Changes to Bahrain's health care sector as it adapts to new conditions

Home to the first modern hospital in the region, founded by American missionaries in 1902, Bahrain has one of the oldest health care sectors in the Gulf. Over the course of the 20th century, the country developed a comprehensive health care system, substantially modernised with a large injection of funds during the 1970s oil boom. Now the authorities are looking to meet new challenges and introduce greater private sector involvement.

By The Numbers

In 2014 Bahrain had a population of 1.31m, up from 1.25m in 2013 and 1.23m in 2010, according to the latest figures available from the Central Informatics Organisation (CIO), Bahrain’s national statistics bureau. A decade earlier, in 2004, the population stood at 820,000, according to numbers from the World Bank. This rise in population has been driven by immigration in the form of expatriates taking up jobs in Bahrain as well as continuing high birth rates among the national population.

In 2014, according to World Bank indicators, 21% of the population was below the age of 15 and 2% was over the age of 65. The total fertility rate stood at 2.1 births per woman in 2014, down from 4.5 births per woman three decades earlier. In 2013 figures from the World Bank put the crude birth rate at 15 births per 1000 and the crude death rate at two deaths per 1000, while the rate of population growth was 0.9% a year in 2014. Life expectancy stood at 77 in 2013, up from 71 in 1983. Infant mortality was five per 1000 births in 2013, compared to 23 in 1983.

Health care costs accounted for 4.9% of GDP in 2013, as per figures from the World Bank, of which public expenditure comprised 70%. According to the latest financial accounts from the CIO, total spending by the Ministry of Health (MoH) was BD263m ($692.9m) in 2014, compared to BD250m ($658.6m) in 2013. In a 2014 report from Alpen Capital, a regional investment company, the total value of the health care market in Bahrain in 2011 was pegged at $728m, having increased at a compound annual growth rate of 11.4% between 2006 and 2010. The same report projected the value of the health care market will increase at a compound annual growth rate of 5.6% between 2013 and 2018.

Sector Structure

The MoH runs a comprehensive system of hospitals, clinics and specialised centres that is free at the point of use for nationals and open to expatriates for a nominal charge. The National Health Regulatory Authority (NHRA) was formed as a separate body in 2009, and is responsible for regulating and inspecting public and private facilities, as well as licensing medicines, conducting examinations for and licensing medical personnel, and handling complaints. The Supreme Council for Health, founded in 2012, is charged with strategic planning; over the longer term it aims to restructure hospital administration to make each public hospital in Bahrain autonomous and give patients more choice.

Demographic Story

As with many other Gulf nations, Bahrain is now entering a new phase in its demographic development, which over the mid to long term is likely to have significant implications for the country’s health care. As countries develop, they typically start with a situation where both birth and death rates are high. Improvements in sanitation, immunisation and the availability of medical care reduce death rates sharply, while birth rates tend to take a longer time to fall, leading to the development of a youth bulge and rapid population growth.

However, according to World Health Organisation (WHO) figures, Bahrain’s total fertility rate reached the replacement level of 2.1 children born per woman in 2013. While Bahrain’s population is set to continue to grow in absolute terms for some years, as the “bulge generation” comes to have its own children, over the longer term, the age profile of the country is due to rise considerably. According to Alpen, in the GCC as a whole, the proportion of the population over the age of 65 is set to increase from 2% currently to 20% by 2050, or from 1.2m to 14.2m.

Hitherto, Bahrain has successfully managed to meet the health challenges of a young population, as evidenced by the sharp decline in infant mortality. Historically, costs have been relatively low – a young population is, generally speaking, a healthy population, and the high proportion of expatriate workers has further helped, since they tend to go home upon retirement, easing Bahrain’s cost burden for elderly care. Indeed, Alpen estimates that 80% of a person’s health care needs occur after the age of 50.

Non-Communicable Diseases

The rise of lifestyle-related diseases is a trend observed in all countries undergoing economic development, and Bahrain has been no exception. While the country’s investment in sanitation, medicine and facilities has largely made preventable diseases such as cholera, typhoid and tuberculosis a thing of the past, non-communicable diseases like diabetes, heart disease and certain kinds of cancer have become a growing concern.

The rise of these illnesses is largely due to changes in lifestyle. Physically demanding jobs have given way to more sedentary jobs, and cars have largely replaced walking or cycling as the primary means of transport. Processed foods with high levels of salt, sugar and fat have come to form an increasing part of the diet, and consumption of red meat and tobacco has become more common. In Bahrain, as elsewhere, these changes have led to an increasing incidence of obesity and related illnesses. According to WHO figures, in 2012 the leading causes of death in Bahrain were heart disease, diabetes and stroke, followed by road accidents. The probability of dying from non-communicable diseases between the ages of 30 and 70 in 2012 was placed by the WHO at 13%. According to WHO figures, in 2008 some 32.9% of the population was classified as obese.

However, there are signs that efforts to promote a healthier lifestyle are bearing fruit. In February 2015 US survey company Zarca Interactive released some of the details of its 2015 survey of lifestyles in Bahrain, which found that 84% of people were eating breakfast, compared to 69% in 2010. Data from 2014 shows that some 44% of respondents reported doing regular physical activity between once and three times a week, while some 24% had taken part in a health campaign and 87% claimed to be non-smokers.

Public System

Bahrain’s public health service is based around a network of health centres, hospitals and specialised tertiary care centres. As of 2013, the latest year for which CIO figures are available, Bahrain counted five government hospitals, one maternity hospital, 27 health centres, and 16 private hospitals and health units. In the same year, the country had 2704 physicians employed in the government sector and 1385 employed in the private sector. Some 62% of outpatient visits to public facilities were made to health centres, and a further 18% to dedicated outpatient clinics, while outpatient services accounted for 80% of all visits to private hospitals in the country.

The biggest health care facility in Bahrain is the Salmaniya Medical Complex, which dates back to the 1950s, but which was substantially expanded in 1978. It is a multi-speciality secondary and tertiary care facility, as well as the main centre for acute care, and hosts a number of specialised outpatient clinics. It has around 900 beds. Among the other main public hospitals in the country are the Bahrain Defence Forces Hospital (BDFH) and the King Hamad Teaching Hospital. Although it is a military facility, the BDFH is open to all and is the second-largest hospital in the country, with 400 beds. It treats inpatient, outpatient and emergency cases. The Defence Forces medical system, which is run separately from the MoH, employs over 4000 staff and its services are available for free to Bahrainis and non-Bahrainis.

King Hamad University Hospital was established in 2010 and is affiliated with the military medical system, but is open to all Bahrain residents. It enjoys a close relationship with the Royal College of Surgeons in Ireland’s facility in Bahrain to provide teaching for medical personnel in the country. Located in Muharraq, it has 311 beds and a total of 1952 staff.

Ministry Facilities

The MoH operates a number of smaller, specialised treatment centres as well. The Psychiatric Hospital, building on a legacy of mental health care that dates back to the 1930s, has some 226 beds, while the Geriatric Hospital has 70 beds. Beds at the Abdulrahman Kanoo Dialysis Centre number 70 and 44 at the Ebrahim Khalil Al Kanoo Community Medical Centre. According to figures from the MoH, in 2013 the total budget for the ministry’s health care system was BD256m ($674.4m), or some 7.6% of public expenditure, up 10.3% on 2012, when the total budget was BD232m ($611.4m), or 7.1% of public expenditure. Secondary care was the leading item of expense, taking up around 60% of the total budget, followed by primary care (27%), then administration (10%). Over the decade prior to that, health care budgets grew by an average of over 12% a year.

Private Sector

Although the kingdom enjoys a high standard of public health care and well-resourced facilities, waiting times can be long. As a result many people choose to avail themselves of the private health care services on offer. Bahrain had 16 private hospitals in 2013, which admitted 36,000 patients in the same year, according to the CIO. Of these the oldest is the American Mission Hospital (AMH), which is also the longest-standing hospital in the Gulf, dating back to 1902. It remains the only nonprofit hospital in the country and continues to operate on a charitable basis – around 85% of patients pay either out of pocket or through insurance, with the money raised used to subsidise the care of the remaining 15% of patients (mostly low-paid labourers), for whom charges are waived. AMH offers services such as paediatrics, orthodontics, obstetrics and gynaecology, and urology, and treats around 22,000 patients a month.

Other private hospitals in Bahrain include the Royal Bahrain Hospital, part of the KIMS Group, which offers cardiology, cosmetic surgery and gastroenterology services; Ibn Al Nafees Hospital, which offers radiology, ear, nose and throat, and sleep disorder services; and the Bahrain Specialist Hospital in Juffair, which provides pulmonary medicine, internal medicine and oncology services, and operates an outpatient clinic in West Riffa that opened in May 2015. Competition in the sector can be fierce, with many providers from overseas – like the German Orthopaedic Hospital and the Indian firm, KIMS – having entered the market in recent years, setting up joint ventures with local investors, often with a focus on providing five-star accommodation facilities.

New Investment

Bahrain continues to see new investment in the health care sector, from both public bodies and private investors. The Hereditary Blood Disorders Centre opened at the Salmaniya Medical Complex in 2014, at a cost of BD4.7m ($12.4m), providing 90 beds for patients suffering from a variety of haematological conditions, including sickle cell disease. It is the largest centre of its kind in the region. Currently, a $106m specialised cardiology centre is also under construction at Awali and due to open in 2018, while the Mohammed bin Khalifa bin Salman Cardiac Centre is poised to house emergency facilities and 150 beds, under the aegis of the BDFH. The centre is being financed by the Abu Dhabi Fund for Development as part of its assistance programme. The fund has also pledged BD16m ($42.2m) to provide medical equipment and furnishings.

In a sign of further support for Bahrain from its neighbours, in March 2015 local media reported plans for a new teaching hospital subsequent to a SR1bn ($266.5m) bequest from the late Saudi king, Abdullah bin Abdulaziz. The King Abdullah Medical City, in Bahrain’s Southern Governorate, will consist of a 264-bed hospital, four research centres and a medical college to run courses in affiliation with Arabian Gulf University, a pan-GCC institution located in Bahrain.

In the private sector, the Dilmunia Health Island is planned as an integrated health resort to help Bahrain capture a slice of the increasingly lucrative medical tourism market in the Gulf. Developed by Bahraini Islamic finance institution Ithmaar Bank, Dilmunia is being constructed on reclaimed land off Muharraq, with investment totalling $1.6bn. The development is built around health and wellness, and features housing, three boutique hotels and two apart-hotels. At its centre is the Dilmunia Health District, a 165,000-sq-metre complex offering alternative therapies, rehabilitation services and other treatments.

Cost Control

One of the key challenges facing the government is that of balancing rising costs in the sector with the continued investments taking place. To meet this challenge various changes are being considered, principal among which is a shift from the current state-sponsored system to an insurance-based model, which would see patients paying an increased proportion of their health costs themselves. Insurance-based systems have already been successfully introduced in a number of other Gulf states, such as Saudi Arabia and parts of the UAE, and senior industry figures tell OBG it is likely that the system will be implemented at some point in the near future.

“The private sector will benefit from Bahrain’s health care overhaul, as patients will have the freedom to choose their own health care provider and social insurance will apply to both government and private hospitals,” Dr Sheikh Mohammed bin Abdullah Al Khalifa, president of the Supreme Council for Health, told OBG. In tandem with this, the Supreme Council for Health is looking at modifying the care system to increase the role of general practitioners, who would act as a first port of call for patients before referring them to a specialist if necessary. Currently, patients may seek non-urgent medical attention at a hospital without first consulting a family doctor, which is a contributory factor to long waiting lists.

Current Coverage

At present, it is not compulsory for employers to provide health insurance for their expatriate workers, though larger firms often do offer it. Until the end of 2014, employers paid a flat rate of BD5 ($13) per expatriate and BD1.5 ($4) per Bahraini employee, which went toward the health service. Starting from January 2015, however, these charges were raised to BD72 ($190) and BD22.50 ($60) respectively, prompting criticism in parliament, with a number of ministers raising concerns over its potential effect on small businesses.

In March 2015 the Shura Council rejected a bill to introduce compulsory health insurance, saying the proposed measures were too complicated. Currently, companies with over 50 employees may choose to exempt themselves from the health levies, but then have to provide their own 24-hour clinics for employees, or their own health insurance scheme, which is prohibitive cost-wise for all but the largest employers. At present, a number of large firms do provide employee health care, including state-owned firms Aluminium Bahrain and Bahrain Petroleum Company.

In the more immediate term, the authorities are looking at initiatives such e-health to help curb costs. In 2011 the MoH awarded an 11-year contract to Spanish firm Indra for I-Seha, the National Health Information Programme, a database of electronic medical records, which also allows the MoH to provide services such as medical enquiries and access to forms through an online portal.

Accreditation

Any move towards an insurance-based system will further boost the importance of accreditation. This has become increasingly significant over the past few years, with a growing number of hospitals, both public and private, looking to obtain accredited status. The accreditation body most widely used is the Australian Council on Health Standards International, which has been operating in Bahrain since 2007, when the AMH became the first local hospital accredited under the scheme.

In 2015 Bahrain had six hospitals registered with the body, the highest number of any Gulf country. North American accreditation bodies such as Accreditation Canada and Joint Commission International (JCI) of the US are increasingly used also. Accreditation has become important to Bahraini hospitals as it helps smooth out insurance claims. Bahrain Specialist Hospital, for example, was awarded JCI accreditation in both 2011 and 2014. “Gaining new accreditation lends legitimacy to the local health care sector and enables us to compare ourselves to hospitals in other countries across international standards,” Dr Kasim Ardati, CEO of Bahrain Specialist Hospital, told OBG. If cost pressures mean that Bahrain ultimately moves to an insurance-based provision model, having accreditation in place will be especially relevant for hospitals.

Pharmaceuticals

In 2014 the Bahraini pharmaceuticals market was estimated to be worth BD122m ($321.4m), according to Business Monitor International. The NHRA was due to complete its pricing review in September 2015, though as of early 2016 no figures had been released. The review is expected to lead to a drop in the price of treatment for heart disease, circulatory illnesses and diabetes. The market is dominated by imports from Europe, Japan, the US and, to a lesser degree, Saudi Arabia. There is currently one producer in Bahrain, Bahrain Pharma, which produces generic soft-caps and syrups, such as painkillers, analgesics and vitamin supplements. A move to greater common bulk buying in the GCC, which began in 2013, could help realise savings.

Outlook

Bahrain’s health care sector is set to witness substantial change over the near to medium term. The authorities are likely to introduce some form of insurance-based system (initially for expats) to help control the mounting costs of health care and oblige employers to bear more of the burden. Over the near term, investment in facilities is forthcoming from both the government and the private sector, helping to meet rising demand from a growing population, a factor which will likewise create a greater need for medical personnel and training. While an increase in non-communicable diseases seems unavoidable over the next few years, requiring more dedicated facilities, efforts to tackle this are already starting to bear fruit, especially among the young.

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The Report: Bahrain 2016

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