Slow and steady: Health care continues to be a priority for the government

Over the past century health care in the kingdom has advanced substantially: infrastructure has expanded and communicable diseases have been brought under control. Today, Bahrain offers both citizens and residents a wide range of care provided by the government and the private sector. A number of health-related statistics published by the World Bank indicate that Bahrain’s medical sector provides high-quality medical care. For example, life expectancy for the average Bahraini was 75 years in 2010, compared with an average of just over 70 years for the rest of the Arab world. Similarly, the World Bank has noted that the infant mortality rate was less than nine deaths per 1000 live births in 2011, while the average in the Arab world was 35 deaths per 1000 live births during the same year.

In addition, while total health care expenditure in Bahrain as a percentage of GDP dipped to 3.5% in 2006, this figure has risen to 5% of GDP, according to the most recent World Bank data. The Bahrain Economic Development Board (EDB), the kingdom’s investment agency, reported that the 2012-13 federal budget sets spending on health care at nearly 9% of total GDP, a record for the country and a tremendous increase when compared to spending levels recorded in previous years.

PUBLIC CARE: All Bahraini citizens receive free access to health care, and for a small fee, expatriates are able to access a government health centre and receive medicine at no charge for three months, according to the Ministry of Health (MoH). Some employers in Bahrain also offer private medical insurance for their employees, and there are plans under way to ensure that expatriates working at firms with more than 50 employees receive primary health coverage under a compulsory insurance programme, according to the EDB.

The state has always played a key role in Bahrain’s health industry, and the MoH recently reported that the public sector owns and operates around 70% of health-related infrastructure in the country. The remaining 30% is owned and operated by the private sector. Public care was first made available in Bahrain in 1929 when the government opened a small clinic to provide care for pearl divers. That same year the government organised the Public Health Directorate for Preventive Care, and in 1957 the first government hospital opened. Publicly provided health care is now the remit of the MoH. In addition to the provision of medical services, the ministry is responsible for carrying out health-related policymaking and planning.

STRENGTHENING THE SECTOR: In 2010 the MoH designed a strategy for health improvement in the kingdom for the 2011-14 period. The document focuses on a number of key objectives, such as integrating medical services, increasing general health through preventive measures and ensuring that the population has access to quality medical care. The MoH set a goal to ensure that there is one health centre for every 20,000 people. The ministry reported in early 2013 that the current ratio of residents to health centres varies between 1:10,000 and 1:50,000.

According to MoH, government primary care is provided via 24 health care centres, two general clinics and one psychiatric clinic. Patients can receive secondary and tertiary care though the Salmaniya Medical Complex (SMC) – the government’s major hospital – as well as through four maternity hospitals, a geriatric hospital and a psychiatric hospital. Built in the 1970s, the SMC is located in Manama and contains 1068 beds. The hospital offers a range of services, such as general surgery, paediatrics, dentistry, obstetrics and gynaecology (OB/GYN), nephrology, cardiology and emergency care. The general medical and surgery departments were the largest units at the hospital in 2011, providing around 240 beds and 130 beds, respectively. Other large departments included the accident and injury unit and OB/GYN, both of which offered around 100 beds in 2011.

BY THE NUMBERS: The SMC admitted more than 36,000 patients in 2011, with the length of stay for each patient averaging five-and-a-half days. Approximately 25% of admissions – the largest share of admitted patients in 2011 – were related to OB/GYN care. General medical services accounted for the next largest share of admissions (18%) at the SMC during the same year, followed by surgery (15%) and paediatrics (11%), according to the MoH. While the total number of patient days reached nearly 212,000, the average length of stay was longest in the ICU and neurology department.

Bahrain’s public hospitals are not yet autonomous; however, an initiative to transfer autonomy to the SMC was launched in 2006. Studies have been carried out to determine the best method of establishing autonomy at the government hospital, and the MoH has reported that further evaluative work will take place.

Total MoH expenditures in 2011 reached almost BD212m ($557.86m), an increase of close to 8% when compared to the BD196m ($515.75m) spent by the ministry in 2010. Of the MoH’s recurrent expenditures in 2011, secondary care accounted for the largest share, at 58% of the total, followed by primary health care and public health (27%), and administrative and support services (11%), according to recent MoH data.

MILITARY CONTRIBUTION: In addition to the MoH, the government also offers health care through the Bahrain Defence Force (BDF) Royal Medical Services (RMS). Set up in the 1960s as a unit of the Ministry of Defence, the RMS initially provided primary care with an eight-bed capacity. RMS now offers health care through the BDF Hospital. Built in the early 1990s, the BDF Hospital provides medical care to members of the Bahraini military and their families. Emergency and cardiac care is also offered to the general public. The BDF Hospital contains over 340 beds and admitted nearly 20,000 patients in 2011. The largest portion of patients – around 30% of the total – was admitted for OB/GYN care, according to recent MoH data, with cardiac care making up the next largest share (14%) in 2011. Meanwhile, bed occupancy rates were highest in the cardiac surgery (89%), OB/GYN (88%) and paediatrics (84%) units, while the average length of stay in the BDF Hospital in 2011 was close to four days.

Military health services expanded with the opening of the Ibrahim Khalil Kanoo Centre, a geriatric care facility, in 2008. The King Hamad University Hospital (KHUH), officially inaugurated in early 2012, is affiliated with the BDF Hospital but offers its medical services to the general public. The 311-bed facility provides secondary care and employs over 1700 people, according to KHUH figures. A number of specialties are offered at the hospital, which include maxillofacial surgery, gynaecology, hyperbaric oxygen therapy, paediatrics, rehabilitation services, orthopaedics, general surgery and gastroenterology.

PRIVATE CARE: While privately funded medical services account for a smaller share of Bahrain’s health sector, private companies still play a key role, and the government has been encouraging further privatisation of the industry. Private sector growth has been particularly strong in recent years, as new hospitals, clinics and polyclinics have opened. Indeed, according to the MoH, the private health sector has experienced growth of 17% over the past 15 years. For much of its history, the private health sector consisted primarily of general and specialised clinics. This has begun to change, however, with the addition of more private centres offering secondary care. This trend will likely continue as health planners aim to make secondary care the overall specialty of the private sector.

The MoH recently reported there are 14 private hospitals and two private dental hospitals currently in operation in the kingdom. Additional private infrastructure includes nearly 180 medical clinics, 61 dental clinics, 14 24-hour medical clinics, nine centres focused on medical and dental care, over 60 optician retail outlets, around 100 pharmacies, 10 radiology units and 14 laboratories. In addition, a number of private companies offer their employees in-house medical care, and some of these provide services on a not-for-profit basis.

PRIVATELY OWNED HOSPITALS: A number of private hospitals are making a notable contribution to the sector. For example, the Bahrain Specialist Hospital (BSH), which is owned entirely by private investors, is currently the only hospital in the kingdom to have received accreditation from Joint Commission International (JCI), a leading, not-for-profit accrediting body. Inaugurated in early 2003, the BSH is well-known for its treatment of gastrointestinal diseases, comprehensive OB/GYN care including advanced minimally invasive surgery and infertility treatments, and numerous other medical and surgical specialities. The BSH admitted over 6100 patients in 2011, representing an increase of nearly 13% when compared to the 5400 admissions in 2009. According to the most recent figures from the MoH, the number of beds at the BSH rose from 56 in 2007 to 70 in 2011.

Another major private sector hospital is the Royal Bahrain Hospital (RBH). A recent addition to the kingdom’s health care sector, the RBH launched its services at the beginning of 2011. The hospital is owned by the India-based Kerala Institute of Medical Sciences Group and has increased Bahrain’s total bed capacity by 65, according to RBH data. Some of the services provided by the RBH include intensive care, advanced diagnostic procedures, joint replacement surgery, spinal surgery, neonatology, endocrinology, dermatology and cosmetic surgery. In its first year of operation, the RBH admitted over 1000 patients and registered 1674 total patient days. Outpatient visits at the facility reached roughly 30,500 by the end of 2011, with the largest portion of visits – nearly 24% of the total – focused on paediatric care, while dental care accounted for more than 16% of total visits, according to MoH figures. Patients seeking orthopaedic, plastic surgery and OB/GYN care made up the next largest groups of outpatient visits in 2011.

Another local facility involved in the private sector, the International Hospital of Bahrain has been providing health care in the kingdom for many years. The country’s first privately owned hospital, the IHB was established in the 1970s with only a handful of beds. However, the facility has grown significantly and now has more than 60 beds and employs over 175 staff, according to the MoH. The IHB maintains a successful visiting professors programme with Germany, and while currently accredited through an Australian system, the hospital is working on obtaining JCI accreditation. Total admissions at the IHB reached nearly 2300 in 2011, with the average patient staying in the facility for three days.

REGULATORY REFORM: Some of the most important developments for Bahrain’s health sector in recent years include two regulatory changes. In 2009 the responsibility of regulating the health care industry was transferred from the MoH to the newly established National Health Regulatory Authority (NHRA). Although the NHRA is represented by the MoH in Parliament, the authority is a financially and administratively independent organisation. The NHRA’s board was formed in early 2010, and its first CEO appointed in September 2011.

The authority exercises jurisdiction over both government and non-government hospitals, clinics, medical centres and pharmacies. Its other responsibilities include licensing of all medical and medical-related staff, monitoring compliance with medical practice standards, informing medical entities how to boost performance, setting prices for all pharmaceutical products, carrying out comprehensive inspections of all services and facilities, and handling patient complaints regarding public and private care. All experimental medical research must be approved by the NHRA for ethical and safety concerns before tests can be carried out. NHRA-developed hospital standards are based on international guidelines and were introduced in 2012.

The establishment of the NHRA is a positive step for Bahrain’s health sector. The new authority has made the regulatory process more efficient; the licensing process for doctors, nurses and technicians has been reduced from six to two months, according to NHRA data. Similarly, the time required to process patient complaints has also been reduced substantially from several years to less than two months. The quality of inspections has increased with the establishment of the NHRA, and the authority is taking important steps to modernise parts of the regulatory system.

Another key change for Bahrain’s health sector took place in January 2013 with the announcement of the Supreme Council for Health (SCH). With representatives from throughout the country, including public and private hospitals, universities and the NHRA, the SCH will primarily focus on developing a long-term national health strategy.

The council will also set medical training standards, develop a range of policies on insurance and medical staff recruitment, and work to improve the effectiveness of coordination in the medical sector.

STATE-OF-THE-ART CARE: The MoH is developing a programme that will create a common platform for all medical information. Known as the National Health Information System (I-Seha), the new programme aims to transfer medical information to an electronic platform, which will be accessible to health care professionals throughout the country. This will ultimately help medical staff to provide more efficient care.

Certain phases of the programme have already been implemented, and current efforts are focused on integrating areas of the new platform. Indra, a multinational technology firm based in Spain, signed a contract with the MoH in early 2011 to build, operate and own I-Seha. According to the MoH, the contract stipulates that ownership of the programme will be transferred to the government after a period of 11 years.

Further ICT advancements in the health care industry have been made by the NHRA. “The authority has an advanced ICT system that can access any facility across the country directly from the NHRA,” said Dr Bahaa Eldin Fateha, the CEO of the NHRA. “The initial link to public and private facilities will be centralised at the NHRA, and we are in the midst of communicating with other regulatory bodies throughout the GCC to link up for a regional platform.”

BOLSTERING STAFFING FIGURES: One challenge facing the sector is a shortage of medical staff. Several local institutions are working to correct this shortfall, however. A constituent university of the Royal College of Surgeons in Ireland (RCSI), RCSI Bahrain was set up in 2005 and offers bachelor’s degree programmes in nursing and medicine/surgery/obstetrics, in addition to master’s degree programmes in health care management and nursing. Originally located in a temporary facility in the Manama district of Seef, RCSI Bahrain has since moved to purpose-built facilities next to the KHUH.

The university is currently developing a doctoral programme in health policy and plans to establish a post-graduate training programme for doctors. According to RCSI Bahrain, the programme will provide doctors with three to four years of on-the-job training that will lead to consultant status. RCSI Bahrain also has a School of Nursing and Midwifery, which offers both bachelor’s degrees in nursing and post-graduate programmes, as well as a bridging programme for nurses wishing to obtain a higher degree.

Students interested in studying nursing also have the option of attending the College of Health Sciences (CHS), which is located next to the SMC and the Arabian Gulf University. A public institution, the CHS was set up in 1976 under the guidance of the MoH and is essentially a community-based college. With its close proximity to the SMC, the college provides all of its students with the opportunity to gain substantial clinical experience at the hospital.

The institution offers a bachelor’s degree in nursing and associate’s degrees in five health-related specialities: public health, dental hygiene, pharmacy, radiology and medical laboratory technology. A bachelor’s completion programme in nursing is also offered in addition to diploma courses in a number of nursing specialities. The CHS also plans to offer its associate’s degree programmes at the bachelor’s level in the coming years. In 2011 a resolution was adopted to incorporate the CHS into the University of Bahrain, a public institution founded in 1986. The EDB reported in early 2013 that more than 2000 doctors and surgeons are registered in the kingdom, as well as approximately 300 dentists. Some 80% of Bahrain’s physicians, more than half of its nurses and around 85% of its related medical professionals are nationals. A number of educational conferences and workshops are available to the kingdom’s current health care workforce. The BSH, for example, offers conferences on a regular basis, which are accredited by the American Academy of Continuing Medical Education. The MoH also offers conferences and workshops.

MEDICAL TOURISM: Although still in the early stages, Bahrain is taking steps to develop its medical tourism industry. The government is working to increase health care infrastructure and open up economically to other countries. Both of these efforts should encourage greater numbers of tourists to travel to the kingdom for medical care. Much of the current medical tourism industry is centred at the BSH, which attracts visitors, in part, due to its JCI accreditation.

The RBH also treats medical tourists, with the largest share travelling from Saudi Arabia’s Eastern Province. The hospital reported in early 2013 that it typically receives three to four medical tourists from Saudi Arabia every day. The RBH also sees visitors arrive from Qatar, Oman and Kuwait. The majority of medical tourists come to the RBH for cosmetic surgery, orthopaedics-related work, spinal surgery and joint replacements.

New procedures at the RBH will likely facilitate further growth of medical tourism. Starting in April 2013, two Italian surgeons will begin performing weight reduction surgeries at the RBH. In addition, the hospital hopes to begin offering a new procedure used to control diabetes. The Diamond system, which was developed by MetaCure, a regional medical devices firm, is a minimally invasive, implantable device that uses slight electrical stimulation to the stomach, positively affecting fatty acid metabolism and glucose. The device has been used successfully in a number of other countries, and the RBH is currently waiting for MoH approval before offering the procedure.

OUTLOOK: As Bahrain’s health care industry continues to develop, a number of challenges must still be overcome. Perhaps most importantly, a growing population, in combination with rising medical costs and efforts to improve care, has placed some financial stress on the health system. Another challenge is the increasing prevalence of non-communicable diseases, such as cancer and diabetes, in the kingdom.

Bahrain’s health sector continues to develop despite these challenges. The NHRA is speeding up the licensing procedure for health care professionals and increasing the quality of inspections. The anticipated formation of the SCH should facilitate more collaboration between the firms and organisations within the health sector, and ensure a role for the private sector.