Bahrain seeks to raise the efficiency and quality of health care

With the pending introduction of a national health insurance scheme and an administrative transformation that promises to bind the kingdom’s hospital system more closely together to improve transparency, efficiency and patient care, the short-term prognosis for health care in Bahrain is positive. The government has devoted more of its national wealth to the sector than any of its Gulf neighbours in recent years and its health reform agenda is designed to ensure the most efficient use of that expenditure, while also opening the door for wider participation by private providers. Unlike other countries in the region, the kingdom can draw on a deep pool of home-grown professional talent, with Bahraini doctors and nurses outnumbering expatriates in its hospitals and clinics.

STATISTICS: The mean life expectancy at birth in Bahrain was 76.9 in 2015, according to the World Health Organisation (WHO), while the infant mortality rate was five per 1000 births and the maternal mortality rate stood at 15 per 100,000 births. The WHO reported in 2017 that non-communicable diseases (NCDs) were responsible for 77.9% of deaths. The four main NCDs are cardiovascular illnesses, which account for 26.3%, cancers (12.8%), respiratory diseases (5.9%) and diabetes (12.7%).

BUDGET: In the 2017-18 state budget, the Ministry of Finance (MoF) estimated expenditure excluding government debt interest would be BD3.1bn ($8.2bn) in 2018, 6% lower than in 2014 when spending was BD3.3bn ($8.8bn). This reduction in spending reflects the fall in the global price of oil and the subsequent impact on Bahrain’s fiscal balances. In 2018 the MoF expects expenditure by ministries to account for 85% of all government spending with a further 15% being used to finance interest on loans.

Planned expenditure on health services for the period is BD664m ($1.8bn), or 11% of total public spending. As well as costs associated with the provision of health care for citizens at public facilities, the budget covers subsidies for medicines, medical materials and overseas treatment for eligible patients.

Capital works include expansion of Salmaniya Medical Complex and construction and maintenance costs for primary health centres. That proportion of public expenditure does not include health care improvements being financed as part of the $10bn Gulf Development Programme under which GCC countries such as Saudi Arabia, Kuwait and the UAE are funding a range of improvements to Bahrain’s infrastructure, housing and citizen services. Major health care projects being financed by the fund include the Mohammed Bin Khalifa Al Khalifa Specialist Cardiac Centre, a long-stay treatment centre, a dialysis centre and infrastructure works for King Abdullah Bin Abdulaziz Medical City.

REGIONAL RANKINGS: According to Alpen Capital’s 2016 analysis of the most recent WHO data for 2013, Bahrain had the highest health care spending as a percentage of GDP of any GCC country at 4.9%, while the proportion of spending in Qatar was the lowest at 2.2%. The global average is 10%. Alpen Capital also reported that in 2008-13 health care spending in Bahrain saw a compound annual growth rate (CAGR) of 11.9%, the third-highest rate of any GCC country. In real terms, Bahrain spent $1067 per capita on health in 2013, placing it squarely in the middle compared to $2043 in Qatar, $1569 in the UAE, $1507 in Kuwait, $808 in Saudi Arabia and $678 in Oman.

The report also notes that one of the key drivers of health care spending across the GCC in the coming years will be the ageing population. Alpen Capital predicts that the proportion of GCC citizens over the age of 50 could grow from 11% in 2014 to over 15% in 2020, with Bahrain and Saudi Arabia set to be particularly affected by this demographic trend and concurrent health care demands.

KEY PRIORITIES: In cooperation with the WHO, Bahrain’s public health policy focuses on the control and prevention of communicable diseases and NCDs, as well as the promotion of healthy lifestyles. These objectives, along with providing a safe and sustainable health care system for all, form the basis of Bahrain’s 2015-18 Health Improvement Strategy, which contributes to the country’s 2030 Economic Vision statement. Bahrain is also working with the WHO to strengthen health systems and improve its levels of preparedness, surveillance and response to new or growing health challenges.

The Gulf states fall under the WHO’s Eastern Mediterranean directorate, a region in which improvements can be made to the collection and dissemination of accurate and timely data to enable health administrators to develop evidence-based policies. The WHO has highlighted local health care systems as fragmented with “major gaps or weaknesses in national health information systems”.

There are examples of fragmentation in Bahrain’s own state-run health landscape, with government health services provided by military, police and university hospitals as well as the Ministry of Health (MoH), and with major employers such as Gulf Air and Aluminium Bahrain offering primary care facilities alongside government clinics and private hospitals.

SUPERVISION & PLANS: The key body overseeing medical services strategy in the kingdom is the Supreme Council for Health (SCH), which was created by royal decree No. 5 of 2013. Working alongside the SCH is the National Health Regulatory Authority (NHRA), which was established in 2009 to act as an independent regulator for the health care sector. It oversees the licensing and registration of health care facilities and professionals working in the sector.

In late 2015 the SCH signed an agreement to work with the World Bank to develop a National Health Insurance Programme for Bahrain. A law detailing reforms to funding and health sector organisation has been drafted following public consultation and is due to be passed in 2018. The SCH says the changes will give public hospitals more autonomy, but also increase transparency and improve the sharing of medical records and information across care facilities. The reforms are designed to create a more cohesive system to address gaps in provision while also preventing duplication of health care services.

HUMAN RESOURCES: Workforce figures from 2015 showed there were 24 doctors, four dentists, 48.3 nurses and midwives, and 5.7 pharmacists per 10,000 people. The density of service providers across all four professions had declined progressively from 2012 when there had been 27.1 doctors, 4.6 dentists, 52.2 nurses and 6.3 pharmacists per 10,000 people. In 2015 the sector was staffed by 3295 physicians, of which 60% worked in the public sector. At the same time, 78% of all 6612 nurses were employed in government hospitals. Conversely, of the 554 dentists in Bahrain 70% were working in the private sector.

In its 2016 annual report, the NHRA noted there were 4111 physicians in Bahrain, including 3030 general doctors, 704 consultants and 377 specialists. The NHRA report showed there were 437 dentists practising in 2016 and 8962 registered nurses, including 8585 general nurses, 200 midwives, 149 specialist nurses and 28 paediatric nurses. There were 1228 pharmacists in 2016, according to the NHRA, with 80% working in the private sector.

PATIENT NUMBERS: In 2015 care was accessed by 7.4m outpatients and 79,111 inpatients, with public facilities treating 81% of outpatients and 47% of inpatients. The breakdown of outpatient care by sector is largely unchanged from the year before, however a higher proportion of patients went private for inpatient treatment, with the public sector treating 69% of the total number in 2014.

In the first quarter of 2017 MoH data shows that 71,883 patients were treated in accident and emergency wards at Bahrain’s hospitals, the equivalent of 799 per day. Over the same period, an estimated 1.5m patients were treated at the country’s health care centres, or 17,125 patients a day.

BEDS & FACILITIES: The MoH operates and oversees a network of seven publicly run hospitals and 28 clinics. According to the most recent MoH statistics, in 2014 the Salmaniya Medical Complex was the largest ministry-run hospital with just under 900 beds. The network also included 241 beds at the psychiatric hospital, 116 geriatric and long-stay beds, 54 beds at the Jidhafs Maternity Hospitals and a further 15 at the Ebrahim K Kanoo Community Medical Centre. The psychiatric hospital is supported by a network of health centres including eight specialised mental health clinics at primary health centres, working in line with the 2016-20 mental health strategy.

Bed density was 18.9 beds per 10,000 people in 2015, down from 19.5 in 2014. Figures have been falling since the 2011 peak of 20.8. MoH hospitals held the bulk of capacity, with 1325 beds in 2014. Another 456 were provided by Bahrain Defence Force Royal Medical Services and 326 at King Hamad University Hospital, which are also open to the public.

In the private sector, 18 hospitals provided 457 beds, or 25% of the total. The largest were Bahrain Specialist Hospital with 73, International Hospital of Bahrain (62) and Ibn Al Nafees Hospital (52). Overall, the NHRA reported there were 811 health facilities in 2016 including 381 medical facilities, 124 dental surgeries, 149 pharmacies, 127 optical stores, 15 laboratories, three radiology centres and 12 alternative medicine practices.

HEALTH EXPENDITURE: The MoH publishes details of its expenditure, which show that between 2006 and 2015 total spending grew from BD118m ($312.9m) to BD286.5m ($759.7m) with recurrent expenditure rising from BD109.7m ($290.9m) to BD278m ($737.2m). Of that recurrent expenditure total, BD170m ($450.8m) or 61% was spent on secondary health care, 28.59% or BD80m ($212.1m) on primary care and public health, with administration and support accounting for 7.71% of spending and training 1.85%. On the capital spending line of the budget, project expenditure over the period from 2006 to 2015 peaked at BD26.8m ($71.1m) in 2008, but had reduced to BD8.6m ($22.8m) by 2015.

The average cost per inpatient day in 2015 was BD305 ($808) at Salmaniya Medical Complex, BD119 ($316) at the psychiatric hospital, BD42 ($111) at the geriatric hospital and BD238 ($631) at EK Kanoo Community Medical Centre. Outpatient costs per visit were BD76 ($202), BD30 ($80) and BD18 ($48) at Salmaniya Medical Complex, the psychiatric hospital and primary health centres, respectively. Records of the obstetrics departments at Salmaniya Medical Complex’s maternity unit and other state maternity wards show costs per delivery were nearly identical at BD734 ($1946) and BD737 ($1954).

COMMUNICABLE DISEASES: Bahrain has a comprehensive programme of childhood vaccinations with between 97% and 100% of infants and children covered for measles, mumps, rubella, polio, hepatitis B and BCG. Mortality data for communicable diseases reflects, to some extent, medical conditions that expatriate workers may have contracted in their home countries. For instance, in 2014 there were 46 deaths from measles, but all of those patients had been infected outside of the country. In the same year 100 people died of malaria with 100% of cases imported and 145 from pulmonary tuberculosis, four from HIV/AIDS and 185 from other predominantly sexually transmitted diseases.

LIFESTYLE-RELATED ILLNESSES: As is the case elsewhere in the region, Bahrain is facing a significant challenge in preventing and treating NCDs, the prevalence of which is rising. The WHO reported that 13% of adults aged 30 to 70 are expected to die from the four main NCDs – cardiovascular disease, cancer, respiratory disease and diabetes. Tobacco consumption is a concern, with 24% of adolescents aged 13 to 15 reporting they had smoked cigarettes, rising to 34.2% for boys. The survey of adolescents found 38.7% reported they had been affected by passive smoking. Raised blood pressure affects 28.1% of the adult population, while 29.5% of males and 38% of females are categorised as clinically obese.

The WHO has described Bahrain as suffering from an “obesity epidemic” and has called for better food labelling and public awareness to reduce salt intake and sugar levels in drinks marketed at children. The country is planning a 20% reduction in salt levels in bread over five years, and as part of a GCC initiative is to introduce mandatory labelling of salt and fat content on all imported and locally produced foods.

NEW FACILITIES: Hospital and clinics specialising in the treatment of lifestyle illnesses are among the major projects being paid for out the Gulf Development Fund. The Abu Dhabi Fund for Development has donated BD58m ($153.8m) towards the cost of the new Mohammed Bin Khalifa Al Khalifa Specialist Cardiac Centre. The foundation stone for the three-year construction project at Awali was laid in 2015. It will complement the existing cardiology centre at the Bahrain Defence Force Royal Medical Services. The new unit will have 148 beds compared to 68 beds at the existing facility and will offer in- and outpatient care, diagnostic and therapeutic services on a 32,000-sq-metre site.

In September 2017 construction tenders were invited for the development of a long-stay treatment facility in Muharraq. The new $37m unit will have 100 beds. Saudi Arabia is also funding the construction of a $21m dialysis centre with 60 beds in Riffa. In August 2017, 35% of this project had reportedly been completed by Aradous Contracting and Maintenance Company. The government has allocated 21,550 sq metres of land for the project with a built-up area of 8854 sq metres, where a two-storey building is under construction. The ground floor includes a reception and registration area, six outpatient clinics, treatment rooms, a pharmacy, X-ray department and waiting areas, while the floor above will have three wings for peritoneal dialysis and blood wash, an isolation wing and a purification station for dialysis fluids. The centre will have a car park with 232 spaces. It is due to open mid-2018, providing a valuable additional facility for renal patients in Bahrain.

MEDICAL CITY: Another major health care development that has received financing from the Saudi Development Fund (SDF) is the King Abdullah Bin Abdulaziz Medical City, named after the late king of Saudi Arabia who pledged $266m towards the scheme in 2010. The $1bn development in the south of the country at Durrat Al Bahrain is being built on a 100-ha plot donated by King Hamad bin Isa Al Khalifa.

The medical city will comprise a self-contained campus with both academic and medical facilities as well as accommodation blocks and a research centre. It has been reported the first phase will include a 288-bed academic medical centre while in the second phase the facility will expand to 500 beds making it the second-largest hospital in Bahrain. The second phase will include a conference centre, a medical hotel, a rehabilitation centre hospital and a mosque. In October 2017 the Ministry of Works, Municipalities Affairs and Urban Planning said work on the $1bn project is set to begin on July 30, 2018. Earlier in 2017 the SDF and Bahrain signed a $43.4m to construct a 66-KV main power station, sewage facilities and water treatment station.

PRIVATE SECTOR: Although government facilities continue to dominate the health care sector in Bahrain, the 18 private hospitals have been seeing an increasing number of patients, while there are also a number of other independent medical clinics and facilities providing services. Bahrain is working to attract more international health care investment and in July 2016 passed a new law extending the right to 100% foreign ownership of businesses in the kingdom to include health care and social work. In 2016 the NHRA received 346 licence applications for new private health care facilities. In the first quarter of 2017, the authority received a further 85 applications for new premises licences.

Also in that year the NHRA began the process of accrediting the nation’s private sector facilities, visiting two hospitals and three clinics. This followed a SCH decision in 2016 granting accrediting powers to the NHRA. A training workshop was subsequently held to certify staff who will conduct the inspections.

Although the NHRA had not revealed the results of its initial visits as of late 2017, Bahrain Specialist Hospital announced it had been awarded the diamond level in the accreditation process. The facility, which opened in 2003, is the largest private hospital in the kingdom and is also accredited by the Joint Commission International. Based in Juffair, the hospital has an emergency room, a haemodialysis unit, a radiology department with diagnostic imaging equipment including CT scan, magnetic resonance imaging, X-ray, interventional radiography, mammography and ultrasound, as well as laboratories.

Other private players also have international accreditations. For example, International Hospital Bahrain, founded by a UK-qualified Bahraini doctor in 1978, is accredited by ACHS International as well as being rated a quality-assured hospital by BUPA. According to MoH records it had 62 beds and employs 34 physicians in 2015.

The oldest infirmary in Bahrain is American Mission Hospital, opened in 1903. The hospital offers a wide range of services from mental health and family medicine to obstetrics, cardiology and plastic surgery. It employed more physicians than any other private hospital, according to 2015 MoH records, with 72 out of a total of 430 doctors in private sector hospitals.

MEDICAL SCHOOLS: Bahrain has a long history of medical training programmes. In 1980 the GCC formed the Arabian Gulf University, based in Manama, to serve its member countries. Students there can study for an MD in medicine and for a range of master’s of science courses in allied medical professional fields. The private Royal College of Surgeons In Ireland in Bahrain offers a bachelor’s of medicine, bachelor’s of surgery in medicine and a bachelor’s of science (BSc) in nursing. The College of Health Sciences, which is part of the University of Bahrain, has offered a BSc in nursing since 2003 and students there can also take undergraduate degrees in medical laboratory services, diagnostic radiotherapy, public health and pharmacy. The NHRA runs licensing exams for health care professionals and also ensures health workers engage in continuous professional development (CPD) courses.

In 2016 the authority received 684 applications for new medical licences, 682 for allied professionals, 546 for nursing and 83 for pharmacy. In 2017 the NHRA reported that it is planning to link the number of completed CPD hours to renewal of licences.

MEDICAL TOURISM: As the number of qualified medical professionals and private facilities grows, Bahrain is also looking to tap into the medical tourism market. In 2017 the Bahrain Tourism and Exhibitions Authority announced the results of a survey of tourists, which showed that 2% of visitors came to the kingdom for medical treatment. The Bahrain Economic Development Board published a tourism white paper in 2016, which said that 58% of tourists visiting Bahrain for treatment were Saudi nationals, with other visitors seeking medical services coming from Kuwait, Iraq, Jordan and Yemen.

Medical tourism is set to benefit the country’s private hospitals, with related wellness services being an important aspect of one of the country’s upcoming large-scale tourism projects. The masterplan for the Dilmunia Island development includes a 165,000-sq-metre health district, which is being marketed as “a health and well-being landmark within the Middle East”. The plan highlights the provision of preventive, curative and rehabilitation services, including chronic disease management and diagnoses as well as alternative therapies and a range of wellness programmes (see Tourism chapter).

PHARMACEUTICALS: With the GCC’s biggest market, Saudi Arabia, just across the King Fahd Causeway and a strong record in the training of medical professionals, the country has a strong value proposition as a manufacturing and distribution centre for pharmaceuticals. Among the companies already operating in the kingdom is Bahrain Pharma, which develops, manufactures, markets and distributes branded pharmaceuticals and generics. Its products include soft gel capsules, syrups and injectables. The company also specialises in food supplements, or nutraceutical products.

In 2016 the NHRA licensed 178 new medicines for use in Bahrain, a 38% increase on the previous year. It also registered 79 pharmaceuticals manufacturing sites, 20 more than in the previous year. The NHRA also regulates the pricing of pharmaceuticals used in Bahrain and set prices for 516 medicines in 2016, including 252 innovative drugs and 51 generics.

OUTLOOK: With newly liberalised laws on the foreign ownership and the introduction of local accreditation for private providers to build their reputation in the local and medical tourism markets, there is strong potential in the Bahrain health sector. Development of national insurance plans should provide a boost to private players as well, while the rising prevalence of lifestyle-related illnesses and an ageing population point to long-term demand for treatment. Financing from the Gulf Development Fund for new specialist facilities will add to the array of services and reduce the need to send citizens abroad for treatment.