A rise in population is slowly putting pressure on Bahrain’s public health care sector, which is the oldest in the GCC region, with the first modern hospital in the Gulf established in Bahrain in 1902. The health care sector in Bahrain has historically been heavily dependent on government-run facilities and public funding, but moves in recent years have set in motion the growth of the private sector. With new legislation allowing for 100% foreign ownership of private health care facilities, coupled with the arrival of a national health insurance scheme, there is currently a drive for greater involvement by private sector players in the near future, which will further push the development and expansion of the sector.

BY THE NUMBERS: In 2014 the population of Bahrain was 1.31m, with 20.5% of the population under 25, and 2.9% over the age of 65. The country’s fertility rate stood at approximately 2.1 births per woman, down from 4.5 births per woman just three decades earlier, while the birth rate stood at 15.9. Infant mortality was 10.4 per 1000 live births, with the overall life expectancy 76.5, unchanged since 2010.

Primary health care centres saw 60% of outpatient visits in 2014, the latest year data is available, followed by 19% for the private sector and 9% going to Salmaniya Medical Complex. According to the Ministry of Health (MoH), non-communicable diseases such as cardiovascular diseases, diabetes and cancer are rising in Bahrain, and represent the leading causes of death in the country; the leading cause of death in Bahrain in 2014 were diseases of the circulatory system, accounting for 21.1% of total deaths, followed by endocrine, nutritional and metabolic diseases, accounting for 19%.

Meanwhile, childhood infectious diseases have been largely eradicated in the kingdom, with the country having had effective immunisation programmes in place since the 1980s. For example, the Expanded Programme on Immunisation was created in 1981, and it was followed by the introduction of a second dose of measles vaccine in 1985. This programme led the Infectious Diseases Society of America to observe that measles cases had been significantly reduced to 2.7 cases per 1m people as of 2009.

BUDGET: MoH expenditure, including for health care related projects, was BD274.4m ($727.8m) in 2014, up from BD256m ($679m) in 2013 and BD232.1m ($615.6m) in 2012. Meanwhile, the budgetary allocation for health care rose slightly year-on-year (y-o-y), from 7.6% of the total government budget to 7.7%. According to official figures, the MoH annual budget per capita was BD208.7 ($553.6m) in 2014, up from BD204.3m ($541.9m) in 2013, having risen steadily from BD159.7m ($423.6m) in 2010.

Bahrain leads the region in health care expenditure as a percentage of GDP, at 4.6%, versus 3.7% in Saudi Arabia and 3.3% in both Kuwait and the UAE. According to a 2016 investment report by professional services firm EY on the health care and life sciences sectors across the GCC, the Bahraini government’s share of health care spending came to 70% in 2014, which is expected to drop to 66% by 2024. The reliance on government spending in Bahrain is cause for concern; in countries like the US and Singapore government spending on health care comes to just 47% and 41% of total expenditure, respectively.

OVERSIGHT: The MoH oversees Bahrain’s network of public hospitals, clinics and specialised health care centres that form the basis of the health system in the kingdom. Meanwhile the National Health Regulatory Authority (NHRA), made into a separate body in 2009, is responsible for inspecting public and private health care facilities, licensing medicines and medical personnel, as well as addressing complaints. In 2012 Bahrain established the Supreme Council for Health, which is charged with strategic planning with the aim of making each public sector hospital in Bahrain autonomous, while giving patients more choice when it comes to their own treatment and care. Bahrain’s public health care system is free at the point of use for nationals and open to expatriates for a nominal charge.

INFRASTRUCTURE: Bahrain has seven public hospitals and 18 private ones, with the number of available hospital beds standing at 2107 in the public sector versus 457 in the private sector. According to MoH data, in 2014 there were approximately 19.5 hospital beds per 10,000 people living in the kingdom; however, with the addition of new facilities already opened or set to come online in the near future, the rate is expected to improve to 24 beds per 10,000 residents. In addition, the government also has 28 primary health care units and centres distributed across the kingdom.

The main public hospitals in Bahrain include the 1200-bed Salmaniya Medical Complex, the biggest health care facility in the kingdom, originally founded in the 1950s but later expanded to its current size. The multi-speciality secondary and tertiary care facility is the main centre for acute patient care in Bahrain and has a number of specialised outpatient clinics. Other public hospitals include Bahrain Defence Forces Hospital (BDFH), which although a military facility is open to the public and treats inpatient, outpatient and emergency cases. It has 400 beds and is the second largest hospital in Bahrain. In May 2016 the International Federation for the Surgery of Obesity awarded BDFH international accreditation as a specialised centre for surgery related to obesity and diabetes.

The King Hamad Teaching Hospital in Muharraq, with its 311 beds and 1952 staff, was established in 2010 and is also affiliated with the BDF, though again its services are available to all Bahrain residents. The Defence Forces medical system, which runs separately from the MoH, employs more than 4000 staff, with its services free for both Bahrainis and non-Bahrainis. Meanwhile Bahrain’s Psychiatric Hospital has 226 beds, while the Geriatric Hospital has 70 beds.

NEW DEVELOPMENTS: In terms of new health infrastructure, there are notable developments taking place in specialised care, with the recent trend being towards smaller, more specialised health centres, clinics and facilities. In 2014, a BD4.7m ($12.5m) Hereditary Blood Disorders Centre opened at the Salmaniya Medical Complex, providing 90 beds for patients suffering from a variety of haematological conditions, including sickle cell disease and other genetic blood disorders. It is the largest centre of its kind in the region.

Another specialised care facility under development includes a 120 – bed cancer centre located within King Hamad University Hospital, Muharraq, which was still under construction in late 2016, and a 150-bed complex centre for people with disabilities to be completed by 2018, and aimed at treating patients with conditions like Down syndrome and autism.

Also under development is the 200-bed Muharraq Hospital, focused on obstetrics, gynaecology, diabetes and long-term care, and the 150-bed Sheik Mohammed Bin Khalifa bin Salman Cardiac Centre in Awali, an integrated facility to treat cardiac diseases and conduct heart surgeries. The $153m cardiac facility is being partly financed by the Abu Dhabi Fund for Development, on behalf of the UAE government, as part of its assistance programme, and will help to meet the demand for specialised cardiology services.

According to Dr George Cheriyan, CEO and chief medical officer at the American Mission Hospital (AMH) – the first hospital to be opened in the GCC – access to an integrated and well-coordinated tertiary cardiac care, stroke care and oncology services are essential for the kingdom. “They are available but patchy and difficult to access,” Cheriyan told OBG. “With high birth rates, the need for tertiary perinatal services is [also] essential so also is a central ambulance service that can be accessible to all citizens from all parts of Bahrain.” Ambulance centralization is under way and will be run by the Ministry of Interior.

PRIVATE SECTOR: In recent years the private sector in Bahrain has been expanding, with the arrival of international health care operators and new facilities being opened. This is likely to continue, with greater private sector involvement and the establishment of a national health insurance scheme. However, private care still remains a largely underused market. “Private-public partnerships in Bahrain are still nonexistent, and the entire healthcare system could benefit from increased government use of private-sector capabilities,” Kasim Ardati, CEO of Bahrain Specialist Hospital, told OBG.

PRIVATE CARE: The oldest private hospital operating in Bahrain is AMH, which dates back to 1902 and is the only non-profit private hospital in the country. AMH treats more than 20,000 patients a month, with services including paediatrics, orthodontics, obstetrics and gynaecology and free or heavily subsidised treatment for those who cannot afford the costs, which is around 15% of patients, according to Cheriyan. AMH also has a new ambulatory care facility in Riffa, set to open in mid-2017, covering all specialties, and a specialised physiotherapy service, which includes hydrotherapy and a wellness centre. Other private hospitals include the Royal Bahrain Hospital, part of the KIMS Group, Ibn Al Nafees Hospital and the Bahrain Specialist Hospital in Juffair.

In December 2015 Dr Mariam Adhbi Al Jalahma, the CEO of the National Health Regulatory Authority (NHRA), announced that 46 applications had been submitted to invest in the health sector in Bahrain, focusing on the construction of new hospitals and medical centres. Al Jalahma pointed to continued efforts to remove obstacles that had significantly hampered private investments, including developing legislation that would streamline the issuing of medical licences without impacting quality, with a series of edicts to be issued to regulated health care institutions. She also unveiled plans to start categorising private hospitals in accordance with international quality standards, which began rolling out in 2016.

NEW GROWTH: The latest private hospital set to open is the 70-bed, multi-speciality Al Salam Specialist Hospital located between Isa Town and Riffa, which began operations in late 2016. The hospital has inpatient and outpatient care, advanced diagnostic laboratories and specialised surgery. In addition, Al Hilal Hospital, a 50-bed private hospital in Muharraq, announced in February 2015 that it plans to open satellite clinics in Manama, Isa Town and Hidd, after the success of its first satellite facility – the Al Hilal Multi Specialty Medical Centre in Riffa – saw 100,000 patients pass through its doors in its first year. Al Hilal Hospital began operations in Muharraq in 2006 and now has more than 75 doctors and over 25 departments. Aster DM Healthcare, headquartered in Dubai, which opened its first clinic in Bahrain in December 2015, the Aster DM Medical Centre, has also said that it plans to invest a further BD10m ($26.5m) in Bahrain in the next five years, with the opening of four additional clinics and a multi-speciality hospital.

Meanwhile, in August 2016 Indian health care consultancy Philip Augustine entered into a memorandum of understanding with Middle East Hospital, to open a gastroenterology and liver disease department at the hospital, staffed by Indian doctors and offering advanced therapeutic endoscopy, hepatology and other gastroenterology services. A specialised pancreas clinic and a clinic for the treatment of patients with Crohn’s disease are also planned.

Despite all of this, Bahrain’s private sector is heavily underutilised. “Some 75% of our services are provided by the public sector, and not more than 35% of outpatient services are provided by the private sector,” Waleed Khalifa Al Manea, assistant undersecretary for hospitals at the MoH, told OBG. “If you want intensive care units you will not find in the private sector. Why? Because the MoH has full and comprehensive services, but we cannot continue like this for the coming years, the resources are not there. Our hospitals are overcrowded now. The private sector is not well utilised as we do not have health insurance that will cover both; it is accessible only for the public sector so patients have access to private care but out of pocket payments will be higher,” he added. However, that is likely to change in the near future, with the arrival of Bahrain’s first national health insurance programme.

NATIONAL HEALTH INSURANCE: Bahrain’s first national health insurance programme is expected to come online at the beginning of 2019, with work on the programme divided into two stages. The first phase, which began in 2015, involves studying international best practices when it comes to the health insurance industry and establishing working groups and workshops to assess the options available for Bahrain to implement. The second phase will involve the drafting of a health insurance law in coordination with the different government agencies and engaging with various industry stakeholders.

According to Sheikh Mohammed bin Abdullah Al Khalifa, chairman of the Supreme Council for Health, the government aims to fund contributions for Bahrainis towards mandatory basic health insurance, with employers then doing the same for expatriate workers and residents. In June 2016 the authorities dismissed reports claiming that residents would be compelled to pay a monthly subscription to obtain health services, with the government committed to paying the monthly subscriptions on their behalf into the Health Insurance Fund. Details related to the cost of the health insurance programme had not yet been released as of January 2017. However, the overall goals of the programme had been made clear. The fund is intended to both improve the standards of medical services provision throughout the kingdom, and to also ensure that the overall health care system can be sustained for the long term.

In December 2015 it was announced that the government had signed a cooperation agreement with the World Bank for the implementation of the National Health Insurance Programme for the country. The BD1.5m ($4m) deal is expected to see the World Bank acting as a partner with the kingdom while it moves forward with one of its primary strategic health care projects, which is aimed at upgrading, improving and developing the overall quality of the kingdom’s health care services and providers.

MEDICAL TOURISM: Like other countries in the Gulf region, Bahrain is hoping to benefit from the rise in medical tourism, in particular when it comes to patients visiting from Saudi Arabia. Significant projects include Dilmunia Health Island and the King Abdullah Medical City, with media reports suggesting that Bahrain is targeting Russian investors to develop health care facilities for medical tourists.

Much of the focus for medical tourism is centred on the Dilmunia Health Island, which is being developed by Ithmaar Bank, a Bahraini Islamic finance institution. The mixed-use project, built on a man-made island off of the coast of Muharraq, is expected to see investments of $1.6bn, with the development featuring residential properties, three boutique hotel and leisure facilities, all based around a 165,000-sq-metre health and wellness cluster offering alternative therapies, rehabilitation services and other treatments. However, progress has been slow, with the master plan for development only finalised in 2015 and little visible progress made in regards to developers for aspects of the project.“Medical tourism is a big opportunity, but maybe we are not yet ready enough for it,” said Al Manea. “We have primary care facilities and a limited number of secondary facilities, but not any tertiary. Because of that, we are not ready now. The good thing about Bahrain is that the country is very strategic for tourism in general, not just medical tourism. It is one of top tourism destinations in Arab world.”

HUMAN RESOURCES: According to MoH data, in 2014 there were 25.3 doctors per 10,000 people, down from 26.5 in 2013, with the number of nurses and midwives at 50.1 per 10,000, down from 52.2 per 10,000. The number of physicians working in the public sector reached 1957, up from 1932 y-o-y, while 1367 were employed in the private sector.

There are two institutions that offer medical training, the Arabian Gulf University, founded in 1979 as a GCC institution offering courses in medicine, business, IT and accounting, and the Royal College of Surgeons in Ireland Medical University of Bahrain, founded in 2004 by the Royal College of Surgeons in Ireland, Dublin by invitation of the Bahraini Government.

Like many countries in the Gulf region, Bahrain has been pushing hard in recent years for a greater number of Bahraini doctors and nurses to be employed in the system, which has had strong results. “Nurses in Bahrain are 50% Bahraini,” Al Manea told OBG. “If you compare that to other GCC countries the highest level is Oman, with about 60%. We have a strategy that worked for us. Some 60-70% of physicians are Bahraini. This is a tremendous asset for us.”

In late 2015 Bahrain announced that it planned to reduce medical costs for flying patients out of the country to receive specialised health care that is not currently available in the Kingdom. To achieve this, the country is instead flying in the doctors and medical teams in so that they perform the surgeries domestically. The new policy is a change from the previous policy of sending Bahrainis abroad for treatment, with the government covering the cost of treatment as well as flights, hotel accommodation and spending money. The health minister, Faeqa bint Saeed Al Saleh, told local media in December 2015 that the new policy will help to reduce the BD25m ($66.3m) that is currently being spent on treating Bahrainis abroad every year.

“We cannot go on with the current system; it is not serving the intended purpose, as it costs a lot and could be addressed by flying in doctors,” she told reporters. “We have contacted several hospitals and doctors who are experts in treating the illnesses that we cannot deal with here, such as certain types of cancers, and the response has been positive.” The goal is to have doctors fly in to perform multiple surgeries during the same trip, with doctors from India, Singapore, Thailand, Germany, the UK and the US among those agreeing to be part of the scheme.

OVERSEAS ACQUISITIONS: In August 2016 it was announced that the government of Bahrain’s sovereign wealth fund, the Bahrain Mumtalakat Holding Company, had acquired an equity stake in KOS Group, an Italian health care provider focused on long-term care and rehabilitation services, and hospital equipment management, diagnostics and cancer care. The company has more than 76 facilities, with over 7200 beds.

Meanwhile, the Bahrain-based private equity firm Investcorp Bank is reported to be in talks over upcoming plans to buy a minority stake in Saudi Arabia-based Al Borg Medical Laboratories, which has the largest chain of private medical laboratories in the Middle East, conducting medical testing for health care providers and individuals alike.

PHARMACEUTICALS: In 2015 the Bahraini pharmaceuticals market was estimated to be worth BD131m ($347.5m), with that figure likely to rise to BD139m ($368.7m) in 2016, according to analysis firm BMI Research. The domestic market is dominated by imports from Europe, Japan and the US, with just one producer active domestically, Bahrain Pharma, which manufactures generic softgel caps and syrups such as painkillers, analgesics and vitamin supplements. Bahrain Pharma is investing to serve the larger international market, making the export market its number one goal. It recently partnered with Osool Capital Holding, which began work on Gulf Biotech, an insulin factory, and previously established IFAD Labs, a food and drug inspection laboratory.

OUTLOOK: With the introduction of a national health insurance scheme and the growth of the private sector, Bahrain’s health care system is expected to undergo changes in the near future. The government will continue to play the major role in the sector, but alternative health care facilities and improved prospects for foreign investment in the sector are expected to lead to greater private provision. At the same time, the growth of smaller, specialised medical facilities should help tackle the rise in non-communicable diseases.