The health profile of the Kuwaiti population has changed significantly in the past several decades. Kuwaiti citizens, who account for around 30% of the population of just over 4.2m, have become more prone to non-communicable diseases (NCDs). While deaths from infectious diseases are posing less and less of a threat, NCDs – the four main categories of which are heart disease, cancers, diabetes and upper respiratory diseases – accounted for 72% of deaths in Kuwait in 2015, according to the World Bank.
In the coming years the government will aim to address the increasing prevalence of NCDs, which are also associated with rising health care costs. Efforts to reduce public health care expenditures will also require a shift in the financing of care for the large expatriate population – a challenge for which solutions are now being modelled.
Structure & Regulation
The public health system in Kuwait is run by the Ministry of Health (MoH), which was established more than 80 years ago. The ministry is responsible for a primary health network of over 100 centres offering general practice, dentistry, maternity care, nursing care, preventive care, pharmaceuticals and family medicine. Kuwaiti citizens benefit from publicly funded health provision, free at the point of delivery. Expatriates pay a fee for health services received from the public system and are encouraged to use medical insurance.
The MoH provides secondary care through six facilities: Jahra Hospital, Amiri Hospital, the Mubarak Al Kabeer Hospital, the Sabah Hospital, the Farwaniya Hospital and the Adan Hospital. Tertiary health care is available through specialised centres, and occasionally through MoH-funded trips abroad.
According to a MoH report, a total of 104 medical centres operated in Kuwait in 2017, receiving 21m patient visits. Of these, 64% were from Kuwaiti citizens and the remaining 36% were from expatriates. Apart from the six major public hospitals, the report cited 12 private hospitals operating in the country as well as three hospitals affiliated to the oil industry. According to official statistics, in 2014 there were 9789 doctors in the country, of which 7640 (78%) were employed by the MoH and 2149 (22%) in the private sector. This was the equivalent of 2.4 physicians per 1000 inhabitants, and compares to an average of 3 per 1000 across OECD countries.
In January 2017 Kuwait launched its Vision 2035 programme, also known as New Kuwait. The objective of this long-term development plan, according to the government, is to transform Kuwait into “a financial and trade hub attractive to investors, where the private sector leads the economy”. To this end Vision 2035 lays out plans to diversify the economy and reduce dependence on oil revenues.
The plan has seven pillars, one of which is health care. This part of the scheme calls for the government to “improve service quality in the public health care system and develop national capabilities at a reasonable cost”. Delivering on this promise will require commitment to reducing NCDs and to increasing bed capacity in public hospitals to ensure the local population has access to proper health care.
Recent policy has in part been dictated by fiscal considerations. The combination of rapid population growth together with the rising resources needed to treat NCDs has been costly. The population is expected to continue to expand at around 3% per annum to reach 4.7m by 2020, and in 2014 alone the government spent over $1.5bn to send Kuwaitis abroad for tertiary medical care. Spending by the MoH doubled in the five years to 2016, reaching KD2bn ($6.63bn), or around 7% of total public sector expenditure. “The health sector in Kuwait will likely face rapid growth over the next five years due to the huge investment in the health care infrastructure,” Osama Abdelrazek, the manager of global market insights for the Upper Gulf Region at health information technology company QuintilesIMS, told local media. However, spending on health as a proportion of GDP remains relatively low at around 3% of GDP, compared to 9% in some more advanced economies. The public sector currently accounts for around 80% of all health spending in Kuwait.
According to a report by Global Investment House, a local investment bank, total health care expenditure is set to rise at a compound annual growth rate (CAGR) of 7.5%, from $5.2bn in 2014 to $8bn in 2020. The government is increasingly looking to the private sector to shoulder some of this burden. Indeed, the government’s share of total health spending is the second highest in the GCC, coming after Oman and standing at over 80%.
One way the government is working to reduce the financial squeeze on public sector health provision and boosting private sector participation is by treating more Kuwaitis at home, while also promoting inward health tourism – an inflow of foreigners seeking treatment at hospitals in Kuwait. It is acknowledged that this is a long-term goal since the country’s health infrastructure and specialised medical expertise needs to be further developed to allow it to compete more effectively as a destination for medical tourists.
Nonetheless, moving forward, the government is interested in pursuing public-private partnerships with international companies to help develop this potentially lucrative segment of the health care market.
Taking Control of NCD
The changing health profile of the Kuwaiti population is largely due to lifestyle factors. In the span of just a few generations, a sedentary, desk- and car-bound existence has replaced a previously active nomadic lifestyle, and traditional diets have given way to one of high-sugar and low-nutrition foods. Furthermore, while the country has made progress in reducing tobacco use – a major cause of cancer – in recent years, an estimated 28.5% of adults in the country were using tobacco in 2015.
The government is increasingly aware of the need to tackle NCDs. The Supreme Council for Planning and Development has listed fighting NCDs as a priority for Vision 2035. Responsibility for this task has been allocated to the MoH, the Kuwait Institute for Scientific Research, the Public Authority for Food and Nutrition, and the Public Authority for Sports.
According to the World Health Organisation, Kuwait has one of the highest obesity rates in the Middle East, with 39.7% of the population classified as obese – higher than 35% in the US and 22.7% in Germany. While the government has begun to focus on this problem, for example by locating obesity clinics within primary health centres, a comprehensive programme of population education and prevention remains under development.
According to Dedef Kayrouz, the head of Marketing and Communications at Abu-Dhabi-based health care group Capital Health, the population of Kuwait is in this way very similar to those of neighbouring states in the GCC, including Saudi Arabia and Bahrain. Policymakers in Kuwait and other countries in the GCC region have, for example, suggested implementing taxes to disincentivise the consumption of sugary products – a policy that has already been debated in some EU countries and is intended to work similarly to tobacco and alcohol taxes.
Dr. Siddig Salih, a principal research specialist at the Kuwait Institute for Scientific Research, told OBG that the health sector could be considered a “rising star” of the Kuwaiti economy, delivering high-value-added activities within the services sector as part of the country’s desired diversification away from excessive reliance on oil and gas. The challenge, he said, will be for the country to formulate a more specific strategy for development within the health care sector so it can achieve the objectives laid out in Vision 2035.
“From a structural perspective the Kuwaiti health sector is only dealing with curative aspects so far,” Salih told OBG. “It needs to do more to develop preventive medicine, to move into developing high-tech, and into pursuing value-added activities.” For example, Salih said Kuwait has an opportunity to invest and develop its expertise in combating obesity not just in treatment techniques, but also in terms of awareness, education and the promotion of healthy lifestyles.
If the country could create a centre or cluster of expertise in obesity and related medical conditions, Salih said, it could rise to meet significant regional demand for theses services – particularly given that the GCC as a whole is working to combat high incidence rates of obesity and NCDs.
A key policy milestone came in late 2017, when for the first time in a number of years the MoH announced an increase in medical fees charged to expatriates at public hospitals. The fee for a single hospital consultation was quintupled, from KD2 ($6.63) to KD10 ($33.15) for expatriates. A charge for each day of hospitalisation spent in a public ward, which had previously been free, was introduced at KD10 ($33.15). Fees were also brought in or raised for intensive care and for the use of private rooms.
The increases came as members of the Kuwaiti National Assembly called for the state to stop providing subsidised health care to the expatriate community. Syed M Aljunid, a health professor at Kuwait University, told OBG that in some hospitals, in the period immediately after the revision of charges, expatriate patient numbers fell by as much as 17-18%.
One effect of the fee changes may be a growing separation of health care structures and treatment pathways for Kuwaiti nationals and expatriates. According to Jamal Al Harbi, the minster of health, hospitals accepting private health insurance plans will now serve expatriates working in the private sector, while those employed in the public sector would still be treated at public hospitals.
A first step towards separating health funding streams arrived in 2014 with the launch of the Kuwait Health Assurance Company (KHAC), known as Daman, which was established to insure expatriates, attract private investment and build new hospitals. KHAC has charged a flat health insurance premium of KD50 ($166) per annum. While the premium is designed to cover the cost of basic medical services, there have been some discussions over possibly increasing it in future to KD175 ($580) to enable it to fund the capital costs of new private hospitals capable of catering to the needs of 1.75m people.
Though all foreign residents are required to purchase insurance, many blue-collar workers remain uninsured, while white-collar employees are usually able to use a mix of private and state-provided coverage. Although required by law to have health coverage through Daman, many blue-collar expatriates simply remain uninsured. Moving forward, Daman will play a larger role in insuring the expatriate community through a programme to build six hospitals and a network of primary care centres. This system will be based on the US model, operating as a health maintenance organisation (HMO), in which access to care is coordinated through a primary care physician.
There has been some discussion of the right balance between health charges at the point of delivery and medical insurance premiums. In August 2018 Ahmad Al Shatti, a MoH spokesman, told local news organisation the Arab Times that expatriates would soon enjoy “health relief” which would include “the provision of health care services at moderate prices to ensure a balance between insurance coverage and health care service charges”.
Hospital Building Programme
A prominent feature of Vision 2035 and subsequent government policy has been a major ongoing infrastructure investment programme to build new hospitals. One of the aims of Vision 2035 is to boost the number of hospital beds per 1000 inhabitants, which stood at an estimated 2.2 in 2012, according to the World Bank. As of 2016, there were 20 major government health care projects in the pipeline, with a value of KD3.5bn ($11.6bn). Together they will add around 11,200 hospital beds. Expansion programmes at eight existing hospitals are expected to add a further 4600 beds.
One of the biggest new facilities is Jaber Hospital, now one of the largest in the Middle East, with a total of 1168 beds and covers 750,000 sq metres over 13 floors. Jaber Hospital includes specialised centres for general surgery, paediatrics, obstetrics, gynaecology, and ear, nose and throat treatment, as well as associated buildings for dentistry and nurse accommodation. It also has a trauma centre, three helipads and 50 ambulance bays, construction of which was completed in November 2017.
Decisions have yet to be taken on the best operating model for the hospital, with the government ultimately opting for it to be run by a specially created private company. It is intended that Jaber will serve all potential markets, including government-financed patients, private patients, insured expatriates and patients coming in from the GCC or other parts of the Middle East. Details on the hiring of specialised staff are also awaited with estimates placing staffing needs at 2200 doctors and 9000 nurses.
Another major project is the 1115-bed New Al Jahra Hospital, a $1.18bn project that was completed in July 2018, after a three-year construction period. It has eight buildings, with the main tower rising to 15 stories. This hospital includes secondary and tertiary care facilities, a trauma centre and outpatient clinics, as well as renal dialysis and radiology centres. It also has a women’s centre, 32 operating suites, and CT and MRI centres, and parking for 5000 cars.
Among the other projects in the pipeline are the New Kuwait University Medical Centre, with 600 beds, the 500-bed New Medical City for Retirees, the 500-bed New Police Hospital, and a new facility for physical medicine and rehabilitation, expected to have between 600 and 750 beds.
The MoH is also working on a range of expansion projects, including the Farwaniyah Hospital (955 beds), the Farwaniyah Infectious Diseases Hospital (224 beds) and the Kuwait Centre for Cancer Control (618 beds), with completion dates running up to 2020. Meanwhile, KHAC has a $765m budget to engage in public-private partnerships for the construction of three 250-bed hospitals, 20 primary care clinics, and one day-surgery centre by 2020.
There have been some delays bringing completed hospital buildings into service. This has been attributed in part to significant turnover of MoH officials that has led to some projects being paused.
As the hospitals are completed and come into operation, there will also be a significant rise in demand for specialist staff. In March 2018 the MoH said it was ready to hire around 2000 expatriate medical personnel to staff for the new hospitals and clinics, and was seeking approval from the Civil Service Commission to begin recruitment.
The MoH said it needed more than 500 doctors and 1500 nurses, radiology technicians and other support staff, but was nevertheless seeking to reduce the number of expatriate administrative staff, recruiting Kuwaitis to fill those positions. The ministry estimated it would take a minimum of 10 years to train a sufficient number of doctors and nurses in order to fully staff domestic hospitals.
A combination of high income levels, rising demand for treatment of chronic disease and an ambitious hospital building programme virtually guarantees strong sector growth and a wide range of opportunities for private health providers.
There are, however, areas where more needs to be done to ensure health provision is effective, efficient and sustainable. While new facilities are part of the necessary response to rising rates of NCDs, a shift in the focus of health outreach efforts towards prevention at the primary care level will help build a sustainable structure for the sector. Promoting healthier lifestyles could help the population avoid expensive secondary and tertiary treatments in the long term, contributing to significant cost savings.
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