Health Systems Performance Assessment and Sustainable Improvement in Bahrain, Kuwait and Qatar By Aisha Soleman Hamad Al Ghafri Department of Public Health and Primary Care School of Public Health Faculty of Medicine Imperial College London 2018 Submitted for the Degree of Doctor of Philosophy 1 Declaration of originality I, Aisha Al Ghafri declare that the contents of this thesis are my own work. Where the work of others has been used, this has been indicated and appropriately referenced. Copyright Declaration The copyright of this thesis rests with the author and is available under a Creative Commons Attribution Non-Commercial No Derivatives license. Researchers are free to copy, distribute or transmit the thesis on the condition that they attribute it, that they do not use it for commercial purposes and that they do not alter, transform or build upon it. For any reuse or redistribution, the researcher must make clear to others the licence terms of this work. 2 Acknowledgements First and foremost, I would like to thank God for giving me the strength to see this thesis to completion. I am indebted to my supervisors Professor Salman Rawaf and Professor Azeem Majeed, for providing me with insight, guidance, advice, continuous support and huge amount of their valuable time. Without them, this work would not be completed and published. I would like to thank my husband Hamad Al Nahdi, my parents and my children for their tolerance, support and encouragement. I must convey my sincere thanks to my fellow PhD colleagues, especially Fahdah Al Shaikh, Dr Sondus Hassounah, Dr Mays Raheem, Dr Harumi Quezada Yamamoto, Mohammed Al-Saffar, and Dr Zaina Al-Kanaani. I thank Imperial College London, as well as Professor Ali Mokdad and his team at the Institute of Health Metrics and Evaluation in Seattle who have provided me with extensive training to access the most valuable databases at the Institute of Health Metrics and Evaluation IHME. Thank you to Dr Roger Newson and Dr Geva Greenfield for their statistical advice. I am so grateful to Rebecca Jones, Library Manager and Lead Librarian for Medicine, for her professionalism and kind support during my years of study at Imperial. I would like to acknowledge the support of the Hamad Medical Corporation in Qatar for funding me during my studies. This work would not have been undertaken without the immense support of many people at the three Ministries of Health in Bahrain, Kuwait and Qatar. Without them, I would not have been able to get insights on the work of these Ministries and accessed the most valuable unpublished data. I am grateful to His Excellency Professor Tawfik Khoja, Director General of the Executive Council of GCC Health Ministers, for his wisdom, support and guidance during this work. To the people of Bahrain, Kuwait and Qatar I dedicate this work with the aim of achieving better healthcare for everyone living and working in these three countries and the rest of the GCC. 3 Abstract Health systems vary in their complexity and application. Each health system is the product of a country’s culture and the way in which people are willing to fund it, to ensure equity and fairness. There is no ideal health system, as each has its strengths and weaknesses. Since the late nineties, the variety of health system performance assessment (HSPA) frameworks and methods used in high-income countries were either not applied in relation to low and middle-income countries or not suitable, mainly due to lack of expertise and data. The application of these frameworks is exacerbated by lack of defined standards for HSPA and each of these frameworks used different terminologies and indicators to assess performance. The six Gulf Corporation Council (GCC) countries are unique in their social structure with fast- growing populations, half of which are non-nationals who moved to these countries for economic reasons. This thesis will focus on three of these countries: Bahrain, Kuwait and Qatar. This study, the first of its kind, aims at enhancing our understanding of the health systems and their performances in the GCC countries. It addresses the question of whether health systems in the GCC can achieve sustainable improvements in population health. The study postulates various scenarios to assess the current health systems operation, management, and performance of three countries (Bahrain, Kuwait and Qatar) using both quantitative and qualitative research methods. An extensive and systematic literature review was conducted to understand the current situation in GCC. National and international data were collected and used to compare the health systems in these countries. Further data were retrieved through means of a survey and face-to-face interviews of key policy makers and senior managers. Furthermore, the HealthCare Access and Quality index (HAQ index) was employed to further standardise data collection and combat missing information. 4 The results of the systematic review showed the lack of any meaningful systematic or pragmatic health system performance assessment in the GCC countries. Results from the HAQ index showed that in general, there is improvement in the health system between 1990 and 2015. Among the studied countries, the three health systems showed some improvement by 2015 and at least one exceeded the projected best possible scenario, as measured by HAQ index. Political instability and conflicts in the region may have influenced the performance of health systems in both Kuwait and Bahrain. The lack of health management expertise, demonstrated by the health managers’ survey and face-to-face interviews, may have hampered health systems development and progress in addressing the challenges identified for better outcomes and better population’s health. Furthermore, managing the health needs requires accurate, up-to-date statistics, which are not always available in the GCC, limiting the ability to identify priorities, allocate resources, developing relevant policies and decision-making. The study concludes, from these findings, that while the overall health of the GCC population has improved over the last three decades, new emerging risks to health are challenging. Furthermore, it shows how strongly access to health service and quality relate to the health spending per capita using the HAQ Index. Thus, any further reduction in health spending will lower access to and the overall quality of healthcare, and reduce the confidence of the population in their health systems. Taking into account the current slow economic growth, it is unlikely that GCC governments will increase their share of total health expenditure required to achieve universal health coverage as envisaged by the Sustainable Development Goals (SDGs). As a result of this, health policy will change by introducing more robust financing methods such as social health insurance. The study shows that governments are aiming to shift the so-called ‘burden’ to the individuals and employers outside government through expansion of the private health sectors, for health insurance and health providers. 5 This is the first-ever substantial assessment of the GCC health systems of Bahrain, Kuwait and Qatar. Added Value of this Study The study provides added value in several areas. First, this is the first study on health system performance in the Gulf Region. The findings will undoubtedly be of value and hopefully drive and support the implementation of both GCC Health Ministers and WHO Eastern Mediterranean Regional Office EMRO Resolutions of introducing HSPA. Second, the comparative assessment of burden of disease using mortality data, preventable death, DALY and risk to health provided a platform for comparative health systems performance between the six countries. Third, the study provided some financial projections based on needs, which will be of value in planning health services and defining priorities. Fourth, an exploratory analysis of national HAQ Index levels and potential determinants of performance was conducted. This method of HSPA is being used for the first time in the GCC. Fifth, the relationship between HAQ Index and per capita spending in the GCC and neighbouring countries was examined for the first time, highlighting the value of sustainable funding to address challenges and improve health. Lastly, the study also provided new data on primary care needs and the number of family physicians needed to provide quality first contact and continuity of care through primary care. Primary care is a prerequisite for any effective health system, which is able and willing to secure good health for the whole population. 6 Contents Declaration of originality ...................................................................................................................... 2 Copyright Declaration .......................................................................................................................... 2 Acknowledgements ............................................................................................................................. 3 Abstract................................................................................................................................................ 4 Contents .............................................................................................................................................. 7 List of Tables ..................................................................................................................................... 11 List of Figures ...................................................................................................................................