicable diseases while instituting nationwide universal health services, which have drastically reduced mortality rates and increased life expectancy, the Sultanate is now shifting its efforts towards combating non-communicable diseases such as diabetes, heart disease and cancer.

Universal Care

With a population of just over 400,000 and a relatively high GDP per capita of BN$49,600 ($38,900) in 2013, Brunei Darussalam has so far been able to spend a relatively high amount per person on health care without breaking the bank. The total allocation for health in the 2014/15 budget was up 1.8% to BN$373.21m ($292.7m), although this was down from the 5.3% rise to BN$366.48m ($287.43m) in 2013/14.

Brunei Darussalam’s Ministry of Health (MoH), which is tasked with providing free health care services for every Bruneian, acts as the primary conduit for the distribution of the funds from the Ministry of Finance (MoF). While the exact allocations and priorities for spending vary from year to year, the MoH acts primarily in accordance with five core policy pillars: promoting primary health care; focusing on the management of high-priority chronic diseases; pursuing a high quality of health care; achieving more equitable allocation of funds for diverse health services and venturing into alternative sources of health care financing; and promoting selected areas of excellence in health services.

These strategic priorities reflect the changing demands on the health care system not only in Brunei Darussalam but globally as well. Two trends are particularly pronounced in the Sultanate: an ageing population and unhealthy lifestyles, which are affecting the scope of demand as well as contributing to the growing costs of health care. Even as infant and maternal mortality and crude death rates have declined, and diseases such as malaria and polio have been eradicated, new threats have emerged (see analysis). As a result of both longer life spans and the growing cost of sophisticated diagnostic and treatment regimes for these ailments, health care costs continue to mount, with budgets increasing every year. Per capita spending on health care has risen significantly over the past two decades, from less than $500 per head in 1995 to about $900 per person by 2012, according to data from the World Health Organisation (WHO).

Laying The Ground Work

To carry out these directives, the government and the MoH have extended a growing network of hospitals and health centres across the country. As of 2013, six hospitals with a combined total of 1143 beds were in operation, two of which are privately run, according to data from the Department of Economic Planning and Development (JPKE). These are further supplemented by eight medical centres, which treat more specialised ailments. Last but not least, basic health services are extended to rural areas through a network of 17 health centres and 22 health clinics, as well as travelling clinics and flying medical services to access the most remote villages.

In addition to the existing facilities, the government is providing new infrastructure to keep pace with rising health care demand. The largest local hospital, Raja Isteri Pengiran Anak Saleha (RIPAS), is due to open a new maternal and paediatric wing in October 2014. The new 12-floor block will provide 353 beds and house services for maternity, neonatal, obstetrics and paediatric wards, obstetrics (maternity) and gynaecology. The project exceeded its initial BN$60m ($47m) budget because of alterations to the plan and will now include oscillation rooms, a pharmacy, negative pressure rooms, an operating room, labour room and special units such as a paediatric intensive care unit, surgical intensive care and a medical care unit.

Rural areas are also benefitting from increased outreach of the medical network, most recently with the construction of a new $14m health centre located in Kg Lambak Kanan to serve patients from Mukim Berakus, which includes the enclaves of Kg Sg Hanching, Kg Salambigar, Kg Sg Tilong, Kg Manggis and Lambak Kanan National Housing Scheme, and Mukim Berakas B. Built as a replacement for the ageing Berakas “B” Health Centre in Kg Sg Hanching, the new facility broke ground in May 2014 and is expected to be completed within 15 months. It will offer a range of general services, including public, chronic disease and flu clinics; pharmaceutical, dental and, mother and child health services; as well as additional support infrastructure, such as a prayer hall, lecture hall and conference room.

High Marks

Brunei Darussalam has made great strides in achieving its own goals in terms of providing quality health services for its citizens. Indeed, the Sultanate has managed to elevate its health care standards to among the best in the region and well above the average for developing economies.

On the three health-related goals outlined by the UN Development Programme (UNDP) in its Millennium Development Goals (MDG), the Sultanate has shown substantial progress across the board. For the fourth MDG – to reduce by two-thirds the under-five mortality rate between 1990 and 2015 – Brunei Darussalam has managed to reduce the infant mortality rate from 42.3 per 1000 live births in 1966 to 9.3 per 1000 live births in 2012, according to the MoH. For children under the age of five, the mortality rate also declined from 22.7 per 1000 live births in 1980 to 10.3 per 1000 live births in 2012, although the WHO puts the 2012 figure even lower at eight deaths per 1000 live births. Measles immunisation rates were good too, with 99% of one-year-olds vaccinated in 2012, according to the WHO, compared with a 97% regional average.

Brunei Darussalam also fared well in maternal health – the fifth MDG target is to reduce by three-quarters the maternal mortality rate between 1990 and 2015 – posting a maternal mortality rate of 27 per 100,000 births in 2013 compared to regional and global averages of 45 and 210, respectively. In addition, 100% of births were attended by skilled health personnel compared to a regional average of 93%.

The final health-oriented MDG, number six, is to combat HIV/AIDS, malaria and other diseases. Brunei Darussalam was declared malaria free by the WHO in 1987 and continues prevention efforts through the Malaria Vigilance and Vector Control Unit within the MoH. The Sultanate was also declared polio free in 2000, while the prevalence of HIV/AIDS remains at a very low level despite an increase in the number of cases since 2006. Brunei Darussalam was included in the “Very High Human Development” category of the health segment of the UNDP 2013 Human Development Index, ranking 30th out of 186 countries. As a result of these improvements, life expectancy has increased dramatically over the past generation. From an average of 62 years in 1971, life expectancy has risen by more than a decade and a half to 78 years as of 2012, according to the WHO. This is two years higher than the regional average of 76 years and is significantly greater than the global average of 70 years.

Private Practice

Complementing the universal government coverage are two private hospitals, the Jerudong Park Medical Centre (JPMC) and the Gleneagles JPMC Cardiac Centre. Although independently operated and autonomous from the MoH, the JPMC and related centres of excellence do receive funding through the MoF, which pays the tab for Bruneian citizens treated there provided they could not be treated in public facilities. The JPMC primarily serves two categories of patients: referrals from public hospitals that may not have the technical equipment or expertise to treat a particular patient, and those with private insurance or those insured by large companies, such as Brunei Shell Petroleum and Royal Brunei Airlines.

The government is also addressing its two most serious and common health problems, cancer and cardiac disease, via the JPMC through the creation of two medical centres of excellence (see analysis). The Brunei Cancer Centre is in the midst of a major upgrade initiative, with a new 13-story building being constructed on the medical campus that will offer comprehensive services, including medical oncology, radiation therapy, chemotherapy, and facilities to treat and rehabilitate stroke victims, some of which are currently unavailable in the country. The initial phase of the project is set to finish by the end of 2014, with all work slated for completion in 2015.

The Neuroscience Stroke and Rehabilitation Centre has also been housed in the JPMC since its inception in 2010. A partnership between the JPMC and the Department of Neurology and Neuroradiology of Krankenhaus Nordwest of Frankfurt, Germany, the unit includes a specialised stroke unit, a neurological intensive care unit, regular and rehab wards, and all laboratories necessary for neurology services, which are staffed by German-trained personnel.

Through these partnerships, the Bruneian government has been able to address many of the country’s most significant health challenges by developing specialised health care options locally, thus providing an alternative to the more costly practice of sending patients overseas for treatment.

Healing Touch

Complementing the expansion of infrastructure, a second area of priority for the MoH is medical training. Local training programmes are being carried out at the Pengiran Anak Puteri Rashidah Saadatul Bolkiah Institute of Health Sciences at the Universiti Brunei Darussalam. Launched in 2000, the institute now offers undergraduate programmes in four main disciplines – medicine, biomedical sciences, nursing and midwifery – along with the possibility of completing post-graduate degrees at international universities. Between 20 and 25 doctors a year are enrolled in three-year programmes domestically, which are then followed up with further stints in partner schools abroad in countries including Australia, New Zealand, Canada and the UK. Afterwards graduates are required to return to Brunei Darussalam to practise for at least 10 years.

Due in part to ongoing education and recruitment efforts, the Sultanate has also been successful in recent years in expanding its pool of medical personnel despite of tough regional competition. As a result, the population per doctor has decreased from 647 in 2011 to 619 in 2013 as the number of physicians working in Bruneian medical facilities has risen from 608 in 2011 to 656 in 2013, according to figures from the JPKE. Over the same period the number of dentists has also increased by 10 to 105, while the number of pharmacists went from 48 to 62. The number of nurses working in Brunei Darussalam has remained relatively stable in recent years, at 2628 in 2011, 2585 in 2012 and 2596 in 2013.

Outlook

Having already implemented an effective universal system capable of providing basic quality health care to the furthest reaches of the country, Brunei Darussalam is now turning its attention to address health issues more common in developed nations, including cancer, diabetes, heart disease and other so-called lifestyle aliments. In order to reduce mounting hospital fees from sending seriously ill citizens abroad for treatment (not to mention travel expenses for them and their families, as well as increased medical risks), the government has created a successful blueprint to develop its own domestic medical centres to treat these ailments at home through public-private partnerships.

This model looks set to continue to pay dividends, as more technology and expertise is added to the JPMC in the coming years, allowing an even wider range of health care services to be offered locally. One possible next step for expansion could be to fold the existing cardiology units under the RIPAS hospital into the Gleneagles JPMC Cardiac Centre (whose contract runs only until 2017), thus creating a new public-private partnership similar to the existing cancer and stroke/neurology centres of excellence.

In the longer term the expansion of the private sector could help to shape the future evolution of the health industry. Although Brunei Darussalam has so far been enable to provide high-quality care to all Bruneians, the existing system is unlikely to be sustainable in the long term due to rapid increases in health care costs and the finite nature of the country’s resources. As a result, the government may need to take measures to boost efficiency within the health care system, further engage with the private sector through the privatisation of some services such as pharmaceutical operations, as well as introduce a type of co-pay system or greater incentives for citizens to opt into private health care plans.