Sector shake-up: Restructuring of the system gets under way

The Kuwaiti welfare state’s two sacrosanct pillars are health care and education. Since 1962, the state has been obliged by law to provide health care to all citizens under article 15 of the constitution. Free health care remains much prized by Kuwaitis and is now widely regarded as a civic privilege to be closely guarded.

INDICATORS: The country’s basic health indicators are high by international standards. Life expectancy at birth for males and females in 2009 stood at 77 years, one of the most favourable among Gulf states and in the wider region. The figure was higher than Saudi Arabia (72), Qatar (76), Lebanon (72), Jordan (72) and on par with the UAE. Kuwait’s global ranking puts it only two places behind Finland and the UK (both at 80), according to the World Health Organisation (WHO).

Immunisation coverage among infants is also high, with 99% of one-year-olds immunised against measles, diphtheria, bacterial meningitis and Hepatitis B. Much of Kuwait’s success in global health tables is due to a firm commitment to government health spending.

RISING COSTS: Between 2000 and 2009 the state spent approximately 2.6-3.3% of its GDP on health care provision. For 2001-02 this figure rose as high as 3.7%, before settling at 3.3% by 2009. Government spending accounted for 83.9% of the country’s total health expenditure in 2009, with the remaining 16.1% being contributed by the private sector, according to WHO.

But as in other developed countries, the cost of providing care to all citizens is straining state finances. The current and future challenge is to provide a high level of care to a growing population, and the state is considering a number of options to restructure the current system so that it can survive. “Attention to health promotion, and a focus on the improvement of primary health care as a first point of entrance to the system is the most effective priority in the country,” Waleed Al Falah, the assistant undersecretary for planning and quality at the Ministry of Health (MoH), told OBG.

Rising costs are the main driver behind the need for reform. Per capita operating expenditure (the funding required just to maintain the present system) has risen by an average annual growth rate of 12.6% between 2002 and 2009. According to statistics supplied by The Advisory Group, a consulting firm currently engaged in several health care projects in Kuwait, average annual expenditure on health care is forecast to rise from KD1bn ($3.6bn) in 2009 to KD8bn ($28.8bn) by 2025.

EXPATRIATES: Given the state’s responsibility to provide health care, Kuwait is becoming a victim of its own economic success. Nominal GDP growth is set to rise to KD51.4bn ($185.3bn) by 2012, with a real GDP growth rate of 5.6%, according to the IMF’s Article IV Consultation with Kuwait in July 2011. This growth is attracting large numbers of expatriate workers to Kuwait’s construction, financial, retail and service sectors. Providing health plans to Kuwaitis as well as these workers while maintaining the annual rate of spending is making reform of the current system essential.

At present all expatriates in Kuwait must purchase the MoH’s health assurance plans via international expatriate insurance brokers to be able to obtain residency permits. The public health coverage provided by the government helps subsidise their medical costs and, in some instances, provides free medical services in cases of emergency. Employers are also encouraged to offer their employees private medical insurance.

A NEW SYSTEM: Despite rising costs, the government has ruled out a full privatisation of the sector. In May 2010 parliament agreed to exclude the health, oil and education sectors from a new privatisation bill.

However, for 2011/12 the MoH is looking to vastly increase the role of the private sector in the management and administration of health care facilities across the country. “The ministry encourages the participation of the private health sector as a partner and not a competitor, urging it to expand its services and to implement high quality standards,” Al Falah told OBG.

The government will launch a new private health care provider by 2015 – the Kuwait Health Assurance Company (KHAC), which will have a mandate to manage the health care needs of all expatriates in Kuwait. By 2015 the estimated expatriate population eligible for KHAC health plans is forecast to be 1.73m, a figure that is expected to rise to 2.23m by 2024. Kuwaitis will also be able to use the KHAC on a fee-for-service basis.

KHAC: KHAC will sell health assurance plans and either provide or manage the provision of services covered in the plans. If successful, the new project will be the largest private health care system in the GCC, and will meet all the health care, insurance and assurance needs of the country’s expatriate population. The MoH and the Kuwait Investment Authority (KIA) are leading the project while the Kuwait-based International Counsel Bureau and The Advisory Group are advising.

“I think it will have a huge impact on health care in the country,” Mohammad Saad Al Munaifi, the chairman of the soon-to-be-formed KHAC, told OBG. “The objective is to raise the level of services even further with the result that the private sector will have a much larger share of the health market. Currently it has around 10% but we would like to see this market share increase to 40-50% over the next 20 years.”

The government is offering 26% of KHAC to private health care consortiums. The state will retain a 24% share via the KIA and offer the remaining 50% stake to Kuwaiti nationals in a public offering. “This new company will be a test case because it will be the first of its kind – a privatised health care company,” Al Munaifi said.

INFRASTRUCTURE INVESTMENT: KHAC will provide its own primary and secondary care using a network of 15 primary care centres and three general hospitals. The company will oversee the construction of these facilities as part of its remit. The hospitals will be built in Jahra in the north, Farwaniya in the centre and Ahmadi in the south. These areas represent the three health regions around which the KHAC’s provision will be managed. The new facilities will add 1292 hospital beds to the existing stock. According to 2009 data, public, government-run hospitals currently have 6072 beds while private hospitals have a total of 772.

For a population of 2.8m people, Kuwait has a comparably good level of health coverage. According to WHO, Kuwait has 18 hospital beds per 10,000 people, compared to 22 beds in Saudi Arabia and 139 in Japan. In terms of staff, the country has a ratio of 18 doctors per 10,000 people and 37 nurses per 10,000 people, compared to 16 and 36, respectively, in Saudi Arabia.

Under the KD30bn ($108.2bn) five-year National Development Plan, launched in February 2010, health care was identified as a key target area for investment. The government allocated KD1.1bn ($4bn) to expand and upgrade nine existing hospitals across the country, adding some 4369 beds to the facilities in one of the largest health care planning projects in the GCC region. Work is due to be completed by 2014.

“We started work on the health planning package for the hospitals in January 2011,” Ahmad Nsouli, a partner at the Advisory Group, told OBG. “The aim is not to put Kuwait on the health care map, but to bring existing institutions up to higher international standards.”

The firm is working with project manager Hill International to ensure that each new department and ward added is fully integrated into its hospital. They will look at the functional space within each hospital, the electromechanical needs and specifications for medical equipment, as well as ensure procedures are put in place for improved administration and management.

CHRONIC DISEASES: Significant investment in medical infrastructure over the next five years will be needed for the state to cope with a rising population (which reached an annual growth rate of 2.4% in 2008) as well as an increase in chronic diseases.

Diabetes, obesity and cancer are the main diseases affecting Kuwaitis. Obesity levels have reached 80.4% for women and 69.5% for men, according to the Kuwait National Development Society. Meanwhile, diabetes is a particular concern, as Kuwait is one of the top five nations in terms of prevalence rates. According to WHO, diabetes has now reached an “epidemic level” in the country, with up to 26% of the population affected.

DIABETES INSTITUTE: The government has responded to this by launching the Dasman Diabetes Institute in Kuwait City, a state-of-the-art research, treatment and training facility for diabetes in the Middle East region. It houses the latest standard medical equipment, a genome and cell therapy centre, clinics and labs as well as a fitness centre and healthy cooking area.

The director general of the institute, Dr Kazem Behbehani, is clear on the dangers facing the country. “Type 2 diabetes levels are very high in Kuwait and must be addressed through a mixture of treatment and lifestyle awareness,” he told OBG. The patients with diabetes are getting younger, with some as young as 10 years old requiring treatment. This is alarming because type 1 diabetes is genetic whereas type 2 (adult-onset) results from a combination of lifestyle factors that include nutrition, obesity and a lack of exercise.

The institute runs lifestyle courses for both children and their parents. First they are tested for diabetes and then meet with a nutritionist. Once assessed, they participate in an educational programme and a cooking class, and are then encouraged to exercise in the Fitness Centre. Parents and children can have a check-up once a year. Dasman also provides a general health assessment, including screenings for other diseases.

Over the long term, Dasman is trying to create a more holistic approach to diabetes and related diseases, involving prevention and management. Changing the public’s behaviour patterns is Dasman’s main challenge, and it is now looking at public awareness campaigns to inform people of the dangers of unhealthy lifestyles.

E-HEALTH: The institute is currently working with the MoH to put these campaigns together. A new initiative called Mobile Health (mHealth) is also being developed with telecoms operator Zain to send SMS messages on the subject to its subscribers.

“Health promotion has benefitted greatly from the technical advances in the field of computing and telecommunications, with the internet, mobile phones and satellite channels providing the means to reach a wide audience in the country,” Al Falah told OBG.

The institute is also working closely with the MoH on the development of an interoperable e-health record. This is information technology software that will link all patient medical data to primary health care clinics and general hospitals so that patients’ personal electronic file are available to any doctor that may be treating them. This will enable medical staff to have a greater understanding of the patient’s state of health, any medication they are taking and what treatment might be required. The system will also be used for research purposes to better inform health care strategies.

Perhaps the most important technological innovation is the planned geographical information system (GIS). GIS is an emerging technology in the analysis of health from a geographical or location context based on health indicators. GIS is a potentially powerful assessment tool for the investigation of health care access, health outcomes and the possible resulting health disparities. The ability to integrate health data with mapping functions allows for the visualisation, exploration and modelling of health patterns.

OUTLOOK: With the increasing costs of providing health care to a growing population, which now includes a burgeoning number of expatriates, the government is looking for ways to reduce the burden on the treasury while maintaining a high level of care. Further involvement from the private sector in the provision of health insurance and services for expatriates is a key step in the government’s plans. KHAC will be a test case, and its development will be closely watched. If it is successful among the expatriate community, it is likely that the government will look at widening the programme as an option to Kuwaiti citizens as well.

The rise in chronic diseases among Kuwaitis is another challenge the government looking to confront head-on. Specialised institutes, prevention campaigns and the use of new technologies and e-health services are all strategies through which the country is working towards improving its health indicators in terms of lifestyle-related diseases. With the work that will be needed to ensure healthy outcomes for future generations of Kuwaitis, combined with the government’s agenda to involve the private sector in provision and management of services, opportunities for private investors look set to increase, creating a healthy business environment.