Bahrain's national health insurance system improves access and provision

 

With its first hospital dating back to the 1890s, Bahrain has long had solid fundamentals for care provision. A number of recent moves saw the government make major strides in its health care development agenda, including with the passing of the National Health Insurance Law (NHIL) and the establishment of the national ambulance system in 2018. In addition, the kingdom is also enhancing its research and development (R&D) capabilities with initiatives from the Ministry of Health (MoH) to establish the Bahrain Genome Project, a specialised centre for genetic analysis, and plans to open the $1bn King Abdullah Bin Abdulaziz Medical City in 2021.

Challenges, of course, still remain. High numbers of small-scale primary and secondary practitioners in the private sector have resulted in price wars over services and undercut private providers’ ability to make big-ticket investments. Growing local medical needs are also putting pressure on the kingdom’s import bill, as equipment and pharmaceuticals are largely manufactured abroad. Meanwhile, elevated incidence of non-communicable diseases (NCDs), such as diabetes, obesity and cardiovascular disease, continue to demonstrate the need for additional public health awareness campaigns.

Structure & Oversight

The MoH, headed by Faeqa bint Saeed Al Saleh as of October 2019, is the main government body tasked with formulating health policy in Bahrain, with a mandate to ensure the kingdom’s population has lifetime access to quality health care. A network of hospitals, specialty care centres and clinics are run by the MoH that offer free health care to Bahraini nationals. The MoH works with stakeholders to achieve its goals, including the National Health Regulatory Authority (NHRA), which was originally established in 2009 as the private sector regulator; and more recently the Supreme Council of Health (SCH), which was established in 2013 and also determines the kingdom’s national health care strategy. Sector development, meanwhile, is guided by several mid- and long-term strategies and policy documents, including the National Health Plan 2016-25; the NHRA 2016-20 Strategy, which emphasises inspection and accreditation activities; and the kingdom’s long-term development plan Bahrain Economic Vision 2030, which aims to modernise the health care sector.

Insurance Law

Due to increasing budgetary pressure on the kingdom’s universal health care system, in mid-2018 Bahrain passed the NHIL, which came into force the following December. The legislation supersedes previous laws under which the MoH had operated and applies to all nationals, residents and visitors, with the exception of Bahrain Defence Force (BDF) personnel and foreign diplomats. The NHIL established the Health Information and Knowledge Management Centre, which is responsible for collecting, processing and evaluating the medical data of all beneficiaries enrolled in the national health scheme. In addition, the law sets up a dedicated insurance fund, with the proceeds used to finance the health system. The fund was established via coordination between the SCH and the NHRA, and is run by a board of directors. The fund also collects and manages insurance contributions.

Via the NHIL, the adoption of the Social Health Insurance Programme, known as Sehati, is expected to improve the utilisation of available resources and alleviate challenges created by population growth and rising incidences of NCDs. All those covered by the programme will have to pay insurance contributions to the fund, with employers also now obliged to make payments for any foreign employees. Indeed, this may bring into the system many of those previously without coverage – such as domestic workers and other low-income foreign workers. The fund then operates a mechanism under which licensed insurers – who have been evaluated and entered on an approved list – pay the claims of those who have contributed, with the law also stating what treatments and services are covered by the system.

Bahraini nationals are able to take out additional, voluntary health insurance packages via the fund, with the government subsidising up to 60% of the cost of treatment at a private sector facility. Advocates hope this will encourage more nationals to register with private hospitals, encouraging competition and relieving pressure on state institutions.

General Indicators

According to the most recent statistics from the MoH, there were 22.6 doctors and 3.7 dentists per 10,000 people in Bahrain in 2017. This is compared with 26.5 doctors and 4.4 dentists in 2013. Nurses and midwives show a similar downward trend, with the number of such providers falling from approximately 52.2 per 10,000 people in 2013 to 45.4 in 2017.

The number of hospital beds was also down over the same period, from 20.3 beds per 10,000 people to 17.2. The high level of competition in the private primary and secondary health segments, in particular, have driven down profitability and thus impacted salaries, making Bahrain less attractive to expatriate medical professionals – a major source of employment for the kingdom’s health facilities.

There were seven government and 22 private hospitals, along with 30 government primary health care units and centres operating in 2017. There were also five private company clinics, run by outfits such as Aluminium Bahrain and Gulf Petrochemical Industries Company. NHRA figures for 2018 show that the number of public and private registered facilities increased by 7% to 716. This included 21 hospitals, 95 general centres, 91 dental centres, 41 specialised centres and 132 dental and medical clinics.

Spending

In terms of health care expenditure, Bahrain has long ranked among the highest in the region as a percentage of GDP. In 2019 BD307.4m ($815.4m) was allocated to the health sector, with BD224.2m ($594.7m) going to the MoH and BD2.5m ($6.6m) to the NHRA. Some BD35.7m ($94.7m) went to the King Hamad University Hospital (KHUH), BD19.6m ($52m) to the Mohammed Bin Khalifa Bin Salman Al Khalifa Cardiac Centre, and BD25m ($66.3m) was allocated to the Bahrain Oncology Centre. The SCH accounted for BD420,000 ($1.1m).

The 2020 budget saw figure moderate somewhat, with public spending standing at BD299m ($793.1m), though this cut came entirely in the MoH’s budget, which fell to BD215m ($570.3m). All other spending allocations remained relatively stable. The efforts of the government to reduce its fiscal deficit are largely behind the budget numbers (see Economy chapter), although health and education have been largely protected from major cuts, as Bahrain continues to see these as vital to future growth.

Disease Burden

As in many other GCC countries, the principle health threats in Bahrain are largely lifestyle-related NCDs, with cancer, diabetes and cardiovascular disease among the biggest public health risks. MoH figures for 2017 show that diseases of the circulatory system were responsible for 28.7% and 15.3% of male and female deaths that year, respectively. Cancer accounted for 7.5% of male and 8% of all female deaths, while external causes of morbidity and mortality were the next biggest killer for males (7%) and diseases of the genito-urinary system for females (3.1%). Among communicable diseases, malaria caused the most fatalities, with 133 cases reported in 2017, although Bahrain has no malaria transmission of its own – the cases were recorded among visitors to the kingdom.

Emphasis has been given to public health awareness campaigns for a number of years. The MoH’s Health Improvement Strategy 2015-18 made “sustaining the population’s health through health promotion and prevention” its primary objective. This has helped mobilise state bodies, including the General Organisation for Youth and Sports, the Ministry of Education, the Ministry of Social Development, municipalities and governorates, along with the private sector. The non-profit Bahrain Diabetes Society is also a key body combatting rising NCD rates in the kingdom, where 2017 figures show a 16.2% prevalence in adults of this disease.

Public Sector

The government primary health care network breaks down into five geographical areas, with the busiest being Health Region III, seeing 836,559 general clinic visits in 2017. Of this figure, the Yousef Abdul Rahman Engineer Health Centre accounted for nearly 30%, or around 346,011 patient visits. Meanwhile, the big four state hospitals in the country are the Salmaniya Medical Complex (SMC), KHUH, the Bahrain Royal Medical Services (BRMS) hospital, and the Psychiatric Hospital of Bahrain (PHoB). The largest is the SMC, which had some 881 beds in 2017 and a total of 45,334 admissions. This was followed by the BRMS hospital with 390 beds and approximately 22,304 admissions; the PHoB (215 beds, 1192 admissions); and the KHUH (186 beds, 23,055 admissions).

The government is also overseeing the infrastructure development of the King Abdullah Bin Abdulaziz Medical City. The project is being constructed on a 100-ha site on the artificial island of Durrat Al Bahrain, and is due to receive its first patients in 2021. The initial phase will see the construction of the 288-bed King Abdullah Bin Abdulaziz Medical City, which will also offer training to students from Arabian Gulf University (AGU). “Our teaching hospital will be public and is slated to provide health services to nationals,” Khaled Tabbara, vice-president of AGU, told OBG. “This will benefit the national system, plus, as it will be our own hospital, we will be able to implement our own rules and guidelines.” The first phase also includes a range of administrative buildings, accommodation and a power station. The second phase will expand the facility to 500 beds, add a medical college, physiotherapy and child care centres, and a number of R&D centres.

Private Sector

Private providers are expected to benefit from the rollout of the Sehati national insurance system, with such institutions now able to benefit from government subsidies on patient costs, making private care more widely affordable. The private sector is, however, already fairly extensive. At the secondary level, hospitals include the Al Noor Specialist Hospital, the Bahrain Specialist Hospital, the American Mission Hospital, Royal Bahrain Hospital, German Orthopaedic Hospital, Al Hilal Hospital, Al Kindi Specialised Hospital, Al Amal Hospital and the Gulf Dental Speciality Hospital.

Private sector hospitals are generally smaller facilities and tend to focus on specialist treatments. The American Mission Hospital, for example, had 36 beds in 2017, while the Bahrain Specialist Hospital had 73. In 2017 obstetrics and gynaecology, along with surgical procedures, accounted for 80.5% of all bed use at the former and 72% at the latter.

Furthermore, such specialities are also now set to include post-acute care, with the scheduled opening of the $20m KIMS Bahrain Hospital in Umm Al Hassan currently planned for summer 2020.

Medical Staff

New facilities, along with all other public and private sector health institutions, will be subject to the kingdom’s Bahrainisation policy, a strategic nationalisation programme under which various industries will be required to hit a target ratio of national employees. In September 2019 the upper house of the National Assembly, also known as the Shura Council, amended an earlier ruling on the policy regarding the health sector, with Bahraini nationals now to be prioritised over expats in the hiring of staff for private health facilities.

This may create challenges in the short term for health employers given the small size of the Bahraini population, the low number of qualified and experienced medical professionals, as well as a long-standing preference among many nationals for jobs in the public sector. The new law does, however, stress that priority should be given to nationals, should they also meet the qualifications and degrees of experience specified in the relevant job specifications. This should allow for the continued recruitment of expats, should no suitable local be available.

Pharmaceuticals

With Bahrain importing much of its pharmaceutical and medical equipment requirements, there have been growing calls in recent years for the kingdom to establish its own, domestic pharmaceutical industry.

According to the organisers of the October 2019 BDFEX Health Care Investment Forum in Bahrain, the kingdom’s medical product import bill stood at BD70m ($185.7m) in 2018, of which an estimated BD7.7m ($20.4m) came from neighbouring Gulf states. A large portion of the import bill is also made up of low-tech products, such as needles, catheter tubes, bandages and other medical supplies that might be easily manufactured locally. The year 2020 will therefore see a number of further moves to facilitate regulatory and licensing requirements for pharmaceutical and medical equipment manufacturers looking to open in Bahrain.

Currently, the NHRA – whose Pharmaceutical Regulation Department oversees the sector – has an Investor’s Office in the Seef, a commercial district in the capital Manama, to assist foreign companies looking to set up in the kingdom’s health sector.

Outlook

The coming years will be characterised by the continued rollout of Sehati national insurance system. Further infrastructure development will also remain a focus as the King Abdullah Bin Abdulaziz Medical City takes shape. Encouragement of local content and staffing is also on the rise, along with the Bahrainisation of medical personnel and support for locally based pharmaceutical and medical equipment manufacturers. In the longer term, the provision of local teaching and training facilities will assist in reducing the shortage of local staff, while also further encouraging R&D. Meanwhile, as the Sehati programme is implemented, demand for treatment at private medical facilities will likely rise.

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